A 23-year-old woman comes to the office because of a 2-day history of right knee pain. She says, "I can't run anymore because my knee hurts." The pain is localized "somewhere under the kneecap" and is achy, rated 5/10, but increases to 8/10 with prolonged sitting. She reports an occasional "popping" sound and sensation when she rises from a seated position. She has no history of trauma to the knee. She had a right clavicular fracture 2 years ago that was treated with a shoulder sling. She takes a daily multivitamin and has no known drug allergies. She does not smoke and drinks up to three glasses of wine weekly.
Vital signs: Temperature 37°C (98.6°F), pulse 65/min, respirations 15/min, blood pressure 108/62 mm Hg. Height 173 cm (5 ft 8 in), weight 54 kg (119 lb), BMI 18 kg/m².
Physical examination shows no acute distress. Pulmonary examination shows lungs clear to auscultation. Cardiac examination shows regular rate and rhythm with normal S1 and S2; no murmurs, rubs, or gallops. The abdomen is thin with no tenderness, guarding, masses, bruits, or hepatosplenomegaly. Extremities show no joint erythema, edema, or warmth; dorsalis pedis, radial, and femoral pulses are intact. Musculoskeletal examination shows diffuse tenderness to palpation over the right anterior knee, worse with full extension of the knee; no associated effusion or erythema; full, symmetric strength of quadriceps, hip abductors, and hip external rotators; crepitus with knee range of motion; and antalgic gait. Neurologic examination shows the patient is alert and oriented with cranial nerves grossly intact and no focal neurologic deficits.
Which of the following is the most appropriate next step in management?
Q192
A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?
Q193
A 22-year-old woman in the intensive care unit has had persistent oozing from the margins of wounds for 2 hours that is not controlled by pressure bandages. She was admitted to the hospital 13 hours ago following a high-speed motor vehicle collision. Initial focused assessment with sonography for trauma was negative. An x-ray survey showed opacification of the right lung field and fractures of multiple ribs, the tibia, fibula, calcaneus, right acetabulum, and bilateral pubic rami. Laboratory studies showed a hemoglobin concentration of 14.8 g/dL, leukocyte count of 10,300/mm3, platelet count of 175,000/mm3, and blood glucose concentration of 77 mg/dL. Infusion of 0.9% saline was begun. Multiple lacerations on the forehead and extremities were sutured, and fractures were stabilized. Repeat laboratory studies now show a hemoglobin concentration of 12.4 g/dL, platelet count of 102,000/mm3, prothrombin time of 26 seconds (INR=1.8), and activated partial thromboplastin time of 63 seconds. Which of the following is the next best step in management?
Q194
A 27-year-old male arrives in the emergency department with a stab wound over the precordial chest wall. The patient is in distress and is cold, sweaty, and pale. Initial physical examination is significant for muffled heart sounds, distended neck veins, and a 3 cm stab wound near the left sternal border. Breath sounds are present bilaterally without evidence of tracheal deviation. Which of the following additional findings would be expected on further evaluation?
Q195
A 34-year-old woman presents to the emergency department with moderate right wrist pain after falling on her outstretched hand. She has numbness in the lateral 3 digits. The patient has no known previous medical conditions. Her family history is not pertinent, and she currently takes no medications. Physical examination shows her blood pressure is 134/82 mm Hg, the respirations are 14/min, the pulse is 87/min, and the temperature is 36.7°C (98.0°F). When asked to make a fist, the patient is unable to flex the lateral 2 digits. Tapping the anterior portion of her wrist elicits tingling in the lateral 3 digits. The patient is taken to get an X-ray. Which of the following is the most likely diagnosis for this patient's injury?
Q196
A 66-year-old female with hypertension and a recent history of acute ST-elevation myocardial infarction (STEMI) 6 days previous, treated with percutaneous transluminal angioplasty (PTA), presents with sudden onset chest pain, shortness of breath, diaphoresis, and syncope. Vitals are temperature 37°C (98.6°F), blood pressure 80/50 mm Hg, pulse 125/min, respirations 12/min, and oxygen saturation 92% on room air. On physical examination, the patient is pale and unresponsive. Cardiac exam reveals tachycardia and a pronounced holosystolic murmur loudest at the apex and radiates to the back. Lungs are clear to auscultation. Chest X-ray shows cardiomegaly with clear lung fields. ECG is significant for ST elevations in the precordial leads (V2-V4) and low-voltage QRS complexes. Emergency transthoracic echocardiography shows a left ventricular wall motion abnormality along with a significant pericardial effusion. The patient is intubated, and aggressive fluid resuscitation is initiated. What is the next best step in management?
Q197
An 87-year-old woman is brought to the emergency department 30 minutes after a fall onto a hardwood floor. She landed on her left side and hit the left side of her head. She did not lose consciousness. She has a mild headache over the left temple and severe left hip pain. She has had nasal congestion, a sore throat, and a productive cough for the last 2 days. She has a history of atrial fibrillation, coronary artery disease, hypertension, and osteoporosis. She underwent two coronary artery bypass grafts 5 years ago. She had smoked one pack of cigarettes daily for 30 years but quit 30 years ago. Her current medications include aspirin, apixaban, diltiazem, omeprazole, and vitamin D supplementation. The patient is oriented to person, place, and time. There is a 2-cm ecchymosis over the left temple. Examination of the left hip shows swelling and tenderness; range of motion is limited. Intravenous morphine 2 mg is started. During further examination, the patient complains of dizziness and palpitations. She is diaphoretic and pale. Her skin is cold and clammy. Her pulse is 110/min and faint, respirations are 20/min, and blood pressure is 70/30 mm Hg. Cranial nerves are intact. Cardiac examinations shows no murmurs, rubs, or gallops. An ECG shows absent P waves and nonspecific changes of the ST segment and the T wave. Which of the following is the most likely underlying mechanism for the patient's sudden decline in her condition?
Q198
A 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms?
Q199
A 33-year-old man is brought to the emergency department after being involved in a bar fight. Physical examination shows tenderness to palpation over the left side of the back. An x-ray of the chest shows a fracture of the 12th rib on the left side. Further evaluation is most likely to show which of the following injuries?
Q200
A 47-year-old man is brought to the emergency department 1 hour after injuring his genital area when he fell astride his backyard fence. He was trimming a tree from the fence when he lost his balance. His vital signs are within normal limits. Examination shows blood at the urethral meatus, perineal ecchymoses, and a scrotal hematoma. An x-ray of the pelvis shows swelling of the soft tissue but no other abnormalities. Which part of the urinary tract is most likely damaged in this patient?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 191: A 23-year-old woman comes to the office because of a 2-day history of right knee pain. She says, "I can't run anymore because my knee hurts." The pain is localized "somewhere under the kneecap" and is achy, rated 5/10, but increases to 8/10 with prolonged sitting. She reports an occasional "popping" sound and sensation when she rises from a seated position. She has no history of trauma to the knee. She had a right clavicular fracture 2 years ago that was treated with a shoulder sling. She takes a daily multivitamin and has no known drug allergies. She does not smoke and drinks up to three glasses of wine weekly.
Vital signs: Temperature 37°C (98.6°F), pulse 65/min, respirations 15/min, blood pressure 108/62 mm Hg. Height 173 cm (5 ft 8 in), weight 54 kg (119 lb), BMI 18 kg/m².
Physical examination shows no acute distress. Pulmonary examination shows lungs clear to auscultation. Cardiac examination shows regular rate and rhythm with normal S1 and S2; no murmurs, rubs, or gallops. The abdomen is thin with no tenderness, guarding, masses, bruits, or hepatosplenomegaly. Extremities show no joint erythema, edema, or warmth; dorsalis pedis, radial, and femoral pulses are intact. Musculoskeletal examination shows diffuse tenderness to palpation over the right anterior knee, worse with full extension of the knee; no associated effusion or erythema; full, symmetric strength of quadriceps, hip abductors, and hip external rotators; crepitus with knee range of motion; and antalgic gait. Neurologic examination shows the patient is alert and oriented with cranial nerves grossly intact and no focal neurologic deficits.
Which of the following is the most appropriate next step in management?
A. Physical therapy (Correct Answer)
B. Pain control and rest
C. Synovial fluid analysis
D. Intraarticular steroid injection
E. Arthroscopy of the knee
Explanation: ***Physical therapy***
- This patient presents with symptoms highly suggestive of **patellofemoral pain syndrome (PFPS)**, including anterior knee pain, pain worse with prolonged sitting and activity, and crepitus. **Physical therapy** focusing on quadriceps strengthening, hip abductor strengthening, and core stability is the cornerstone of PFPS management.
- PFPS is often related to **biomechanical imbalances** and muscle weakness (e.g., weak vastus medialis obliquus or hip abductors), which can be effectively addressed through a structured physical therapy program.
*Pain control and rest*
- While **rest** can temporarily alleviate symptoms, it does not address the underlying biomechanical issues contributing to PFPS and can lead to **deconditioning**, potentially worsening the condition in the long term.
- **Pain control**, often with NSAIDs, can be used adjunctively, but it is not the primary or sole management strategy for PFPS as it also does not address the root cause.
*Synovial fluid analysis*
- **Synovial fluid analysis** is indicated for suspected inflammatory or infectious arthritis, which is not suggested by this patient's presentation of an atraumatic, "achy" pain without signs of inflammation (e.g., warmth, effusion, erythema).
- The patient's symptoms are more consistent with a **mechanical issue** rather than an intra-articular pathology requiring fluid analysis.
*Intraarticular steroid injection*
- **Intraarticular steroid injections** are generally not recommended for PFPS as the condition is typically not inflammatory within the joint space itself, but rather an issue of patellar tracking or soft tissue irritation.
- Steroid injections carry risks and provide only **temporary symptom relief** for inflammatory conditions, and their efficacy in PFPS is limited.
*Arthroscopy of the knee*
- **Arthroscopy** is an invasive surgical procedure and is typically reserved for cases where conservative management has failed, or when there is suspicion of a specific intra-articular lesion like a meniscal tear or loose body, which are not indicated here.
- This patient's symptoms are classic for PFPS, which is a **non-surgical condition** in the first line of management.
Question 192: A 16-year-old man presents to the emergency department with a 2-hour history of sudden-onset abdominal pain. He was playing football when his symptoms started. The patient’s past medical history is notable only for asthma. Social history is notable for unprotected sex with 4 women in the past month. His temperature is 99.3°F (37.4°C), blood pressure is 120/88 mmHg, pulse is 117/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is noted for a non-tender abdomen. Testicular exam reveals a right testicle which is elevated with a horizontal lie and the scrotum is neither swollen nor discolored. Which of the following is the most likely diagnosis?
A. Traumatic urethral injury
B. Seminoma
C. Appendicitis
D. Epididymitis
E. Testicular torsion (Correct Answer)
Explanation: ***Testicular torsion***
- The sudden onset of **unilateral scrotal pain** in an adolescent, accompanied by an **elevated testicle** with a **horizontal lie**, is highly suggestive of testicular torsion. The absence of scrotal swelling or discoloration in the early stages is also consistent.
- Testicular torsion is a **surgical emergency** requiring prompt intervention to preserve testicular viability.
*Traumatic urethral injury*
- This would typically present with **dysuria**, **hematuria**, inability to void, and potentially **blood at the urethral meatus**, none of which are described.
- A traumatic urethral injury often results from falls, straddle injuries, or pelvic fractures, not typically from playing football without direct trauma to the perineum.
*Seminoma*
- Seminoma is a type of **testicular cancer** that typically presents as a **painless testicular mass**.
- It would not cause sudden, acute abdominal pain and would not manifest with an acutely elevated testicle and horizontal lie.
*Appendicitis*
- Although appendicitis can cause abdominal pain, the **non-tender abdomen** on examination and the specific findings on **testicular examination** (elevated testicle, horizontal lie) make appendicitis unlikely.
- Appendicitis pain typically localizes to the right lower quadrant, often associated with fever, nausea, and vomiting.
*Epididymitis*
- Epididymitis causes **scrotal pain** and **swelling**, often with fever and **dysuria**, usually developing over days, not hours.
- It is often associated with the **Prehn's sign** (pain relief with elevation of the testicle), which is usually absent or negative in torsion. The patient's sexual history might suggest an STI, but the acute presentation and examination findings point away from epididymitis.
Question 193: A 22-year-old woman in the intensive care unit has had persistent oozing from the margins of wounds for 2 hours that is not controlled by pressure bandages. She was admitted to the hospital 13 hours ago following a high-speed motor vehicle collision. Initial focused assessment with sonography for trauma was negative. An x-ray survey showed opacification of the right lung field and fractures of multiple ribs, the tibia, fibula, calcaneus, right acetabulum, and bilateral pubic rami. Laboratory studies showed a hemoglobin concentration of 14.8 g/dL, leukocyte count of 10,300/mm3, platelet count of 175,000/mm3, and blood glucose concentration of 77 mg/dL. Infusion of 0.9% saline was begun. Multiple lacerations on the forehead and extremities were sutured, and fractures were stabilized. Repeat laboratory studies now show a hemoglobin concentration of 12.4 g/dL, platelet count of 102,000/mm3, prothrombin time of 26 seconds (INR=1.8), and activated partial thromboplastin time of 63 seconds. Which of the following is the next best step in management?
A. Transfuse packed RBC
B. Transfuse packed RBC and fresh frozen plasma in a 1:1 ratio
C. Transfuse fresh frozen plasma and platelet concentrate in a 1:1 ratio
D. Transfuse whole blood and administer vitamin K
E. Transfuse packed RBC, fresh frozen plasma, and platelet concentrate in a 1:1:1 ratio (Correct Answer)
Explanation: ***Transfuse packed RBC, fresh frozen plasma, and platelet concentrate in a 1:1:1 ratio***
- The patient exhibits signs of **massive hemorrhage and coagulopathy** (persistent oozing, decreasing hemoglobin, prolonged PT and aPTT, decreasing platelets) following severe trauma.
- A **1:1:1 ratio transfusion** of packed red blood cells (RBCs), fresh frozen plasma (FFP), and platelet concentrate is the recommended **massive transfusion protocol** to address hypovolemia, anemia, and consumptive coagulopathy simultaneously.
*Transfuse packed RBC*
- While the patient is anemic (Hb dropped from 14.8 to 12.4 g/dL), transfusing only RBCs would not address the significant **coagulopathy** evidenced by prolonged PT/aPTT and decreasing platelets.
- This option would correct **hypovolemia and oxygen-carrying capacity** but fail to resolve the underlying bleeding disorder, potentially worsening hemorrhage.
*Transfuse packed RBC and fresh frozen plasma in a 1:1 ratio*
- This approach addresses **anemia and coagulopathy** by providing clotting factors, but it neglects the patient's **thrombocytopenia** (platelets dropped from 175,000 to 102,000/mm3 with ongoing bleeding).
- Platelet transfusion is crucial for **hemostasis**, especially in uncontrolled traumatic bleeding.
*Transfuse fresh frozen plasma and platelet concentrate in a 1:1 ratio*
- This option targets **coagulopathy and thrombocytopenia** but completely ignores the significant **anemia and hypovolemia** (Hb 12.4 g/dL with ongoing bleeding) that is likely contributing to hypoperfusion.
- **RBCs** are essential to restore oxygen delivery to tissues and manage hemorrhagic shock.
*Transfuse whole blood and administer vitamin K*
- **Whole blood** is rarely used in civilian trauma settings due to practical limitations, and its components can be provided separately.
- **Vitamin K** is primarily used for warfarin reversal or vitamin K deficiency, which is not the acute cause of coagulopathy in severe trauma; the issue is **dilutional and consumptive coagulopathy**.
Question 194: A 27-year-old male arrives in the emergency department with a stab wound over the precordial chest wall. The patient is in distress and is cold, sweaty, and pale. Initial physical examination is significant for muffled heart sounds, distended neck veins, and a 3 cm stab wound near the left sternal border. Breath sounds are present bilaterally without evidence of tracheal deviation. Which of the following additional findings would be expected on further evaluation?
A. Decrease in central venous pressure by 5 mmHg with inspiration
B. 15 mmHg decrease in systolic blood pressure with inspiration (Correct Answer)
C. Decrease in the patient's heart rate by 15 beats per minute with inspiration
D. Steadily decreasing heart rate to 60 beats per minute
E. Elevated blood pressure to 170/110
Explanation: ***15 mmHg decrease in systolic blood pressure with inspiration***
- The constellation of muffled heart sounds, distended neck veins, and hypotension (implied by cold, sweaty, and pale appearance) following a precordial stab wound points to **cardiac tamponade**, an acutely life-threatening condition.
- A significant drop in systolic blood pressure (>10 mmHg) during inspiration, known as **pulsus paradoxus**, is a classic sign of cardiac tamponade as the increased venous return to the right heart during inspiration bows the interventricular septum, impinging on left ventricular filling.
*Decrease in central venous pressure by 5 mmHg with inspiration*
- In cardiac tamponade, the **central venous pressure (CVP) is typically elevated** and would not decrease significantly with inspiration due to impaired right ventricular filling.
- The elevated CVP contributes to the observed **distended neck veins**.
*Decrease in the patient's heart rate by 15 beats per minute with inspiration*
- In cardiac tamponade, the body attempts to compensate for reduced cardiac output with **reflex tachycardia**, so a decrease in heart rate is unexpected.
- Heart rate usually remains elevated or variable as the heart struggles to maintain perfusion.
*Steadily decreasing heart rate to 60 beats per minute*
- A steadily decreasing heart rate to 60 bpm (bradycardia) is contrary to the expected physiological response of **tachycardia** in cardiac tamponade as the body compensates for hypoperfusion.
- Bradycardia in this context would indicate severe decompensation and imminent cardiac arrest rather than a compensatory mechanism.
*Elevated blood pressure to 170/110*
- This patient is in **obstructive shock** due to cardiac tamponade; therefore, their blood pressure would be **hypotensive**, not hypertensive.
- **Hypotension** is a key component of Beck's triad (muffled heart sounds, distended neck veins, hypotension) which strongly suggests cardiac tamponade.
Question 195: A 34-year-old woman presents to the emergency department with moderate right wrist pain after falling on her outstretched hand. She has numbness in the lateral 3 digits. The patient has no known previous medical conditions. Her family history is not pertinent, and she currently takes no medications. Physical examination shows her blood pressure is 134/82 mm Hg, the respirations are 14/min, the pulse is 87/min, and the temperature is 36.7°C (98.0°F). When asked to make a fist, the patient is unable to flex the lateral 2 digits. Tapping the anterior portion of her wrist elicits tingling in the lateral 3 digits. The patient is taken to get an X-ray. Which of the following is the most likely diagnosis for this patient's injury?
A. Interosseous ligament rupture
B. Fracture of distal radius
C. Lunate dislocation (Correct Answer)
D. Scaphoid fracture
E. Palmar aponeurosis tear
Explanation: ***Lunate dislocation***
* A fall on an **outstretched hand** can lead to a **lunate dislocation**, particularly if the force is significant and causes hyperextension of the wrist.
* The **numbness in the lateral 3 digits** and positive **Tinel's sign** reflect compression of the **median nerve**, which commonly occurs with lunate dislocations due to its close proximity to the lunate bone and the carpal tunnel.
* The **inability to flex the lateral 2 digits** (thumb and index finger) indicates median nerve motor dysfunction affecting the thenar muscles and flexor digitorum superficialis/profundus to these digits.
*Interosseous ligament rupture*
* While a fall on an outstretched hand can cause ligamentous injuries, a pure **interosseous ligament rupture** typically does not present with specific **median nerve compression** symptoms like numbness in the lateral digits and Tinel's sign as the primary neurological finding.
* It would usually lead to wrist instability and pain, possibly with clicking or popping, without the distinct neurological signs described.
*Fracture of distal radius*
* A **distal radius fracture** (e.g., Colles' fracture) is common after a fall on an outstretched hand and causes severe pain and deformity.
* It can sometimes cause **median nerve compression** acutely, but the specific pattern of median nerve dysfunction with Tinel's sign over the anterior wrist (classic for median nerve entrapment due to lunate displacement into the carpal tunnel) is more indicative of a lunate dislocation.
*Scaphoid fracture*
* A **scaphoid fracture** is another common injury from falls on an outstretched hand, typically causing pain in the **anatomical snuffbox**.
* It does not usually result in immediate and pronounced **median nerve compression symptoms** like numbness in the lateral 3 digits or a positive Tinel's sign unless there is significant associated soft tissue swelling or carpal instability.
*Palmar aponeurosis tear*
* A **palmar aponeurosis tear** is an uncommon injury from a fall and would primarily cause pain and tenderness in the palm, potentially affecting grip strength.
* It does not explain the **median nerve symptoms** (numbness in lateral 3 digits, Tinel's sign) or the specific inability to flex the lateral 2 digits.
Question 196: A 66-year-old female with hypertension and a recent history of acute ST-elevation myocardial infarction (STEMI) 6 days previous, treated with percutaneous transluminal angioplasty (PTA), presents with sudden onset chest pain, shortness of breath, diaphoresis, and syncope. Vitals are temperature 37°C (98.6°F), blood pressure 80/50 mm Hg, pulse 125/min, respirations 12/min, and oxygen saturation 92% on room air. On physical examination, the patient is pale and unresponsive. Cardiac exam reveals tachycardia and a pronounced holosystolic murmur loudest at the apex and radiates to the back. Lungs are clear to auscultation. Chest X-ray shows cardiomegaly with clear lung fields. ECG is significant for ST elevations in the precordial leads (V2-V4) and low-voltage QRS complexes. Emergency transthoracic echocardiography shows a left ventricular wall motion abnormality along with a significant pericardial effusion. The patient is intubated, and aggressive fluid resuscitation is initiated. What is the next best step in management?
A. Immediate cardiac catheterization
B. Immediate transfer to the operating room (Correct Answer)
C. Emergency pericardiocentesis
D. Intra-aortic balloon counterpulsation
E. Administer dobutamine 5-10 mcg/kg/min IV
Explanation: ***Immediate transfer to the operating room***
- The patient's presentation with sudden onset chest pain, shortness of breath, profound cardiogenic shock, and a new **holosystolic murmur at the apex radiating to the back** in the context of a recent **STEMI**, strongly suggests **acute papillary muscle rupture** causing severe mitral regurgitation. This is a surgical emergency requiring immediate intervention.
- The holosystolic murmur at the apex is pathognomonic for acute mitral regurgitation, distinguishing this from ventricular free wall rupture (which would present with tamponade physiology without a murmur).
- The patient requires urgent surgical repair (mitral valve replacement or repair) to address this mechanical complication of **myocardial infarction (MI)**, which is causing severe hemodynamic compromise.
*Immediate cardiac catheterization*
- While cardiac catheterization is essential for diagnosing coronary artery disease and revascularization, in this emergent situation with profound shock and a mechanical complication (papillary muscle rupture), the primary issue is structural cardiac damage requiring surgical repair, not ongoing ischemia alone.
- Delaying surgical intervention for catheterization in this hemodynamically unstable patient would be detrimental and potentially fatal.
*Emergency pericardiocentesis*
- Although there is a **pericardial effusion** on echocardiography, the patient's presentation with a new holosystolic murmur and profound shock after STEMI indicates **papillary muscle rupture with acute mitral regurgitation**, not cardiac tamponade.
- The presence of a loud murmur excludes ventricular free wall rupture as the primary cause. The effusion is likely reactive or incidental.
- Pericardiocentesis would not address the underlying mitral valve pathology causing the hemodynamic collapse.
*Intra-aortic balloon counterpulsation*
- **Intra-aortic balloon pump (IABP)** can improve cardiac output and reduce afterload, which may provide temporary hemodynamic support in cardiogenic shock.
- However, in cases of **papillary muscle rupture** with severe acute mitral regurgitation, IABP provides only temporary support and does not fix the underlying structural problem.
- It could be considered as a bridge to surgery, but the definitive treatment is surgical repair, which should be expedited without delay.
*Administer dobutamine 5-10 mcg/kg/min IV*
- **Dobutamine** is an inotrope that increases cardiac contractility. While it might improve cardiac output in some forms of cardiogenic shock, in the setting of **acute severe mitral regurgitation from papillary muscle rupture**, it cannot resolve the structural valvular incompetence.
- Increasing contractility may paradoxically worsen the regurgitant fraction and further compromise forward cardiac output.
- Medical management alone cannot resolve this mechanical complication, necessitating urgent surgical intervention.
Question 197: An 87-year-old woman is brought to the emergency department 30 minutes after a fall onto a hardwood floor. She landed on her left side and hit the left side of her head. She did not lose consciousness. She has a mild headache over the left temple and severe left hip pain. She has had nasal congestion, a sore throat, and a productive cough for the last 2 days. She has a history of atrial fibrillation, coronary artery disease, hypertension, and osteoporosis. She underwent two coronary artery bypass grafts 5 years ago. She had smoked one pack of cigarettes daily for 30 years but quit 30 years ago. Her current medications include aspirin, apixaban, diltiazem, omeprazole, and vitamin D supplementation. The patient is oriented to person, place, and time. There is a 2-cm ecchymosis over the left temple. Examination of the left hip shows swelling and tenderness; range of motion is limited. Intravenous morphine 2 mg is started. During further examination, the patient complains of dizziness and palpitations. She is diaphoretic and pale. Her skin is cold and clammy. Her pulse is 110/min and faint, respirations are 20/min, and blood pressure is 70/30 mm Hg. Cranial nerves are intact. Cardiac examinations shows no murmurs, rubs, or gallops. An ECG shows absent P waves and nonspecific changes of the ST segment and the T wave. Which of the following is the most likely underlying mechanism for the patient's sudden decline in her condition?
A. Brain herniation
B. Pulmonary embolism
C. Blood loss (Correct Answer)
D. Sepsis
E. Cardiac tamponade
Explanation: ***Blood loss***
- The patient's sudden decline, marked by **dizziness, palpitations, diaphoresis, pallor, cold/clammy skin, and hypotension (BP 70/30 mmHg)**, after a fall and hip injury, strongly suggests **hypovolemic shock due to significant blood loss**.
- Given her age, history of osteoporosis, and fall mechanism (landing on her side), a **femoral neck fracture or intertrochanteric fracture** of the hip is highly likely, which can lead to substantial internal bleeding, especially in a patient on **anticoagulation (apixaban)**.
*Brain herniation*
- While the patient hit her head and has a mild headache, her **neurological examination (oriented, intact cranial nerves)** does not indicate the severe neurological deterioration expected with brain herniation.
- Brain herniation typically presents with altered consciousness, pupillary changes, and focal neurological deficits, none of which are described.
*Pulmonary embolism*
- Although the patient has risk factors for PE (immobility due to hip pain, atrial fibrillation, advanced age), her symptoms of **acute hypotension, pallor, and diaphoresis following trauma** are more consistent with hypovolemic shock.
- A PE would typically cause **dyspnea, pleuritic chest pain, and hypoxemia**, which are not the primary acute symptoms presented.
*Sepsis*
- The patient has an upper respiratory tract infection, but the **sudden and immediate onset of profound hypotension and shock symptoms** directly after a fall, without preceding signs of severe systemic infection or worsening respiratory distress, makes sepsis less likely as the primary cause of acute decline.
- Sepsis typically evolves over a longer period, with signs such as fever, tachycardia, and altered mental status being prominent.
*Cardiac tamponade*
- Cardiac tamponade would cause similar signs of shock (hypotension, tachycardia, cold/clammy skin) but is typically associated with **jugular venous distension, muffled heart sounds, and pulsus paradoxus**.
- The patient's cardiac exam showed no murmurs, rubs, or gallops, which does not support cardiac tamponade as the cause of her acute decline.
Question 198: A 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms?
A. Exercise and smoking cessation (Correct Answer)
B. Lovenox and atorvastatin
C. Lisinopril and atorvastatin
D. Balloon angioplasty with stenting
E. Femoral-popliteal bypass
Explanation: ***Exercise and smoking cessation***
- This patient presents with symptoms highly suggestive of **peripheral artery disease (PAD)**, characterized by **intermittent claudication** (leg pain worsening with activity and improving with rest), and risk factors like diabetes, hypertension, hyperlipidemia, and smoking.
- **Smoking cessation** is the single most important modifiable risk factor, and a supervised **exercise program** (walking to the point of claudication) is the most effective initial treatment to improve walking distance and quality of life for PAD patients.
*Lovenox and atorvastatin*
- **Atorvastatin** is appropriate for dyslipidemia and cardiovascular risk reduction in PAD patients, but **Lovenox (low molecular weight heparin)** is an anticoagulant typically used for acute thrombotic events or VTE prophylaxis, not initial management of chronic stable claudication.
- While statins are important for secondary prevention, Lovenox does not directly address the primary management of claudication symptoms or underlying atherosclerotic progression in this stable setting.
*Lisinopril and atorvastatin*
- **Lisinopril** is an ACE inhibitor suitable for hypertension, which is important for overall cardiovascular health but not the primary initial treatment for claudication symptoms.
- While both medications address risk factors, they do not directly target the improvement of walking function and symptom relief as effectively as exercise and smoking cessation in the initial phase.
*Balloon angioplasty with stenting*
- Invasive revascularization procedures like **balloon angioplasty with stenting** are typically reserved for patients with more severe symptoms (e.g., rest pain, non-healing ulcers, critical limb ischemia) or those who have failed conservative management like exercise therapy.
- This is not the **best initial treatment** for a patient with stable claudication.
*Femoral-popliteal bypass*
- **Femoral-popliteal bypass** is a surgical revascularization procedure indicated for more severe PAD, particularly in cases of critical limb ischemia or long-segment occlusions that are not amenable to endovascular repair.
- Like angioplasty, it is a more aggressive intervention and not the **initial treatment of choice** for intermittent claudication.
Question 199: A 33-year-old man is brought to the emergency department after being involved in a bar fight. Physical examination shows tenderness to palpation over the left side of the back. An x-ray of the chest shows a fracture of the 12th rib on the left side. Further evaluation is most likely to show which of the following injuries?
A. Pneumothorax
B. Liver hematoma
C. Kidney laceration (Correct Answer)
D. Colon perforation
E. Pancreatic transection
Explanation: ***Kidney laceration***
- A fracture of the **12th rib** often suggests significant force applied to the **posterolateral torso**, making the underlying **kidney** vulnerable to injury.
- The kidneys are retroperitoneal organs located at the level of the T12-L3 vertebrae, so a fracture of the **12th rib** directly overlies this region.
*Pneumothorax*
- While rib fractures can cause pneumothorax, it is more commonly associated with fractures of the **upper and middle ribs (ribs 1-10)**, as these directly protect the lungs.
- The **12th rib** is a floating rib, and its fracture is less likely to directly puncture the pleural cavity.
*Liver hematoma*
- The **liver** is located primarily under the **right lower ribs (ribs 7-11)**, and a fracture of the **left 12th rib** would not typically cause a liver injury.
- Liver injuries usually result from significant direct trauma to the right upper quadrant or generalized anterior abdominal trauma.
*Colon perforation*
- The **colon** is located primarily within the abdominal cavity, either in the lower abdomen or more anteriorly, and is generally protected from direct injury by a **12th rib fracture**.
- Colon injuries typically result from penetrating trauma or severe blunt force to the anterior abdomen, not localized posterior rib trauma.
*Pancreatic transection*
- The **pancreas** is a deep retroperitoneal organ located centrally in the upper abdomen.
- Pancreatic injuries, particularly transection, usually result from severe **deceleration injuries** or direct compression to the epigastrium (e.g., handlebar injury), not from a **12th rib fracture**.
Question 200: A 47-year-old man is brought to the emergency department 1 hour after injuring his genital area when he fell astride his backyard fence. He was trimming a tree from the fence when he lost his balance. His vital signs are within normal limits. Examination shows blood at the urethral meatus, perineal ecchymoses, and a scrotal hematoma. An x-ray of the pelvis shows swelling of the soft tissue but no other abnormalities. Which part of the urinary tract is most likely damaged in this patient?
A. Penile urethra
B. Bulbous urethra (Correct Answer)
C. Anterior bladder wall
D. Prostatic urethra
E. Membranous urethra
Explanation: ***Bulbous urethra***
- Straddle injuries (falling astride an object) cause **direct compression of the bulbous urethra** against the inferior pubic ramus
- Classic triad: **blood at urethral meatus, perineal ecchymoses, and scrotal/perineal hematoma** (butterfly pattern)
- The bulbous urethra is part of the **anterior urethra** and is most vulnerable in blunt perineal trauma
- This is a **Buck's fascia injury** with characteristic perineal and scrotal swelling
*Penile urethra*
- More distal portion of anterior urethra within the penis
- Typically injured by **direct penile trauma** (penile fracture, penetrating injury, instrumentation)
- Would not produce the perineal ecchymoses and scrotal hematoma seen in this case
*Membranous urethra*
- Part of **posterior urethra** located within the urogenital diaphragm
- Typically injured with **pelvic fractures** (pubic rami fractures), which are absent in this case
- Would present with high-riding prostate on rectal exam and inability to void
*Prostatic urethra*
- Most proximal portion of posterior urethra, well-protected within the prostate
- Injured in **severe pelvic trauma** with disruption of puboprostatic ligaments
- Also associated with pelvic fractures, not straddle injuries
*Anterior bladder wall*
- Requires **pelvic fracture** or penetrating trauma
- Would present with **gross hematuria** and suprapubic pain/tenderness
- Blood at meatus is not typical; more likely to have abdominal distension and peritoneal signs
