A 65-year-old man comes to his primary care physician with a 6-month history of bilateral calf pain. The pain usually occurs after walking his dog a few blocks and is more severe on the right side. He has coronary artery disease, essential hypertension, and type 2 diabetes mellitus. He has smoked two packs of cigarettes daily for 43 years and drinks two alcoholic beverages a day. Current medications include metformin, lisinopril, and aspirin. He is 183 cm (5 ft 11 in) tall and weighs 113 kg (250 lb); BMI is 34.9 kg/m2. His temperature is 37°C (98.6°F), pulse is 84/min, and blood pressure is 129/72 mm Hg. Cardiac examination shows a gallop without murmurs. The legs have shiny skin with reduced hair below the knee. Femoral and popliteal pulses are palpable bilaterally. Dorsal pedal pulses are 1+ on the left and absent on the right. Ankle-brachial index (ABI) is performed in the office. ABI is 0.5 in the right leg, and 0.6 in the left leg. Which of the following is the most appropriate initial step in management?
Q212
A 33-year-old man with a history of alcohol abuse and cirrhosis presents to the emergency department with profuse vomiting. The patient is aggressive, combative, emotionally labile, and has to be chemically restrained. The patient continues to vomit and blood is noted in the vomitus. His temperature is 99.2°F (37.3°C), blood pressure is 139/88 mmHg, pulse is 106/min, respirations are 17/min, and oxygen saturation is 100% on room air. The patient complains of sudden onset chest pain during his physical exam. A crunching and rasping sound is heard while auscultating the heart. Which of the following is the pathophysiology of the most likely diagnosis?
Q213
A 29-year-old man is brought to the emergency department 20 minutes after being stabbed in the left thigh. His pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Examination shows a 2-cm wound overlying a pulsatile mass on the left anterior thigh, 4 cm below the inguinal crease. A thrill is palpated, and a bruit is heard over this area. Peripheral pulses are normal bilaterally. The patient is at greatest risk for which of the following?
Q214
A 35-year-old man arrives at the emergency department within minutes after a head-on motor vehicle accident. He suffered from blunt abdominal trauma, several lacerations to his face as well as lacerations to his upper and lower extremities. The patient is afebrile, blood pressure is 45/25 mmHg and pulse is 160/minute. A CBC is obtained and is most likely to demonstrate which of the following?
Q215
A 30-year-old male presents with a testicular mass of unknown duration. The patient states he first noticed something unusual with his right testicle two weeks ago, but states he did not think it was urgent because it was not painful and believed it would resolve on its own. It has not changed since he first noticed the mass, and the patient still denies pain. On exam, the patient’s right testicle is non-tender, and a firm mass is felt. There is a negative transillumination test, and the mass is non-reducible. Which of the following is the best next step in management?
Q216
A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
Q217
A 5-year-old boy is brought to the emergency department for right elbow swelling and pain 45 minutes after he fell while playing on the monkey bars during recess. He has been unable to move his right elbow since the fall. Examination shows ecchymosis, swelling, and tenderness of the right elbow; range of motion is limited by pain. The remainder of the examination shows no abnormalities. An x-ray of the right arm is shown. Which of the following is the most likely complication of this patient's injury?
Q218
A 54-year-old man comes to the physician because of a painful mass in his left thigh for 3 days. He underwent a left lower limb angiography for femoral artery stenosis and had a stent placed 2 weeks ago. He has peripheral artery disease, coronary artery disease, hypercholesterolemia and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 34 years. Current medications include enalapril, aspirin, simvastatin, metformin, and sitagliptin. His temperature is 36.7°C (98°F), pulse is 88/min, and blood pressure is 116/72 mm Hg. Examination shows a 3-cm (1.2-in) tender, pulsatile mass in the left groin. The skin over the area of the mass shows no erythema and is cool to the touch. A loud bruit is heard on auscultation over this area. The remainder of the examination shows no abnormalities. Results of a complete blood count and serum electrolyte concentrations show no abnormalities. Duplex ultrasonography shows an echolucent sac connected to the common femoral artery, with pulsatile and turbulent blood flow between the artery and the sac. Which of the following is the most appropriate next best step in management?
Q219
A 45-year-old man is brought to the emergency department following a house fire. Following initial stabilization, the patient is transferred to the ICU for management of his third-degree burn injuries. On the second day of hospitalization, a routine laboratory panel is obtained, and the results are demonstrated below. Per the nurse, he remains stable compared to the day prior. His temperature is 99°F (37°C), blood pressure is 92/64 mmHg, pulse is 98/min, respirations are 14/min, and SpO2 is 98%. A physical examination demonstrates an unresponsive patient with extensive burn injuries throughout his torso and lower extremities.
Hemoglobin: 13 g/dL
Hematocrit: 36%
Leukocyte count: 10,670/mm^3 with normal differential
Platelet count: 180,000/mm^3
Serum:
Na+: 135 mEq/L
Cl-: 98 mEq/L
K+: 4.7 mEq/L
HCO3-: 25 mEq/L
BUN: 10 mg/dL
Glucose: 123 mg/dL
Creatinine: 1.8 mg/dL
Thyroid-stimulating hormone: 4.3 µU/mL
Triiodothyronine: 48 ng/dL
Thyroxine: 10 ug/dL
Ca2+: 8.7 mg/dL
AST: 89 U/L
ALT: 135 U/L
What is the best course of management for this patient?
Q220
A 22-year-old man comes to the physician because of a progressive swelling and pain in his right ring finger for the past 2 days. The pain began while playing football, when his finger got caught in the jersey of another player who forcefully pulled away. Examination shows that the right ring finger is extended. There is pain and swelling at the distal interphalangeal joint. When the patient is asked to make a fist, his right ring finger does not flex at the distal interphalangeal joint. There is no joint laxity. Which of the following is the most likely diagnosis?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 211: A 65-year-old man comes to his primary care physician with a 6-month history of bilateral calf pain. The pain usually occurs after walking his dog a few blocks and is more severe on the right side. He has coronary artery disease, essential hypertension, and type 2 diabetes mellitus. He has smoked two packs of cigarettes daily for 43 years and drinks two alcoholic beverages a day. Current medications include metformin, lisinopril, and aspirin. He is 183 cm (5 ft 11 in) tall and weighs 113 kg (250 lb); BMI is 34.9 kg/m2. His temperature is 37°C (98.6°F), pulse is 84/min, and blood pressure is 129/72 mm Hg. Cardiac examination shows a gallop without murmurs. The legs have shiny skin with reduced hair below the knee. Femoral and popliteal pulses are palpable bilaterally. Dorsal pedal pulses are 1+ on the left and absent on the right. Ankle-brachial index (ABI) is performed in the office. ABI is 0.5 in the right leg, and 0.6 in the left leg. Which of the following is the most appropriate initial step in management?
A. Propranolol therapy
B. Graded exercise therapy (Correct Answer)
C. Vascular bypass surgery
D. Spinal cord stimulation
E. Percutaneous transluminal angioplasty with stenting
Explanation: ***Graded exercise therapy***
- **Graded exercise therapy** is the recommended initial treatment for patients with **intermittent claudication** due to peripheral artery disease (PAD). It improves walking distance and reduces symptoms by promoting collateral circulation and endothelial function.
- This patient's symptoms (bilateral calf pain with exertion, shiny skin, reduced hair, absent dorsal pedal pulse on the right, and low ABI scores) are classic for **PAD with claudication**.
*Propranolol therapy*
- **Propranolol** is a non-selective beta-blocker that can worsen claudication symptoms by inhibiting beta-2 mediated vasodilation in peripheral arteries.
- While beta-blockers may be indicated for some cardiac conditions, they are generally avoided or used cautiously in PAD due to their potential to exacerbate peripheral vasoconstriction.
*Vascular bypass surgery*
- **Vascular bypass surgery** is typically reserved for patients with **severe, limb-threatening ischemia** (critical limb ischemia) or those with claudication that is refractory to conservative management.
- This patient's symptoms, while significant, are consistent with intermittent claudication, which is usually managed initially with lifestyle modifications and exercise.
*Spinal cord stimulation*
- **Spinal cord stimulation** is a treatment option primarily for **refractory chronic neuropathic pain** or **critical limb ischemia** not amenable to revascularization, aiming to reduce pain and potentially improve wound healing.
- It is not an initial treatment for intermittent claudication and doesn't address the underlying vascular obstruction causing claudication.
*Percutaneous transluminal angioplasty with stenting*
- **Percutaneous transluminal angioplasty with stenting** is a revascularization procedure considered when conservative therapies fail to improve claudication or for critical limb ischemia.
- It is not the initial step in management for intermittent claudication. **Lifestyle modifications** and supervised exercise are the first-line treatments.
Question 212: A 33-year-old man with a history of alcohol abuse and cirrhosis presents to the emergency department with profuse vomiting. The patient is aggressive, combative, emotionally labile, and has to be chemically restrained. The patient continues to vomit and blood is noted in the vomitus. His temperature is 99.2°F (37.3°C), blood pressure is 139/88 mmHg, pulse is 106/min, respirations are 17/min, and oxygen saturation is 100% on room air. The patient complains of sudden onset chest pain during his physical exam. A crunching and rasping sound is heard while auscultating the heart. Which of the following is the pathophysiology of the most likely diagnosis?
A. Pericardial fluid accumulation
B. Inflammation of the pericardium
C. Dilated and tortuous veins
D. Mucosal tear
E. Transmural tear (Correct Answer)
Explanation: ***Transmural tear***
- The patient's presentation with **profuse vomiting**, followed by **chest pain**, vomiting blood (**hematemesis**), and a **crunching/rasping sound** on cardiac auscultation (**Hamman's sign**), is highly indicative of esophageal rupture or Boerhaave syndrome.
- A transmural tear of the esophagus leads to the leakage of gastric contents into the mediastinum, causing **mediastinitis** and potentially **pneumomediastinum**, which produces Hamman's sign.
*Pericardial fluid accumulation*
- While pericardial fluid accumulation (e.g., in cardiac tamponade) can cause chest pain, it doesn't typically present with **hematemesis** or a history of forceful vomiting.
- The classic auscultatory finding for pericardial fluid accumulation is muffled heart sounds, not a crunching sound.
*Inflammation of the pericardium*
- Pericardial inflammation (**pericarditis**) causes sharp, pleuritic chest pain that often improves with leaning forward, and can be associated with a **pericardial friction rub**.
- However, it does not typically cause **hematemesis** or a crunching/rasping sound associated with mediastinal air.
*Dilated and tortuous veins*
- **Dilated and tortuous veins** (esophageal varices) are common in patients with **cirrhosis** and can lead to profuse hematemesis.
- While this patient has cirrhosis and hematemesis, the sudden onset of **chest pain** and the characteristic **Hamman's sign** point away from uncomplicated variceal bleeding and towards esophageal rupture.
*Mucosal tear*
- A mucosal tear (**Mallory-Weiss tear**) of the esophagus is a common cause of hematemesis after forceful vomiting, especially in alcoholics.
- However, it is a **partial-thickness tear** and usually does not cause **chest pain** or **pneumomediastinum** (and thus Hamman's sign), which are hallmark features of a transmural tear.
Question 213: A 29-year-old man is brought to the emergency department 20 minutes after being stabbed in the left thigh. His pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Examination shows a 2-cm wound overlying a pulsatile mass on the left anterior thigh, 4 cm below the inguinal crease. A thrill is palpated, and a bruit is heard over this area. Peripheral pulses are normal bilaterally. The patient is at greatest risk for which of the following?
A. Erectile dysfunction
B. High-output cardiac failure (Correct Answer)
C. Pudendal nerve compression
D. Femoral head necrosis
E. Iliac artery aneurysm
Explanation: **High-output cardiac failure**
- The pulsatile mass, thrill, and bruit over the stab wound indicate an **arteriovenous (AV) fistula**, where arterial blood shunts directly into a vein.
- A large AV fistula significantly reduces systemic vascular resistance, increasing venous return and cardiac output, which can lead to **high-output cardiac failure** over time.
*Erectile dysfunction*
- While a vascular injury could, in rare cases, affect **penile blood supply**, the described injury in the anterior thigh (likely involving the femoral artery/vein) is not typically associated with erectile dysfunction as a primary or immediate complication.
- Erectile dysfunction is often related to injuries to the **internal pudendal arteries** or nerve damage (e.g., sacral plexus), which are not directly implicated by a femoral AV fistula.
*Pudendal nerve compression*
- A stab wound in the **anterior thigh** is anatomically distant from the pudendal nerve, which is located more medially and posteriorly in the pelvis and perineum.
- Pudendal nerve compression typically causes **perineal pain** or numbness, not symptoms related to a femoral AV fistula.
*Femoral head necrosis*
- **Avascular necrosis of the femoral head** is usually caused by disruption of the blood supply via the medial femoral circumflex artery, often due to trauma like hip dislocation or chronic corticosteroid use.
- The described injury is to the **superficial femoral vessels** and is not directly upstream of the typical blood supply to the femoral head sufficient to cause necrosis.
*Iliac artery aneurysm*
- An aneurysm is a **localized dilation** of an artery, usually due to weakening of the vessel wall, and it's distinct from an AV fistula which involves a direct connection between an artery and a vein.
- While the iliac artery feeds into the femoral artery, the pulsatile mass and bruit directly at the wound site are characteristic of a **traumatic AV fistula**, not an iliac artery aneurysm.
Question 214: A 35-year-old man arrives at the emergency department within minutes after a head-on motor vehicle accident. He suffered from blunt abdominal trauma, several lacerations to his face as well as lacerations to his upper and lower extremities. The patient is afebrile, blood pressure is 45/25 mmHg and pulse is 160/minute. A CBC is obtained and is most likely to demonstrate which of the following?
A. Hb 17 g/dL, Hct 20%
B. Hb 15 g/dL, Hct 45% (Correct Answer)
C. Hb 5 g/dL, Hct 30%
D. Hb 20 g/dL, Hct 60%
E. Hb 5 g/dL, Hct 20%
Explanation: ***Hb 15 g/dL, Hct 45%***
- This option represents **normal hemoglobin and hematocrit values**, which are expected in the **initial minutes following acute hemorrhage**.
- In acute blood loss, **whole blood is lost** (both RBCs and plasma together), so the **concentration of RBCs remains unchanged** initially.
- **Hemodilution has not yet occurred**, as there hasn't been enough time for fluid shifts from the extravascular to the intravascular space to dilute the blood.
- This is a **critical teaching point**: early CBC values can be **falsely reassuring** and don't reflect the severity of hemorrhagic shock.
*Hb 17 g/dL, Hct 20%*
- This option shows a **medically implausible combination** - the normal Hb:Hct ratio is approximately **1:3**, so an Hb of 17 g/dL should correspond to an Hct of approximately 51%, not 20%.
- This combination cannot occur physiologically and does not represent any stage of acute blood loss.
*Hb 5 g/dL, Hct 30%*
- This shows an **incorrect Hb:Hct ratio** (6:1 instead of the expected 3:1) - if Hb is 5 g/dL, the Hct should be approximately 15%, not 30%.
- While severe anemia can occur with massive blood loss, this would only be apparent **hours after injury** once hemodilution from fluid shifts occurs, not within minutes.
- The implausible ratio makes this medically incorrect.
*Hb 20 g/dL, Hct 60%*
- These values represent **polycythemia** (abnormally high red blood cell counts), which is the opposite of what would be expected after acute traumatic blood loss.
- The Hb:Hct ratio is appropriate (1:3), but the elevated values suggest chronic hypoxemia, dehydration, or myeloproliferative disorders - not acute hemorrhage.
*Hb 5 g/dL, Hct 20%*
- This shows an **incorrect Hb:Hct ratio** (4:1 instead of the expected 3:1) - if Hb is 5 g/dL, the Hct should be approximately 15%, not 20%.
- Even if we accept these as severe anemia values, they would only be seen **several hours after injury** when sufficient time has passed for fluid shifts and hemodilution to occur, not within minutes of the trauma.
Question 215: A 30-year-old male presents with a testicular mass of unknown duration. The patient states he first noticed something unusual with his right testicle two weeks ago, but states he did not think it was urgent because it was not painful and believed it would resolve on its own. It has not changed since he first noticed the mass, and the patient still denies pain. On exam, the patient’s right testicle is non-tender, and a firm mass is felt. There is a negative transillumination test, and the mass is non-reducible. Which of the following is the best next step in management?
A. MRI abdomen and pelvis
B. CT abdomen and pelvis
C. Testicular ultrasound (Correct Answer)
D. Send labs
E. Needle biopsy
Explanation: ***Testicular ultrasound***
- A **testicular ultrasound** is the diagnostic study of choice for evaluating a **scrotal mass** to determine if it is intratesticular or extratesticular, and to assess its characteristics (solid, cystic).
- The patient's presentation with a **painless, firm, non-transilluminating testicular mass** is highly suspicious for a **testicular tumor**, making immediate ultrasound essential to confirm the diagnosis.
*MRI abdomen and pelvis*
- While MRI can provide detailed anatomical information, it is typically performed for **staging** a confirmed testicular cancer, not as the initial diagnostic step.
- Its higher cost and longer imaging time make it less suitable for initial evaluation than ultrasound.
*CT abdomen and pelvis*
- CT scans are primarily used for **staging** testicular cancer, particularly to evaluate for **lymph node involvement** or distant metastases.
- It does not provide the resolution needed for precise characterization of an intratesticular mass and exposes the patient to **ionizing radiation**.
*Send labs*
- **Tumor markers** such as **alpha-fetoprotein (AFP)**, **beta-human chorionic gonadotropin (beta-hCG)**, and **lactate dehydrogenase (LDH)** are important for the diagnosis, staging, and monitoring of testicular cancer.
- However, blood tests alone cannot definitively diagnose a testicular mass or determine its nature; imaging is necessary.
*Needle biopsy*
- **Needle biopsy** is generally **contraindicated** for suspected testicular masses due to the risk of **tumor seeding** within the scrotum or along the biopsy tract.
- Diagnosis and tumor removal are typically achieved through an **inguinal orchiectomy** if malignancy is suspected.
Question 216: A 28-year-old soldier is brought back to a military treatment facility 45 minutes after sustaining injuries in a building fire from a mortar attack. He was trapped inside the building for around 20 minutes. On arrival, he is confused and appears uncomfortable. He has a Glasgow Coma Score of 13. His pulse is 113/min, respirations are 18/min, and blood pressure is 108/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows multiple second-degree burns over the chest and bilateral upper extremities and third-degree burns over the face. There are black sediments seen within the nose and mouth. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?
A. Insertion of nasogastric tube and enteral nutrition
B. Intravenous antibiotic therapy
C. Intubation and mechanical ventilation (Correct Answer)
D. Immediate bronchoscopy
E. Intravenous corticosteroid therapy
Explanation: ***Intubation and mechanical ventilation***
- The patient exhibits several signs of impending **airway compromise** due to **inhalation injury**, including perioral burns, black sediments in the nose and mouth, and being trapped in a fire.
- While current oxygen saturation is 96%, **airway edema** can rapidly worsen, leading to respiratory failure. **Early intubation** is crucial to secure the airway before it becomes obstructed.
*Insertion of nasogastric tube and enteral nutrition*
- A nasogastric tube is often placed in burn patients to decompress the stomach and provide nutritional support, but it is **not the immediate priority** when there is a risk of airway obstruction.
- **Enteral nutrition** is important but should be initiated only after airway control is established and the patient is stable for feeding.
*Intravenous antibiotic therapy*
- **Prophylactic antibiotics** are generally **not recommended** in the immediate management of burn patients unless there is clear evidence of infection, which is not present here.
- Unnecessary antibiotic use can lead to **antibiotic resistance** and fungal infections.
*Immediate bronchoscopy*
- While **bronchoscopy** can confirm the extent of inhalation injury, it is not the primary immediate step. **Securing the airway** through intubation takes precedence over diagnostic procedures when airway compromise is imminent.
- Bronchoscopy can be considered *after* intubation to assess the lower airway for damage and guide further management.
*Intravenous corticosteroid therapy*
- **Corticosteroids** are typically **contraindicated** in the management of inhalation injury because they can **impair immune function** and increase the risk of infection in burn patients.
- Evidence does not support the routine use of corticosteroids to reduce inflammation in inhalation injury, and they may worsen outcomes.
Question 217: A 5-year-old boy is brought to the emergency department for right elbow swelling and pain 45 minutes after he fell while playing on the monkey bars during recess. He has been unable to move his right elbow since the fall. Examination shows ecchymosis, swelling, and tenderness of the right elbow; range of motion is limited by pain. The remainder of the examination shows no abnormalities. An x-ray of the right arm is shown. Which of the following is the most likely complication of this patient's injury?
A. Polymicrobial infection
B. Impaired extension of the wrist and hand
C. Adhesive capsulitis
D. Avascular necrosis of the humeral head
E. Absent radial pulse (Correct Answer)
Explanation: ***Absent radial pulse***
- The image likely shows a **supracondylar fracture** of the humerus, a common injury in children following a fall on an outstretched hand.
- The **brachial artery** runs anterior to the humerus and is highly susceptible to injury or compression in supracondylar fractures, leading to an **absent radial pulse** and potential for **compartment syndrome** if not promptly managed.
*Polymicrobial infection*
- **Polymicrobial infections** are typically associated with open fractures, contaminated wounds, or immunocompromised states.
- This patient's injury is described as a closed fracture with ecchymosis and swelling; there is no indication of an open wound or infection.
*Impaired extension of the wrist and hand*
- This symptom is characteristic of **radial nerve injury**, which is less commonly associated with supracondylar fractures than brachial artery or median nerve injury.
- While possible, the immediate concern for a supracondylar fracture usually revolves around **vascular compromise**.
*Adhesive capsulitis*
- **Adhesive capsulitis** (frozen shoulder) is a condition primarily affecting the shoulder joint in adults, characterized by pain and stiffness.
- It is not a typical complication of an acute elbow fracture in a child and is more of a chronic condition.
*Avascular necrosis of the humeral head*
- **Avascular necrosis of the humeral head** is a rare complication, usually associated with **proximal humerus fractures** or dislocations, chronic steroid use, or sickle cell disease.
- It is not a direct or immediate complication of a **distal humerus (supracondylar) fracture**.
Question 218: A 54-year-old man comes to the physician because of a painful mass in his left thigh for 3 days. He underwent a left lower limb angiography for femoral artery stenosis and had a stent placed 2 weeks ago. He has peripheral artery disease, coronary artery disease, hypercholesterolemia and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 34 years. Current medications include enalapril, aspirin, simvastatin, metformin, and sitagliptin. His temperature is 36.7°C (98°F), pulse is 88/min, and blood pressure is 116/72 mm Hg. Examination shows a 3-cm (1.2-in) tender, pulsatile mass in the left groin. The skin over the area of the mass shows no erythema and is cool to the touch. A loud bruit is heard on auscultation over this area. The remainder of the examination shows no abnormalities. Results of a complete blood count and serum electrolyte concentrations show no abnormalities. Duplex ultrasonography shows an echolucent sac connected to the common femoral artery, with pulsatile and turbulent blood flow between the artery and the sac. Which of the following is the most appropriate next best step in management?
A. Ultrasound-guided thrombin injection (Correct Answer)
B. Covered stent implantation
C. Ultrasound-guided compression
D. Coil embolization
E. Schedule surgical repair
Explanation: ***Ultrasound-guided thrombin injection***
- The patient presents with a **post-catheterization pseudoaneurysm** as indicated by the pulsatile, tender mass with a bruit after recent femoral angiography, and confirmed by duplex ultrasonography showing an echolucent sac connected to the common femoral artery with pulsatile flow.
- **Ultrasound-guided thrombin injection** is the preferred treatment for pseudoaneurysms that are larger than 2-3 cm or have been present for more than 1 week, as it effectively closes the pseudoaneurysm sac with a high success rate and minimal invasiveness.
*Covered stent implantation*
- This is a treatment for arterial injury or aneurysm, but it is generally reserved for **larger or more complex pseudoaneurysms**, or those that have failed less invasive treatments, due to its greater invasiveness and potential complications.
- It involves placing a stent graft to exclude the pseudoaneurysm from the circulation.
*Ultrasound-guided compression*
- This technique involves applying sustained pressure to the pseudoaneurysm neck, which can lead to thrombosis. However, it has a **lower success rate** compared to thrombin injection, especially for larger pseudoaneurysms, and is often painful and time-consuming.
- It is often considered a first-line therapy for smaller pseudoaneurysms (<2-3 cm) before thrombin injection, but in this case, the pseudoaneurysm is 3 cm.
*Coil embolization*
- This procedure is typically used to treat **arteriovenous malformations** or high-flow bleeding rather than pseudoaneurysms.
- It involves placing coils into the vessel to induce thrombosis, but carries risks of distal embolization and might be overly aggressive for a femoral pseudoaneurysm.
*Schedule surgical repair*
- **Surgical repair** is indicated for pseudoaneurysms that are rapidly expanding, symptomatic with critical limb ischemia, infected, or those that have failed less invasive treatments.
- In this case, given the patient's stable condition and the availability of less invasive options, surgical repair is not the initial best step.
Question 219: A 45-year-old man is brought to the emergency department following a house fire. Following initial stabilization, the patient is transferred to the ICU for management of his third-degree burn injuries. On the second day of hospitalization, a routine laboratory panel is obtained, and the results are demonstrated below. Per the nurse, he remains stable compared to the day prior. His temperature is 99°F (37°C), blood pressure is 92/64 mmHg, pulse is 98/min, respirations are 14/min, and SpO2 is 98%. A physical examination demonstrates an unresponsive patient with extensive burn injuries throughout his torso and lower extremities.
Hemoglobin: 13 g/dL
Hematocrit: 36%
Leukocyte count: 10,670/mm^3 with normal differential
Platelet count: 180,000/mm^3
Serum:
Na+: 135 mEq/L
Cl-: 98 mEq/L
K+: 4.7 mEq/L
HCO3-: 25 mEq/L
BUN: 10 mg/dL
Glucose: 123 mg/dL
Creatinine: 1.8 mg/dL
Thyroid-stimulating hormone: 4.3 µU/mL
Triiodothyronine: 48 ng/dL
Thyroxine: 10 ug/dL
Ca2+: 8.7 mg/dL
AST: 89 U/L
ALT: 135 U/L
What is the best course of management for this patient?
A. Continued management of his burn wounds (Correct Answer)
B. Increase opioid dosage
C. Start patient on intravenous ceftriaxone and vancomycin
D. Regular levothyroxine sodium injections
E. Immediate administration of propranolol
Explanation: ***Continued management of his burn wounds***
- The patient, despite extensive third-degree burns and several laboratory abnormalities, is **hemodynamically stable**, afebrile, and has an unremarkable white blood cell count and differential, indicating no immediate need for aggressive interventions beyond ongoing burn care.
- The abnormal laboratory values (e.g., elevated creatinine, AST/ALT, low T3) are common in critically ill patients with severe burns and often represent **"sick euthyroid syndrome"** or systemic stress responses rather than primary organ dysfunction requiring specific drug therapy.
*Increase opioid dosage*
- While burn patients experience significant pain, the patient is described as **unresponsive**, suggesting that his current pain management is likely adequate or that he is not consciously perceiving pain.
- Increasing opioids in an unresponsive patient could lead to **respiratory depression** and further hemodynamic compromise, which is not indicated given his current stable vital signs.
*Start patient on intravenous ceftriaxone and vancomycin*
- Although burn wounds are prone to infection, the patient's **normal temperature**, stable vital signs, and **unremarkable leukocyte count** and differential do not suggest an active bacterial infection requiring broad-spectrum antibiotics at this time.
- Prophylactic antibiotic use in burn patients is generally **discouraged** due to the risk of promoting antibiotic resistance and fungal infections.
*Immediate administration of propanolol*
- Propranolol is sometimes used in severe burn patients to modulate the hypermetabolic response, but this is typically a **long-term management strategy**, not an immediate intervention in the acute phase, especially with a BP of 92/64 mmHg.
- Given his slightly low blood pressure, administering a beta-blocker like propranolol could **worsen hypotension** and reduce cardiac output.
*Regular levothyroxine sodium injections*
- The patient's low T3 and normal TSH are consistent with **"euthyroid sick syndrome,"** a common adaptive response to critical illness, including severe burns.
- In euthyroid sick syndrome, **thyroid hormone replacement is not indicated** and may even be harmful, as it does not improve outcomes and can exacerbate catecholamine effects.
Question 220: A 22-year-old man comes to the physician because of a progressive swelling and pain in his right ring finger for the past 2 days. The pain began while playing football, when his finger got caught in the jersey of another player who forcefully pulled away. Examination shows that the right ring finger is extended. There is pain and swelling at the distal interphalangeal joint. When the patient is asked to make a fist, his right ring finger does not flex at the distal interphalangeal joint. There is no joint laxity. Which of the following is the most likely diagnosis?
A. Inflammation of the flexor digitorum profundus tendon sheath
B. Closed fracture of the distal phalanx
C. Rupture of the extensor digitorum tendon at its point of insertion
D. Rupture of the flexor digitorum profundus tendon at its point of insertion (Correct Answer)
E. Slipping of the central band of the extensor digitorum tendon
Explanation: ***Rupture of the flexor digitorum profundus tendon at its point of insertion***
- The inability to flex the **distal interphalangeal (DIP) joint** of the right ring finger, despite attempts to make a fist, is the hallmark sign of a **flexor digitorum profundus (FDP) tendon rupture**.
- The mechanism of injury, where the finger is forcibly extended while trying to flex (e.g., getting caught in a jersey), is a classic presentation for an **FDP avulsion**, often referred to as "jersey finger."
*Inflammation of the flexor digitorum profundus tendon sheath*
- While inflammation of the **tendon sheath** (tenosynovitis) would cause pain and swelling, it would typically not result in a complete inability to flex the **DIP joint**.
- Tendon sheath inflammation is often associated with repetitive strain or infection, not typically an acute traumatic avulsion like presented.
*Closed fracture of the distal phalanx*
- A **closed fracture** of the distal phalanx would cause pain and swelling, but finger extension would likely be impaired or severely painful, not specifically the isolated inability to flex the **DIP joint**.
- While an avulsion fracture could occur with the FDP rupture, the primary functional deficit points more directly to the tendon injury itself.
*Rupture of the extensor digitorum tendon at its point of insertion*
- A rupture of the **extensor digitorum tendon** at its insertion (mallet finger) would lead to an inability to extend the **DIP joint**, causing the finger to remain in a flexed position.
- The patient's finger is described as extended, and the issue is an inability to flex, which contradicts a **mallet finger** diagnosis.
*Slipping of the central band of the extensor digitorum tendon*
- Slipping of the **central band** of the extensor digitorum tendon is characteristic of a **Boutonnière deformity**, which results in flexion of the **proximal interphalangeal (PIP) joint** and hyperextension of the DIP joint.
- This condition is typically chronic and progressive, not an acute traumatic event causing a sudden loss of DIP flexion.
