A 26-year-old man presents with a 2-day history of worsening right lower leg pain. He states that he believes his right leg is swollen when compared to his left leg. Past medical history is significant for generalized anxiety disorder, managed effectively with psychotherapy. He smokes a pack of cigarettes daily but denies alcohol and illicit drug use. His father died of a pulmonary embolism at the age of 43. His vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, respiratory rate 14/min. On physical examination, the right lower leg is warmer than the left, and dorsiflexion of the right foot produces pain. Which of the following conditions is most likely responsible for this patient’s presentation?
Q2
A 70-year-old man with a recent above-the-knee amputation of the left lower extremity, due to wet gangrene secondary to refractory peripheral artery disease, presents with weakness and dizziness. He says that the symptoms began acutely 24 hours after surgery and have not improved. The amputation was complicated by substantial blood loss. He was placed on empiric antibiotic therapy with ciprofloxacin and clindamycin before the procedure, and blood and wound culture results are still pending. The medical history is significant for type 2 diabetes mellitus and hypertension. Current medications are metformin and lisinopril. The family history is significant for type 2 diabetes mellitus in both parents. Review of symptoms is significant for palpitations and a mild headache for the past 24 hours. His temperature is 38.2°C (100.8°F); blood pressure, 120/70 mm Hg (supine); pulse, 102/min; respiratory rate, 16/min; and oxygen saturation, 99% on room air. When standing, the blood pressure is 90/65 mm Hg and the pulse is 115/min. On physical examination, the patient appears pale and listless. The surgical amputation site does not show any signs of ongoing blood loss or infection. Laboratory tests and an ECG are pending. Which of the following is the next best step in management?
Q3
An 8-year-old boy and his 26-year-old babysitter are brought into the emergency department with severe injuries caused by a motor vehicle accident. The child is wheeled to the pediatric intensive care unit with a severe injury to his right arm, as well as other external and internal injuries. He is hemorrhaging and found to be hemodynamically unstable. He subsequently requires transfusion and surgery, and he is currently unconscious. The pediatric trauma surgeon evaluates the child’s arm and realizes it will need to be amputated at the elbow. Which of the following is the most appropriate course of action to take with regards to the amputation?
Q4
A 53-year-old Asian woman comes to the physician because of a 2-month history of severe pain in her right leg while walking. She used to be able to walk a half-mile (800-m) to the grocery store but has been unable to walk 200 meters without stopping because of the pain over the past month. She can continue to walk after a break of around 5 minutes. She has hypertension, atrial fibrillation, and type 2 diabetes mellitus. She has smoked one pack of cigarettes daily for the past 32 years. Current medications include metformin, enalapril, aspirin, and warfarin. Vital signs are within normal limits. Examination shows an irregularly irregular pulse. The right lower extremity is cooler than the left lower extremity. The skin over the right leg appears shiny and dry. Femoral pulses are palpated bilaterally; pedal pulses are diminished on the right side. Which of the following is the most appropriate next step in management?
Q5
A 73-year-old man comes to the physician because of worsening bilateral lower extremity pain for the past 8 months. The pain begins after walking one to two blocks and radiates bilaterally down the buttocks with cramping and tingling. He reports that the pain is worse while walking downhill and is relieved by sitting and leaning forward. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He had a myocardial infarction at the age of 55 years and an abdominal aortic aneurysm repair at the age of 60 years. He has smoked one pack of cigarettes daily for the past 30 years. He does not drink alcohol or use illicit drugs. His current medications include sitagliptin, metformin, atorvastatin, metoprolol succinate, amlodipine, and hydrochlorothiazide. His temperature is 37.5°C (99.5°F), pulse is 82/min, respirations are 17/min, and blood pressure is 150/87 mm Hg. Examination shows full muscle strength. Sensation is reduced bilaterally in the feet and toes. Straight leg raise is negative. X-ray of the spine shows degenerative changes. Which of the following is the most appropriate next step in diagnosis?
Q6
An 11-year-old boy with a history of attention deficit disorder presents to a general medicine clinic with leg pain. He is accompanied by his mother. He reports dull, throbbing, diffuse pain in his bilateral lower extremities. He reports that the pain feels deep in his muscles. He has awakened several times at night with the pain, and his symptoms tend to be better during the daylight hours. He denies fatigue, fever, or pain in his joints. On physical examination, his vital signs are stable, and he is afebrile. Physical examination reveals full range of motion in the hip and knee joints without pain. He has no joint effusions, erythema, or warmth. What is the next best step in management?
Q7
A 31-year-old man presents to the Emergency Department with severe left leg pain and paresthesias 4 hours after his leg got trapped by the closing door of a bus. Initially, he had a mild pain which gradually increased to unbearable levels. Past medical history is noncontributory. In the Emergency Department, his blood pressure is 130/80 mm Hg, heart rate is 87/min, respiratory rate is 14/min, and temperature is 36.8℃ (98.2℉). On physical exam, his left calf is firm and severely tender on palpation. The patient cannot actively dorsiflex his left foot, and passive dorsiflexion is limited. Posterior tibial and dorsalis pedis pulses are 2+ in the right leg and 1+ in the left leg. Axial load does not increase the pain. Which of the following is the best next step in the management of this patient?
Q8
A 25-year-old patient is brought into the emergency department after he was found down by the police in 5 degree celsius weather. The police state the patient is a heroin-user and is homeless. The patient's vitals are T 95.3 HR 80 and regular BP 150/90 RR 10. After warming the patient, you notice his left lower leg is now much larger than his right leg. On exam, the patient has a loss of sensation on his left lower extremity. There is a faint palpable dorsalis pedal pulse, but no posterior tibial pulse. The patient is unresponsive to normal commands, but shrieks in pain upon passive stretch of his left lower leg. What is the most probable cause of this patient's condition?
Q9
Paramedics are called to a 35-year-old man who had accidentally amputated his left index finger tip with a knife. He has no significant past medical history. His temperature is 37.2°C (99°F), pulse is 96/min, and blood pressure is 112/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. His left index finger is amputated distal to the distal interphalangeal joint at the level of the nail bed, and exposed bone is visible. There is profuse bleeding from the wound site. His ability to flex, extend, abduct, and adduct the joints is preserved and sensation is intact. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step prior to transporting this patient to the emergency department?
Q10
A 25-year-old man comes to the physician because of left-sided knee pain for 2 weeks. The pain started while playing basketball after suddenly hearing a popping sound. He has been unable to run since this incident. He has asthma, allergic rhinitis, and had a progressive bilateral sensorineural hearing impairment at birth treated with cochlear implants. His only medication is a salbutamol inhaler. The patient appears healthy and well-nourished. His temperature is 37°C (98.6°F), pulse is 67/min, and blood pressure is 120/80 mm Hg. Examination of the left knee shows medial joint line tenderness. Total knee extension is not possible and a clicking sound is heard when the knee is extended. An x-ray of the left knee shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?
Amputation indications and techniques US Medical PG Practice Questions and MCQs
Question 1: A 26-year-old man presents with a 2-day history of worsening right lower leg pain. He states that he believes his right leg is swollen when compared to his left leg. Past medical history is significant for generalized anxiety disorder, managed effectively with psychotherapy. He smokes a pack of cigarettes daily but denies alcohol and illicit drug use. His father died of a pulmonary embolism at the age of 43. His vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, respiratory rate 14/min. On physical examination, the right lower leg is warmer than the left, and dorsiflexion of the right foot produces pain. Which of the following conditions is most likely responsible for this patient’s presentation?
A. Vitamin K deficiency
B. Hemophilia A
C. von Willebrand disease
D. Factor V Leiden (Correct Answer)
E. Factor XI deficiency
Explanation: ***Factor V Leiden***
- The patient presents with classic symptoms of a **deep vein thrombosis (DVT)** in the right lower leg: pain, swelling, warmth, and pain on dorsiflexion (**Homans' sign**). His history of smoking and a family history of **pulmonary embolism (PE)** in a young father strongly suggest an underlying **thrombophilia**.
- **Factor V Leiden** is the most common inherited thrombophilia, predisposing individuals to venous thromboembolism. The constellation of symptoms and risk factors points directly to this condition.
*Vitamin K deficiency*
- **Vitamin K deficiency** primarily leads to impaired production of clotting factors II, VII, IX, and X, resulting in a **bleeding diathesis**, not thrombotic events.
- Patients would typically present with **bruising, petechiae, gastrointestinal bleeding, or hematuria**, which are not seen here.
*Hemophilia A*
- **Hemophilia A** is an X-linked recessive disorder characterized by a deficiency of **Factor VIII**, leading to severe **bleeding**.
- Symptoms include **spontaneous or prolonged bleeding** into joints (hemarthrosis), muscles, or following trauma, which is the opposite of the patient's presentation.
*von Willebrand disease*
- **Von Willebrand disease (vWD)** is the most common inherited bleeding disorder, caused by a deficiency or defect in **von Willebrand factor**.
- It primarily causes **mucocutaneous bleeding**, such as epistaxis, menorrhagia, and easy bruising, not thrombotic episodes.
*Factor XI deficiency*
- **Factor XI deficiency** is a rare inherited bleeding disorder that typically causes **mild to moderate bleeding**, often associated with trauma or surgery.
- It is not associated with an increased risk of thrombosis and would present with bleeding, not a DVT.
Question 2: A 70-year-old man with a recent above-the-knee amputation of the left lower extremity, due to wet gangrene secondary to refractory peripheral artery disease, presents with weakness and dizziness. He says that the symptoms began acutely 24 hours after surgery and have not improved. The amputation was complicated by substantial blood loss. He was placed on empiric antibiotic therapy with ciprofloxacin and clindamycin before the procedure, and blood and wound culture results are still pending. The medical history is significant for type 2 diabetes mellitus and hypertension. Current medications are metformin and lisinopril. The family history is significant for type 2 diabetes mellitus in both parents. Review of symptoms is significant for palpitations and a mild headache for the past 24 hours. His temperature is 38.2°C (100.8°F); blood pressure, 120/70 mm Hg (supine); pulse, 102/min; respiratory rate, 16/min; and oxygen saturation, 99% on room air. When standing, the blood pressure is 90/65 mm Hg and the pulse is 115/min. On physical examination, the patient appears pale and listless. The surgical amputation site does not show any signs of ongoing blood loss or infection. Laboratory tests and an ECG are pending. Which of the following is the next best step in management?
A. Administer IV fluids
B. Administer oral fludrocortisone
C. Administer IV norepinephrine
D. Administer oral midodrine
E. Administer IV fluids and withhold lisinopril (Correct Answer)
Explanation: ***Administer IV fluids and withhold lisinopril***
- The patient's **postural orthostatic hypotension** (blood pressure drop upon standing) and symptoms (weakness, dizziness, palpitations, pallor) following significant blood loss during surgery strongly suggest **hypovolemia**, which should be managed immediately with IV fluids.
- **Lisinopril**, an ACE inhibitor, can exacerbate hypotension by blocking angiotensin II-mediated vasoconstriction and aldosterone secretion, so withholding it is crucial in this hypotensive patient.
*Administer IV fluids*
- While administration of IV fluids is a correct component of management for hypovolemia, it is incomplete without addressing potential medication-induced hypotension in this patient.
- Simply administering IV fluids without withholding **lisinopril** may lead to suboptimal correction of the patient's hypotension.
*Administer oral fludrocortisone*
- **Fludrocortisone** is a mineralocorticoid used primarily for chronic orthostatic hypotension, such as in autonomic dysfunction, and would not be appropriate for acute, likely hypovolemia-induced hypotension in a postoperative setting.
- Its effects are not immediate, and it does not address the acute fluid deficit or the potential exacerbating effect of **lisinopril**.
*Administer IV norepinephrine*
- **Norepinephrine** is a potent vasopressor used in distributive or cardiogenic shock, which is not indicated as the initial management for suspected hypovolemia.
- Administering vasopressors in an unresuscitated hypovolemic patient can be dangerous, as it can worsen tissue perfusion by increasing systemic vascular resistance without adequate intravascular volume.
*Administer oral midodrine*
- **Midodrine** is an alpha-1 adrenergic agonist used for chronic orthostatic hypotension to increase peripheral vascular tone, similar to fludrocortisone.
- It works slowly and is not indicated for the acute management of hypovolemic shock or postoperative hypotension.
Question 3: An 8-year-old boy and his 26-year-old babysitter are brought into the emergency department with severe injuries caused by a motor vehicle accident. The child is wheeled to the pediatric intensive care unit with a severe injury to his right arm, as well as other external and internal injuries. He is hemorrhaging and found to be hemodynamically unstable. He subsequently requires transfusion and surgery, and he is currently unconscious. The pediatric trauma surgeon evaluates the child’s arm and realizes it will need to be amputated at the elbow. Which of the following is the most appropriate course of action to take with regards to the amputation?
A. Obtain an emergency court order from a judge to obtain consent to amputate the child’s arm
B. Find the child’s parents to obtain consent to amputate the child’s arm
C. Amputate the child’s arm at the elbow joint (Correct Answer)
D. Wait for the child’s babysitter to recover from her injuries to obtain her consent to amputate the child’s arm
E. Wait for the child to gain consciousness to obtain his consent to amputate his arm
Explanation: ***Amputate the child’s arm at the elbow joint***
- In an emergency situation where a child's life is at risk and a procedure is immediately necessary to save their life or prevent significant harm, **implied consent** allows for medical intervention without explicit parental consent. The child's **hemodynamic instability** and **severe hemorrhage** indicate an immediate threat to life.
- The decision to amputate to save the child's life is a **medically necessary emergency intervention**. Waiting for consent would cause a dangerous delay.
*Obtain an emergency court order from a judge to obtain consent to amputate the child’s arm*
- While court orders can be used in cases of parental refusal or unavailability for non-emergency procedures, the **urgent nature** of this life-threatening situation precludes waiting for a court order.
- The delay in obtaining a court order could significantly worsen the child's prognosis or lead to death.
*Find the child’s parents to obtain consent to amputate the child’s arm*
- Although parental consent is generally required for minors, the child's **critical condition** and **hemodynamic instability** mean delaying life-saving treatment to locate parents would be medically irresponsible.
- The principle of **beneficence** (acting in the best interest of the patient) and avoiding harm takes precedence in this emergency.
*Wait for the child’s babysitter to recover from her injuries to obtain her consent to amputate the child’s arm*
- A babysitter is generally not legally authorized to provide consent for major medical procedures for a child, especially an amputation.
- Even if the babysitter had some form of temporary custody, her own injury makes her an unreliable source of consent, and the delay would be critical.
*Wait for the child to gain consciousness to obtain his consent to amputate his arm*
- An 8-year-old child is generally not considered mature enough to provide **informed consent** for such a major medical decision.
- The child is **unconscious and hemodynamically unstable**, making it impossible to obtain consent and dangerously delaying a life-saving procedure.
Question 4: A 53-year-old Asian woman comes to the physician because of a 2-month history of severe pain in her right leg while walking. She used to be able to walk a half-mile (800-m) to the grocery store but has been unable to walk 200 meters without stopping because of the pain over the past month. She can continue to walk after a break of around 5 minutes. She has hypertension, atrial fibrillation, and type 2 diabetes mellitus. She has smoked one pack of cigarettes daily for the past 32 years. Current medications include metformin, enalapril, aspirin, and warfarin. Vital signs are within normal limits. Examination shows an irregularly irregular pulse. The right lower extremity is cooler than the left lower extremity. The skin over the right leg appears shiny and dry. Femoral pulses are palpated bilaterally; pedal pulses are diminished on the right side. Which of the following is the most appropriate next step in management?
A. MRI spine screening
B. Duplex ultrasonography
C. Ankle-brachial index (Correct Answer)
D. Nerve conduction studies
E. Biopsy of tibial artery
Explanation: ***Ankle-brachial index***
- The patient's symptoms of **intermittent claudication** (leg pain with exertion relieved by rest) and risk factors (smoking, diabetes, atrial fibrillation, hypertension) are highly suggestive of **peripheral artery disease (PAD)**. The **ankle-brachial index (ABI)** is the most appropriate initial diagnostic step as it is a quick, non-invasive, and reliable test to screen for PAD by comparing blood pressure in the ankles to blood pressure in the arms.
- A **diminished pedal pulse** on the right side and **cooler, shiny, dry skin** further support the suspicion of PAD, making ABI crucial for confirming the diagnosis and assessing its severity.
*MRI spine screening*
- While spinal pathology can cause leg pain, symptoms like **neurogenic claudication** typically improve with leaning forward or sitting and are not consistently relieved by standing still. The patient's pain relief with rest after walking points away from spinal stenosis.
- The patient's specific peripheral signs like a **cooler leg**, **diminished pedal pulses**, and **trophic changes** are not typical findings for spinal compression.
*Duplex ultrasonography*
- **Duplex ultrasonography** is a more advanced imaging technique used to visualize the blood vessels and assess blood flow, typically performed *after* an abnormal ABI confirms the presence of PAD.
- It helps in **localizing stenoses** and assessing their severity, but it is not the primary diagnostic screening tool in the initial evaluation of suspected PAD.
*Nerve conduction studies*
- **Nerve conduction studies (NCS)** are used to diagnose neuropathies. While diabetes is a risk factor for neuropathy, the patient's symptoms are classic for **vascular claudication** (pain with exertion, relieved by rest), rather than neuropathic pain, which is often described as burning, tingling, or numbing and does not typically resolve promptly with rest.
- The physical exam findings of a **cool leg** and **diminished pulses** are not consistent with a primary neurological problem.
*Biopsy of tibial artery*
- A **biopsy of the tibial artery** is an invasive procedure generally reserved for specific types of vasculitis (e.g., giant cell arteritis, polyarteritis nodosa) when other less invasive diagnostics have been inconclusive or raised suspicion for these conditions.
- It is not indicated for the initial workup of suspected **atherosclerotic peripheral artery disease**, which is the most likely diagnosis given the patient's risk factors and symptoms.
Question 5: A 73-year-old man comes to the physician because of worsening bilateral lower extremity pain for the past 8 months. The pain begins after walking one to two blocks and radiates bilaterally down the buttocks with cramping and tingling. He reports that the pain is worse while walking downhill and is relieved by sitting and leaning forward. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He had a myocardial infarction at the age of 55 years and an abdominal aortic aneurysm repair at the age of 60 years. He has smoked one pack of cigarettes daily for the past 30 years. He does not drink alcohol or use illicit drugs. His current medications include sitagliptin, metformin, atorvastatin, metoprolol succinate, amlodipine, and hydrochlorothiazide. His temperature is 37.5°C (99.5°F), pulse is 82/min, respirations are 17/min, and blood pressure is 150/87 mm Hg. Examination shows full muscle strength. Sensation is reduced bilaterally in the feet and toes. Straight leg raise is negative. X-ray of the spine shows degenerative changes. Which of the following is the most appropriate next step in diagnosis?
A. MRI scan of the spine (Correct Answer)
B. Measurement of the ankle brachial index
C. Measurement of serum creatine kinase
D. Polysomnography
E. Measurement of HLA-B27 antigen
Explanation: ***MRI scan of the spine***
- The patient's symptoms of **neurogenic claudication** (pain worse with walking downhill, relieved by sitting and leaning forward) are highly suggestive of **spinal stenosis**.
- An MRI provides detailed imaging of the spinal canal, nerve roots, and surrounding soft tissues, which is essential for confirming **spinal stenosis** and identifying the precise location and extent of nerve compression.
*Measurement of the ankle brachial index*
- An ABI measures peripheral arterial disease (PAD), which can cause **vascular claudication** (pain worse with uphill walking, relieved by standing still).
- The patient's symptoms (pain worse downhill, relieved by leaning forward) are not typical for **vascular claudication** despite his vascular risk factors.
*Measurement of serum creatine kinase*
- Creatine kinase is an enzyme released from damaged muscle, used to diagnose **myopathies** or significant muscle injury.
- The clinical presentation is more consistent with a **neurological compression** than a primary muscle disorder, and the patient has full muscle strength.
*Polysomnography*
- Polysomnography is a sleep study used to diagnose sleep disorders such as **sleep apnea** or **narcolepsy**.
- It is unrelated to lower extremity pain and claudication symptoms.
*Measurement of HLA-B27 antigen*
- HLA-B27 is a genetic marker associated with **spondyloarthropathies** like ankylosing spondylitis, reactive arthritis, and psoriatic arthritis.
- The patient's age of onset and specific symptoms of neurogenic claudication are not characteristic of inflammatory rheumatologic conditions.
Question 6: An 11-year-old boy with a history of attention deficit disorder presents to a general medicine clinic with leg pain. He is accompanied by his mother. He reports dull, throbbing, diffuse pain in his bilateral lower extremities. He reports that the pain feels deep in his muscles. He has awakened several times at night with the pain, and his symptoms tend to be better during the daylight hours. He denies fatigue, fever, or pain in his joints. On physical examination, his vital signs are stable, and he is afebrile. Physical examination reveals full range of motion in the hip and knee joints without pain. He has no joint effusions, erythema, or warmth. What is the next best step in management?
A. X-ray of the knees
B. Send ESR and CRP
C. Reassurance (Correct Answer)
D. MRI of the knees
E. Lower extremity venous ultrasound
Explanation: ***Reassurance***
- The patient's presentation is classic for **growing pains**, characterized by bilateral, diffuse, deep leg pain, often worse at night and improving with activity or during the day.
- The absence of fever, joint swelling, erythema, tenderness, or gait abnormalities, along with normal physical examination findings, supports this benign diagnosis.
*X-ray of the knees*
- This symptom complex is a **diagnosis of exclusion**; imaging studies like X-rays are typically normal and not indicated unless there are focal pain, limping, or other concerning signs.
- An X-ray would not show any abnormalities related to growing pains and would expose the child to unnecessary radiation.
*Send ESR and CRP*
- **Inflammatory markers** (ESR, CRP) are used to detect conditions like arthritis, osteomyelitis, or malignancy, which would cause systemic symptoms (e.g., fever, fatigue) or localized inflammatory signs.
- In growing pains, these markers are typically normal, and ordering them without other clinical indications is unnecessary.
*MRI of the knees*
- An MRI is highly sensitive for detecting bone and soft tissue pathologies but is generally not indicated for the typical presentation of growing pains.
- It would be considered if there were signs of **osteomyelitis**, **tumors**, or specific internal derangement of the joint, none of which are present here.
*Lower extremity venous ultrasound*
- This test is used to evaluate for **deep vein thrombosis (DVT)**, which typically presents with unilateral leg swelling, warmth, and tenderness.
- The patient's symptoms are bilateral, diffuse, and lack any signs of vascular compromise, making a venous ultrasound inappropriate.
Question 7: A 31-year-old man presents to the Emergency Department with severe left leg pain and paresthesias 4 hours after his leg got trapped by the closing door of a bus. Initially, he had a mild pain which gradually increased to unbearable levels. Past medical history is noncontributory. In the Emergency Department, his blood pressure is 130/80 mm Hg, heart rate is 87/min, respiratory rate is 14/min, and temperature is 36.8℃ (98.2℉). On physical exam, his left calf is firm and severely tender on palpation. The patient cannot actively dorsiflex his left foot, and passive dorsiflexion is limited. Posterior tibial and dorsalis pedis pulses are 2+ in the right leg and 1+ in the left leg. Axial load does not increase the pain. Which of the following is the best next step in the management of this patient?
A. Lower limb CT scan
B. Lower limb ultrasound
C. Splinting and limb rest
D. Fasciotomy (Correct Answer)
E. Lower limb X-ray in two projections
Explanation: ***Fasciotomy***
- The patient presents with classic signs and symptoms of **acute compartment syndrome**, including unrelieved pain by analgesics, paresthesias, pain with passive stretching, and a tense compartment due to the bus door trauma.
- **Fasciotomy** is the definitive and urgent treatment to relieve pressure within the muscle compartments, prevent muscle ischemia, and avoid permanent nerve damage or limb loss.
*Lower limb CT scan*
- A **CT scan** is primarily used to evaluate bony structures and soft tissue injuries but is not the most immediate or definitive diagnostic tool for acute compartment syndrome.
- Delaying **fasciotomy** for imaging in a clear case of compartment syndrome can lead to irreversible damage.
*Lower limb ultrasound*
- **Ultrasound** can assess vascular flow and some soft tissue aspects but is not accurate or rapid enough for diagnosing compartment syndrome.
- It would not provide the necessary information to guide urgent surgical intervention.
*Splinting and limb rest*
- This approach is appropriate for fractures or soft tissue injuries without compartment syndrome; however, in acute compartment syndrome, **splinting or limb rest** will worsen the condition.
- **Immobilization** and elevation are contraindicated as they can further decrease blood flow and increase compartment pressure.
*Lower limb X-ray in two projections*
- An **X-ray** is useful for ruling out fractures but will not provide information about compartment pressure or muscle viability.
- While a fracture can sometimes cause compartment syndrome, the immediate concern here is the compartment syndrome itself, for which **X-rays** are not diagnostic.
Question 8: A 25-year-old patient is brought into the emergency department after he was found down by the police in 5 degree celsius weather. The police state the patient is a heroin-user and is homeless. The patient's vitals are T 95.3 HR 80 and regular BP 150/90 RR 10. After warming the patient, you notice his left lower leg is now much larger than his right leg. On exam, the patient has a loss of sensation on his left lower extremity. There is a faint palpable dorsalis pedal pulse, but no posterior tibial pulse. The patient is unresponsive to normal commands, but shrieks in pain upon passive stretch of his left lower leg. What is the most probable cause of this patient's condition?
A. Diabetes
B. Cellulitis
C. Embolized clot
D. Reperfusion associated edema (Correct Answer)
E. Necrotizing fasciitis
Explanation: ***Reperfusion associated edema***
- The patient's history of being found in cold weather, along with signs of **hypothermia** (T 95.3), suggests a period of **ischemia** followed by reperfusion. The sudden swelling, pain on passive stretch, and sensory loss in the left lower leg are classic signs of **compartment syndrome**, which can be triggered by reperfusion injury and edema.
- While a faint dorsalis pedis pulse is present, the absence of a posterior tibial pulse indicates significant compromised blood flow, and the severe pain on passive stretch is a hallmark of increased pressure within a muscle compartment.
*Diabetes*
- While diabetes can cause neuropathy and vascular complications, it does not typically present with acute, severe localized swelling and pain on passive stretch in a previously healthy 25-year-old.
- The acute nature of the symptoms following exposure to cold and subsequent warming points away from chronic diabetic complications.
*Cellulitis*
- Cellulitis is a bacterial skin infection that would typically present with **erythema**, **warmth**, and spreading tenderness, but not the severe, deep, and acute pain on passive stretch or the profound sensory deficit seen here.
- It does not explain the initial period of cold exposure followed by reperfusion.
*Embolized clot*
- An embolized clot would cause acute limb ischemia, characterized by the "6 Ps" (**pain, pallor, pulselessness, paresthesias, paralysis, poikilothermia**). While the patient has some of these, the dramatic swelling *after warming* and the pain on passive stretch are more indicative of compartment syndrome due to reperfusion.
- The presence of a faint dorsalis pedal pulse makes complete arterial occlusion less likely, though significant compromise is present.
*Necrotizing fasciitis*
- Necrotizing fasciitis presents with rapidly progressing pain out of proportion to exam, skin changes (e.g., **bullae, crepitus, discoloration**), and systemic toxicity. While serious, it does not fit the context of acute swelling and pain primarily triggered by reperfusion after cold exposure.
- The primary presentation here is related to pressure-induced injury from edema, not primarily an aggressive bacterial infection of the fascia.
Question 9: Paramedics are called to a 35-year-old man who had accidentally amputated his left index finger tip with a knife. He has no significant past medical history. His temperature is 37.2°C (99°F), pulse is 96/min, and blood pressure is 112/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. His left index finger is amputated distal to the distal interphalangeal joint at the level of the nail bed, and exposed bone is visible. There is profuse bleeding from the wound site. His ability to flex, extend, abduct, and adduct the joints is preserved and sensation is intact. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step prior to transporting this patient to the emergency department?
A. Preserve finger tip in warm saline water
B. Wrap finger tip in gauze damp with saline in a sealed plastic bag placed on ice water (Correct Answer)
C. Wrap finger in gauze wet with iodine in a sealed plastic bag placed on ice
D. Place finger tip on ice in a sealed plastic bag
E. Preserve finger tip in cooled saline water
Explanation: ***Wrap finger tip in gauze damp with saline in a sealed plastic bag placed on ice water***
- This method ensures the **amputated part** remains **moist** and **cool** without direct contact with ice, which can cause **frostbite** and damage tissue viability.
- The use of saline-dampened gauze prevents **desiccation**, while the sealed bag and ice water maintain a **hypothermic environment**, crucial for preserving tissue for potential **replantation**.
*Preserve finger tip in warm saline water*
- **Warm temperatures** accelerate **tissue degradation** and reduce the viability of the amputated part for replantation.
- While saline prevents desiccation, the warmth is detrimental to **ischemic tissue**.
*Wrap finger in gauze wet with iodine in a sealed plastic bag placed on ice*
- **Iodine** is a **cytotoxic agent** that can damage delicate tissues and compromise the viability of the amputated part.
- While cooling is important, the use of iodine makes this method unsuitable for preserving tissue for replantation.
*Place finger tip on ice in a sealed plastic bag*
- **Direct contact with ice** can lead to **frostbite** and **ischemic damage** to the amputated tissue, severely reducing the chances of successful replantation.
- Although cooling is beneficial, it must be done indirectly to protect the tissue from freezing.
*Preserve finger tip in cooled saline water*
- While cooling is appropriate and saline prevents desiccation, immersing the tissue directly in water, even cooled saline, can cause **tissue maceration** and **cell lysis** due to osmotic effects.
- The preferred method involves indirect cooling with a damp dressing to maintain optimal moisture and temperature without direct immersion.
Question 10: A 25-year-old man comes to the physician because of left-sided knee pain for 2 weeks. The pain started while playing basketball after suddenly hearing a popping sound. He has been unable to run since this incident. He has asthma, allergic rhinitis, and had a progressive bilateral sensorineural hearing impairment at birth treated with cochlear implants. His only medication is a salbutamol inhaler. The patient appears healthy and well-nourished. His temperature is 37°C (98.6°F), pulse is 67/min, and blood pressure is 120/80 mm Hg. Examination of the left knee shows medial joint line tenderness. Total knee extension is not possible and a clicking sound is heard when the knee is extended. An x-ray of the left knee shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?
A. Reassurance and follow-up
B. Arthrocentesis of the left knee
C. Open meniscal repair
D. Arthroscopy of the left knee
E. MRI scan of the left knee (Correct Answer)
Explanation: ***MRI scan of the left knee***
- The patient's presentation with a **popping sound**, inability to run, **medial joint line tenderness**, limited extension, and a clicking sound suggests a **meniscal tear**, which is not visible on X-ray.
- An **MRI scan** is the *most appropriate* next step as it is the **gold standard** for diagnosing meniscal tears and other soft tissue injuries of the knee.
*Reassurance and follow-up*
- This option is *inappropriate* given the clear signs and symptoms of a **significant knee injury** that warrants further investigation.
- Delaying diagnosis and treatment could lead to **worsening of the injury** and chronic pain.
*Arthrocentesis of the left knee*
- Arthrocentesis involves aspirating joint fluid, which is primarily indicated for diagnosing **septic arthritis** or **gout**, neither of which is suggested by this patient's acute trauma history.
- While a meniscal tear can cause an effusion, the primary diagnostic goal here is imaging the soft tissue injury, not analyzing synovial fluid.
*Open meniscal repair*
- **Open meniscal repair** is a surgical intervention, and it is *premature* to consider surgery before a definitive diagnosis is established.
- The *most appropriate* initial step after physical exam and X-ray is often an MRI to confirm the pathology.
*Arthroscopy of the left knee*
- **Arthroscopy** is both a **diagnostic and therapeutic procedure**, but it is generally reserved after non-invasive imaging like MRI has been performed.
- Although it can confirm a meniscal tear, an MRI is less invasive and can provide comparable if not superior detail for surgical planning.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
