A 43-year-old man is brought to the emergency department 30 minutes after falling from the roof of a construction site. He reports abdominal and right-sided flank pain. His temperature is 37.1°C (98.8°F), pulse is 114/min, and blood pressure is 100/68 mm Hg. Physical examination shows numerous ecchymoses over the trunk and flanks and a tender right abdomen without a palpable mass. Focused assessment with sonography for trauma (FAST) shows no intraperitoneal fluid collections. His hemoglobin concentration is 7.6 g/dL. The most likely cause of his presentation is injury to which of the following organs?
Q102
A 45-year-old male is brought into the emergency room by emergency medical services due to a stab wound in the chest. The wound is located superior and medial to the left nipple. Upon entry, the patient appears alert and is conversational, but soon becomes confused and loses consciousness. The patient's blood pressure is 80/40 mmHg, pulse 110/min, respirations 26/min, and temperature 97.0 deg F (36.1 deg C). On exam, the patient has distended neck veins with distant heart sounds. What is the next best step to increase this patient's survival?
Q103
A 13-year-old boy is brought to the emergency room 30 minutes after being hit in the face with a baseball at high velocity. Examination shows left periorbital swelling, posterior displacement of the left globe, and tenderness to palpation over the left infraorbital rim. There is limited left upward gaze and normal horizontal eye movement. Further evaluation is most likely to show which of the following as a result of this patient's trauma?
Q104
A 32-year-old woman presents to the office with complaints of intense anal pain every time she has a bowel movement. The pain has been present for the past 4 weeks, and it is dull and throbbing in nature. It is associated with mild bright red bleeding from the rectum that is aggravated during defecation. She has no relevant past medical history. When asked about her sexual history, she reports practicing anal intercourse. The vital signs include heart rate 98/min, respiratory rate 16/min, temperature 37.6°C (99.7°F), and blood pressure 110/66 mm Hg. On physical examination, the anal sphincter tone is markedly increased, and it's impossible to introduce the finger due to severe pain. What is the most likely diagnosis?
Q105
A 55-year-old man presents to the emergency department with a concern of having sprayed a chemical in his eye. He states he was working on his car when his car battery sprayed a chemical on his face and eye. He states his eye is currently burning. His temperature is 99.0°F (37.2°C), blood pressure is 129/94 mmHg, pulse is 85/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a teary and red left eye. Which of the following is the most appropriate next step in management?
Q106
A 35-year-old woman is brought to the emergency department 45 minutes after being rescued from a house fire. On arrival, she appears confused and has shortness of breath. The patient is 165 cm (5 ft 5 in) tall and weighs 55 kg (121 lb); BMI is 20 kg/m2. Her pulse is 125/min, respirations are 29/min, and blood pressure is 105/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows second and third-degree burns over the anterior surfaces of the chest and abdomen, and the anterior surface of the upper extremities. There is black debris in the mouth and nose. There are coarse breath sounds over the lung bases. Cardiac examination shows no murmurs, rubs, or gallop. Femoral and pedal pulses are palpable bilaterally. Which of the following is the most appropriate fluid regimen for this patient according to the Parkland formula?
Q107
A 25-year-old male presents to his primary care physician for pain in his knee. The patient was in a wrestling match when his legs were grabbed from behind and he was taken to the floor. The patient states that the moment this impact happened, he felt a snapping and sudden pain in his knee. When the match ended and he stood back up, his knee felt unstable. Minutes later, his knee was swollen and painful. Since then, the patient claims that he has felt unstable bearing weight on the leg. The patient has no significant past medical history, and is currently taking a multivitamin and protein supplements. On physical exam you note a tender right knee, with erythema and an effusion. Which of the following is the most likely physical exam finding in this patient?
Q108
A 17-year-old boy presents to his primary care physician for eye pain. The patient states that it has been going on for the past 3 days and has been steadily worsening. He recently suffered a superior orbital fracture secondary to playing football without a helmet that required no treatment other than to refrain from contact sports. The patient's past medical history is non-contributory, and his vitals are within normal limits. Physical exam demonstrates pain and swelling inferior to the patient's eye near the lacrimal duct. When pressure is applied to the area expressible pus is noted. Cranial nerves II-XII are grossly intact. Which of the following is the most likely diagnosis?
Q109
A 35-year-old man is pulled out of a burning building. He is unconscious and severely injured. He is transported to the nearest emergency department. Upon arrival, he is stabilized and evaluated for burns and trauma. Approximately 40% of his body is covered in burns. The burned areas appear blackened and charred but the skin is mostly intact. It is noted that the patient has loss of pain sensation in the burnt areas with minimal blanching on palpation. The affected area is leathery when palpated. What category of burn did the patient most likely to suffer from?
Q110
A 20-year-old woman college volleyball player presents with left shoulder pain and difficulty elevating her left arm. The patient began to experience dull pain in her left shoulder 5 days ago after a volleyball game. The pain is worse when she sleeps with her arm under the pillow or elevates or abducts her left arm. Her temperature is 37.0℃ (98.6℉), the blood pressure is 110/75 mm Hg, the pulse is 66/min, the respiratory rate is 13/min, and the oxygen saturation is 99% on room air. On physical examination, she is alert and cooperative. The left shoulder is normal on the inspection with no swelling or bony deformities. There is point tenderness to palpation of the anterolateral aspect of the left shoulder. Active range of motion of abduction of the left arm is restricted to 70°. Passive range of motion of abduction of the left arm is normal but elicits pain. Strength in the left shoulder is 4/5 and strength in the right shoulder is 5/5. Deep tendon reflexes are 2+ bilaterally. The sensation is intact. Which of the following is the most likely cause of this patient’s condition?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 101: A 43-year-old man is brought to the emergency department 30 minutes after falling from the roof of a construction site. He reports abdominal and right-sided flank pain. His temperature is 37.1°C (98.8°F), pulse is 114/min, and blood pressure is 100/68 mm Hg. Physical examination shows numerous ecchymoses over the trunk and flanks and a tender right abdomen without a palpable mass. Focused assessment with sonography for trauma (FAST) shows no intraperitoneal fluid collections. His hemoglobin concentration is 7.6 g/dL. The most likely cause of his presentation is injury to which of the following organs?
A. Liver
B. Kidney (Correct Answer)
C. Stomach
D. Small bowel
E. Spleen
Explanation: ***Kidney***
- The patient's presentation with **flank pain**, **ecchymoses over the flank**, and **hypotension** following a fall from height is highly suggestive of **renal injury**. The absence of intraperitoneal fluid on FAST scan further supports an injury to a retroperitoneal organ like the kidney.
- The **significantly decreased hemoglobin (7.6 g/dL)** indicates substantial blood loss, which is consistent with the vascular nature of the kidney and potential for severe hemorrhage following trauma.
*Liver*
- While liver injury can cause **hypotension** and **abdominal pain** after trauma, the primary pain would typically be in the **right upper quadrant**, not specifically the flank.
- Liver injuries often result in **intraperitoneal fluid collections** (hemoperitoneum), which were explicitly absent on the FAST scan in this patient.
*Stomach*
- Stomach injuries typically result from penetrating trauma or severe blunt force, leading to **peritonitis** and potential **gastric content leakage**, which would cause diffuse abdominal pain and potentially peritonitis signs.
- It is an **intraperitoneal organ**, and injury might be seen on a FAST scan as free fluid, which is not present here.
*Small bowel*
- Small bowel injuries typically present with **diffuse abdominal pain**, **peritoneal signs**, and can lead to **sepsis** due to contamination.
- These injuries often cause **intraperitoneal fluid** or air, neither of which is reported.
*Spleen*
- Splenic injuries typically cause **left upper quadrant pain** and can lead to significant **intraperitoneal bleeding**, which would be detected by a FAST scan.
- The patient's symptoms are localized to the **right side** and flank, making splenic injury less likely.
Question 102: A 45-year-old male is brought into the emergency room by emergency medical services due to a stab wound in the chest. The wound is located superior and medial to the left nipple. Upon entry, the patient appears alert and is conversational, but soon becomes confused and loses consciousness. The patient's blood pressure is 80/40 mmHg, pulse 110/min, respirations 26/min, and temperature 97.0 deg F (36.1 deg C). On exam, the patient has distended neck veins with distant heart sounds. What is the next best step to increase this patient's survival?
A. Heparin
B. Intravenous fluids
C. Aspirin
D. Intravenous colloids
E. Pericardiocentesis (Correct Answer)
Explanation: ***Pericardiocentesis***
- The patient's presentation with **hypotension**, **tachycardia**, **distended neck veins**, and **distant heart sounds** after a chest stab wound is classic for **cardiac tamponade** (Beck's triad).
- **Pericardiocentesis** is the immediate life-saving procedure to drain the pericardial fluid and relieve pressure on the heart, improving cardiac output.
- In penetrating trauma, this serves as a **bridge to definitive surgical management** (thoracotomy or sternotomy).
*Heparin*
- **Heparin** is an anticoagulant and would worsen the situation by increasing bleeding into the pericardial space due to the stab wound.
- It is contraindicated in active bleeding and traumatic injury.
*Intravenous fluids*
- While **IV fluid resuscitation is recommended** in cardiac tamponade to maintain preload and support cardiac output, fluids alone **do not address the underlying mechanical obstruction**.
- The primary issue is **extrinsic compression of the heart** requiring drainage, not hypovolemia alone.
- Fluids are supportive but not definitive—**pericardiocentesis is the life-saving intervention**.
*Aspirin*
- **Aspirin** is an antiplatelet agent and would increase the risk of bleeding, exacerbating the patient's condition.
- It is used for conditions like myocardial infarction or stroke prevention, not for acute traumatic bleeding.
*Intravenous colloids*
- Similar to crystalloid fluids, **colloids** may provide temporary hemodynamic support but do not relieve the mechanical compression of the heart.
- They are supportive measures that **do not substitute for definitive pericardial drainage**.
Question 103: A 13-year-old boy is brought to the emergency room 30 minutes after being hit in the face with a baseball at high velocity. Examination shows left periorbital swelling, posterior displacement of the left globe, and tenderness to palpation over the left infraorbital rim. There is limited left upward gaze and normal horizontal eye movement. Further evaluation is most likely to show which of the following as a result of this patient's trauma?
A. Cerebrospinal fluid leak
B. Pneumatization of frontal sinus
C. Injury to lacrimal duct system
D. Clouding of maxillary sinus (Correct Answer)
E. Disruption of medial canthal ligament
Explanation: ***Clouding of maxillary sinus***
- This patient's symptoms (periorbital swelling, globe displacement, infraorbital rim tenderness, limited upward gaze) are strongly suggestive of an **orbital floor (blowout) fracture**. The orbital floor is the roof of the **maxillary sinus**, so a fracture often causes blood to leak into the sinus, leading to **clouding on imaging**.
- Limited upward gaze is a classic sign due to **entrapment of the inferior rectus muscle** or its surrounding soft tissues in the fracture site.
*Cerebrospinal fluid leak*
- A CSF leak is associated with fractures involving the **skull base**, particularly the **cribriform plate** or **petrous bone**, which is not directly indicated by these symptoms.
- While possible with severe facial trauma, it's less direct consequence of the localized orbital floor fracture described.
*Pneumatization of frontal sinus*
- **Pneumatization** refers to the development of air cells within a bone, a normal physiological process, not an acute traumatic finding.
- The frontal sinus is located superior to the orbit, and while it can be involved in trauma, the described symptoms point specifically to the **orbital floor** and infraorbital region.
*Injury to lacrimal duct system*
- Injury to the lacrimal duct system typically presents with **epiphora** (excessive tearing) or dacryocystitis.
- This type of injury is more common with trauma to the **medial canthus** or nasal area, not primarily the infraorbital rim.
*Disruption of medial canthal ligament*
- Disruption of the medial canthal ligament would lead to a widened space between the eyelids (telecanthus) and often involve the **lacrimal drainage system**.
- This is typically associated with fractures of the **naso-orbital-ethmoid complex**, which is distinct from the orbital floor fracture described.
Question 104: A 32-year-old woman presents to the office with complaints of intense anal pain every time she has a bowel movement. The pain has been present for the past 4 weeks, and it is dull and throbbing in nature. It is associated with mild bright red bleeding from the rectum that is aggravated during defecation. She has no relevant past medical history. When asked about her sexual history, she reports practicing anal intercourse. The vital signs include heart rate 98/min, respiratory rate 16/min, temperature 37.6°C (99.7°F), and blood pressure 110/66 mm Hg. On physical examination, the anal sphincter tone is markedly increased, and it's impossible to introduce the finger due to severe pain. What is the most likely diagnosis?
A. Local anal trauma (Correct Answer)
B. Rectal prolapse and paradoxical contraction of the puborectalis muscle
C. Inflammatory bowel disease
D. Anorectal abscess
E. Hemorrhoidal disease
Explanation: ***Local anal trauma***
- The patient's history of **anal intercourse**, severe **anal pain** during bowel movements, **bright red bleeding**, and a markedly **increased anal sphincter tone** with inability to perform a DRE due to pain are highly indicative of an **anal fissure** caused by local trauma.
- The dull, throbbing pain suggests associated spasm of the internal anal sphincter, a common complication of anal fissures.
*Rectal prolapse and paradoxical contraction of the puborectalis muscle*
- **Rectal prolapse** typically presents with a sensation of a mass protruding from the anus and difficulty with bowel movements, not usually intense, sharp pain and bright red bleeding.
- **Paradoxical contraction of the puborectalis muscle** (anismus) causes difficult defecation and straining but is not typically associated with acute, severe pain and bright red bleeding as primary symptoms.
*Inflammatory bowel disease*
- While IBD can cause rectal bleeding and anal pain (e.g., in Crohn's disease with perianal fistulas or fissures), the presentation here is acute and highly suggestive of a mechanical cause, without other systemic symptoms of IBD like diarrhea, weight loss, or abdominal pain.
- The **isolated acute anal pain** and bleeding linked to defecation and anal intercourse are less typical for an initial presentation of IBD without other associated symptoms.
*Anorectal abscess*
- Anorectal abscesses typically present with severe, constant, throbbing **perianal pain** that is often worse when sitting, and may be accompanied by fever, chills, and localized swelling or erythema, which are not described here.
- While an abscess might cause throbbing pain, the association with **defecation-induced pain** and **bright red bleeding** from a visible source like an anal fissure is less characteristic.
*Hemorrhoidal disease*
- Hemorrhoids often cause **painless bright red bleeding** during defecation or can cause itching and discomfort. **Thrombosed external hemorrhoids** can cause acute, severe pain but usually present with a palpable, tender nodule.
- The description of **intense, sharp anal pain** during bowel movements, increased sphincter tone, and inability to perform a digital rectal exam are more consistent with an anal fissure than typical hemorrhoidal disease.
Question 105: A 55-year-old man presents to the emergency department with a concern of having sprayed a chemical in his eye. He states he was working on his car when his car battery sprayed a chemical on his face and eye. He states his eye is currently burning. His temperature is 99.0°F (37.2°C), blood pressure is 129/94 mmHg, pulse is 85/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for a teary and red left eye. Which of the following is the most appropriate next step in management?
A. Irrigation (Correct Answer)
B. Visual acuity test
C. Slit lamp exam
D. CT orbits
E. Surgical debridement
Explanation: ***Irrigation***
- Immediate and copious **irrigation** is the most crucial step in managing a chemical eye injury to dilute and remove the corrosive substance, preventing further ocular damage.
- Delaying irrigation can lead to irreversible damage, especially with **acid burns** from battery acid (sulfuric acid).
*Visual acuity test*
- While important, assessing **visual acuity** should occur *after* initial irrigation to prioritize minimizing chemical exposure and preserving ocular health.
- Performing it before irrigation delays critical treatment, potentially worsening the prognosis.
*Slit lamp exam*
- A **slit lamp exam** is essential for evaluating the extent of ocular damage but should only be performed *after* adequate irrigation has been completed.
- It provides detailed information on corneal and conjunctival integrity but is not the immediate priority in an acute chemical exposure.
*CT orbits*
- A **CT scan of the orbits** is not indicated for a chemical eye injury unless there is suspicion of a **globe rupture** or **orbital fracture**, which are not suggested by the patient's presentation.
- This imaging study would unnecessarily delay vital treatment for the chemical burn.
*Surgical debridement*
- **Surgical debridement** is reserved for severe cases of chemical burns with significant tissue necrosis or foreign bodies that cannot be removed by irrigation.
- It is not the initial management step and would be considered much later, if at all, based on the severity of the injury after initial stabilization.
Question 106: A 35-year-old woman is brought to the emergency department 45 minutes after being rescued from a house fire. On arrival, she appears confused and has shortness of breath. The patient is 165 cm (5 ft 5 in) tall and weighs 55 kg (121 lb); BMI is 20 kg/m2. Her pulse is 125/min, respirations are 29/min, and blood pressure is 105/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows second and third-degree burns over the anterior surfaces of the chest and abdomen, and the anterior surface of the upper extremities. There is black debris in the mouth and nose. There are coarse breath sounds over the lung bases. Cardiac examination shows no murmurs, rubs, or gallop. Femoral and pedal pulses are palpable bilaterally. Which of the following is the most appropriate fluid regimen for this patient according to the Parkland formula?
A. Administer 4 liters of intravenous colloids over the next 8 hours
B. Administer 5 liters of intravenous colloids over the next 6 hours
C. Administer 5 liters of intravenous crystalloids over the next 6 hours
D. Administer 8 liters of intravenous colloids over the next 12 hours
E. Administer 6 liters of intravenous crystalloids over the next 24 hours (Correct Answer)
Explanation: ***Administer 6 liters of intravenous crystalloids over the next 24 hours***
- The **Parkland formula** is 4 mL × weight (kg) × %TBSA burn. The patient's weight is 55 kg. The burns cover the anterior chest (9%), anterior abdomen (9%), and anterior surfaces of both upper extremities (4.5% + 4.5% = 9%), totaling **27% TBSA**.
- Calculation: 4 mL × 55 kg × 27% = **5,940 mL ≈ 6 liters**. Half is given in the first 8 hours (approximately 3 L), and the remaining half over the next 16 hours (approximately 3 L). Total fluid in 24 hours is approximately **6 liters of crystalloids**.
*Administer 4 liters of intravenous colloids over the next 8 hours*
- The Parkland formula primarily uses **crystalloids** (lactated Ringer's solution) for initial fluid resuscitation in burn patients, not colloids.
- Administering only 4 liters would be insufficient given the patient's 27% TBSA burn, and colloids are not first-line.
*Administer 5 liters of intravenous colloids over the next 6 hours*
- **Colloids** are not the first-line fluid for initial burn resuscitation under the Parkland formula; crystalloids are used.
- The timing of 6 hours does not align with the Parkland formula's 24-hour resuscitation period (half in first 8 hours, half in next 16 hours).
*Administer 5 liters of intravenous crystalloids over the next 6 hours*
- While **crystalloids** are appropriate, 5 liters over 6 hours represents an inappropriately rapid infusion rate that does not follow the Parkland formula timing.
- The first 8 hours should receive approximately 3 liters, not 5 liters over 6 hours, which could lead to complications such as **pulmonary edema or compartment syndrome**.
*Administer 8 liters of intravenous colloids over the next 12 hours*
- This option incorrectly specifies **colloids** instead of crystalloids as the primary fluid for burn resuscitation according to the Parkland formula.
- The volume of 8 liters exceeds the calculated requirement of 6 liters for this patient's 27% TBSA burn.
Question 107: A 25-year-old male presents to his primary care physician for pain in his knee. The patient was in a wrestling match when his legs were grabbed from behind and he was taken to the floor. The patient states that the moment this impact happened, he felt a snapping and sudden pain in his knee. When the match ended and he stood back up, his knee felt unstable. Minutes later, his knee was swollen and painful. Since then, the patient claims that he has felt unstable bearing weight on the leg. The patient has no significant past medical history, and is currently taking a multivitamin and protein supplements. On physical exam you note a tender right knee, with erythema and an effusion. Which of the following is the most likely physical exam finding in this patient?
A. Laxity to valgus stress
B. Anterior translation of the tibia relative to the femur (Correct Answer)
C. Clicking and locking of the joint with motion
D. Laxity to varus stress
E. Posterior translation of the tibia relative to the femur
Explanation: ***Anterior translation of the tibia relative to the femur***
- The rapid onset of a "snapping" sensation, immediate swelling, and instability after a traumatic event involving twisting or hyperextension of the knee is highly suggestive of an **anterior cruciate ligament (ACL) tear**.
- A torn ACL allows for excessive **anterior translation** of the tibia relative to the femur, which is assessed clinically with tests like the **Lachman test** or **anterior drawer test**.
*Laxity to valgus stress*
- **Laxity to valgus stress** indicates injury to the **medial collateral ligament (MCL)**. While MCL tears can occur with ACL tears, the mechanism described (legs grabbed from behind, taken to the floor, resulting in instability) more directly points to an ACL injury rather than primarily an MCL tear, which often results from a direct blow to the lateral knee.
- The patient's primary complaint of a single "snapping" event followed by instability is more characteristic of an ACL tear than an isolated MCL injury.
*Clicking and locking of the joint with motion*
- **Clicking and locking** of the joint are classic signs of a **meniscal tear**, which can accompany ACL injuries but are not the primary or most likely *initial* physical exam finding for an acute ACL tear.
- While instability is also present in meniscal tears, the immediate swelling and "snapping" described are more characteristic of ligamentous damage.
*Laxity to varus stress*
- **Laxity to varus stress** indicates injury to the **lateral collateral ligament (LCL)**, which is much less common than ACL or MCL tears and typically results from a varus force applied to the knee.
- The mechanism described (being taken to the floor from behind) does not strongly suggest an LCL injury as the primary lesion.
*Posterior translation of the tibia relative to the femur*
- **Posterior translation of the tibia relative to the femur** is indicative of a **posterior cruciate ligament (PCL) tear**, which usually results from a direct blow to the anterior tibia when the knee is flexed (dashboard injury) or a fall onto a flexed knee.
- The mechanism of injury in this patient (legs grabbed from behind, twisting/hyperextension) is not typical for a PCL injury.
Question 108: A 17-year-old boy presents to his primary care physician for eye pain. The patient states that it has been going on for the past 3 days and has been steadily worsening. He recently suffered a superior orbital fracture secondary to playing football without a helmet that required no treatment other than to refrain from contact sports. The patient's past medical history is non-contributory, and his vitals are within normal limits. Physical exam demonstrates pain and swelling inferior to the patient's eye near the lacrimal duct. When pressure is applied to the area expressible pus is noted. Cranial nerves II-XII are grossly intact. Which of the following is the most likely diagnosis?
A. Orbital cellulitis
B. Hordeolum
C. Periorbital cellulitis
D. Dacrocystitis (Correct Answer)
E. Abscess
Explanation: ***Dacrocystitis***
- The presentation of **eye pain**, swelling inferior to the eye near the **lacrimal duct**, and the presence of **expressible pus** upon pressure strongly indicates dacryocystitis, which is an infection of the **lacrimal sac**.
- The history of a recent orbital fracture, while not directly causing the infection, could predispose the area to inflammation or obstruction leading to infection.
*Orbital cellulitis*
- This condition would present with more severe symptoms, including **pain with eye movement**, **proptosis** (exophthalmos), **ophthalmoplegia**, and vision changes, which are not described.
- Infection is **posterior to the orbital septum**, often extending from sinusitis, and is a medical emergency.
*Hordeolum*
- A hordeolum (stye) is an acute infection of the glands of the eyelid, presenting as a **tender, red bump on the eyelid margin**, not inferior to the eye near the lacrimal duct.
- It typically involves the **sebaceous glands** (external hordeolum) or **Meibomian glands** (internal hordeolum).
*Periorbital cellulitis*
- Also known as preseptal cellulitis, this involves infection of the tissues **anterior to the orbital septum**, causing eyelid swelling and redness but **without pain on eye movement**, proptosis, or vision changes.
- Unlike dacryocystitis, the infection is more diffuse around the periorbital area and not specifically focused on the lacrimal sac with expressible pus.
*Abscess*
- While dacryocystitis can lead to an abscess of the lacrimal sac, "abscess" alone is a general term. **Dacryocystitis** specifically describes the infection and inflammation of the lacrimal sac, which is the most precise diagnosis here given the location and expressible pus.
- An abscess typically implies a **localized collection of pus** within a tissue, but dacryocystitis defines the primary affected structure.
Question 109: A 35-year-old man is pulled out of a burning building. He is unconscious and severely injured. He is transported to the nearest emergency department. Upon arrival, he is stabilized and evaluated for burns and trauma. Approximately 40% of his body is covered in burns. The burned areas appear blackened and charred but the skin is mostly intact. It is noted that the patient has loss of pain sensation in the burnt areas with minimal blanching on palpation. The affected area is leathery when palpated. What category of burn did the patient most likely to suffer from?
A. Superficial (1st degree)
B. Full-thickness (3rd degree) (Correct Answer)
C. Superficial-partial thickness (2nd degree)
D. Deep-partial thickness (deep 2nd degree)
E. Full-thickness with extension to underlying structures (4th degree)
Explanation: ***Full-thickness (3rd degree)***
- The description of **blackened, charred appearance**, **loss of pain sensation**, **minimal blanching**, and **leathery texture** are classic signs of a **full-thickness (3rd-degree) burn**.
- **Full-thickness burns** destroy the entire dermis, including nerve endings, leading to a painless area.
- The leathery texture results from protein coagulation in the destroyed dermis.
*Superficial (1st degree)*
- This type of burn affects only the **epidermis**, causing redness, pain, and no blistering.
- The patient's presentation of charred skin and insensitivity to pain is inconsistent with a **superficial burn**.
*Superficial-partial thickness (2nd degree)*
- **Superficial partial-thickness burns** involve the epidermis and superficial dermis, characterized by painful blisters and redness.
- The absence of pain and presence of charred skin rule out this type of burn.
*Deep-partial thickness (deep 2nd degree)*
- **Deep partial-thickness burns** extend into the deep dermis and may have **decreased pain sensation** due to nerve damage.
- However, these burns typically appear **mottled red or white** rather than blackened and charred, and usually have some blanching response.
- The completely charred, blackened appearance with absent pain indicates full-thickness injury.
*Full-thickness with extension to underlying structures (4th degree)*
- A **4th-degree burn** extends beyond the skin into **muscle, bone, or tendons**, often with visible destruction of these structures.
- The affected area would typically be **very firm or hard** with exposed deeper tissues.
- While the burn is severe, the description focuses on skin characteristics without obvious involvement of deeper anatomical structures like muscle or bone.
Question 110: A 20-year-old woman college volleyball player presents with left shoulder pain and difficulty elevating her left arm. The patient began to experience dull pain in her left shoulder 5 days ago after a volleyball game. The pain is worse when she sleeps with her arm under the pillow or elevates or abducts her left arm. Her temperature is 37.0℃ (98.6℉), the blood pressure is 110/75 mm Hg, the pulse is 66/min, the respiratory rate is 13/min, and the oxygen saturation is 99% on room air. On physical examination, she is alert and cooperative. The left shoulder is normal on the inspection with no swelling or bony deformities. There is point tenderness to palpation of the anterolateral aspect of the left shoulder. Active range of motion of abduction of the left arm is restricted to 70°. Passive range of motion of abduction of the left arm is normal but elicits pain. Strength in the left shoulder is 4/5 and strength in the right shoulder is 5/5. Deep tendon reflexes are 2+ bilaterally. The sensation is intact. Which of the following is the most likely cause of this patient’s condition?
A. Tear of the supraspinatus muscle (Correct Answer)
B. Shoulder joint dislocation
C. Intra-articular humeral fracture
D. Entrapment of the axillary nerve
E. Intervertebral disk protrusion at the C4-5 level
Explanation: ***Tear of the supraspinatus muscle***
- Pain on **palpation of the anterolateral aspect of the shoulder**, pain with **elevation** and **abduction**, and **restricted active range of motion** with normal but painful passive range of motion are classic signs of rotator cuff injury, often involving the supraspinatus in athletes.
- The volleyball player's history of **dull shoulder pain** after a game, worsened by sleeping on the arm or abducting/elevating it, further points towards a **rotator cuff tear** or tendinopathy, with the supraspinatus being the most commonly affected.
*Intervertebral disk protrusion at the C4-5 level*
- **Cervical radiculopathy** would typically present with **neuropathic pain**, sensory deficits, or motor weakness in a dermatomal or myotomal distribution, which is not evident here.
- The localized shoulder pain and tenderness, along with pain on **active movement** but normal passive movement, are more indicative of a local shoulder issue rather than a cervical spine problem.
*Shoulder joint dislocation*
- A shoulder dislocation would present with **severe pain**, **obvious deformity** of the shoulder joint, and a complete inability to move the arm, which is not described.
- The patient has restricted active range of motion but normal passive range of motion, and no bony deformities or swelling, ruling out a dislocation.
*Intra-articular humeral fracture*
- A fracture would cause **severe, acute pain**, **swelling**, **bruising**, and a likely **deformity** of the shoulder, along with an inability to move the arm actively or passively.
- The absence of swelling, deformity, and severe acute pain that would typically follow a fracture makes this diagnosis less likely.
*Entrapment of the axillary nerve*
- **Axillary nerve entrapment** would primarily cause **deltoid muscle weakness**, leading to difficulty with abduction, and **sensory loss over the lateral shoulder**.
- While there is some weakness with abduction, the specific point tenderness and pain with active movement point more towards a musculoskeletal injury rather than isolated nerve entrapment.
