A 45-year-old man presents to the emergency department because of fever and scrotal pain for 2 days. Medical history includes diabetes mellitus and morbid obesity. His temperature is 40.0°C (104.0°F), the pulse is 130/min, the respirations are 35/min, and the blood pressure is 90/68 mm Hg. Physical examination shows a large area of ecchymosis, edema, and crepitus in his perineal area. Fournier gangrene is suspected. A right internal jugular central venous catheter is placed without complication under ultrasound guidance for vascular access in preparation for the administration of vasopressors. Which of the following is the most appropriate next step?
Q162
A 75-year-old man is brought to the emergency department because of a 5-hour history of worsening chest pain and dyspnea. Six days ago, he fell in the shower and since then has had mild pain in his left chest. He appears pale and anxious. His temperature is 36.5°C (97.7°F), pulse is 108/min, respirations are 30/min, and blood pressure is 115/58 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Examination shows decreased breath sounds and dullness to percussion over the left lung base. There is a 3-cm (1.2-in) hematoma over the left lower chest. An x-ray of the chest shows fractures of the left 8th and 9th rib, increased opacity of the left lung, and mild tracheal deviation to the right. Which of the following is the most appropriate next step in management?
Q163
A 43-year-old man is brought to the emergency department 25 minutes after being involved in a high-speed motor vehicle collision in which he was a restrained passenger. On arrival, he has shortness of breath and is in severe pain. His pulse is 130/min, respirations are 35/min, and blood pressure is 90/40 mm Hg. Examination shows superficial abrasions and diffuse crepitus at the left shoulder level. Cardiac examination shows tachycardia with no murmurs, rubs, or gallops. The upper part of the left chest wall moves inward during inspiration. Breath sounds are absent on the left. He is intubated and mechanically ventilated. Two large bore intravenous catheters are placed and infusion of 0.9% saline is begun. Which of the following is the most likely cause of his symptoms?
Q164
A 32-year-old woman is brought to the emergency department for the evaluation of burn injuries that she sustained after stumbling into a bonfire 1 hour ago. The patient has severe pain in her left leg and torso, and minimal pain in her right arm. She does not smoke cigarettes. She takes no medications. She is tearful and in moderate distress. Her temperature is 37.2°C (99.0°F), pulse is 88/min, respirations are 19/min, and blood pressure is 118/65 mm Hg. Her pulse oximetry is 98% on room air. Cardiopulmonary examination shows no abnormalities. There are two tender, blanchable erythemas without blisters over a 5 x 6 -cm area of the left abdomen and a 3 x 2-cm area of the left anterior thigh. There is also an area of white, leathery skin and tissue necrosis encircling the right upper extremity just proximal to the elbow, which is dry and nontender. An ECG shows normal sinus rhythm with no ST or T wave changes. She is started on intravenous fluids. Which of the following is the most appropriate next step in management?
Q165
A 17-year-old boy is brought to the emergency department by his brother after losing consciousness 1 hour ago. The brother reports that the patient was skateboarding outside when he fell on the ground and started to have generalized contractions. There was also some blood coming from his mouth. The contractions stopped after about 1 minute, but he remained unconscious for a few minutes afterward. He has never had a similar episode before. There is no personal or family history of serious illness. He does not smoke or drink alcohol. He does not use illicit drugs. He takes no medications. On arrival, he is confused and oriented only to person and place. He cannot recall what happened and reports diffuse muscle ache, headache, and fatigue. He appears pale. His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 130/80 mm Hg. There is a small wound on the left side of the tongue. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference ranges. Toxicology screening is negative. An ECG shows no abnormalities. Which of the following is the most appropriate next step in management?
Q166
A 25-year-old man comes to the physician because of right-sided painless scrotal swelling that he noticed yesterday while taking a shower. He is currently sexually active with two female partners and uses condoms inconsistently. He immigrated to the US from Argentina 2 years ago. His immunization records are unavailable. He has smoked one pack of cigarettes daily for the last 5 years. He is 170 cm (5 ft 7 in) tall and weighs 70 kg (154 lb); BMI is 24.2 kg/m2. He appears healthy and well nourished. His temperature is 37°C (98.6°F), pulse is 72/min, and blood pressure is 125/75 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft with dull lower abdominal discomfort. Testicular examination shows a solid mass in the right testis that is firm and nontender. A light held behind the scrotum does not shine through. The mass is not reduced when the patient is in a supine position. The remainder of the physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?
Q167
A 62-year-old man is brought to his primary care physician by his wife because she is concerned that he has become more confused over the past month. Specifically, he has been having difficulty finding words and recently started forgetting the names of their friends. She became particularly worried when he got lost in their neighborhood during a morning walk. Finally, he has had several episodes of incontinence and has tripped over objects because he "does not lift his feet off the ground" while walking. He has a history of hypertension and diabetes but has otherwise been healthy. His family history is significant for many family members with early onset dementia. Which of the following treatments would most likely be effective for this patient?
Q168
A 22-year-old male presents to the emergency department after a motor vehicle accident. The patient is conscious and communicating with hospital personnel. He is in pain and covered in bruises and scrapes. The patient was the driver in a head-on motor vehicle collision. The patient's temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 120/70 mmHg, respirations are 18/min, and oxygen saturation is 99% on room air. A full trauma assessment is being performed and is notable for 0/5 strength in the right upper extremity for extension of the wrist. The patient is started on IV fluids and morphine, and radiography is ordered. The patient has bilateral breath sounds, a normal S1 and S2, and no signs of JVD. His blood pressure 30 minutes later is 122/70 mmHg. Which of the following fractures is most likely in this patient?
Q169
A 24-year-old 70 kilogram African-American man with epilepsy refractory to valproic acid, phenytoin, and levetiracetam undergoes magnetic resonance imaging of his brain under monitored anesthetic care. He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg. He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn. Overnight, the nurse continues to increase the patient's midazolam infusion rate, but she also notices that his left toes are cold to touch with significant edema. His temperature is 100°F (37.8°C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula. No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity. A delta pressure of 25 mmHg is obtained in the left leg. What is the best next step in management?
Q170
A 58-year-old woman comes to the physician because of headaches for 1 month. She describes them as 7 out of 10 in intensity. She has no nausea. Two years ago, she was treated for invasive lobular carcinoma of the left breast. She underwent a left mastectomy and multiple cycles of chemotherapy. She has been in good health since this treatment. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 118/72 mm Hg. There is a well-healed scar on the left side of the chest. There is no lymphadenopathy. The abdomen is soft and nontender; there is no organomegaly. Neurologic examination shows no focal findings. An MRI of the brain shows a 4-cm temporal hyperintense mass near the surface of the brain. Which of the following is the most appropriate next step in management?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 161: A 45-year-old man presents to the emergency department because of fever and scrotal pain for 2 days. Medical history includes diabetes mellitus and morbid obesity. His temperature is 40.0°C (104.0°F), the pulse is 130/min, the respirations are 35/min, and the blood pressure is 90/68 mm Hg. Physical examination shows a large area of ecchymosis, edema, and crepitus in his perineal area. Fournier gangrene is suspected. A right internal jugular central venous catheter is placed without complication under ultrasound guidance for vascular access in preparation for the administration of vasopressors. Which of the following is the most appropriate next step?
A. Confirm line placement by ultrasound
B. Begin to use the line after documenting the return of dark, non-pulsatile blood from all ports
C. Begin infusion of normal saline through a central line
D. Obtain an immediate portable chest radiograph to evaluate line placement (Correct Answer)
E. Begin infusion of norepinephrine to maintain systolic blood pressure over 90 mm Hg
Explanation: **Obtain an immediate portable chest radiograph to evaluate line placement**
- The most appropriate next step after central venous catheter placement is to **confirm its correct position** and rule out complications like **pneumothorax** via imaging.
- A **chest radiograph** is the standard and immediate method to confirm proper placement of the tip in the lower superior vena cava and rule out pneumothorax, especially given the patient's critical condition.
*Confirm line placement by ultrasound*
- While ultrasound is used during placement to visualize the vessel and guide needle insertion, it is **not sufficient for confirming the final tip position** of the catheter or for ruling out pneumothorax.
- Ultrasound confirmation usually involves visualizing a **saline flush** in the right atrium, but a chest X-ray is still required for comprehensive evaluation.
*Begin to use the line after documenting the return of dark, non-pulsatile blood from all ports*
- Documenting blood return confirms that the catheter is in a vein but does not confirm **optimal tip placement** or exclude potential complications like **pneumothorax**.
- Using the line without radiological confirmation can lead to administering medications into incorrect locations (e.g., subclavian artery) or exacerbating unnoticed complications.
*Begin infusion of normal saline through a central line*
- Administering fluids before confirming proper line placement carries the risk of **extravasation** or infusing into an artery or other unintended space, which could worsen the patient's condition.
- Although IV fluids are needed in this septic patient, **confirmation of line placement** is a higher priority before commencing infusions.
*Begin infusion of norepinephrine to maintain systolic blood pressure over 90 mm Hg*
- While norepinephrine is crucial for managing septic shock and **hypotension** in this patient, starting it before confirming central line placement is dangerous.
- **Vasopressors require a secure central line** to prevent severe local tissue damage if extravasation occurs.
Question 162: A 75-year-old man is brought to the emergency department because of a 5-hour history of worsening chest pain and dyspnea. Six days ago, he fell in the shower and since then has had mild pain in his left chest. He appears pale and anxious. His temperature is 36.5°C (97.7°F), pulse is 108/min, respirations are 30/min, and blood pressure is 115/58 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Examination shows decreased breath sounds and dullness to percussion over the left lung base. There is a 3-cm (1.2-in) hematoma over the left lower chest. An x-ray of the chest shows fractures of the left 8th and 9th rib, increased opacity of the left lung, and mild tracheal deviation to the right. Which of the following is the most appropriate next step in management?
A. Pericardiocentesis
B. Emergency thoracotomy
C. Admission to the ICU and observation
D. Needle thoracentesis in the eighth intercostal space at the posterior axillary line
E. Chest tube insertion in the fifth intercostal space at the midaxillary line (Correct Answer)
Explanation: ***Chest tube insertion in the fifth intercostal space at the midaxillary line***
- The patient's symptoms (worsening chest pain, dyspnea, pallor, anxiety, tachycardia, tachypnea, hypotension, hypoxemia) and signs (decreased breath sounds, dullness to percussion, increased opacity on X-ray, rib fractures) are highly suggestive of a **hemothorax** secondary to trauma, which requires urgent drainage.
- Placement of a **large-bore chest tube** in the **fifth intercostal space at the midaxillary line** is the appropriate intervention for evacuating blood and air from the pleural space, allowing lung re-expansion and improving respiratory and hemodynamic status.
*Pericardiocentesis*
- This procedure is indicated for **cardiac tamponade**, which is characterized by jugular venous distension, muffled heart sounds, and pulsus paradoxus, none of which are classic findings here.
- The patient's symptoms are more consistent with a pleural space issue rather than pericardial compression.
*Emergency thoracotomy*
- This is an invasive surgical procedure typically reserved for patients with severe, life-threatening thoracic trauma, such as massive hemorrhage or penetrating cardiac injury, who are unresponsive to less invasive resuscitation efforts.
- While the patient is unstable, a chest tube is the initial, less invasive, and often sufficient intervention for hemothorax.
*Admission to the ICU and observation*
- The patient's **hemodynamic instability** (ongoing hypotension, tachycardia), **respiratory distress** (tachypnea, hypoxemia), and clear radiographic evidence of a significant pleural effusion/hemothorax (increased opacity, tracheal deviation) indicate an urgent need for intervention, not just observation.
- Delaying definitive treatment for a large hemothorax can lead to further decompensation and poor outcomes.
*Needle thoracentesis in the eighth intercostal space at the posterior axillary line*
- While needle thoracentesis can be used for pleural fluid sampling or temporary relief of tension pneumothorax, it is insufficient for draining a significant **hemothorax**, which involves large volumes of blood and often clots.
- A chest tube is required for adequate drainage in such cases. The eighth intercostal space is also lower than the typical placement for chest tube insertion in trauma for drainage of general fluid/air and might be less effective for complete drainage or carry a higher risk of abdominal organ injury if fluid levels are typical.
Question 163: A 43-year-old man is brought to the emergency department 25 minutes after being involved in a high-speed motor vehicle collision in which he was a restrained passenger. On arrival, he has shortness of breath and is in severe pain. His pulse is 130/min, respirations are 35/min, and blood pressure is 90/40 mm Hg. Examination shows superficial abrasions and diffuse crepitus at the left shoulder level. Cardiac examination shows tachycardia with no murmurs, rubs, or gallops. The upper part of the left chest wall moves inward during inspiration. Breath sounds are absent on the left. He is intubated and mechanically ventilated. Two large bore intravenous catheters are placed and infusion of 0.9% saline is begun. Which of the following is the most likely cause of his symptoms?
A. Cardiac tamponade
B. Flail chest (Correct Answer)
C. Diaphragmatic rupture
D. Phrenic nerve paralysis
E. Sternal fracture
Explanation: ***Flail chest***
- The inward movement of the **left chest wall during inspiration (paradoxical movement)** is a classic sign of **flail chest**, caused by fractures of three or more adjacent ribs in two or more places.
- This condition is often associated with significant pain, **shortness of breath**, and can compromise ventilation, leading to **tachycardia** and **hypotension** due to impaired gas exchange and hypovolemia from associated injuries.
*Cardiac tamponade*
- While it causes **tachycardia and hypotension**, it typically presents with muffled heart sounds, jugular venous distension, and pulsus paradoxus, which are not described.
- The primary respiratory findings would not be *absent breath sounds* or *paradoxical chest wall motion*.
*Diaphragmatic rupture*
- This typically presents with **abdominal contents in the chest**, leading to respiratory distress and potentially absent breath sounds on the affected side.
- However, it does not explain the **diffuse crepitus at the left shoulder level** or the **paradoxical chest wall movement**.
*Phrenic nerve paralysis*
- **Unilateral phrenic nerve paralysis** would lead to paralysis of the diaphragm on one side, causing **elevated hemidiaphragm** on chest X-ray and reduced lung expansion.
- It would not cause *diffuse crepitus*, *paradoxical chest wall movement*, or the acute, severe presentation described after trauma.
*Sternal fracture*
- A sternal fracture can cause severe chest pain and can be associated with cardiac contusion or other intrathoracic injuries.
- However, it does not directly explain **absent breath sounds** or **paradoxical chest wall movement** as the primary cause of respiratory distress, although it can coexist with flail chest.
Question 164: A 32-year-old woman is brought to the emergency department for the evaluation of burn injuries that she sustained after stumbling into a bonfire 1 hour ago. The patient has severe pain in her left leg and torso, and minimal pain in her right arm. She does not smoke cigarettes. She takes no medications. She is tearful and in moderate distress. Her temperature is 37.2°C (99.0°F), pulse is 88/min, respirations are 19/min, and blood pressure is 118/65 mm Hg. Her pulse oximetry is 98% on room air. Cardiopulmonary examination shows no abnormalities. There are two tender, blanchable erythemas without blisters over a 5 x 6 -cm area of the left abdomen and a 3 x 2-cm area of the left anterior thigh. There is also an area of white, leathery skin and tissue necrosis encircling the right upper extremity just proximal to the elbow, which is dry and nontender. An ECG shows normal sinus rhythm with no ST or T wave changes. She is started on intravenous fluids. Which of the following is the most appropriate next step in management?
A. Monitoring of peripheral pulses and capillary filling (Correct Answer)
B. Soft-tissue ultrasound
C. X-ray of the chest
D. Intravenous ampicillin therapy
E. Serial arterial blood gas analysis
Explanation: ***Monitoring of peripheral pulses and capillary filling***
- The presence of a **dry, nontender, leathery, white burn** encircling the right upper extremity suggests a **full-thickness (third-degree) burn**.
- Circumferential full-thickness burns create an **inelastic eschar** that can act as a tourniquet, causing vascular compromise as underlying tissue edema develops.
- **Immediate monitoring** of peripheral pulses, capillary refill, and neurovascular status is essential to detect early signs of vascular compromise that would necessitate **escharotomy**.
- If vascular compromise is detected (diminished pulses, poor capillary refill, paresthesias), emergent escharotomy must be performed to release the constricting eschar.
*Soft-tissue ultrasound*
- While ultrasound can assess tissue depth, it is not the **initial priority** for evaluating potential vascular compromise in a circumferential burn.
- The immediate need is clinical assessment of perfusion through pulse checks and capillary refill, not imaging studies.
*X-ray of the chest*
- A chest X-ray would be indicated if there were concerns for **inhalational injury** or other thoracic trauma, such as abnormalities on cardiopulmonary examination or signs of respiratory distress.
- The patient's pulse oximetry is 98%, respirations are normal, and cardiopulmonary exam shows no abnormalities, making a chest X-ray not the most appropriate immediate next step.
*Intravenous ampicillin therapy*
- **Prophylactic antibiotic therapy** is not routinely administered for burn injuries due to concerns about promoting antibiotic resistance; it is reserved for confirmed infections.
- Management priorities in the immediate post-burn period focus on fluid resuscitation, pain control, wound care, and preventing vascular compromise from circumferential burns.
*Serial arterial blood gas analysis*
- **Arterial blood gas (ABG) analysis** is primarily used to assess for respiratory compromise, such as inhalational injury, carbon monoxide poisoning, or cyanide toxicity.
- The patient's normal pulse oximetry (98% on room air) and unlabored respirations suggest that ABG analysis is not an immediate priority.
Question 165: A 17-year-old boy is brought to the emergency department by his brother after losing consciousness 1 hour ago. The brother reports that the patient was skateboarding outside when he fell on the ground and started to have generalized contractions. There was also some blood coming from his mouth. The contractions stopped after about 1 minute, but he remained unconscious for a few minutes afterward. He has never had a similar episode before. There is no personal or family history of serious illness. He does not smoke or drink alcohol. He does not use illicit drugs. He takes no medications. On arrival, he is confused and oriented only to person and place. He cannot recall what happened and reports diffuse muscle ache, headache, and fatigue. He appears pale. His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 130/80 mm Hg. There is a small wound on the left side of the tongue. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference ranges. Toxicology screening is negative. An ECG shows no abnormalities. Which of the following is the most appropriate next step in management?
A. Electroencephalography
B. Lumbar puncture
C. Lorazepam therapy
D. Reassurance and follow-up
E. CT scan of the head (Correct Answer)
Explanation: ***CT scan of the head***
- Given the **first-time seizure** in an adolescent, especially with a history of head trauma (falling while skateboarding) and subsequent confusion, a **CT scan of the head** is crucial to rule out acute structural lesions like hemorrhage, mass, or edema.
- It is vital for identifying **life-threatening causes** of seizure that require immediate intervention, such as an **intracranial hematoma** or **mass lesion**, which could have been precipitated or exacerbated by the fall.
*Electroencephalography*
- **EEG** is appropriate for later evaluation to diagnose and classify seizure disorders, but it is not the *most appropriate initial step* in the emergency setting for a first-time seizure with a possible traumatic etiology.
- An EEG might be normal shortly after a seizure, and it does not rule out acute structural brain pathology that requires urgent management.
*Lumbar puncture*
- A **lumbar puncture** is indicated if there's suspicion of meningoencephalitis (e.g., fever, nuchal rigidity, immunocompromised status), which are not prominent features in this patient.
- The patient's vital signs are stable, and there are no signs of infection, making this a less urgent initial diagnostic step compared to imaging.
*Lorazepam therapy*
- **Lorazepam** is a benzodiazepine used to terminate ongoing seizures (**status epilepticus**), but this patient's generalized contractions have already stopped.
- Administering lorazepam when the seizure has resolved is unnecessary and would only cause further sedation.
*Reassurance and follow-up*
- While reassurance is part of patient care, it is *insufficient* as the sole next step for a **first-time seizure** episode in an adolescent, especially with features suggesting a possible underlying acute cause.
- A thorough diagnostic workup, beginning with neuroimaging, is necessary to ensure there is no serious underlying pathology before considering discharge and follow-up.
Question 166: A 25-year-old man comes to the physician because of right-sided painless scrotal swelling that he noticed yesterday while taking a shower. He is currently sexually active with two female partners and uses condoms inconsistently. He immigrated to the US from Argentina 2 years ago. His immunization records are unavailable. He has smoked one pack of cigarettes daily for the last 5 years. He is 170 cm (5 ft 7 in) tall and weighs 70 kg (154 lb); BMI is 24.2 kg/m2. He appears healthy and well nourished. His temperature is 37°C (98.6°F), pulse is 72/min, and blood pressure is 125/75 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft with dull lower abdominal discomfort. Testicular examination shows a solid mass in the right testis that is firm and nontender. A light held behind the scrotum does not shine through. The mass is not reduced when the patient is in a supine position. The remainder of the physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?
A. Testicular tumor (Correct Answer)
B. Testicular torsion
C. Scrotal hernia
D. Hydrocele testis
E. Orchitis
Explanation: ***Testicular tumor***
- A **painless, firm, and nontender solid mass** in the testis that does not transilluminate and is not reducible is highly suspicious for a testicular tumor.
- The patient's age (25 years old) is within the typical demographic for **testicular cancer**, and the recent discovery further supports this diagnosis.
*Testicular torsion*
- Characterized by **sudden onset of severe pain**, scrotal swelling, and tenderness, often associated with nausea and vomiting.
- The patient in this case presents with a **painless** mass, which makes testicular torsion unlikely.
*Scrotal hernia*
- A hernia typically presents as a **reducible mass** that may increase in size with maneuvers like coughing, and it often transilluminates.
- The mass described here is **not reducible** and does not transilluminate, ruling out a simple scrotal hernia.
*Hydrocele testis*
- A hydrocele is a collection of fluid in the tunica vaginalis, which typically presents as a **painless, soft, and transilluminating** scrotal swelling.
- The mass in this patient is described as **solid** and does not transilluminate, making hydrocele unlikely.
*Orchitis*
- Orchitis is an **inflammation of the testis**, which usually presents with pain, tenderness, swelling, and sometimes fever.
- The patient's mass is explicitly described as **painless** and nontender, which is inconsistent with orchitis.
Question 167: A 62-year-old man is brought to his primary care physician by his wife because she is concerned that he has become more confused over the past month. Specifically, he has been having difficulty finding words and recently started forgetting the names of their friends. She became particularly worried when he got lost in their neighborhood during a morning walk. Finally, he has had several episodes of incontinence and has tripped over objects because he "does not lift his feet off the ground" while walking. He has a history of hypertension and diabetes but has otherwise been healthy. His family history is significant for many family members with early onset dementia. Which of the following treatments would most likely be effective for this patient?
A. Galantamine
B. Tetrabenazine
C. Better control of diabetes and hypertension
D. Selegiline
E. Placement of shunt (Correct Answer)
Explanation: ***Placement of shunt***
- This patient presents with the classic triad of **normal pressure hydrocephalus (NPH)**: **dementia**, **gait disturbance** ("does not lift his feet off the ground," tripping), and **urinary incontinence**.
- **Ventricular shunting** is the primary and most effective treatment for NPH, as it diverts excess cerebrospinal fluid (CSF) and can lead to significant improvement in symptoms.
*Galantamine*
- **Galantamine** is an **acetylcholinesterase inhibitor** used in the treatment of **Alzheimer's disease** and other dementias to improve cognitive function, but it would not address the underlying pathology of NPH or the gait and incontinence symptoms.
- While dementia is present, the specific combination of symptoms points away from typical Alzheimer's and towards NPH.
*Tetrabenazine*
- **Tetrabenazine** is a **dopamine depletor** used to treat **chorea** in **Huntington's disease** and **tardive dyskinesia**.
- It would not be effective for the dementia, gait, or incontinence associated with NPH.
*Better control of diabetes and hypertension*
- While **vascular risk factors** like hypertension and diabetes can contribute to **vascular dementia**, the specific triad of symptoms (dementia, gait disturbance, and incontinence) strongly suggests NPH.
- Controlling these conditions is important for overall health, but it is not the primary or most effective treatment for the NPH symptoms presented.
*Selegiline*
- **Selegiline** is an **MAO-B inhibitor** used in the treatment of **Parkinson's disease** to manage motor symptoms.
- It is not indicated for the symptoms of NPH and would not address the CSF dynamics involved.
Question 168: A 22-year-old male presents to the emergency department after a motor vehicle accident. The patient is conscious and communicating with hospital personnel. He is in pain and covered in bruises and scrapes. The patient was the driver in a head-on motor vehicle collision. The patient's temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 120/70 mmHg, respirations are 18/min, and oxygen saturation is 99% on room air. A full trauma assessment is being performed and is notable for 0/5 strength in the right upper extremity for extension of the wrist. The patient is started on IV fluids and morphine, and radiography is ordered. The patient has bilateral breath sounds, a normal S1 and S2, and no signs of JVD. His blood pressure 30 minutes later is 122/70 mmHg. Which of the following fractures is most likely in this patient?
A. Humeral neck
B. Midshaft humerus (Correct Answer)
C. Supracondylar
D. Radial head
E. Ulnar
Explanation: ***Midshaft humerus***
- A **midshaft humerus fracture** is classically associated with **radial nerve injury**, which manifests as **wrist drop** (inability to extend the wrist). The mechanism of injury (high-impact trauma) also supports this.
- The radial nerve courses along the spiral groove of the humerus, making it vulnerable to direct injury or entrapment during a midshaft fracture.
*Humeral neck*
- Fractures of the **humeral neck** are more commonly associated with **axillary nerve injury**, leading to deltoid weakness and sensory deficits over the lateral shoulder, not wrist drop.
- This type of fracture is also more common in elderly individuals due to falls.
*Supracondylar*
- **Supracondylar fractures** of the humerus, particularly in children, are associated with injury to the **median nerve** or **brachial artery**, potentially leading to Volkmann's ischemic contracture.
- While they can cause neurological deficits, isolated **wrist drop** as described is not the typical presentation.
*Radial head*
- **Radial head fractures** primarily affect the **elbow joint** and typically present with pain, swelling, and limited pronation/supination.
- They are not typically associated with **wrist drop** because the pattern of nerve injury would more commonly involve the posterior interosseous nerve (causing finger extensor weakness) rather than the radial nerve proper.
*Ulnar*
- **Ulnar fractures** (e.g., in the forearm) can be isolated or part of more complex injuries like a Monteggia fracture.
- These fractures are typically associated with injury to the **ulnar nerve**, leading to sensory deficits in the medial hand and weakness of intrinsic hand muscles, not wrist drop.
Question 169: A 24-year-old 70 kilogram African-American man with epilepsy refractory to valproic acid, phenytoin, and levetiracetam undergoes magnetic resonance imaging of his brain under monitored anesthetic care. He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg. He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn. Overnight, the nurse continues to increase the patient's midazolam infusion rate, but she also notices that his left toes are cold to touch with significant edema. His temperature is 100°F (37.8°C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula. No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity. A delta pressure of 25 mmHg is obtained in the left leg. What is the best next step in management?
A. Intravenous fluid infusion based on Parkland formula
B. Transfer to burn center
C. Fasciotomy
D. Amputation
E. Escharotomy (Correct Answer)
Explanation: ***Escharotomy***
- The patient's symptoms (cold toes, edema, absent pulses in the left lower extremity) and a **delta pressure of 25 mmHg** (compartment pressure of 50 mmHg assuming diastolic pressure of 75 mmHg) are highly indicative of **compartment syndrome** due to a circumferential burn.
- **Escharotomy** is an emergent surgical procedure to relieve pressure caused by a constricting eschar, restoring blood flow and preventing permanent tissue damage.
*Intravenous fluid infusion based on Parkland formula*
- While fluid resuscitation is essential for burn patients, the immediate priority in this case is to address the limb-threatening **compartment syndrome**, not just overall fluid balance.
- Applying the Parkland formula would be part of general burn care but does not directly resolve the acute vascular compromise.
*Transfer to burn center*
- Transfer to a burn center is appropriate for specialized burn care, but the **acute limb ischemia** requires immediate intervention that cannot wait for transfer.
- Delaying treatment for transfer would significantly increase the risk of permanent damage or limb loss.
*Fasciotomy*
- **Fasciotomy** is performed to relieve compartment syndrome caused by internal swelling of the muscles, typically in trauma cases.
- In this burn injury, the compression is primarily due to the constricting **eschar**, which is initially treated with an escharotomy.
*Amputation*
- Amputation is a measure of last resort for irreversible tissue necrosis or overwhelming infection, which has not yet occurred and is preventable with timely escharotomy.
- Performing an amputation at this stage would be premature and an inappropriate first step given the potential for limb salvage.
Question 170: A 58-year-old woman comes to the physician because of headaches for 1 month. She describes them as 7 out of 10 in intensity. She has no nausea. Two years ago, she was treated for invasive lobular carcinoma of the left breast. She underwent a left mastectomy and multiple cycles of chemotherapy. She has been in good health since this treatment. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 118/72 mm Hg. There is a well-healed scar on the left side of the chest. There is no lymphadenopathy. The abdomen is soft and nontender; there is no organomegaly. Neurologic examination shows no focal findings. An MRI of the brain shows a 4-cm temporal hyperintense mass near the surface of the brain. Which of the following is the most appropriate next step in management?
A. Surgical resection (Correct Answer)
B. Whole brain radiation therapy
C. Chemotherapy
D. Palliative care
E. Antibiotic therapy
Explanation: ***Surgical resection***
- Given the patient's history of **breast carcinoma** and the presence of a **solitary, accessible brain lesion** on MRI (4-cm temporal hyperintense mass near the surface), surgical resection is the most appropriate initial management.
- **Surgical removal** offers both a **definitive diagnosis** (biopsy) and **symptomatic relief** by reducing mass effect, and can potentially improve survival in carefully selected patients with solitary resectable metastases.
*Whole brain radiation therapy*
- **Whole brain radiation therapy (WBRT)** is typically reserved for patients with **multiple brain metastases**, large lesions that are not surgically resectable, or as an adjuvant treatment after surgical resection or stereotactic radiosurgery.
- It carries risks of cognitive decline and other side effects, making it a less preferred first-line treatment for a single, resectable lesion.
*Chemotherapy*
- **Chemotherapy** for brain metastases from breast cancer often has limited efficacy due to the **blood-brain barrier**, and is generally not the initial treatment of choice for a solitary, symptomatic lesion.
- Systemic chemotherapy might be considered if there's widespread systemic disease or as part of a multimodal approach after local control of the brain lesion.
*Palliative care*
- While supportive **palliative care** is an important aspect of managing advanced cancer, recommending it as the *next step in management* for a surgically resectable brain metastasis that is likely causing her symptoms is premature.
- The patient has a potential to benefit from active treatment to improve quality of life and potentially extend survival.
*Antibiotic therapy*
- The patient's presentation with a history of cancer and a temporal mass is highly suggestive of a **brain metastasis**, not an infection.
- There are no signs of infection (e.g., fever, meningeal signs, increased inflammatory markers) that would warrant **antibiotic therapy**.
