A 68-year-old man is brought to the emergency department because of a severe headache, nausea, and vomiting for 30 minutes. Forty-five minutes ago, he fell and struck his head, resulting in loss of consciousness for 1 minute. After regaining consciousness, he felt well for 15 minutes before the headache began. On arrival, the patient becomes rigid and his eyes deviate to the right; he is incontinent of urine. Intravenous lorazepam is administered and the rigidity resolves. Which of the following is the most likely cause of the patient's condition?
Q202
A 63-year-old man presents to his family physician with limited movement in his left shoulder that has progressed gradually over the past 6 years. He previously had pain when moving his shoulder, but the pain subsided a year ago and now he experiences the inability to fully flex, abduct, and rotate his left arm. He had an injury to his left shoulder 10 years ago when he fell onto his arms and ‘stretched ligaments’. He did not seek medical care and managed the pain with NSAIDs and rest. He has diabetes mellitus that is well controlled with Metformin. His blood pressure is 130/80 mm Hg, the heart rate is 81/min, the respiratory rate is 15/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals limitations of both active and passive abduction and external rotation in the left arm. The range of motion in the right glenohumeral joint is normal. The muscles of the left shoulder look less bulky than those of the right shoulder. There is no change in shoulder muscle power bilaterally. The reflexes and sensation on the upper extremities are normal. Which of the following is the next best step for this patient?
Q203
A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?
Q204
A 44-year-old man is brought to the emergency department 25 minutes after falling off the roof of a house. He was cleaning the roof when he slipped and fell. He did not lose consciousness and does not have any nausea. On arrival, he is alert and oriented and has a cervical collar on his neck. His pulse is 96/min, respirations are 18/min, and blood pressure is 118/78 mm Hg. Examination shows multiple bruises over the forehead and right cheek. The pupils are equal and reactive to light. There is a 2-cm laceration below the right ear. Bilateral ear canals show no abnormalities. The right wrist is swollen and tender; range of motion is limited by pain. The lungs are clear to auscultation. There is no midline cervical spine tenderness. There is tenderness along the 2nd and 3rd ribs on the right side. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two peripheral venous catheters are placed. Which of the following is the most appropriate next step in management?
Q205
A 17-year-old boy comes to the emergency department following an injury during football practice. He fell and landed on the lateral aspect of his right shoulder. He is holding his right arm supported by his left arm, with his right arm adducted against his side. He is tender to palpation directly over the middle third of his clavicle. Radiographs reveal a non-displaced fracture of the middle third of the clavicle. Which of the following is the most appropriate treatment at this time?
Q206
A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?
Q207
A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?
Q208
A 40-year-old male is brought into the emergency department as the unrestrained passenger in a motor vehicle collision. On presentation he is obtunded with multiple ecchymoses on his chest and abdomen. There is marked distortion of his left lower extremity. His blood pressure is 90/64 mmHg, pulse is 130/min, and respirations are 24/min. Physical exam is limited by the patient’s mental state. The patient appears to be in pain while breathing and has tenderness to palpation of the abdomen. Neck veins are distended. Auscultation of the lungs reveals absent breath sounds on the left and hyperresonance to percussion. An emergent procedure is done and the patient improves. Had a chest radiograph of the patient been obtained on presentation to the ED, which of the following findings would most likely have been seen?
Q209
A 24-year-old woman presents to her primary care physician’s office complaining of right foot pain for the last week. She first noticed this pain when she awoke from bed one morning and describes it as deep at the bottom of her heel. The pain improved as she walked around her apartment but worsened as she attended ballet practice. The patient is a professional ballerina and frequently rehearses for up to 10 hours a day, and she is worried that this heel pain will prevent her from appearing in a new ballet next week. She has no past medical history and has a family history of sarcoidosis in her mother and type II diabetes in her father. She drinks two glasses of wine a week and smokes several cigarettes a day but denies illicit drug use. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 117/68 mmHg, pulse is 80/min, and respirations are 13/min. Examination of the right foot shows no overlying skin changes or swelling, but when the foot is dorsiflexed, there is marked tenderness to palpation of the bottom of the heel. The remainder of her exam is unremarkable. Which of the following is the best next step in management?
Q210
A 14-year-old boy is brought to the emergency department because of acute left-sided chest pain and dyspnea following a motor vehicle accident. His pulse is 122/min and blood pressure is 85/45 mm Hg. Physical examination shows distended neck veins and tracheal displacement to the right side. The left chest is hyperresonant to percussion and there are decreased breath sounds. This patient would most benefit from needle insertion at which of the following anatomical sites?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 201: A 68-year-old man is brought to the emergency department because of a severe headache, nausea, and vomiting for 30 minutes. Forty-five minutes ago, he fell and struck his head, resulting in loss of consciousness for 1 minute. After regaining consciousness, he felt well for 15 minutes before the headache began. On arrival, the patient becomes rigid and his eyes deviate to the right; he is incontinent of urine. Intravenous lorazepam is administered and the rigidity resolves. Which of the following is the most likely cause of the patient's condition?
A. Rupture of bridging veins
B. Cerebrospinal fluid production/absorption mismatch
C. Acute insufficiency of cerebral blood flow
D. Bleeding between dura mater and skull (Correct Answer)
E. Intracerebral hemorrhage
Explanation: ***Bleeding between dura mater and skull***
- The classic presentation of an **epidural hematoma** includes a brief **loss of consciousness** followed by a **lucent interval** (patient feeling well) and then rapid neurological deterioration with symptoms like **severe headache**, **nausea**, **vomiting**, and **seizures** due to increasing intracranial pressure.
- This type of bleeding is typically arterial, usually from the **middle meningeal artery**, and occurs between the dura mater and the inner table of the skull.
*Rupture of bridging veins*
- This describes a **subdural hematoma**, which usually results in a more gradual onset of symptoms due to slower venous bleeding, often over days to weeks.
- While a fall can cause it, the rapid deterioration after a lucid interval is less typical for a subdural hematoma.
*Cerebrospinal fluid production/absorption mismatch*
- This mechanism is associated with conditions like **hydrocephalus** or **idiopathic intracranial hypertension**, which typically present with a more gradual onset of symptoms such as chronic headache, visual changes, or gait disturbances.
- It does not account for an acute traumatic event, loss of consciousness, and rapid deterioration seen in this patient.
*Acute insufficiency of cerebral blood flow*
- This typically refers to an **ischemic stroke** or **transient ischemic attack (TIA)**, where symptoms arise from a lack of oxygenated blood to brain regions.
- While it can cause neurological deficits, the history of head trauma, lucid interval, and rapid progression to severe symptoms and seizures points away from a primary ischemic event.
*Intracerebral hemorrhage*
- This involves bleeding within the **brain parenchyma** itself, which can present acutely with headache, vomiting, and neurological deficits.
- However, the distinct **lucid interval** following initial loss of consciousness, as described, is much more characteristic of an **epidural hematoma** rather than bleeding directly into the brain tissue.
Question 202: A 63-year-old man presents to his family physician with limited movement in his left shoulder that has progressed gradually over the past 6 years. He previously had pain when moving his shoulder, but the pain subsided a year ago and now he experiences the inability to fully flex, abduct, and rotate his left arm. He had an injury to his left shoulder 10 years ago when he fell onto his arms and ‘stretched ligaments’. He did not seek medical care and managed the pain with NSAIDs and rest. He has diabetes mellitus that is well controlled with Metformin. His blood pressure is 130/80 mm Hg, the heart rate is 81/min, the respiratory rate is 15/min, and the temperature is 36.6°C (97.9°F). Physical examination reveals limitations of both active and passive abduction and external rotation in the left arm. The range of motion in the right glenohumeral joint is normal. The muscles of the left shoulder look less bulky than those of the right shoulder. There is no change in shoulder muscle power bilaterally. The reflexes and sensation on the upper extremities are normal. Which of the following is the next best step for this patient?
A. NSAID prescription for 1–2 weeks
B. Arthroscopic capsular release
C. Physical therapy (Correct Answer)
D. No interventions are required at this stage
E. Corticosteroid injections
Explanation: ***Physical therapy***
- This patient presents with symptoms highly suggestive of **adhesive capsulitis**, or **frozen shoulder**, characterized by progressive stiffness and limited range of motion, particularly in abduction and external rotation, following a history of injury and chronic inflammation.
- **Physical therapy** is the cornerstone of treatment for frozen shoulder, focusing on stretching exercises and range-of-motion improvement to restore function.
*NSAID prescription for 1–2 weeks*
- While NSAIDs can manage pain and inflammation, the patient's pain has already subsided, and the primary issue is now **limited range of motion**, not acute pain.
- NSAIDs alone will not address the underlying capsular restriction and will not improve the long-term functional outcome in this chronic phase.
*Arthroscopic capsular release*
- **Arthroscopic capsular release** is an invasive surgical procedure considered for severe, refractory cases of frozen shoulder that have not responded to extensive conservative management.
- It is not typically the initial "next best step," especially before a trial of non-invasive treatments like physical therapy.
*No interventions are required at this stage*
- The patient has significant **functional impairment** and muscle atrophy, indicating a need for intervention to improve his quality of life and prevent further deterioration.
- Ignoring these symptoms would lead to continued disability and potentially worsen muscle loss.
*Corticosteroid injections*
- **Corticosteroid injections** are more effective during the painful, early inflammatory (freezing) stage of adhesive capsulitis, helping to reduce pain and inflammation.
- In the current "thawing" or chronic stiffness stage, where pain has subsided and the primary issue is mechanical restriction, their benefit is limited compared to physical therapy for restoring range of motion.
Question 203: A 27-year-old man is brought to the emergency department by emergency medical services. The patient was an unrestrained passenger in a head-on collision that occurred 15 minutes ago and is currently unresponsive. His temperature is 99.5°F (37.5°C), blood pressure is 60/33 mmHg, pulse is 180/min, respirations are 17/min, and oxygen saturation is 95% on room air. A FAST exam demonstrates fluid in Morrison’s pouch. Laboratory values are drawn upon presentation to the ED and sent off. The patient is started on IV fluids and an initial trauma survey is started. Twenty minutes later, his blood pressure is 95/65 mmHg, and his pulse is 110/min. The patient is further stabilized and is scheduled for emergency surgery. Which of the following best represents this patient’s most likely initial laboratory values?
A. Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3
B. Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3
C. Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3
E. Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3
Explanation: ***Hemoglobin: 11 g/dL, Hematocrit: 33%, MCV: 88 µm^3***
- The patient experienced significant trauma and is experiencing **hemorrhagic shock**, as evidenced by his initial **hypotension** (BP 60/33 mmHg), **tachycardia** (pulse 180/min), and positive **FAST exam** for fluid in Morrison's pouch, indicating intra-abdominal bleeding.
- The initial hemoglobin and hematocrit could be mildly decreased due to acute blood loss, but significant drops are often *not immediately apparent* as plasma volume has not yet moved into the intravascular compartment to dilute the remaining red blood cells. A hemoglobin of 11 g/dL and hematocrit of 33% are consistent with **acute blood loss** before significant hemodilution occurs. MCV of 88 µm^3 is within the normal range for **normocytic anemia** seen in acute hemorrhage.
*Hemoglobin: 10 g/dL, Hematocrit: 30%, MCV: 110 µm^3*
- While a hemoglobin of 10 g/dL and hematocrit of 30% are consistent with anemia due to blood loss, an **MCV of 110 µm^3** (macrocytic) is not typically seen in acute hemorrhage.
- Macrocytic anemia usually results from conditions like **B12 or folate deficiency**, alcoholism, or liver disease, which are not suggested by the acute traumatic scenario.
*Hemoglobin: 19 g/dL, Hematocrit: 55%, MCV: 95 µm^3*
- This indicates **polycythemia** (abnormally high red blood cell count), which is the opposite of what would be expected in a patient experiencing acute hemorrhagic shock.
- These values would suggest conditions like **polycythemia vera** or severe dehydration, which are not relevant in this acute trauma setting.
*Hemoglobin: 7 g/dL, Hematocrit: 21%, MCV: 75 µm^3*
- While a hemoglobin of 7 g/dL and hematocrit of 21% represent significant anemia consistent with major blood loss, these values are typically seen *later* as **hemodilution** occurs, or in cases of chronic blood loss.
- An **MCV of 75 µm^3** (microcytic) is generally indicative of **iron deficiency anemia** or thalassemia, which develops over time and is not characteristic of acute traumatic blood loss.
*Hemoglobin: 15 g/dL, Hematocrit: 45%, MCV: 90 µm^3*
- These values are within the **normal range** for hemoglobin and hematocrit, which would not be expected in a patient presenting with signs of **hemorrhagic shock** and a positive FAST exam indicating significant internal bleeding.
- This would suggest either very minor blood loss or that the values were taken before any bleeding had occurred or before hemodilution had a chance to manifest.
Question 204: A 44-year-old man is brought to the emergency department 25 minutes after falling off the roof of a house. He was cleaning the roof when he slipped and fell. He did not lose consciousness and does not have any nausea. On arrival, he is alert and oriented and has a cervical collar on his neck. His pulse is 96/min, respirations are 18/min, and blood pressure is 118/78 mm Hg. Examination shows multiple bruises over the forehead and right cheek. The pupils are equal and reactive to light. There is a 2-cm laceration below the right ear. Bilateral ear canals show no abnormalities. The right wrist is swollen and tender; range of motion is limited by pain. The lungs are clear to auscultation. There is no midline cervical spine tenderness. There is tenderness along the 2nd and 3rd ribs on the right side. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two peripheral venous catheters are placed. Which of the following is the most appropriate next step in management?
A. CT scan of the cervical spine (Correct Answer)
B. Focused Assessment with Sonography in Trauma
C. X-ray of the neck
D. X-ray of the chest
E. X-ray of the right wrist
Explanation: ***CT scan of the cervical spine***
- This patient suffered a significant fall from a height, which is a **high-risk mechanism of injury** for cervical spine trauma, even without immediate neurologic deficits or midline tenderness.
- Due to the high-energy trauma and the potential for severe consequences from an unstable cervical spine injury, a **CT scan** is the preferred imaging modality as it offers superior detail compared to plain X-rays, especially in complex anatomy.
- The patient is **hemodynamically stable** with a benign abdominal exam, and the cervical collar is already in place, indicating that spinal precautions are the immediate priority before any further movement or transfers.
*Focused Assessment with Sonography in Trauma (FAST)*
- FAST exam is primarily used to detect **free fluid (hemorrhage)** in the pericardial, perihepatic, perisplenic, and pelvic spaces in trauma patients.
- While important in trauma evaluation, this patient is **hemodynamically stable** (normal blood pressure, normal pulse) with a **soft, nontender abdomen**, making urgent FAST less critical than clearing the cervical spine.
- The primary concern in a patient with a significant fall mechanism and cervical collar in place is ruling out **cervical spine instability** before further interventions or movement.
*X-ray of the neck*
- While an X-ray can assess the cervical spine, a **CT scan** is generally superior for detecting subtle fractures, ligamentous injuries, and malalignments, especially in patients with high-energy trauma.
- Given the patient's mechanism of injury, an X-ray might miss critical injuries that a CT would identify, leading to potential delays in diagnosis and treatment.
*X-ray of the chest*
- A chest X-ray would be appropriate to assess the patient's **rib fractures** and potential associated injuries like pneumothorax or hemothorax.
- However, the most immediate life-threatening injury in this context, after airway and breathing are secured, is an unstable cervical spine injury, which takes precedence in a stable patient with high-risk mechanism.
*X-ray of the right wrist*
- An X-ray of the right wrist is indicated to evaluate the **swollen and tender wrist** for a fracture or dislocation.
- While important for comprehensive trauma management, it is not the most immediate or life-threatening concern compared to potential cervical spine injury from a high-impact fall.
Question 205: A 17-year-old boy comes to the emergency department following an injury during football practice. He fell and landed on the lateral aspect of his right shoulder. He is holding his right arm supported by his left arm, with his right arm adducted against his side. He is tender to palpation directly over the middle third of his clavicle. Radiographs reveal a non-displaced fracture of the middle third of the clavicle. Which of the following is the most appropriate treatment at this time?
A. Open reduction and internal fixation with a compression plate
B. Open reduction and internal fixation with an intramedullary nail
C. Figure-of-eight splinting (Correct Answer)
D. Mobilization
E. Open reduction and internal fixation with lag screws
Explanation: ***Figure-of-eight splinting***
- For **undisplaced or minimally displaced midshaft clavicle fractures**, conservative management with a **simple arm sling or figure-of-eight splint** is the preferred initial treatment.
- Both methods provide **adequate immobilization** and support for healing, especially in pediatric and adolescent patients, with excellent functional outcomes.
- Current evidence suggests **simple sling support** is equally effective and often better tolerated than figure-of-eight splinting.
*Open reduction and internal fixation with a compression plate*
- **ORIF with a compression plate** is typically reserved for **displaced or comminuted clavicle fractures** (displacement >2cm, shortening >2cm, or open fractures), or those with associated neurovascular compromise, which are not present in this non-displaced fracture.
- Surgical intervention for non-displaced fractures carries **risks of infection, hardware irritation**, and non-union that often outweigh the benefits when conservative options are effective.
*Open reduction and internal fixation with an intramedullary nail*
- **Intramedullary nailing** is an alternative surgical option for some clavicle fractures but is generally considered for **displaced or comminuted fracture patterns**, and is not indicated for a non-displaced fracture.
- It involves specific technical challenges and is **less commonly used** for routine, non-displaced mid-shaft clavicle fractures, especially when simpler conservative measures suffice.
*Mobilization*
- **Immediate mobilization** without any form of immobilization would **risk further displacement** of the non-displaced fracture and hinder proper bone healing in the acute phase.
- Although early motion is introduced during the healing process, **initial support and immobilization** is crucial for stability and pain control.
*Open reduction and internal fixation with lag screws*
- **Lag screws** are primarily used for **interfragmentary compression** in specific oblique or spiral fracture patterns, which is not the typical mechanism for midshaft clavicle fractures.
- This method is a form of surgical fixation, which is **not indicated for a non-displaced clavicle fracture** given the excellent outcomes (>95% union rate) with conservative care.
Question 206: A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?
A. Replace the cast with a sling
B. Measurement of compartment pressure (Correct Answer)
C. Ibuprofen and reassurance
D. Emergency fasciotomy
E. Radiography
Explanation: ***Measurement of compartment pressure***
- The patient exhibits classic signs of **compartment syndrome**, including severe pain out of proportion to injury, pain with passive stretching, and a history of trauma followed by casting. Measuring compartment pressure is crucial for diagnosis despite palpable pulses.
- Early measurement of compartment pressures can confirm the diagnosis and guide the decision for an **emergency fasciotomy** to prevent irreversible tissue damage.
*Replace the cast with a sling*
- This action would likely worsen the patient's condition by delaying the diagnosis and treatment of potential **compartment syndrome**.
- A sling does not address the underlying issue of increased pressure within the muscle compartments.
*Ibuprofen and reassurance*
- Administering **Ibuprofen (NSAID)** might mask the pain but will not resolve the increased pressure within the compartment, which is a surgical emergency.
- Reassurance without proper assessment of compartment syndrome could lead to irreversible muscle and nerve damage.
*Emergency fasciotomy*
- While a fasciotomy is the definitive treatment for confirmed compartment syndrome, it should only be performed **after compartment pressures have been measured** and the diagnosis confirmed, unless the clinical suspicion is extremely high and pressures cannot be obtained.
- Performing a fasciotomy without objective confirmation is generally not the immediate next step, as it is an invasive procedure with its own risks.
*Radiography*
- **Radiography** would be useful to assess the healing of the fracture or rule out new fractures, but it will not provide information about the soft tissue pressure changes characteristic of compartment syndrome.
- The patient's symptoms are more indicative of a circulatory or soft tissue issue rather than a new bony problem.
Question 207: A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?
A. AP and lateral radiographs of hips
B. Lateral radiograph (x-ray) of hips
C. Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area
D. Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area
E. Computed tomography (CT) scan of cervical spine, hips, and lumbar area (Correct Answer)
Explanation: ***Computed tomography (CT) scan of cervical spine, hips, and lumbar area***
- In **high-energy trauma** (fall from height), a CT scan is the **gold standard** for evaluating the **spine and pelvis**, providing detailed cross-sectional images superior to plain radiographs.
- Since the **cervical exam was not performed**, cervical spine imaging is **mandatory** per ATLS (Advanced Trauma Life Support) protocols. High-energy falls carry significant risk of **cervical spine injury** even without obvious neurological symptoms.
- CT allows comprehensive assessment of **hip fractures, pelvic injuries, and the entire spine** (cervical, thoracic, lumbar), identifying both obvious and **subtle fractures** that may be missed on plain films.
- This approach provides the most **efficient and thorough evaluation** in the acute trauma setting, allowing for appropriate surgical planning and ruling out life-threatening spinal instability.
*AP and lateral radiographs of hips*
- Plain radiographs provide **limited detail** and may **miss subtle fractures**, particularly in complex areas like the pelvis and acetabulum.
- This option **fails to address cervical spine clearance**, which is essential in all high-energy trauma patients, especially when cervical exam has not been performed.
- Radiographs are insufficient for **comprehensive trauma evaluation** after a fall from height.
*Lateral radiograph (x-ray) of hips*
- A single lateral view is **grossly insufficient** for evaluating hip and pelvic fractures, providing only a **two-dimensional perspective** that can miss significant injuries.
- This option **completely neglects spinal evaluation**, which is dangerous in an uncleared trauma patient with a high-energy mechanism.
*Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area*
- While MRI excels at evaluating **soft tissues, ligaments, and bone marrow**, it is **not the initial imaging modality** for acute bony trauma due to longer scan times and lower sensitivity for acute fractures compared to CT.
- MRI is **time-consuming and impractical** in the emergency setting for initial fracture assessment, potentially delaying definitive treatment.
- CT is superior for evaluating **acute skeletal injuries** in the trauma bay.
*Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area*
- Multiple plain radiographs have **limited sensitivity** for complex or non-displaced fractures, particularly in the **spine and pelvis**, making them inadequate for high-energy trauma evaluation.
- Obtaining multiple radiographic views requires **numerous patient repositionings**, which risks further injury if **spinal instability** is present.
- Plain films provide significantly **less diagnostic information** than CT scanning for trauma assessment.
Question 208: A 40-year-old male is brought into the emergency department as the unrestrained passenger in a motor vehicle collision. On presentation he is obtunded with multiple ecchymoses on his chest and abdomen. There is marked distortion of his left lower extremity. His blood pressure is 90/64 mmHg, pulse is 130/min, and respirations are 24/min. Physical exam is limited by the patient’s mental state. The patient appears to be in pain while breathing and has tenderness to palpation of the abdomen. Neck veins are distended. Auscultation of the lungs reveals absent breath sounds on the left and hyperresonance to percussion. An emergent procedure is done and the patient improves. Had a chest radiograph of the patient been obtained on presentation to the ED, which of the following findings would most likely have been seen?
A. Collection of fluid in the left lung base
B. Consolidation of the left lower lobe
C. Tracheal deviation to the right (Correct Answer)
D. Bilateral fluffy infiltrates at the lung bases
E. Fractured rib on the left
Explanation: ***Tracheal deviation to the right***
- The patient's presentation with **absent breath sounds** on the left, **hyperresonance** to percussion, **distended neck veins**, and **hypotension** after trauma is highly suggestive of a **tension pneumothorax**.
- In a tension pneumothorax, air accumulates under high pressure in the pleural space, pushing the **mediastinum** (including the trachea) to the **contralateral side**.
*Collection of fluid in the left lung base*
- A collection of fluid, such as in a **hemothorax** or **pleural effusion**, would typically cause **dullness to percussion**, not hyperresonance.
- While possible with trauma, effusions do not typically cause the acute, severe hemodynamic compromise or tracheal deviation seen here.
*Consolidation of the left lower lobe*
- **Consolidation**, typically seen in pneumonia or atelectasis, would present with **dullness to percussion** and potentially **bronchial breath sounds** or crackles, which contrasts with the absent breath sounds and hyperresonance described.
- It would also not explain the distended neck veins or mediastinal shift.
*Bilateral fluffy infiltrates at the lung bases*
- **Bilateral fluffy infiltrates** are characteristic of conditions like **pulmonary edema** or **Acute Respiratory Distress Syndrome (ARDS)**.
- These conditions do not fit with the unilateral findings (absent breath sounds, hyperresonance on the left) or the acute traumatic etiology and signs of mediastinal shift.
*Fractured rib on the left*
- While a **fractured rib** is common in motor vehicle collisions, it is a cause rather than a direct radiographic finding that explains all the given symptoms.
- A rib fracture itself would not cause absent breath sounds, hyperresonance, distended neck veins, or tracheal deviation unless it led to a more severe complication like a **pneumothorax**.
Question 209: A 24-year-old woman presents to her primary care physician’s office complaining of right foot pain for the last week. She first noticed this pain when she awoke from bed one morning and describes it as deep at the bottom of her heel. The pain improved as she walked around her apartment but worsened as she attended ballet practice. The patient is a professional ballerina and frequently rehearses for up to 10 hours a day, and she is worried that this heel pain will prevent her from appearing in a new ballet next week. She has no past medical history and has a family history of sarcoidosis in her mother and type II diabetes in her father. She drinks two glasses of wine a week and smokes several cigarettes a day but denies illicit drug use. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 117/68 mmHg, pulse is 80/min, and respirations are 13/min. Examination of the right foot shows no overlying skin changes or swelling, but when the foot is dorsiflexed, there is marked tenderness to palpation of the bottom of the heel. The remainder of her exam is unremarkable. Which of the following is the best next step in management?
A. Glucocorticoid injection
B. Orthotic shoe inserts
C. Ultrasound of the foot
D. Plain radiograph of the foot
E. Resting of the foot (Correct Answer)
Explanation: ***Resting of the foot***
- The patient's symptoms are highly suggestive of **plantar fasciitis**, a common overuse injury, and **rest** is foundational for healing and reducing inflammation.
- Given the patient's profession and upcoming performance, **activity modification** and rest are crucial to prevent further strain and allow the inflamed plantar fascia to recover.
*Glucocorticoid injection*
- While **glucocorticoid injections** can provide short-term pain relief, they carry risks such as **fascial rupture** and fat pad atrophy, especially in weight-bearing areas like the heel.
- They are typically reserved for cases unresponsive to conservative measures due to potential side effects and the risk of **accelerating tissue degeneration**.
*Orthotic shoe inserts*
- **Orthotic shoe inserts** can help support the arch and reduce stress on the plantar fascia, but this is a **supportive measure**, not the primary treatment for acute inflammation.
- While beneficial for **long-term management** and prevention of recurrence, they are not the immediate "best next step" for an acute, painful exacerbation that requires initial symptom reduction.
*Ultrasound of the foot*
- A **clinical diagnosis** of plantar fasciitis can usually be made based on the characteristic history and physical examination findings, making imaging often unnecessary.
- An **ultrasound** might show thickening of the plantar fascia but is generally not required for initial diagnosis or management unless there is suspicion of other pathologies or if symptoms are atypical.
*Plain radiograph of the foot*
- **Plain radiographs** are typically not necessary for diagnosing plantar fasciitis as they primarily detect **bone abnormalities** and will generally be normal in this condition.
- While a heel spur may be visible on X-ray, **heel spurs** are common even in asymptomatic individuals and are rarely the direct cause of pain, thus a radiograph would not change the initial management.
Question 210: A 14-year-old boy is brought to the emergency department because of acute left-sided chest pain and dyspnea following a motor vehicle accident. His pulse is 122/min and blood pressure is 85/45 mm Hg. Physical examination shows distended neck veins and tracheal displacement to the right side. The left chest is hyperresonant to percussion and there are decreased breath sounds. This patient would most benefit from needle insertion at which of the following anatomical sites?
A. 5th left intercostal space along the midclavicular line
B. 8th left intercostal space along the posterior axillary line
C. 2nd left intercostal space along the midclavicular line (Correct Answer)
D. Subxiphoid space in the left sternocostal margin
E. 5th left intercostal space along the midaxillary line
Explanation: ***2nd left intercostal space along the midclavicular line***
- The patient's symptoms (chest pain, dyspnea, hypotension, distended neck veins, tracheal deviation, hyperresonance, and decreased breath sounds on the left) are classic signs of a **tension pneumothorax**.
- Immediate treatment for **tension pneumothorax** involves needle decompression at the **2nd intercostal space** in the midclavicular line to relieve pressure and restore hemodynamic stability.
*5th left intercostal space along the midclavicular line*
- This location is typically used for **chest tube insertion** in a more controlled setting, not for emergent needle decompression of a tension pneumothorax.
- While it's a safe location for pleural access, it is not the **first-line site** for immediate life-saving decompression.
*8th left intercostal space along the posterior axillary line*
- This site is too low and posterior for effective needle decompression of a tension pneumothorax, which requires rapid access to the **apex of the lung**.
- It is more commonly used for **thoracentesis** to drain fluid from the pleural cavity.
*Subxiphoid space in the left sternocostal margin*
- This location is primarily used for **pericardiocentesis** to drain fluid from the pericardial sac in cases of cardiac tamponade.
- It is not appropriate for addressing a **pneumothorax**, which involves air in the pleural space.
*5th left intercostal space along the midaxillary line*
- This site is a common alternative for **chest tube insertion** but is not the preferred or most immediate site for needle decompression of a tension pneumothorax.
- While it offers pleural access, the **2nd intercostal space** anteriorly is chosen for expediency and safety in an emergency.
