A 30-year-old male gang member is brought to the emergency room with a gunshot wound to the abdomen. The patient was intubated and taken for an exploratory laparotomy, which found peritoneal hemorrhage and injury to the small bowel. He required 5 units of blood during this procedure. Following the operation, the patient was sedated and remained on a ventilator in the surgical intensive care unit (SICU). The next day, a central line is placed and the patient is started on total parenteral nutrition. Which of the following complications is most likely in this patient?
Q2
A 45-year-old man is brought to the trauma bay by emergency services after a motorbike accident in which the patient, who was not wearing a helmet, hit a pole of a streetlight with his head. When initially evaluated by the paramedics, the patient was responsive, albeit confused, opened his eyes spontaneously, and was able to follow commands. An hour later, upon admission, the patient only opened his eyes to painful stimuli, made incomprehensible sounds, and assumed a flexed posture. The vital signs are as follows: blood pressure 140/80 mm Hg; heart rate 59/min; respiratory rate 11/min; temperature 37.0℃ (99.1℉), and SaO2, 95% on room air. The examination shows a laceration and bruising on the left side of the head. There is anisocoria with the left pupil 3 mm more dilated than the right. Both pupils react sluggishly to light. There is an increase in tone and hyperreflexia in the right upper and lower extremities. The patient is intubated and mechanically ventilated, head elevated to 30°, and sent for a CT scan. Which of the following management strategies should be used in this patient, considering his most probable diagnosis?
Q3
An 18-year-old man presents to the emergency department with complaints of sudden severe groin pain and swelling of his left testicle. It started roughly 5 hours ago and has been progressively worsening. History reveals that he has had multiple sexual partners but uses condoms regularly. Vital signs include: blood pressure 120/80 mm Hg, heart rate 84/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F). Physical examination reveals that he has an impaired gait and a tender, horizontal, high-riding left testicle and absent cremasteric reflex. Which of the following is the best next step for this patient?
Q4
A 63-year-old female with known breast cancer presents with progressive motor weakness in bilateral lower extremities and difficulty ambulating. Physical exam shows 4 of 5 motor strength in her legs and hyper-reflexia in her patellar tendons. Neurologic examination 2 weeks prior was normal. Imaging studies, including an MRI, show significant spinal cord compression by the metastatic lesion and complete erosion of the T12 vertebrae. She has no metastatic disease to the visceral organs and her oncologist reports her life expectancy to be greater than one year. What is the most appropriate treatment?
Q5
A 25-year-old man is brought to the emergency department because of a 6-day history of fever and chills. During this period, he has had generalized weakness, chest pain, and night sweats. He has a bicuspid aortic valve and recurrent migraine attacks. He has smoked one pack of cigarettes daily for 5 years. He does not drink alcohol. He has experimented with intravenous drugs in the past but has not used any illicit drugs in the last two months. Current medications include propranolol and a multivitamin. He appears ill. His temperature is 39°C (102.2°F), pulse is 108/min, respirations are 14/min, and blood pressure is 150/50 mm Hg. Diffuse crackles are heard. A grade 3/6 high-pitched, early diastolic, decrescendo murmur is best heard along the left sternal border. An S3 gallop is heard. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 13.1 g/dL
Leukocyte count 13,300/mm3
Platelet count 270,000/mm3
Serum
Glucose 92 mg/dL
Creatinine 0.9 mg/dL
Total bilirubin 0.4 mg/dL
AST 25 U/L
ALT 28 U/L
Three sets of blood cultures are sent to the laboratory. Transthoracic echocardiography confirms the diagnosis. In addition to antibiotic therapy, which of the following is the most appropriate next step in management?
Q6
A 47-year-old man is admitted to the emergency room after a fight in which he was hit in the head with a hammer. The witnesses say that the patient initially lost consciousness, but regained consciousness by the time emergency services arrived. On admission, the patient complained of a diffuse headache. He opened his eyes spontaneously, was verbally responsive, albeit confused, and was able to follow commands. He could not elevate his left hand and leg. He did not remember the events prior to the loss of consciousness and had difficulty remembering information, such as the names of nurses or doctors. His airway was not compromised. The vital signs are as follows: blood pressure, 180/100 mm Hg; heart rate, 59/min; respiratory rate, 12/min; temperature 37.0℃ (98.6℉); and SaO2, 96% on room air. The examination revealed bruising in the right frontotemporal region. The pupils are round, equal, and show a poor response to light. The neurologic examination shows hyperreflexia and decreased power in the left upper and lower limbs. There is questionable nuchal rigidity, but no Kernig and Brudzinski signs. The CT scan is shown in the image. Which of the following options is recommended for this patient?
Q7
A 65-year-old man is brought to his primary care provider by his concerned wife. She reports he has had this "thing" on his eye for years and refuses to seek care. He denies any pain or discharge from the affected eye. A picture of his eye is shown below. Given the diagnosis, what are you most likely to discover when taking this patient's history?
Q8
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?
Q9
A 41-year-old man is brought to the emergency department 3 hours after falling while mountain biking and hitting his head. Initially, he refused treatment, but an hour ago he began to develop a severe headache, nausea, and left leg weakness. He has no visual changes and is oriented to person, time, and place. His temperature is 37°C (98.6°F), pulse is 68/min, respirations are 17/min and regular, and blood pressure is 130/78 mm Hg. Examination shows a 5-cm bruise on the right side of his skull. The pupils are equal, round, and reactive to light and accommodation. Muscle strength is 0/5 in his left knee and foot. Which of the following is the most likely cause of this patient's presentation?
Q10
A 27-year-old woman presents with right knee pain over the last 3 weeks. The pain is moderate in severity but makes any physical activity that involves bending her knee extremely uncomfortable. Her pain worsens with running and squatting, in particular. The patient has no history of medical conditions nor does she have any immediate family member with a similar condition. At the physician's office, her vitals are normal. On physical examination, there is localized pain in the right anterior knee. There are no passive or active movement limitations at her knee joint. Erythema, swelling, and crepitations are not present. Which of the following is the best option for definitively managing this patient's condition?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 1: A 30-year-old male gang member is brought to the emergency room with a gunshot wound to the abdomen. The patient was intubated and taken for an exploratory laparotomy, which found peritoneal hemorrhage and injury to the small bowel. He required 5 units of blood during this procedure. Following the operation, the patient was sedated and remained on a ventilator in the surgical intensive care unit (SICU). The next day, a central line is placed and the patient is started on total parenteral nutrition. Which of the following complications is most likely in this patient?
A. Mesenteric ischemia
B. Hypocalcemia
C. Refeeding syndrome
D. Sepsis (Correct Answer)
E. Cholelithiasis
Explanation: ***Sepsis***
- This patient has undergone **major abdominal surgery** after a **gunshot wound**, which carries a high risk of **peritoneal contamination** and subsequent infection.
- He also has several risk factors for sepsis, including **intubation**, central line placement, and possibly prolonged ventilation, all of which increase the risk of nosocomial infections and subsequent sepsis.
*Mesenteric ischemia*
- While possible in critically ill patients, there is no direct evidence such as advanced age, atherosclerosis, or specific signs of **bowel ischemia** (e.g., severe abdominal pain disproportionate to exam, bloody diarrhea) presenting in this case.
- The initial injury was to the small bowel, but the current context points more to systemic complications rather than a focal vascular event.
*Hypocalcemia*
- Hypocalcemia can occur in critically ill patients due to various reasons, but it is not the *most likely* complication given the patient's presentation primarily focused on surgical trauma and subsequent interventions.
- Dilutional effects from massive transfusions or **citrate toxicity** could contribute to temporary hypocalcemia, but sepsis poses a more immediate and widespread threat.
*Refeeding syndrome*
- Refeeding syndrome occurs when severely malnourished patients are rapidly refed, leading to shifts in **electrolytes** (especially **phosphate**, potassium, magnesium).
- Although the patient is starting **total parenteral nutrition (TPN)**, there's no indication of prior severe malnutrition, making sepsis a more prominent immediate concern due to the gunshot wound and surgery.
*Cholelithiasis*
- **Cholelithiasis** (gallstones) can be a long-term complication of total parenteral nutrition (TPN) due to gallbladder stasis.
- However, it is unlikely to develop so acutely within a day of starting TPN and is thus not the most immediate or likely complication for this patient's acute critical state.
Question 2: A 45-year-old man is brought to the trauma bay by emergency services after a motorbike accident in which the patient, who was not wearing a helmet, hit a pole of a streetlight with his head. When initially evaluated by the paramedics, the patient was responsive, albeit confused, opened his eyes spontaneously, and was able to follow commands. An hour later, upon admission, the patient only opened his eyes to painful stimuli, made incomprehensible sounds, and assumed a flexed posture. The vital signs are as follows: blood pressure 140/80 mm Hg; heart rate 59/min; respiratory rate 11/min; temperature 37.0℃ (99.1℉), and SaO2, 95% on room air. The examination shows a laceration and bruising on the left side of the head. There is anisocoria with the left pupil 3 mm more dilated than the right. Both pupils react sluggishly to light. There is an increase in tone and hyperreflexia in the right upper and lower extremities. The patient is intubated and mechanically ventilated, head elevated to 30°, and sent for a CT scan. Which of the following management strategies should be used in this patient, considering his most probable diagnosis?
A. Middle meningeal artery embolization
B. Ventricular drainage
C. Surgical evacuation (Correct Answer)
D. Decompressive craniectomy
E. Conservative management with hyperosmolar solutions
Explanation: ***Surgical evacuation***
- This patient presents with a classic picture of **epidural hematoma** (EDH) with signs of herniation, indicated by the rapid neurological decline, **anisocoria**, and contralateral motor deficits. **Urgent surgical evacuation** is the definitive treatment for EDH to relieve mass effect.
- The rapid progression from responsive to severely neurologically compromised, coupled with a history of head trauma and a potential lucid interval, points to an expanding intracranial lesion requiring immediate decompression.
*Middle meningeal artery embolization*
- While the **middle meningeal artery** is often the source of bleeding in EDH, embolization is typically reserved for cases where surgery is contraindicated or as an adjunct for persistent bleeding, not as a primary definitive treatment in an unstable patient.
- It does not immediately relieve the mass effect from a large, established hematoma, which is the acute life-threatening issue.
*Ventricular drainage*
- **Ventricular drainage** is primarily used to reduce **intracranial pressure** (ICP) in cases of **hydrocephalus** or intraventricular hemorrhage.
- It is not the primary treatment for an epidural hematoma, which is an extra-axial collection of blood.
*Decompressive craniectomy*
- **Decompressive craniectomy** involves removing a portion of the skull to allow the brain to swell and reduce ICP, often used in cases of diffuse brain injury and intractable ICP elevation refractory to other measures.
- In cases of an epidural hematoma with a treatable mass, **direct evacuation of the hematoma** and closure is preferred over decompressive craniectomy alone, although craniectomy might be needed if there's underlying brain swelling.
*Conservative management with hyperosmolar solutions*
- **Hyperosmolar solutions** (like mannitol or hypertonic saline) can acutely reduce ICP by drawing fluid from the brain, but they are a temporizing measure.
- They are used to manage ICP while preparing for definitive treatment or in diffuse brain injury, not as a primary treatment for a large, surgically accessible mass lesion causing rapid deterioration and herniation.
Question 3: An 18-year-old man presents to the emergency department with complaints of sudden severe groin pain and swelling of his left testicle. It started roughly 5 hours ago and has been progressively worsening. History reveals that he has had multiple sexual partners but uses condoms regularly. Vital signs include: blood pressure 120/80 mm Hg, heart rate 84/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F). Physical examination reveals that he has an impaired gait and a tender, horizontal, high-riding left testicle and absent cremasteric reflex. Which of the following is the best next step for this patient?
A. Ultrasound of the scrotum
B. Analgesia and rest
C. Antibiotics
D. Urinalysis
E. Surgery (Correct Answer)
Explanation: ***Surgery***
- The patient presents with classic signs of **testicular torsion**, including sudden severe groin pain, a tender, horizontal, high-riding testicle, and absent cremasteric reflex, which constitutes a surgical emergency.
- Due to the onset of symptoms 5 hours ago, **immediate surgical exploration and detorsion** within 6 hours significantly increases the chances of testicular salvage.
*Ultrasound of the scrotum*
- While a scrotal ultrasound with Doppler flow can confirm the diagnosis of testicular torsion by showing **absent blood flow**, it should **not delay immediate surgical intervention**, especially when clinical suspicion is high.
- Given the classic presentation and the time-sensitive nature of testicular torsion, delaying surgery for an ultrasound could lead to **irreversible testicular ischemia** and loss.
*Analgesia and rest*
- Administering analgesia and recommending rest would only **manage symptoms temporarily** without addressing the underlying pathology.
- This approach would **delay definitive treatment** for testicular torsion, leading to prolonged ischemia and increased risk of testicular necrosis.
*Antibiotics*
- Antibiotics are indicated for **epididymo-orchitis**, which usually presents with a more gradual onset of pain, fever, and a positive cremasteric reflex.
- The patient's presentation with acute, severe pain, and an absent cremasteric reflex, along with a normal temperature, makes infection less likely as the primary cause.
*Urinalysis*
- Urinalysis is primarily useful for diagnosing **urinary tract infections** or **kidney stones**, which can sometimes cause testicular pain.
- However, the classic physical examination findings observed in this patient are much more indicative of testicular torsion, making urinalysis less of a priority compared to surgical consultation.
Question 4: A 63-year-old female with known breast cancer presents with progressive motor weakness in bilateral lower extremities and difficulty ambulating. Physical exam shows 4 of 5 motor strength in her legs and hyper-reflexia in her patellar tendons. Neurologic examination 2 weeks prior was normal. Imaging studies, including an MRI, show significant spinal cord compression by the metastatic lesion and complete erosion of the T12 vertebrae. She has no metastatic disease to the visceral organs and her oncologist reports her life expectancy to be greater than one year. What is the most appropriate treatment?
A. Palliative pain management consultation
B. Surgical decompression and postoperative radiotherapy (Correct Answer)
C. High-dose corticosteroids and clinical observation
D. Radiation therapy alone
E. Chemotherapy alone
Explanation: ***Surgical decompression and postoperative radiotherapy***
- There is **spinal cord compression** by a metastatic lesion in a patient with a good prognosis (>1 year life expectancy) and rapidly progressive neurological deficits. **Surgical decompression** offers immediate relief of compression, while **postoperative radiotherapy** helps local tumor control.
- This combined approach is superior in preserving neurological function and improving quality of life for patients with **epidural spinal cord compression (ESCC)** in this clinical context.
*Palliative pain management consultation*
- While pain management is important in cancer care, this option alone does not address the **progressive neurological deficits** due to spinal cord compression.
- This patient's condition requires active treatment to prevent further neurological compromise and is not solely focused on comfort measures at this stage given her prognosis.
*Spinal dose corticosteroids and clinical observation*
- **Corticosteroids** can temporarily reduce edema around the spinal cord, but they do not resolve the mechanical compression caused by the eroded T12 vertebrae.
- **Clinical observation** without definitive intervention risks irreversible neurological damage given the rapid progression of symptoms.
*Radiation therapy alone*
- While radiation therapy is effective for local tumor control, it may not provide **rapid enough decompression** for acute or rapidly progressing neurological deficits due to significant mechanical compression.
- In cases of severe compression, such as bone erosion and cord involvement, surgery is usually needed prior to or in combination with radiation.
*Chemotherapy alone*
- **Chemotherapy** for breast cancer is a systemic treatment and may take time to reduce tumor burden, which is not suitable for urgent relief of **spinal cord compression**.
- It does not provide immediate mechanical decompression and is generally not the primary treatment for acute ESCC, especially with bone involvement.
Question 5: A 25-year-old man is brought to the emergency department because of a 6-day history of fever and chills. During this period, he has had generalized weakness, chest pain, and night sweats. He has a bicuspid aortic valve and recurrent migraine attacks. He has smoked one pack of cigarettes daily for 5 years. He does not drink alcohol. He has experimented with intravenous drugs in the past but has not used any illicit drugs in the last two months. Current medications include propranolol and a multivitamin. He appears ill. His temperature is 39°C (102.2°F), pulse is 108/min, respirations are 14/min, and blood pressure is 150/50 mm Hg. Diffuse crackles are heard. A grade 3/6 high-pitched, early diastolic, decrescendo murmur is best heard along the left sternal border. An S3 gallop is heard. The remainder of the physical examination shows no abnormalities. Laboratory studies show:
Hemoglobin 13.1 g/dL
Leukocyte count 13,300/mm3
Platelet count 270,000/mm3
Serum
Glucose 92 mg/dL
Creatinine 0.9 mg/dL
Total bilirubin 0.4 mg/dL
AST 25 U/L
ALT 28 U/L
Three sets of blood cultures are sent to the laboratory. Transthoracic echocardiography confirms the diagnosis. In addition to antibiotic therapy, which of the following is the most appropriate next step in management?
A. Transcatheter aortic valve implantation (TAVI)
B. Repeat echocardiography in 4 weeks
C. Cardiac MRI
D. Mechanical valve replacement of the aortic valve
E. Porcine valve replacement of the aortic valve (Correct Answer)
Explanation: ***Porcine valve replacement of the aortic valve***
- The patient presents with **infective endocarditis** (fever, history of IV drug use, bicuspid aortic valve) complicated by **severe aortic regurgitation** with **hemodynamic compromise** (wide pulse pressure 150/50 mmHg, diffuse crackles, S3 gallop indicating heart failure). The presence of heart failure, severe regurgitation, and hemodynamic instability are **class I indications for urgent surgical valve replacement** in infective endocarditis.
- For this **25-year-old with a history of IV drug use**, a **bioprosthetic (porcine) valve** is preferred over mechanical valve because it **avoids the need for lifelong anticoagulation**. In patients with **history of substance abuse**, there are significant concerns about **compliance with warfarin therapy** and the associated bleeding risks. Additionally, the risk of **recurrent endocarditis** from future IV drug use makes avoiding anticoagulation particularly important, as warfarin increases bleeding complications.
- The **new diastolic murmur**, **S3 gallop**, and **low diastolic blood pressure (50 mmHg)** indicate critical hemodynamic compromise requiring prompt surgical intervention once antibiotic therapy is initiated.
*Mechanical valve replacement of the aortic valve*
- While mechanical valves offer **greater durability** and are often considered for young patients due to longevity (avoiding repeat surgery), they require **lifelong anticoagulation with warfarin**.
- In this patient with **recent IV drug use history** (stopped only 2 months ago), there are significant concerns about **medication compliance** and the **high risk of bleeding complications** with anticoagulation. The risk of **recurrent IV drug use** and potential for trauma also makes anticoagulation particularly hazardous.
- Though mechanical valve is a viable option, the **patient's social history** makes bioprosthetic valve the safer choice despite his young age.
*Transcatheter aortic valve implantation (TAVI)*
- **TAVI** is primarily indicated for **aortic stenosis** in elderly or high-surgical-risk patients, not for **aortic regurgitation** in young patients.
- The presence of **active infection** is a **relative contraindication** to TAVI due to risk of seeding the new prosthetic valve and technical challenges with valve seating in an inflamed annulus.
*Repeat echocardiography in 4 weeks*
- Delayed follow-up would be appropriate for **stable, medically managed endocarditis** or mild valve dysfunction.
- This patient has **acute, severe heart failure** with hemodynamic instability requiring **urgent surgical intervention**, not watchful waiting.
*Cardiac MRI*
- While cardiac MRI provides detailed anatomical and functional information, it is **not indicated** when the diagnosis has already been **confirmed by echocardiography** and the patient requires **urgent surgical management**.
- Further imaging would only delay necessary treatment in a hemodynamically unstable patient.
Question 6: A 47-year-old man is admitted to the emergency room after a fight in which he was hit in the head with a hammer. The witnesses say that the patient initially lost consciousness, but regained consciousness by the time emergency services arrived. On admission, the patient complained of a diffuse headache. He opened his eyes spontaneously, was verbally responsive, albeit confused, and was able to follow commands. He could not elevate his left hand and leg. He did not remember the events prior to the loss of consciousness and had difficulty remembering information, such as the names of nurses or doctors. His airway was not compromised. The vital signs are as follows: blood pressure, 180/100 mm Hg; heart rate, 59/min; respiratory rate, 12/min; temperature 37.0℃ (98.6℉); and SaO2, 96% on room air. The examination revealed bruising in the right frontotemporal region. The pupils are round, equal, and show a poor response to light. The neurologic examination shows hyperreflexia and decreased power in the left upper and lower limbs. There is questionable nuchal rigidity, but no Kernig and Brudzinski signs. The CT scan is shown in the image. Which of the following options is recommended for this patient?
A. Lumbar puncture
B. Decompressive craniectomy
C. Administration of levetiracetam
D. Administration of methylprednisolone
E. Surgical evacuation of the clots (Correct Answer)
Explanation: ***Surgical evacuation of the clots***
- The CT scan image shows a **biconvex (lenticular) hyperdensity** consistent with an **epidural hematoma (EDH)**, which typically results from arterial bleeding (often from the **middle meningeal artery**). This patient's **"lucid interval"** (initial loss of consciousness, regain consciousness, then deterioration) is classic for EDH.
- Given the patient's neurological deterioration (left-sided weakness, pupillary changes, confusion, memory issues) and signs of increased intracranial pressure (hypertension, bradycardia - part of Cushing's triad), urgent surgical evacuation of the hematoma is indicated to relieve pressure and prevent herniation.
*Lumbar puncture*
- A lumbar puncture is **contraindicated** in the setting of suspected or confirmed **increased intracranial pressure (ICP)**, as it can precipitate **cerebral herniation**.
- The CT scan clearly demonstrates a space-occupying lesion, making a lumbar puncture unnecessary and potentially dangerous.
*Decompressive craniectomy*
- While decompressive craniectomy is a neurosurgical procedure used to reduce ICP, it is generally considered when other measures have failed or in cases of **diffuse brain swelling** or large **intracerebral hematomas** not amenable to simple evacuation.
- In this case of a localized epidural hematoma with a clear surgical target, direct evacuation is the primary and most effective intervention.
*Administration of levetiracetam*
- Levetiracetam is an **anticonvulsant** used to prevent seizures. While seizures can occur after traumatic brain injury, there is no indication that the patient is currently seizing.
- Prophylactic anticonvulsants are sometimes used in severe TBI, but addressing the life-threatening hematoma takes **precedence** over seizure prophylaxis.
*Administration of methylprednisolone*
- **Corticosteroids** like methylprednisolone are generally **contraindicated** in traumatic brain injury (TBI) as studies have shown **worse outcomes** and increased mortality.
- They are primarily used for their **anti-inflammatory effects** in conditions like spinal cord injury or vasogenic edema from tumors, not for acute head trauma with hematoma.
Question 7: A 65-year-old man is brought to his primary care provider by his concerned wife. She reports he has had this "thing" on his eye for years and refuses to seek care. He denies any pain or discharge from the affected eye. A picture of his eye is shown below. Given the diagnosis, what are you most likely to discover when taking this patient's history?
A. He suffered from recurrent conjunctivitis in his youth
B. He experienced shingles three years ago, with a positive Hutchinson's sign
C. He suffered a burn to his eye while cleaning his bathroom with bleach 5 years earlier
D. He grew up in Ecuador, where he worked outdoors as a farmer for 30 years (Correct Answer)
E. He was involved in a bar fight and experienced a ruptured globe 10 years ago
Explanation: ***He grew up in Ecuador, where he worked outdoors as a farmer for 30 years***
- The image shows a **pterygium**, a triangular growth of conjunctival tissue that extends onto the cornea, often associated with chronic **UV exposure**.
- A history of working outdoors in a sunny climate like Ecuador strongly supports the development of a pterygium due to **sunlight exposure** and **environmental irritants**.
*He suffered from recurrent conjunctivitis in his youth*
- While recurrent **conjunctivitis** can cause chronic ocular irritation, it is not typically associated with the fleshy, vascularized growth onto the cornea characteristic of a **pterygium**.
- Conjunctivitis usually resolves without leaving such a specific corneal lesion.
*He experienced shingles three years ago, with a positive Hutchinson's sign*
- **Herpes zoster ophthalmicus** with Hutchinson's sign indicates involvement of the nasociliary nerve, which can lead to complications such as **keratitis**, uveitis, and glaucoma, but not a pterygium.
- The lesion seen is morphologically distinct from sequelae of herpes zoster.
*He suffered a burn to his eye while cleaning his bathroom with bleach 5 years earlier*
- A **chemical burn** to the eye can cause significant corneal and conjunctival damage, including scarring, opacification, and symblepharon (adhesion of the conjunctiva to itself or the cornea).
- However, it does not typically result in the characteristic triangular, vascularized tissue growth of a **pterygium**.
*He was involved in a bar fight and experienced a ruptured globe 10 years ago*
- A **ruptured globe** is a severe ocular trauma that would cause extensive damage, including vision loss, corneal and scleral lacerations, and intraocular contents prolapse, often leading to surgical repair and significant scar tissue.
- This type of injury is inconsistent with the appearance of a **pterygium**, which is a chronic, benign growth, not an acute traumatic rupture.
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 41-year-old man is brought to the emergency department 3 hours after falling while mountain biking and hitting his head. Initially, he refused treatment, but an hour ago he began to develop a severe headache, nausea, and left leg weakness. He has no visual changes and is oriented to person, time, and place. His temperature is 37°C (98.6°F), pulse is 68/min, respirations are 17/min and regular, and blood pressure is 130/78 mm Hg. Examination shows a 5-cm bruise on the right side of his skull. The pupils are equal, round, and reactive to light and accommodation. Muscle strength is 0/5 in his left knee and foot. Which of the following is the most likely cause of this patient's presentation?
A. Epidural hematoma (Correct Answer)
B. Subdural hematoma
C. Diffuse axonal injury
D. Subarachnoid hemorrhage
E. Cerebral contusion
Explanation: ***Epidural hematoma***
- The presentation of a **traumatic brain injury** with a **lucid interval** (initially alert, then deteriorating hours later) is the **classic presentation** of an epidural hematoma, typically caused by rupture of the **middle meningeal artery** following skull fracture.
- **Left-sided weakness** indicates a lesion affecting the contralateral (right) motor cortex, consistent with a right-sided epidural hematoma at the site of the **5-cm bruise on the right side of his skull**.
- The **rapid neurological deterioration** after a lucid interval is characteristic of **arterial bleeding** in the epidural space, which expands quickly and causes mass effect.
- Epidural hematomas appear as **lens-shaped (biconvex)** collections on CT scan that do not cross suture lines.
*Subdural hematoma*
- Subdural hematomas typically result from tearing of **bridging veins** between the cortex and dural sinuses, causing slower **venous bleeding**.
- They **rarely present with a classic lucid interval**; instead, they more commonly cause gradual symptom onset or are seen in elderly patients, alcoholics, or those on anticoagulation.
- Acute subdural hematomas that occur in trauma usually present with **immediate symptoms** rather than a delayed lucid interval presentation.
- On CT, subdural hematomas appear **crescent-shaped** and can cross suture lines.
*Diffuse axonal injury*
- **Diffuse axonal injury (DAI)** results from widespread shearing forces in the brain due to rotational acceleration-deceleration injury.
- DAI typically causes **immediate and prolonged loss of consciousness** from the time of injury, not a lucid interval followed by deterioration.
- Patients with DAI often remain comatose or in a persistent vegetative state, which is inconsistent with this patient's initial alertness.
*Subarachnoid hemorrhage*
- **Traumatic subarachnoid hemorrhage** presents with sudden, severe headache and often **meningeal signs** such as nuchal rigidity and photophobia.
- While it can cause headache and nausea, it typically does not cause **focal motor deficits** as the primary presenting symptom.
- The lucid interval with progressive focal neurological deficit points more toward an expanding extra-axial hematoma (epidural) rather than subarachnoid blood.
*Cerebral contusion*
- A **cerebral contusion** is bruising of brain parenchyma itself and can cause neurological symptoms depending on location and severity.
- Contusions typically present with **immediate symptoms** at the time of injury rather than a lucid interval.
- While contusions can worsen due to edema, the **classic lucid interval** followed by rapid deterioration with focal deficits is pathognomonic for epidural hematoma, not contusion.
Question 10: A 27-year-old woman presents with right knee pain over the last 3 weeks. The pain is moderate in severity but makes any physical activity that involves bending her knee extremely uncomfortable. Her pain worsens with running and squatting, in particular. The patient has no history of medical conditions nor does she have any immediate family member with a similar condition. At the physician's office, her vitals are normal. On physical examination, there is localized pain in the right anterior knee. There are no passive or active movement limitations at her knee joint. Erythema, swelling, and crepitations are not present. Which of the following is the best option for definitively managing this patient's condition?
A. Colchicine
B. Quadriceps strengthening (Correct Answer)
C. Intra-articular glycosaminoglycan polysulfate injections
D. Nonsteroidal anti-inflammatory drugs (NSAIDS)
E. Intra-articular steroid injections
Explanation: ***Quadriceps strengthening***
- The patient's symptoms of **anterior knee pain** worsening with running and squatting, without signs of inflammation or structural damage, are classic for **patellofemoral pain syndrome (PFPS)**.
- **Quadriceps strengthening**, particularly of the vastus medialis obliquus, is the **mainstay of treatment** for PFPS to improve patellar tracking and reduce stress on the joint.
*Colchicine*
- **Colchicine** is primarily used to treat **gout** and sometimes pseudogout, conditions that involve crystal deposition and acute inflammation.
- The patient's presentation lacks any signs of acute inflammation, swelling, or a history that would suggest a crystal-induced arthropathy.
*Intra-articular glycosaminoglycan polysulfate injections*
- **Intra-articular glycosaminoglycan polysulfate injections** are typically used in the management of **osteoarthritis**, primarily to reduce pain and improve joint function by providing components of cartilage.
- The patient's young age, lack of crepitus, and absence of movement limitations make osteoarthritis an unlikely diagnosis.
*Nonsteroidal anti-inflammatory drugs (NSAIDS)*
- While **NSAIDs** can provide symptomatic relief for pain, they do not address the underlying biomechanical issues contributing to **patellofemoral pain syndrome**.
- Long-term use of NSAIDs carries risks, and they are not considered a definitive management strategy for PFPS, which requires addressing muscle imbalances.
*Intra-articular steroid injections*
- **Intra-articular steroid injections** are used for conditions with significant inflammation within the joint, such as **rheumatoid arthritis** or **osteoarthritis with effusion**.
- The patient's physical examination reveals no erythema, swelling, or other signs of inflammation, making steroid injections inappropriate and not a definitive treatment.
