This question has a 45% incorrect rate, and that generally indicates a rewrite is needed.
In the actual exams across most specialties, that’s how they handle extremely high miss rates. But we’ll go through the question as-is, because this type of unclear learning objective does occur even on live exam questions.
Your exam trick here is to cue in on even slight mentions of prior history. Ninety percent of the time they are there to refine the testing objective. Ten percent of the time they are there to mislead you.
PEM is already one of the hardest exams out there.
14 yo adolescent boy who is otherwise healthy presents with acute onset left sided chest pain while playing basketball with his friends. He has mild dyspnea with no fevers or cough. He has no known trauma and states that this feels similar to the last time he had a collapsed lung.
You can hear diminished breath sounds on the left compared to the right, but the rest of his physical exam is normal. VS: T 36.8°C HR 87 RR 18 BP 111/82 SpO2 99% on RA. You perform a beside US and see a sliding lung point on the left side at the 2nd intercostal space. CXR identifies a small pneumothorax on the left with no pneumothorax on the right. After ibuprofen, his pain is improved and he is breathing comfortably.
What is the best treatment option for this patient?
Answers:
- 14 Fr Chest catheter placement and admission
- 36 Fr Chest tube placement and admission
- Observation and discharge if stable
- Oxygen via non-rebreather mask and admission
The key to the question here is in the first paragraph. “…this feels similar to the last time he had a collapsed lung”. His height and weight are not given. Spontaneous primary pneumothorax occurs most frequently in tall, thin young males, and can recur in some patients.
The most common incorrect answer however is #2, meaning the test-takers got the recurrent spontaneous pneumothorax correct, but put in a larger chest tube that would normally be reserved for larger or tension pneumothoraces - unnecessarily aggressive in this setting.
The correct answer is #1, 14 Fr Chest catheter placement. A small-bore chest catheter is preferred for managing a small recurrent spontaneous pneumothorax.
And for those test-takers that answered observation and discharge (which were several), it’s probably an indication that they missed the little bit in the first paragraph about the “last time”.
Perhaps a clearer example might be:
That hits the recurrence twice in the question, and leaves the knowledge test here as the catheter size to use for treatment, with the distractor answers being obviously incorrect.
This question appears in Med-Challenger Pediatric Emergency Medicine 3rd Edition Exam Review with CME
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