A 27-year-old woman presents to her family physician with pain on the front of her right knee. The pain started 2 months ago after she began training for a marathon, and it was gradual in onset and has slowly worsened. The pain increases with prolonged sitting and climbing stairs. She denies significant knee trauma. Her only medication is diclofenac sodium as needed for pain. Medical history is unremarkable. The vital signs include: temperature 36.9°C (98.4°F), blood pressure 100/70 mm Hg, and heart rate 78/min. Her body mass index is 26 kg/m2. The pain is reproduced by applying direct pressure to the right patella, and there is increased patellar laxity with medial and lateral displacement. The remainder of the examination is otherwise unremarkable. Which of the following is the most likely diagnosis?
Q132
A 27-year-old man presents to the emergency department after he was assaulted and shot during a robbery. The patient was beaten with a baseball bat and has a bullet entry wound in his neck. He is currently complaining of diffuse pains but is able to speak. His voice sounds muffled, and he is requesting pain medications. An initial resuscitation is begun in the trauma bay. The patient's general appearance reveals ecchymosis throughout his body and minor scrapes and cuts, and possible multiple facial bone fractures. There is another bullet wound found in the left side of his back without an exit wound. Which of the following is the best next step in management?
Q133
A 36-year-old man was sent to the Emergency Department after a stray baseball hit him in the left eye during a game. Paramedics on sight could not perform the necessary testing and encouraged the patient to visit an ED for further testing and imaging. At the Emergency Department, the patient complains of slight pain in the orbital region and minimal diplopia that mildly increases with upward gaze. The patient’s blood pressure is 110/60 mm Hg, heart rate is 53/min, respiratory rate is 13/min, and temperature 36.6℃ (97.9℉). On physical examination, the patient is alert and responsive. There is an ecchymosis involving the lower lid and infraorbital area on the left side, with a slight downward deviation of the left globe, and conjunctival injection of the left eye. An upward gaze is limited on the left side. The visual acuity is 5/20 bilaterally. A head and neck CT shows a small (0.4 cm), nondisplaced, linear fracture of the left orbital floor. Which of the following statements about the condition the patient presents with is the most accurate?
Q134
A 28-year-old woman is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which she was the unrestrained driver. On arrival, she is semiconscious and incoherent. She has shortness of breath and is cyanotic. Her pulse is 112/min, respirations are 59/min, and blood pressure is 128/89 mm Hg. Examination shows a 3-cm (1.2-in) laceration on the forehead and multiple abrasions over the thorax and abdomen. There is crepitation on palpation of the thorax on the right. Auscultation of the lung shows decreased breath sounds on the right side. A crunching sound synchronous with the heartbeat is heard best over the precordium. There is dullness on percussion of the right hemithorax. The lips and tongue have a bluish discoloration. There is an open femur fracture on the left. The remainder of the examination shows no abnormalities. Arterial blood gas analysis on room air shows:
pH 7.31
PCO2 55 mm Hg
PO2 42 mm Hg
HCO3- 22 mEq/L
O2 saturation 76%
The patient is intubated and mechanically ventilated. Infusion of 0.9% saline is begun. Which of the following is the most likely diagnosis?
Q135
A 27-year-old soldier stationed in Libya sustains a shrapnel injury during an attack, causing a traumatic above-elbow amputation. The resulting arterial bleed is managed with a tourniquet prior to transport to the military treatment facility. On arrival, he is alert and oriented to person, place, and time. His armor and clothing are removed. His pulse is 145/min, respirations are 28/min, and blood pressure is 95/52 mm Hg. Pulmonary examination shows symmetric chest rise. The lungs are clear to auscultation. Abdominal examination shows no abnormalities. There are multiple shrapnel wounds over the upper and lower extremities. A tourniquet is in place around the right upper extremity; the right proximal forearm has been amputated. One large-bore intravenous catheter is placed in the left antecubital fossa. Despite multiple attempts, medical staff is unable to establish additional intravenous access. Which of the following is the most appropriate next step in management?
Q136
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?
Q137
A 72-year-old man comes to the physician for a 5-month history of hoarseness, exertional dyspnea, and fatigue. He does not smoke or drink alcohol. His pulse is 98/min and irregular. His voice is coarse in quality. Physical examination shows a liver span of 16 cm and a soft diastolic murmur heard best at the apex. Which of the following is the most likely cause of this patient's hoarseness?
Q138
A 33-year-old man presents to his primary care physician with shoulder pain. He states that he can't remember a specific instance when the injury occurred. He is a weight lifter and competes in martial arts. The patient has no past medical history and is currently taking a multivitamin. Physical exam demonstrates pain with abduction of the patient's right shoulder and with external rotation of the right arm. There is subacromial tenderness with palpation. His left arm demonstrates 10/10 strength with abduction as compared to 4/10 strength with abduction of the right arm. Which of the following best confirms the underlying diagnosis?
Q139
A 17-year-old boy is brought to the emergency department by his parents 6 hours after he suddenly began to experience dyspnea and pleuritic chest pain at home. He has a remote history of asthma in childhood but has not required any treatment since the age of four. His temperature is 98.4°F (36.9°C), blood pressure is 100/76 mmHg, pulse is 125/min, respirations are 24/min. On exam, he has decreased lung sounds and hyperresonance in the left upper lung field. A chest radiograph shows a slight tracheal shift to the right. What is the best next step in management?
Q140
A 27-year-old soldier is brought to the emergency department of a military hospital 20 minutes after being involved in a motor vehicle accident during a training exercise. He was an unrestrained passenger. On arrival, he has shortness of breath and chest pain. He appears pale and anxious. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 100/65 mm Hg. He is alert and oriented to person, place, and time. Examination shows pale conjunctivae and mucous membranes. There is bruising on the chest, extremities, and abdomen. The lungs are clear to auscultation. He has normal heart sounds and flat neck veins. The abdomen is flat, soft, and mildly tender. The remainder of the physical examination shows no abnormalities. High-flow oxygen is applied, and intravenous fluid resuscitation is begun. A chest x-ray is obtained. Which of the following is the most appropriate next step in management?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 131: A 27-year-old woman presents to her family physician with pain on the front of her right knee. The pain started 2 months ago after she began training for a marathon, and it was gradual in onset and has slowly worsened. The pain increases with prolonged sitting and climbing stairs. She denies significant knee trauma. Her only medication is diclofenac sodium as needed for pain. Medical history is unremarkable. The vital signs include: temperature 36.9°C (98.4°F), blood pressure 100/70 mm Hg, and heart rate 78/min. Her body mass index is 26 kg/m2. The pain is reproduced by applying direct pressure to the right patella, and there is increased patellar laxity with medial and lateral displacement. The remainder of the examination is otherwise unremarkable. Which of the following is the most likely diagnosis?
A. Prepatellar bursitis
B. Osgood-Schlatter's disease
C. Patellofemoral pain syndrome (Correct Answer)
D. Iliotibial band syndrome
E. Patellar tendonitis
Explanation: ***Patellofemoral pain syndrome***
- The patient's presentation of **anterior knee pain** exacerbated by **prolonged sitting** and **climbing stairs** (classic for "theater sign" and "runner's knee") is highly characteristic of patellofemoral pain syndrome.
- Pain reproduced by **direct patellar pressure** and increased **patellar laxity** further support this diagnosis, indicating issues with patellar tracking and cartilage irritation.
*Prepatellar bursitis*
- This condition typically presents with **localized swelling**, **tenderness**, and **warmth directly over the patella**, often due to direct trauma or repetitive kneeling.
- The patient's symptoms are more diffuse anterior knee pain, and there is no mention of visible swelling or warmth.
*Osgood-Schlatter's disease*
- This condition primarily affects **adolescents** experiencing growth spurts and is characterized by pain and swelling at the **tibial tuberosity** due to repetitive stress from quadriceps pull.
- The patient is a 27-year-old woman, outside the typical age range for Osgood-Schlatter's, and her pain is localized to the patella, not the tibial tuberosity.
*Iliotibial band syndrome*
- Iliotibial band syndrome causes **lateral knee pain**, often felt just above the joint line, and is exacerbated by running, especially downhill.
- The patient's pain is on the **front of her knee**, not the lateral aspect, and typical iliotibial band tenderness is absent.
*Patellar tendonitis*
- Also known as "jumper's knee," this condition presents with localized pain and tenderness at the **inferior pole of the patella** or along the patellar tendon, typically seen in athletes involved in jumping sports.
- While running can contribute, the primary symptoms here are more consistent with patellofemoral pain syndrome, particularly the association with prolonged sitting and specific patellar findings.
Question 132: A 27-year-old man presents to the emergency department after he was assaulted and shot during a robbery. The patient was beaten with a baseball bat and has a bullet entry wound in his neck. He is currently complaining of diffuse pains but is able to speak. His voice sounds muffled, and he is requesting pain medications. An initial resuscitation is begun in the trauma bay. The patient's general appearance reveals ecchymosis throughout his body and minor scrapes and cuts, and possible multiple facial bone fractures. There is another bullet wound found in the left side of his back without an exit wound. Which of the following is the best next step in management?
A. Administration of 100% oxygen
B. Laryngeal mask
C. Nasotracheal intubation
D. Orotracheal intubation (Correct Answer)
E. Cricothyroidotomy
Explanation: ***Orotracheal intubation***
- The patient's **muffled voice** suggests an impending **airway compromise** due to trauma, making securing the airway a priority.
- While other methods might be considered, **orotracheal intubation** is generally the quickest and most effective method for establishing a definitive airway in a trauma setting, especially given the potential for significant facial and neck injuries.
*Administration of 100% oxygen*
- Administering oxygen is an important initial step in trauma resuscitation, but it does not address the underlying problem of a **potentially compromised airway** in this patient.
- Oxygenation alone will not prevent future airway obstruction if swelling or hematoma progresses.
*Laryngeal mask*
- A laryngeal mask airway (LMA) is a **supraglottic device** that may not provide a definitive, secure airway, especially in a patient with potential cervical spine injuries or significant upper airway trauma where the anatomy may be distorted.
- LMAs are often considered a temporizing measure but not the primary choice for definitive airway management in patients with significant trauma.
*Nasotracheal intubation*
- **Nasotracheal intubation** is contraindicated in patients with **suspected facial or skull base fractures** due to the risk of intracranial intubation.
- The patient has possible multiple facial bone fractures, making this route unsafe.
*Cricothyroidotomy*
- **Cricothyroidotomy** is a surgical airway technique typically reserved for a "cannot intubate, cannot ventilate" situation when other attempts at intubation have failed.
- It is an invasive procedure and generally not the first line of airway management when conventional intubation is still feasible.
Question 133: A 36-year-old man was sent to the Emergency Department after a stray baseball hit him in the left eye during a game. Paramedics on sight could not perform the necessary testing and encouraged the patient to visit an ED for further testing and imaging. At the Emergency Department, the patient complains of slight pain in the orbital region and minimal diplopia that mildly increases with upward gaze. The patient’s blood pressure is 110/60 mm Hg, heart rate is 53/min, respiratory rate is 13/min, and temperature 36.6℃ (97.9℉). On physical examination, the patient is alert and responsive. There is an ecchymosis involving the lower lid and infraorbital area on the left side, with a slight downward deviation of the left globe, and conjunctival injection of the left eye. An upward gaze is limited on the left side. The visual acuity is 5/20 bilaterally. A head and neck CT shows a small (0.4 cm), nondisplaced, linear fracture of the left orbital floor. Which of the following statements about the condition the patient presents with is the most accurate?
A. MRI is the best method to evaluate the patient’s condition.
B. The patient can be initially managed conservatively with corticosteroids and observation. (Correct Answer)
C. The patient’s condition warrants emergency surgery.
D. There is a low chance of spontaneous improvement of the ocular motility.
E. Surgical intervention within 3 days would help prevent enophthalmos in this patient.
Explanation: ***The patient can be initially managed conservatively with corticosteroids and observation.***
- The patient has a **small, nondisplaced orbital floor fracture** (0.4 cm) and minimal diplopia that only mildly increases with upward gaze, making **conservative management** appropriate.
- **Corticosteroids** can help reduce swelling and inflammation, and close **observation** is necessary to monitor for any worsening of symptoms, especially diplopia or enophthalmos.
*MRI is the best method to evaluate the patient’s condition.*
- While MRI can provide detailed soft tissue imaging, **CT scan** of the orbit is generally preferred for evaluating **orbital fractures** as it better visualizes bony structures and foreign bodies.
- The initial diagnosis was made with a CT scan, and for a small, nondisplaced fracture, a repeat or alternative imaging is not immediately necessary unless symptoms worsen.
*Surgical intervention within 3 days would allow to prevent enophthalmos in this patient.*
- **Early surgical intervention** (within days) is typically reserved for larger fractures (>50% of the orbital floor), significant enophthalmos, severe diplopia in primary gaze, or muscle entrapment.
- With a **small, nondisplaced fracture** and minimal symptoms, surgical intervention within 3 days is not indicated for this patient to prevent enophthalmos, as many such fractures heal spontaneously.
*The patient’s condition warrants emergency surgery.*
- **Emergency surgery** is reserved for severe cases, such as vision-threatening injuries (e.g., orbital compartment syndrome), globe rupture, or severe entrapment with oculocardiac reflex.
- This patient's vital signs are stable, visual acuity is relatively preserved, and the fracture is small and nondisplaced, indicating that emergency surgery is not required.
*There is a low chance of spontaneous improvement of the ocular motility.*
- For small, nondisplaced orbital floor fractures, **spontaneous improvement** of ocular motility and diplopia is common.
- The patient's minimal and gaze-dependent diplopia suggests that the issue might be related to local edema or soft tissue contusion, which often resolves with conservative management, rather than severe muscle entrapment.
Question 134: A 28-year-old woman is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which she was the unrestrained driver. On arrival, she is semiconscious and incoherent. She has shortness of breath and is cyanotic. Her pulse is 112/min, respirations are 59/min, and blood pressure is 128/89 mm Hg. Examination shows a 3-cm (1.2-in) laceration on the forehead and multiple abrasions over the thorax and abdomen. There is crepitation on palpation of the thorax on the right. Auscultation of the lung shows decreased breath sounds on the right side. A crunching sound synchronous with the heartbeat is heard best over the precordium. There is dullness on percussion of the right hemithorax. The lips and tongue have a bluish discoloration. There is an open femur fracture on the left. The remainder of the examination shows no abnormalities. Arterial blood gas analysis on room air shows:
pH 7.31
PCO2 55 mm Hg
PO2 42 mm Hg
HCO3- 22 mEq/L
O2 saturation 76%
The patient is intubated and mechanically ventilated. Infusion of 0.9% saline is begun. Which of the following is the most likely diagnosis?
A. Pulmonary embolism
B. Flail chest
C. Tension pneumothorax
D. Bronchial rupture (Correct Answer)
E. Hemopneumothorax
Explanation: ***Bronchial rupture***
- The presence of a **mediastinal crunching sound (Hamman's sign)** synchronous with the heartbeat, along with **subcutaneous emphysema (crepitation)** and a significant mechanism of injury (high-speed MVA), points strongly towards a bronchial injury.
- **Decreased breath sounds** and **dullness to percussion** on the right side, combined with severe hypoxemia and hypercapnia, suggest a major airway disruption leading to air trapping and potential collapse of the lung.
*Pulmonary embolism*
- While pulmonary embolism can cause **dyspnea** and **hypoxemia**, it typically presents with clear lung auscultation and does not cause **crepitation** or a **mediastinal crunching sound**.
- The mechanism of injury and immediate onset of symptoms are more consistent with a traumatic injury rather than an embolic event.
*Flail chest*
- **Flail chest** involves paradoxical movement of a segment of the chest wall due to multiple rib fractures, which would lead to respiratory distress and crepitation.
- However, flail chest does not typically cause a **mediastinal crunching sound** or the severe degree of hypoxemia and hypercapnia seen with a major airway injury without other concomitant severe lung injury.
*Tension pneumothorax*
- A **tension pneumothorax** would cause severe respiratory distress, diminished breath sounds, and tracheal deviation (which is not described).
- While it can cause crepitation (subcutaneous emphysema) and hypoxemia, it usually presents with **hyperresonance** to percussion, not dullness, and does not produce a **mediastinal crunching sound** as prominently.
*Hemopneumothorax*
- A **hemopneumothorax** would explain **decreased breath sounds** and **dullness to percussion** due to the presence of blood and air in the pleural space.
- However, it would not typically cause a **mediastinal crunching sound** (Hamman's sign), which is highly specific for pneumomediastinum, often secondary to tracheobronchial injury.
Question 135: A 27-year-old soldier stationed in Libya sustains a shrapnel injury during an attack, causing a traumatic above-elbow amputation. The resulting arterial bleed is managed with a tourniquet prior to transport to the military treatment facility. On arrival, he is alert and oriented to person, place, and time. His armor and clothing are removed. His pulse is 145/min, respirations are 28/min, and blood pressure is 95/52 mm Hg. Pulmonary examination shows symmetric chest rise. The lungs are clear to auscultation. Abdominal examination shows no abnormalities. There are multiple shrapnel wounds over the upper and lower extremities. A tourniquet is in place around the right upper extremity; the right proximal forearm has been amputated. One large-bore intravenous catheter is placed in the left antecubital fossa. Despite multiple attempts, medical staff is unable to establish additional intravenous access. Which of the following is the most appropriate next step in management?
A. Irrigate the shrapnel wounds
B. Perform endotracheal intubation
C. Establish intraosseous access (Correct Answer)
D. Establish central venous access
E. Replace the tourniquet with a pressure dressing
Explanation: ***Establish intraosseous access***
- The patient is in **hemorrhagic shock** (tachycardia, hypotension) and requires rapid fluid resuscitation, but peripheral intravenous access is difficult to obtain. **Intraosseous (IO) access** provides a rapid and reliable route for fluids and medications, especially in emergencies when IV access is challenging.
- IO access is a **bridge to definitive venous access** and is crucial for immediate life-saving interventions in trauma.
*Irrigate the shrapnel wounds*
- While wound irrigation is important for preventing infection, it is **not the immediate priority** when the patient is in hemorrhagic shock.
- Addressing the circulatory compromise takes precedence over local wound care.
*Perform endotracheal intubation*
- The patient is **alert and oriented** with symmetric chest rise and clear lungs, indicating he does not currently have an airway crisis requiring intubation.
- Intubation is an invasive procedure that carries risks and should only be performed when indicated for airway protection or respiratory failure.
*Establish central venous access*
- While central venous access is useful for long-term fluid management and monitoring, it is generally **more time-consuming and technically challenging** to establish than IO access, especially in an emergent, unstable patient.
- Given the urgency of rapid fluid administration, IO access is preferred as the immediate next step.
*Replace the tourniquet with a pressure dressing*
- The patient has an above-elbow amputation, suggesting significant injury, and the tourniquet is currently controlling the bleed. Removing the tourniquet prematurely without proximal surgical control can lead to **recurrent catastrophic hemorrhage**.
- A definitive surgical approach is needed to manage the amputation, not simply replacing the tourniquet with a pressure dressing, which may be insufficient to control arterial bleeding.
Question 136: 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 137: A 72-year-old man comes to the physician for a 5-month history of hoarseness, exertional dyspnea, and fatigue. He does not smoke or drink alcohol. His pulse is 98/min and irregular. His voice is coarse in quality. Physical examination shows a liver span of 16 cm and a soft diastolic murmur heard best at the apex. Which of the following is the most likely cause of this patient's hoarseness?
A. Carcinoma arising from the mucosa of the larynx
B. Laryngeal inflammation due to chemical irritant
C. Circulating acetylcholine receptor antibodies
D. Extrinsic impingement of the recurrent laryngeal nerve (Correct Answer)
E. Bacterial infection of the vocal folds
Explanation: ***Extrinsic impingement of the recurrent laryngeal nerve***
- The combination of **hoarseness**, **irregular pulse**, **exertional dyspnea**, a **soft diastolic murmur**, and **hepatomegaly** in an older patient strongly suggests heart failure with left atrial enlargement, which can compress the **left recurrent laryngeal nerve** (Ortner's syndrome).
- The recurrent laryngeal nerve controls the intrinsic muscles of the larynx, and its compression leads to **vocal cord paralysis** and hoarseness.
*Carcinoma arising from the mucosa of the larynx*
- While laryngeal carcinoma can cause hoarseness, the additional symptoms of **exertional dyspnea**, **irregular pulse**, **diastolic murmur**, and **hepatomegaly** are not typically associated with primary laryngeal cancer.
- The patient's lack of smoking and alcohol history makes laryngeal carcinoma less likely, although not impossible.
*Laryngeal inflammation due to chemical irritant*
- This would typically present with hoarseness and possibly cough, but it would not explain the systemic findings of **irregular pulse**, **dyspnea**, **diastolic murmur**, or **hepatomegaly**.
- Without exposure to irritants, this cause is less probable.
*Circulating acetylcholine receptor antibodies*
- This condition is **myasthenia gravis**, which can cause generalized weakness, including weakness of laryngeal muscles leading to hoarseness and dyspnea.
- However, the other findings like an **irregular pulse**, **diastolic murmur**, and **hepatomegaly** are not characteristic features of myasthenia gravis, making it less likely.
*Bacterial infection of the vocal folds*
- A bacterial infection (laryngitis) would typically present with acute onset hoarseness, sore throat, and possibly fever.
- It would not account for the chronic nature of the symptoms (5 months) or the associated cardiac and hepatic findings.
Question 138: A 33-year-old man presents to his primary care physician with shoulder pain. He states that he can't remember a specific instance when the injury occurred. He is a weight lifter and competes in martial arts. The patient has no past medical history and is currently taking a multivitamin. Physical exam demonstrates pain with abduction of the patient's right shoulder and with external rotation of the right arm. There is subacromial tenderness with palpation. His left arm demonstrates 10/10 strength with abduction as compared to 4/10 strength with abduction of the right arm. Which of the following best confirms the underlying diagnosis?
A. Ultrasound
B. Radiography
C. MRI (Correct Answer)
D. CT
E. Physical exam and history
Explanation: ***MRI***
- An **MRI is the gold standard** for diagnosing soft tissue injuries of the shoulder, including **rotator cuff pathology**, which is highly suspected given the patient's symptoms (pain with abduction and external rotation, subacromial tenderness, and weakness).
- It provides detailed imaging of tendons, ligaments, and cartilage, allowing for precise identification of **tears, inflammation, or impingement**.
*Ultrasound*
- While ultrasound can assess **rotator cuff integrity** and identify fluid collections, it is highly operator-dependent and may not provide the same level of detail as MRI for complex tears or associated pathologies.
- It can be a good initial screening tool but might **underestimate the extent** of an injury compared to MRI.
*Radiography*
- **Radiography (X-rays)** primarily visualizes bone structures and would be useful for detecting fractures, dislocations, or significant degenerative joint disease.
- It would **not directly visualize** the soft tissue injuries of the rotator cuff or other tendons that are likely causing this patient's symptoms.
*CT*
- **CT scans** provide excellent detail of bone structures and can identify subtle fractures, erosions, or bony impingement.
- However, like X-rays, they are **less effective for visualizing soft tissues** like tendons and ligaments compared to MRI.
*Physical exam and history*
- The **physical exam and history** are crucial for narrowing down the differential diagnosis and guiding further imaging.
- While strongly suggestive of a rotator cuff injury, they alone **cannot definitively confirm the extent or nature** of the underlying soft tissue pathology.
Question 139: A 17-year-old boy is brought to the emergency department by his parents 6 hours after he suddenly began to experience dyspnea and pleuritic chest pain at home. He has a remote history of asthma in childhood but has not required any treatment since the age of four. His temperature is 98.4°F (36.9°C), blood pressure is 100/76 mmHg, pulse is 125/min, respirations are 24/min. On exam, he has decreased lung sounds and hyperresonance in the left upper lung field. A chest radiograph shows a slight tracheal shift to the right. What is the best next step in management?
A. Needle decompression
B. CT scan for apical blebs
C. Observe for another six hours for resolution
D. Chest tube placement (Correct Answer)
E. Pleurodesis
Explanation: ***Chest tube placement***
- The patient's presentation with **sudden dyspnea**, **pleuritic chest pain**, **decreased lung sounds**, **hyperresonance**, **tachycardia**, and **tracheal shift** indicates a **tension pneumothorax**, which requires immediate **chest tube insertion** for definitive management.
- While the tracheal shift might suggest tension pneumothorax, the patient's relative **hemodynamic stability** (BP 100/76, pulse 125/min) and the fact that he was stable for 6 hours implies it's a large **primary spontaneous pneumothorax** rather than an emergent tension pneumothorax. A chest tube is the appropriate next step for symptomatic patients with a large pneumothorax.
*Needle decompression*
- This procedure is reserved for true **tension pneumothorax** where there is imminent **hemodynamic compromise** (e.g., hypotension, severe tachycardia, hypoxemia) due to severe intrathoracic pressure buildup.
- The patient's blood pressure is stable, indicating that while there is a significant pneumothorax, it's not immediately life-threatening enough to warrant needle decompression before chest tube placement.
*CT scan for apical blebs*
- A **CT scan** might be useful for identifying the cause of the pneumothorax, such as **apical blebs**, but it's not an immediate management step for an acute, symptomatic pneumothorax.
- Prioritizing definitive treatment to reinflate the lung and relieve symptoms is crucial before investigating the underlying cause.
*Observe for another six hours for resolution*
- Observation is only appropriate for **small, asymptomatic pneumothoraces**.
- This patient is symptomatic with significant findings (dyspnea, chest pain, decreased lung sounds, hyperresonance, slight tracheal shift), making observation an unsafe option.
*Pleurodesis*
- **Pleurodesis** is a procedure used to prevent recurrent pneumothoraces and is typically performed after the acute event has been resolved, or for patients with **recurrent pneumothoraces**.
- It is not an acute management step for a new, symptomatic pneumothorax.
Question 140: A 27-year-old soldier is brought to the emergency department of a military hospital 20 minutes after being involved in a motor vehicle accident during a training exercise. He was an unrestrained passenger. On arrival, he has shortness of breath and chest pain. He appears pale and anxious. His temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 100/65 mm Hg. He is alert and oriented to person, place, and time. Examination shows pale conjunctivae and mucous membranes. There is bruising on the chest, extremities, and abdomen. The lungs are clear to auscultation. He has normal heart sounds and flat neck veins. The abdomen is flat, soft, and mildly tender. The remainder of the physical examination shows no abnormalities. High-flow oxygen is applied, and intravenous fluid resuscitation is begun. A chest x-ray is obtained. Which of the following is the most appropriate next step in management?
A. Placement of a chest tube
B. Pericardiocentesis
C. Abdominal ultrasonography
D. Intubation with positive pressure ventilation
E. CT scan of the chest with contrast (Correct Answer)
Explanation: ***CT scan of the chest with contrast***
- The patient has suffered a **blunt chest trauma** with symptoms including shortness of breath, chest pain, and signs of potential internal bleeding (pale, anxious, tachycardia, mild hypotension).
- A chest X-ray was performed; however, a **CT scan with contrast** is essential to further evaluate for **aortic injury**, **pulmonary contusions**, or other subtle thoracic injuries that may not be evident on plain radiographs, especially given the mechanism of injury (unrestrained passenger in a MVA).
*Placement of a chest tube*
- This intervention is indicated for conditions like **pneumothorax** or **hemothorax**, which would typically present with **diminished breath sounds** on the affected side or characteristic X-ray findings.
- The patient's lungs are described as **clear to auscultation**, and no specific X-ray findings are mentioned that would necessitate immediate chest tube placement.
*Pericardiocentesis*
- This procedure is performed for **cardiac tamponade**, which would manifest with muffled heart sounds, jugular venous distention, and pulsus paradoxus.
- The patient has **normal heart sounds** and **flat neck veins**, making cardiac tamponade less likely.
*Abdominal ultrasonography*
- While the patient has bruising and mild tenderness in the abdomen, suggesting potential **abdominal injury**, the primary life-threatening concerns based on his presentation (shortness of breath, chest pain, chest X-ray ordered) are thoracic.
- A **Focused Assessment with Sonography for Trauma (FAST) exam** would be appropriate if the abdominal tenderness was more pronounced or if there were signs of active intra-abdominal bleeding, but the immediate priority is to rule out life-threatening thoracic injuries.
*Intubation with positive pressure ventilation*
- This is indicated for patients with **respiratory failure** or an inability to protect their airway. The patient's respiratory rate is 20/min (within normal limits), and he is **alert and oriented**.
- While high-flow oxygen and fluid resuscitation have been initiated, there is no indication of impending respiratory collapse that would necessitate immediate intubation.
