Conversion to open surgery criteria — MCQs

10 questions

A 34-year-old patient presents with severe pain in the right upper quadrant that radiates to the right shoulder. During laparoscopic cholecystectomy, which of the following anatomical spaces must be carefully identified to prevent bile duct injury?

A 63-year-old woman is brought to the emergency department because of severe abdominal pain and vomiting for 3 hours. She had previous episodes of abdominal pain that lasted for 10–15 minutes and resolved with antacids. She lives with her daughter and grandchildren. She divorced her husband last year. She is alert and oriented. Her temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 90/70 mm Hg. The abdomen is rigid and diffusely tender. Guarding and rebound tenderness are present. Rectal examination shows a collapsed rectum. Infusion of 0.9% saline is begun and a CT of the abdomen shows intestinal perforation. The surgeon discusses the need for emergent exploratory laparotomy with the patient and she agrees to it. Written informed consent is obtained. While in the holding area awaiting emergent transport to the operating room, she calls for the surgeon and informs him that she no longer wants the surgery. He explains the risks of not performing the surgery to her and she indicates she understands but is adamant about not proceeding with surgery. Which of the following is the most appropriate next step in management?

An epidemiologist is evaluating the efficacy of Noxbinle in preventing HCC deaths at the population level. A clinical trial shows that over 5 years, the mortality rate from HCC was 25% in the control group and 15% in patients treated with Noxbinle 100 mg daily. Based on this data, how many patients need to be treated with Noxbinle 100 mg to prevent, on average, one death from HCC?

A 62-year-old woman presents to her primary care physician for a routine physical exam. The patient has no specific complaints but does comment on some mild weight gain. She reports that she recently retired from her job as a math teacher and has taken up hiking. Despite the increase in activity, she believes her pants have become "tighter." She denies headaches, urinary symptoms, or joint pains. She has a history of hypertension, type 2 diabetes, and rheumatoid arthritis. Her medications include aspirin, lisinopril, rovastatin, metformin, and methotrexate. She takes her medications as prescribed and is up to date with her vaccinations. A colonoscopy two years ago and a routine mammography last year were both normal. The patient’s last menstrual period was 10 years ago. The patient has a father who died of colon cancer at 71 years of age and a mother who has breast cancer. Her temperature is 98.7°F (37°C), blood pressure is 132/86 mmHg, pulse is 86/min, respirations are 14/min and oxygen saturation is 98% on room air. Physical exam is notable for a mildly distended abdomen and a firm and non-mobile right adnexal mass. What is the next step in the management of this patient?

A 68-year-old man comes to the emergency department because of sudden onset abdominal pain for 6 hours. On a 10-point scale, he rates the pain as a 8 to 9. The abdominal pain is worst in the right upper quadrant. He has atrial fibrillation and hyperlipidemia. His temperature is 38.7° C (101.7°F), pulse is 110/min, and blood pressure is 146/86 mm Hg. The patient appears acutely ill. Physical examination shows a distended abdomen and tenderness to palpation in all quadrants with guarding, but no rebound. Murphy's sign is positive. Right upper quadrant ultrasound shows thickening of the gallbladder wall, sludging in the gallbladder, and pericolic fat stranding. He is admitted for acute cholecystitis and grants permission for cholecystectomy. His wife is his healthcare power of attorney (POA), but she is out of town on a business trip. He is accompanied today by his brother. After induction and anesthesia, the surgeon removes the gallbladder but also finds a portion of the small intestine is necrotic due to a large thromboembolism occluding a branch of the superior mesenteric artery. The treatment is additional surgery with small bowel resection and thromboendarterectomy. Which of the following is the most appropriate next step in management?

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

A 32-year-old male asks his physician for information regarding a vasectomy. On further questioning, you learn that he and his wife have just had their second child and he asserts that they no longer wish to have additional pregnancies. You ask him if he has discussed a vasectomy with his wife to which he replies, "Well, not yet, but I'm sure she'll agree." What is the next appropriate step prior to scheduling the patient's vasectomy?

A 31-year-old woman is brought to the emergency department 25 minutes after sustaining a gunshot wound to the neck. She did not lose consciousness. On arrival, she has severe neck pain. She appears anxious. Her temperature is 37°C (98.6°F), pulse is 105/min, respirations are 25/min, and blood pressure is 100/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. She is oriented to person, place, and time. Examination shows a bullet entrance wound in the right posterior cervical region of the neck. There is no exit wound. Carotid pulses are palpable bilaterally. There are no carotid bruits. Sensation to pinprick and light touch is normal. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. In addition to intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

A 24-year-old male is brought in by fire rescue after being the restrained driver in a motor vehicle accident. There was a prolonged extraction. At the scene, the patient was GCS 13. The patient was boarded and transported. In the trauma bay, vitals are T 97.2°F, HR 132 bpm, BP 145/90 mmHg, RR 22/min, and O2 Sat 100%. ABCs are intact with a GCS of 15, and on secondary survey you note the following (Figure F). FAST exam is positive at Morrison's pouch. Abdominal exam shows exquisite tenderness to palpation with rebound and guarding. Which of the following radiographs is most likely to be present in this patient?

Q10

A 23-year-old woman presents to the emergency department after being found unresponsive by her friends. The patient is an IV drug user and her friends came over and found her passed out in her room. The patient presented to the emergency department 2 days ago after being involved in a bar fight where she broke her nose and had it treated and packed with gauze. Her temperature is 99.3°F (37.4°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 97% on room air. Physical exam is notable for an obtunded woman with nasal packing and EKG tags from her last hospital stay, as well as a purpuric rash on her arms and legs. Her arms have track marks on them and blisters. Which of the following is the best next step in management?

Conversion to open surgery criteria US Medical PG Practice Questions and MCQs

Question 1: A 34-year-old patient presents with severe pain in the right upper quadrant that radiates to the right shoulder. During laparoscopic cholecystectomy, which of the following anatomical spaces must be carefully identified to prevent bile duct injury?

A. Foramen of Winslow
B. Lesser sac
C. Calot's triangle (Correct Answer)
D. Morrison's pouch

Explanation: ***Calot's triangle*** - **Calot's triangle** is the critical anatomical landmark containing the **cystic artery** and **cystic duct**, whose proper identification is essential to prevent injury to the hepatic artery or bile ducts during cholecystectomy. - Its boundaries are the **cystic duct** (lateral), the **common hepatic duct** (medial), and the **inferior border of the liver** (superior, sometimes described as the cystic artery). *Foramen of Winslow* - The **Foramen of Winslow** (epiploic foramen) is an opening connecting the **greater and lesser sacs** of the peritoneal cavity. - It is not directly relevant to identifying structures during cholecystectomy, but rather to accessing the lesser sac or for surgical procedures involving structures like the portal triad. *Lesser sac* - The **lesser sac** (omental bursa) is a peritoneal cavity posterior to the stomach and lesser omentum. - It is explored in procedures involving the pancreas, posterior gastric wall, or for assessing fluid collections, but not for direct identification of cystic structures during standard cholecystectomy. *Morrison's pouch* - **Morrison's pouch** is the **hepatorenal recess**, a potential space between the posterior aspect of the liver and the right kidney and adrenal gland. - It is a common site for **fluid accumulation** (e.g., ascites, blood) but is not directly incised or dissected for preventing bile duct injury during cholecystectomy.

Question 2: A 63-year-old woman is brought to the emergency department because of severe abdominal pain and vomiting for 3 hours. She had previous episodes of abdominal pain that lasted for 10–15 minutes and resolved with antacids. She lives with her daughter and grandchildren. She divorced her husband last year. She is alert and oriented. Her temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 90/70 mm Hg. The abdomen is rigid and diffusely tender. Guarding and rebound tenderness are present. Rectal examination shows a collapsed rectum. Infusion of 0.9% saline is begun and a CT of the abdomen shows intestinal perforation. The surgeon discusses the need for emergent exploratory laparotomy with the patient and she agrees to it. Written informed consent is obtained. While in the holding area awaiting emergent transport to the operating room, she calls for the surgeon and informs him that she no longer wants the surgery. He explains the risks of not performing the surgery to her and she indicates she understands but is adamant about not proceeding with surgery. Which of the following is the most appropriate next step in management?

A. Consult hospital ethics committee
B. Obtain consent from the patient's daughter
C. Obtain consent from the patient's ex-husband
D. Continue with emergency life-saving surgery
E. Cancel the surgery (Correct Answer)

Explanation: ***Cancel the surgery*** - The patient is **alert and oriented** and has indicated she understands the risks of refusing surgery, demonstrating **decision-making capacity**. An adult with intact capacity has the right to refuse medical treatment, even if it is life-saving. - While the decision may seem medically unwise, **patient autonomy** is a fundamental ethical principle that must be respected once capacity is confirmed. *Consult hospital ethics committee* - An ethics committee consultation is typically reserved for situations where there is **uncertainty about a patient's capacity**, a conflict among healthcare providers, or a difficult ethical dilemma where principles of patient care are in clear conflict. - In this case, the patient's capacity seems clear, and her refusal is unequivocal. *Obtain consent from the patient's daughter* - The patient's daughter cannot provide consent for her mother if the mother is **competent and able to make her own decisions**. **Surrogate decision-makers** are only legally authorized when the patient lacks capacity. - The patient's expressed wishes directly override any potential preferences of her next-of-kin. *Obtain consent from the patient's ex-husband* - As the patient is divorced, her ex-husband has **no legal standing** to make medical decisions on her behalf. - Even if they were still married, a spouse can only act as a surrogate if the patient lacks decision-making capacity. *Continue with emergency life-saving surgery* - Performing surgery against a **competent patient's explicit refusal** would be an act of **battery** and a violation of her **autonomy**. - Even in life-threatening situations, a patient with capacity has the right to refuse treatment.

Question 3: An epidemiologist is evaluating the efficacy of Noxbinle in preventing HCC deaths at the population level. A clinical trial shows that over 5 years, the mortality rate from HCC was 25% in the control group and 15% in patients treated with Noxbinle 100 mg daily. Based on this data, how many patients need to be treated with Noxbinle 100 mg to prevent, on average, one death from HCC?

A. 20
B. 73
C. 10 (Correct Answer)
D. 50
E. 100

Explanation: ***10*** - The **number needed to treat (NNT)** is calculated by first finding the **absolute risk reduction (ARR)**. - **ARR** = Risk in control group - Risk in treatment group = 25% - 15% = **10%** (or 0.10). - **NNT = 1 / ARR** = 1 / 0.10 = **10 patients**. - This means that **10 patients must be treated with Noxbinle to prevent one death from HCC** over 5 years. *20* - This would result from an ARR of 5% (1/0.05 = 20), which is not supported by the data. - May arise from miscalculating the risk difference or incorrectly halving the actual ARR. *73* - This value does not correspond to any standard calculation of NNT from the given mortality rates. - May result from confusion with other epidemiological measures or calculation error. *50* - This would correspond to an ARR of 2% (1/0.02 = 50), which significantly underestimates the actual risk reduction. - Could result from incorrectly calculating the difference as a proportion rather than absolute percentage points. *100* - This would correspond to an ARR of 1% (1/0.01 = 100), grossly underestimating the treatment benefit. - May result from confusing ARR with relative risk reduction or other calculation errors.

Question 4: A 62-year-old woman presents to her primary care physician for a routine physical exam. The patient has no specific complaints but does comment on some mild weight gain. She reports that she recently retired from her job as a math teacher and has taken up hiking. Despite the increase in activity, she believes her pants have become "tighter." She denies headaches, urinary symptoms, or joint pains. She has a history of hypertension, type 2 diabetes, and rheumatoid arthritis. Her medications include aspirin, lisinopril, rovastatin, metformin, and methotrexate. She takes her medications as prescribed and is up to date with her vaccinations. A colonoscopy two years ago and a routine mammography last year were both normal. The patient’s last menstrual period was 10 years ago. The patient has a father who died of colon cancer at 71 years of age and a mother who has breast cancer. Her temperature is 98.7°F (37°C), blood pressure is 132/86 mmHg, pulse is 86/min, respirations are 14/min and oxygen saturation is 98% on room air. Physical exam is notable for a mildly distended abdomen and a firm and non-mobile right adnexal mass. What is the next step in the management of this patient?

A. Pelvic ultrasound (Correct Answer)
B. Abdominal MRI
C. PET-CT
D. Exploratory laparotomy and debulking
E. CA-125 level

Explanation: ***Pelvic ultrasound*** - A **non-mobile right adnexal mass** in a postmenopausal woman, along with vague symptoms like **abdominal distension** and **weight gain**, raises suspicion for **ovarian cancer**. - A **pelvic ultrasound** is the initial, non-invasive, and cost-effective imaging modality to characterize adnexal masses, assessing size, morphology, and vascularity. *Abdominal MRI* - While **MRI** offers excellent soft tissue contrast, it is typically used as a **secondary imaging modality** for further characterization of adnexal masses when ultrasound findings are inconclusive or for surgical planning, not as the initial step. - Its higher cost and longer scan time make it less suitable for initial screening compared to ultrasound. *PET-CT* - **PET-CT** is primarily used for **staging malignancies** and detecting metastatic disease, or in cases of unknown primary, and is not the initial diagnostic test for an adnexal mass. - It involves radiation exposure and is generally reserved for situations where malignancy is already highly suspected or confirmed. *Exploratory laparotomy and debulking* - **Exploratory laparotomy** and **debulking** are surgical procedures performed for the definitive diagnosis, staging, and treatment of ovarian cancer, but only *after* a thorough initial workup has been completed. - It is an invasive procedure and should not be the first step in the investigation of an adnexal mass. *CA-125 level* - Measuring **CA-125** levels is useful as a **tumor marker** in the workup of suspected ovarian cancer, particularly in symptomatic postmenopausal women, and for monitoring treatment response. - However, it has **low specificity** (can be elevated in benign conditions) and should be ordered in conjunction with imaging, not as the sole initial diagnostic step.

Question 5: A 68-year-old man comes to the emergency department because of sudden onset abdominal pain for 6 hours. On a 10-point scale, he rates the pain as a 8 to 9. The abdominal pain is worst in the right upper quadrant. He has atrial fibrillation and hyperlipidemia. His temperature is 38.7° C (101.7°F), pulse is 110/min, and blood pressure is 146/86 mm Hg. The patient appears acutely ill. Physical examination shows a distended abdomen and tenderness to palpation in all quadrants with guarding, but no rebound. Murphy's sign is positive. Right upper quadrant ultrasound shows thickening of the gallbladder wall, sludging in the gallbladder, and pericolic fat stranding. He is admitted for acute cholecystitis and grants permission for cholecystectomy. His wife is his healthcare power of attorney (POA), but she is out of town on a business trip. He is accompanied today by his brother. After induction and anesthesia, the surgeon removes the gallbladder but also finds a portion of the small intestine is necrotic due to a large thromboembolism occluding a branch of the superior mesenteric artery. The treatment is additional surgery with small bowel resection and thromboendarterectomy. Which of the following is the most appropriate next step in management?

A. Decrease the patient's sedation until he is able to give consent
B. Contact the patient's healthcare POA to consent
C. Proceed with additional surgery without obtaining consent (Correct Answer)
D. Ask the patient's brother in the waiting room to consent
E. Close the patient and obtain re-consent for a second operation

Explanation: ***Proceed with additional surgery without obtaining consent*** - In an **emergency situation** where immediate intervention is required to save a patient's life or prevent serious harm, and the patient **lacks capacity** to consent, explicit consent for additional necessary procedures is not required. The surgeon can proceed based on the principle of **implied consent** in emergencies. - The discovery of **necrotic small bowel due to thromboembolism** is a life-threatening condition requiring urgent surgical intervention in an already sedated patient, making it an emergency. *Decrease the patient's sedation until he is able to give consent* - Decreasing sedation to obtain consent in this critical situation would cause a **dangerous delay** in treating a life-threatening condition (bowel necrosis) and could lead to worsening outcomes or death. - The patient is **acutely ill** and likely in a state where he cannot grasp information and make decisions, even with reduced sedation, thus true informed consent would be difficult to obtain quickly. *Contact the patient's healthcare POA to consent* - Contacting the POA who is out of town would introduce **significant and potentially fatal delays** in treating a rapidly progressing, life-threatening condition. - While POAs are crucial for non-emergent decision-making, the **principle of preserving life** takes precedence in an acute emergency when a delay would cause irreversible harm. *Ask the patient's brother in the waiting room to consent* - The brother is **not the designated healthcare POA** and there is no indication he has legal authority to make medical decisions for the patient. - Relying on a non-POA family member for consent in an emergency, when the patient's legally appointed surrogate is known, is generally **not the appropriate first step** unless no other option exists and the brother can confirm the patient's wishes from prior discussions, which is not stated. *Close the patient and obtain re-consent for a second operation* - Closing the patient and then re-opening for another surgery would expose the patient to **two separate anesthetic events and surgical procedures**, significantly increasing morbidity and mortality risks compared to continuous surgery. - This option would also introduce an **unacceptable delay** in addressing the acute bowel necrosis, which requires immediate intervention.

Question 6: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

A. "Does the diarrhea typically precede the constipation, or vice-versa?"
B. "Is the diarrhea foul-smelling?"
C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
D. "Are the symptoms worse in the morning or at night?"
E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)

Explanation: ***Can you tell me more about the symptoms you have been experiencing?*** - This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis. - In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions. *Does the diarrhea typically precede the constipation, or vice-versa?* - While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience. - It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture. *Is the diarrhea foul-smelling?* - Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions. - However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed. *Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life* - Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time. - However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially. *Are the symptoms worse in the morning or at night?* - Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related. - This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.

Question 7: A 32-year-old male asks his physician for information regarding a vasectomy. On further questioning, you learn that he and his wife have just had their second child and he asserts that they no longer wish to have additional pregnancies. You ask him if he has discussed a vasectomy with his wife to which he replies, "Well, not yet, but I'm sure she'll agree." What is the next appropriate step prior to scheduling the patient's vasectomy?

A. Insist that the patient first discuss this procedure with his wife
B. Telephone the patient's wife to inform her of the plan
C. Refuse to perform the vasectomy
D. Explain the risks and benefits of the procedure and request signed consent from the patient and his wife
E. Explain the risks and benefits of the procedure and request signed consent from the patient (Correct Answer)

Explanation: ***Explain the risks and benefits of the procedure and request signed consent from the patient*** - A patient has the **right to make autonomous decisions** about their own medical care, including reproductive choices, regardless of their marital status or spousal approval. - The physician's role is to ensure the patient is fully informed and provides **voluntary, uncoerced consent** after understanding the risks, benefits, and alternatives of the procedure. *Insist that the patient first discuss this procedure with his wife* - This option would be a **violation of patient autonomy** and confidentiality, as a married person has the right to make independent medical decisions. - Requiring spousal consent for a procedure performed solely on one individual is not ethically or legally mandated and could be considered discriminatory. *Telephone the patient's wife to inform her of the plan* - This action would be a **breach of patient confidentiality**, as the patient's medical information, including his intent to have a vasectomy, cannot be shared with a third party, even a spouse, without explicit permission. - Informing the wife without the husband's consent also undermines the patient's autonomy and right to privacy regarding his healthcare decisions. *Refuse to perform the vasectomy* - Refusing to perform the procedure simply because the patient has not discussed it with his wife would be **unethical and inconsistent with medical professionalism**, assuming the patient is competent and fully informed. - A physician should not deny medically appropriate care based on a patient's marital dynamics or the presumed wishes of a spouse, as long as the patient's consent is valid. *Explain the risks and benefits of the procedure and request signed consent from the patient and his wife* - While it is advisable for a patient to discuss major life decisions with their spouse, requiring **spousal consent for a patient's own medical procedure** is not legally or ethically mandated for competent adults. - Obtaining consent from both individuals is typically reserved for procedures affecting both parties directly or for those involving a surrogate decision-maker, not for an autonomous adult's personal medical choice.

Question 8: A 31-year-old woman is brought to the emergency department 25 minutes after sustaining a gunshot wound to the neck. She did not lose consciousness. On arrival, she has severe neck pain. She appears anxious. Her temperature is 37°C (98.6°F), pulse is 105/min, respirations are 25/min, and blood pressure is 100/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. She is oriented to person, place, and time. Examination shows a bullet entrance wound in the right posterior cervical region of the neck. There is no exit wound. Carotid pulses are palpable bilaterally. There are no carotid bruits. Sensation to pinprick and light touch is normal. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. In addition to intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

A. Laryngoscopy
B. Surgical exploration
C. Barium swallow
D. CT angiography (Correct Answer)
E. Esophagoscopy

Explanation: ***CT angiography*** - This patient has a **penetrating neck injury** with significant concern for vascular compromise given the mechanism (gunshot wound) and location (posterior cervical region). - **CT angiography** is the most appropriate initial imaging study to evaluate for **vascular injury** (e.g., artery dissection, pseudoaneurysm, active bleeding) and often provides information about potential airway or esophageal damage. *Laryngoscopy* - While airway injury is a concern with neck trauma, this patient has a **stable airway** (oxygen saturation 96%, no stridor, clear lungs). - Laryngoscopy is more indicated for direct evaluation of the **larynx and pharynx** if there are signs of airway compromise or difficulty breathing. *Surgical exploration* - **Surgical exploration** is typically reserved for patients with clear signs of **hemodynamic instability** or definitive evidence of significant injury (e.g., expanding hematoma, pulsatile bleeding) after initial imaging. - Given the patient's relative stability, a less invasive diagnostic approach is warranted first. *Barium swallow* - A **barium swallow** (esophagography) is used to evaluate for **esophageal injury**. - While esophageal damage is possible with a gunshot wound to the neck, CTA can often provide indirect evidence and is generally performed first due to the higher index of suspicion for vascular injury. *Esophagoscopy* - **Esophagoscopy** is a more invasive procedure for directly visualizing the esophagus. - It would be considered if there is suspicion for esophageal injury, especially after initial imaging, but **CTA is preferred first** for broader assessment of vascular and other structures.

Question 9: A 24-year-old male is brought in by fire rescue after being the restrained driver in a motor vehicle accident. There was a prolonged extraction. At the scene, the patient was GCS 13. The patient was boarded and transported. In the trauma bay, vitals are T 97.2°F, HR 132 bpm, BP 145/90 mmHg, RR 22/min, and O2 Sat 100%. ABCs are intact with a GCS of 15, and on secondary survey you note the following (Figure F). FAST exam is positive at Morrison's pouch. Abdominal exam shows exquisite tenderness to palpation with rebound and guarding. Which of the following radiographs is most likely to be present in this patient?

A. Radiograph C (Correct Answer)
B. Radiograph B
C. Radiograph D
D. Radiograph A
E. Radiograph E

Explanation: ***Radiograph C*** - This radiograph displays a **ruptured spleen** with significant intrasplenic and perisplenic hemorrhage, depicted by contrast extravasation and fluid collection. The patient's presentation with a positive **FAST exam at Morrison's pouch**, exquisite abdominal tenderness, rebound, and guarding strongly indicates significant **intra-abdominal bleeding**, which is consistent with active hemorrhage from a ruptured organ like the spleen. - The patient's **tachycardia (HR 132 bpm)** despite stable blood pressure suggests compensated shock due to blood loss, further supporting the presence of a severe hemorrhagic injury. - Splenic injury is one of the most common solid organ injuries in blunt abdominal trauma from motor vehicle accidents. *Radiograph B* - This radiograph depicts a **pelvic fracture**, which can cause significant blood loss but does not directly explain the positive FAST exam at **Morrison's pouch**, which specifically indicates fluid in the hepatorenal recess of the peritoneal cavity. - While pelvic fractures are common in motor vehicle accidents, the abdominal findings of exquisite tenderness, rebound, and guarding point more towards an **intra-abdominal organ injury** with peritoneal irritation rather than solely a pelvic injury. - Pelvic hematomas are typically **retroperitoneal** and would not cause peritoneal signs. *Radiograph D* - This radiograph shows a **renal injury** with hemorrhage, which accounts for retroperitoneal bleeding. However, renal injuries typically do not result in a positive FAST exam at **Morrison's pouch** because the fluid tends to collect in the retroperitoneum rather than the peritoneal cavity. - While significant, renal hemorrhage would not fully explain the diffuse **peritoneal signs** like rebound and guarding across the abdomen. - The kidneys are retroperitoneal organs, so isolated renal injuries do not typically cause hemoperitoneum. *Radiograph A* - This radiograph shows a **liver laceration**, which can cause a positive FAST exam and intra-abdominal hemorrhage. Liver injuries are also common in blunt abdominal trauma. - However, in the context of this patient's presentation, **splenic rupture** is more likely given the specific clinical findings. Morrison's pouch (hepatorenal recess) can collect blood from either liver or splenic injuries due to gravitational flow. - The degree of peritoneal irritation and hemodynamic changes suggest a more extensive hemorrhagic injury pattern consistent with splenic rupture. *Radiograph E* - This radiograph shows a **bowel injury** that might demonstrate free air or bowel wall thickening. While bowel injuries can occur in trauma, they typically present with **pneumoperitoneum** (free air) rather than the fluid collection seen on FAST exam. - Primary hemorrhage from hollow viscus injury is less common and less severe than solid organ injuries. - The combination of **hemodynamic instability markers** (tachycardia) and clear peritoneal signs with positive FAST for fluid points more definitively to a significant solid organ injury with active bleeding rather than hollow viscus injury.

Question 10: A 23-year-old woman presents to the emergency department after being found unresponsive by her friends. The patient is an IV drug user and her friends came over and found her passed out in her room. The patient presented to the emergency department 2 days ago after being involved in a bar fight where she broke her nose and had it treated and packed with gauze. Her temperature is 99.3°F (37.4°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 24/min, and oxygen saturation is 97% on room air. Physical exam is notable for an obtunded woman with nasal packing and EKG tags from her last hospital stay, as well as a purpuric rash on her arms and legs. Her arms have track marks on them and blisters. Which of the following is the best next step in management?

A. Removal of nasal packing (Correct Answer)
B. Urine toxicology screen and empiric naloxone
C. Nafcillin
D. Vancomycin
E. Norepinephrine

Explanation: ***Removal of nasal packing*** - This patient presents with classic **toxic shock syndrome (TSS)** caused by nasal packing following her nasal fracture repair 2 days ago. - Key diagnostic features include: **purpuric rash** (diffuse macular erythroderma with petechiae), hypotension (90/48 mmHg), tachycardia (150/min), fever, and altered mental status. - TSS is caused by **Staphylococcus aureus** toxin production, with nasal packing being a well-known risk factor. - **Immediate removal of the nasal packing** (the source of infection) is the critical first step, followed by fluid resuscitation and empiric anti-staphylococcal antibiotics. *Urine toxicology screen and empiric naloxone* - While the patient is an IV drug user, opioid overdose does **not** explain the **purpuric rash**, which is the key diagnostic finding. - Opioid overdose typically presents with **respiratory depression** (low respiratory rate), not tachypnea (24/min) with normal oxygen saturation. - The clinical picture is dominated by TSS, not drug toxicity. *Nafcillin* - While **nafcillin** (anti-staphylococcal antibiotic) will be needed for TSS treatment, the **first step** is removal of the source (nasal packing). - Source control takes precedence over antibiotics in foreign body-associated infections. *Vancomycin* - Similar to nafcillin, **vancomycin** is appropriate for empiric TSS coverage (especially for MRSA), but must come **after** removal of nasal packing. - Antibiotics without source control will not adequately treat TSS. *Norepinephrine* - While the patient is hypotensive and may eventually require vasopressor support, the **immediate priority** is removing the infectious source. - TSS-induced shock should be managed with aggressive fluid resuscitation first, and vasopressors are added if fluid resuscitation fails.

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