A 52-year-old woman is brought to the emergency department by fire and rescue after being involved in a motor vehicle accident. The paramedics report that the patient’s car slipped off the road during a rainstorm and rolled into a ditch. The patient was restrained and the airbags deployed during the crash. The patient has a past medical history of hypertension, hyperlipidemia, hypothyroidism, and gout. Her home medications include hydrochlorothiazide, simvastatin, levothyroxine, and allopurinol. The patient is alert on the examination table. Her temperature is 98.2°F (36.8°C), blood pressure is 83/62 mmHg, pulse is 131/min, respirations are 14/min, and SpO2 is 96%. She has equal breath sounds in all fields bilaterally. Her skin is cool with diffuse bruising over her abdomen and superficial lacerations, and her abdomen is diffusely tender to palpation. She is moving all four extremities equally. The patient’s FAST exam is equivocal. She is given several liters of intravenous fluid during her trauma evaluation but her blood pressure does not improve.
Which of the following is the best next step?
Q32
A 27-year-old man comes to the physician because of pain and swelling in his right knee that began 3 days ago when he fell during football practice. He fell on his flexed right knee as he dove to complete a pass. He felt some mild knee pain but continued to practice. Over the next 2 days, the pain worsened and the knee began to swell. Today, the patient has an antalgic gait. Examination shows a swollen and tender right knee; flexion is limited by pain. The right knee is flexed and pressure is applied to proximal tibia; 8 mm of backward translation of the foreleg is observed. Which of the following is most likely injured?
Q33
A 24-year-old woman presents to her primary care physician for unilateral breast pain. The patient states that she has been breastfeeding her son but has been experiencing worsening pain recently. Her pain is severe enough that she is now struggling to breastfeed her son with her left breast. The patient's past medical history is notable for gestational diabetes which was controlled with diet and exercise. Her temperature is 101°F (38.3°C), blood pressure is 137/69 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 97% on room air. Physical exam reveals an erythematous breast with a 3-cm tender and fluctuant mass of the left breast. Which of the following is the best next step in management?
Q34
A 40-year-old woman who works as a secretary presents to your office complaining of new pain and numbness in both of her hands. For the past few weeks, the sensation has occurred after long days of typing, but it now occasionally wakes her up from sleep. You do not note any deformities of her wrists or hands, but you are able to reproduce pain and numbness in the first three and a half digits by tapping the wrist. What is the best initial treatment for this patient's complaint?
Q35
A 32-year-old man is brought to the emergency department 15 minutes after falling 7 feet onto a flat-top wooden post. On arrival, he is in severe pain and breathing rapidly. His pulse is 135/min, respirations are 30/min, and blood pressure is 80/40 mm Hg. There is an impact wound in the left fourth intercostal space at the midaxillary line. Auscultation shows tracheal deviation to the right and absent breath sounds over the left lung. There is dullness to percussion over the left chest. Neck veins are flat. Cardiac examination shows no abnormalities. Two large-bore intravenous catheters are placed and intravenous fluid resuscitation is begun. Which of the following is the most likely diagnosis?
Q36
A 35-year-old man is brought into the emergency department by emergency medical services with his right hand wrapped in bloody bandages. The patient states that he is a carpenter and was cutting some wood for a home renovation project when he looked away and injured one of his digits with a circular table saw. He states that his index finger was sliced off and is being brought in by his wife. On exam, his vitals are within normal limits and stable, and he is missing part of his second digit on his right hand distal to the proximal interphalangeal joint. How should the digit be transported to the hospital for the best outcome?
Q37
A 35-year-old man is brought to the emergency department 20 minutes after being involved in a motor vehicle collision in which he was a restrained passenger. The patient is confused. His pulse is 140/min and blood pressure is 85/60 mm Hg. Examination shows a hand-sized hematoma on the anterior chest wall. An ECG shows sinus tachycardia. Which of the following structures is most likely injured in this patient?
Q38
A 52-year-old man presents to the emergency department because of fatigue, abdominal distension, and swelling of both legs for the last 3 weeks. His wife says that he lost some weight recently. He has had type 2 diabetes mellitus for 12 years, for which he takes metformin and sitagliptin. He has a history of Hodgkin’s lymphoma which was successfully treated with mediastinal radiation 20 years ago. He does not smoke or drink alcohol. He has a family history of type 2 diabetes in his father and elder sister. Vital signs include a blood pressure of 100/70 mm Hg, a temperature of 36.9°C (98.4°F), and a regular radial pulse of 90/min. On physical examination, there is jugular venous distension, most prominently when the patient inhales. Bilateral ankle pitting edema is present, and his abdomen is distended with shifting dullness on percussion. An early diastolic knocking sound is audible on the chest. His chest X-ray is shown in the exhibit. Which of the following is the best treatment for this patient?
Q39
A previously healthy 64-year-old man comes to the physician 3 days after noticing a lump in his right groin while he was bathing. He has no history of trauma to the region. He has hypercholesterolemia and hypertension treated with atorvastatin and labetalol. He has smoked 2 packs of cigarettes daily for 35 years. His vital signs are within normal limits. Examination shows a 4-cm (1.6-in), nontender, pulsatile mass with a palpable thrill at the right midinguinal point. On auscultation, a harsh continuous murmur is heard over the mass. Femoral and pedal pulses are palpable bilaterally. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
Q40
A 62-year-old man presents to the emergency department with sudden onset of severe left leg pain accompanied by numbness and weakness. His medical history is remarkable for hypertension and hyperlipidemia. His vital signs include a blood pressure of 155/92 mm Hg, a temperature of 37.1°C (98.7°F), and an irregular pulse of 92/min. Physical examination reveals absent left popliteal and posterior tibial pulses. His left leg is noticeably cold and pale. There is no significant tissue compromise, nerve damage, or sensory loss. Which of the following will most likely be required for this patient's condition?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 31: A 52-year-old woman is brought to the emergency department by fire and rescue after being involved in a motor vehicle accident. The paramedics report that the patient’s car slipped off the road during a rainstorm and rolled into a ditch. The patient was restrained and the airbags deployed during the crash. The patient has a past medical history of hypertension, hyperlipidemia, hypothyroidism, and gout. Her home medications include hydrochlorothiazide, simvastatin, levothyroxine, and allopurinol. The patient is alert on the examination table. Her temperature is 98.2°F (36.8°C), blood pressure is 83/62 mmHg, pulse is 131/min, respirations are 14/min, and SpO2 is 96%. She has equal breath sounds in all fields bilaterally. Her skin is cool with diffuse bruising over her abdomen and superficial lacerations, and her abdomen is diffusely tender to palpation. She is moving all four extremities equally. The patient’s FAST exam is equivocal. She is given several liters of intravenous fluid during her trauma evaluation but her blood pressure does not improve.
Which of the following is the best next step?
A. Diagnostic laparoscopy
B. Chest radiograph
C. Emergency laparotomy (Correct Answer)
D. Abdominal CT
E. Diagnostic peritoneal lavage
Explanation: ***Emergency laparotomy***
- The patient presents with **hypotension (83/62 mmHg), tachycardia (131/min)**, diffuse abdominal tenderness, and signs of significant trauma (diffuse bruising, superficial lacerations, motor vehicle accident with roll-over). Despite receiving **several liters of intravenous fluids, her blood pressure does not improve**, indicating ongoing hemodynamic instability likely due to uncontrolled intra-abdominal bleeding.
- An **equivocal FAST exam** in a hemodynamically unstable patient, coupled with failure to respond to fluid resuscitation, necessitates immediate surgical intervention to identify and control the source of hemorrhage, making **emergency laparotomy** the most appropriate next step.
*Diagnostic laparoscopy*
- While diagnostic laparoscopy can be used to evaluate abdominal injuries, it is a **minimally invasive procedure** that may not be suitable for a hemodynamically unstable patient with suspected active hemorrhage, as it can be time-consuming and risks missing larger bleeders.
- In this patient's unstable condition, a **more rapid and definitive intervention** is required to control bleeding.
*Chest radiograph*
- A chest radiograph is important for evaluating intrathoracic injuries, but the patient's presentation of **abdominal tenderness, diffuse bruising over her abdomen, and equivocal FAST exam** points more towards an abdominal source of instability.
- While it might be performed as part of a trauma workup, it is **not the best next step to address the immediate life-threatening abdominal bleeding** in a hemodynamically unstable patient.
*Abdominal CT*
- An abdominal CT scan is a valuable diagnostic tool for evaluating abdominal injuries but requires the patient to be **hemodynamically stable** to be safely transported to and through the scanner.
- This patient's **persistent hypotension and tachycardia despite fluid resuscitation** indicate ongoing instability, making transport to CT potentially dangerous and delaying definitive treatment.
*Diagnostic peritoneal lavage*
- Diagnostic peritoneal lavage (DPL) is a highly sensitive test for detecting intra-abdominal hemorrhage but has largely been replaced by the **Focused Assessment with Sonography for Trauma (FAST) exam** in many trauma centers.
- The FAST exam was already performed and was **equivocal**, and given the patient's clinical picture of instability, proceeding directly to **emergency laparotomy** is more efficient and life-saving than performing another diagnostic test that would delay definitive treatment.
Question 32: A 27-year-old man comes to the physician because of pain and swelling in his right knee that began 3 days ago when he fell during football practice. He fell on his flexed right knee as he dove to complete a pass. He felt some mild knee pain but continued to practice. Over the next 2 days, the pain worsened and the knee began to swell. Today, the patient has an antalgic gait. Examination shows a swollen and tender right knee; flexion is limited by pain. The right knee is flexed and pressure is applied to proximal tibia; 8 mm of backward translation of the foreleg is observed. Which of the following is most likely injured?
A. Posterior cruciate ligament (Correct Answer)
B. Anterior cruciate ligament
C. Medial collateral ligament
D. Lateral collateral ligament
E. Lateral meniscus
Explanation: ***Posterior cruciate ligament***
- The mechanism of injury, falling on a **flexed knee** with direct impact to the **proximal tibia**, is classic for a **posterior cruciate ligament (PCL)** injury.
- The finding of **8 mm of backward translation** of the foreleg with pressure applied to the proximal tibia (positive **posterior drawer test**) is diagnostic for PCL injury.
*Anterior cruciate ligament*
- **Anterior cruciate ligament (ACL)** injuries typically result from sudden stopping, pivoting, or direct blows to the **front of the knee**, often causing **anterior translation** of the tibia.
- The **anterior drawer test** or **Lachman test** would show increased anterior translation, not posterior.
*Medial collateral ligament*
- **Medial collateral ligament (MCL)** injuries usually occur due to a force applied to the **outside of the knee** (valgus stress), causing instability on the medial side.
- Associated with tenderness over the medial knee joint line and instability with **valgus stress testing**.
*Lateral collateral ligament*
- **Lateral collateral ligament (LCL)** injuries typically result from a force applied to the **inside of the knee** (varus stress), leading to instability on the lateral aspect.
- Associated with tenderness over the lateral knee joint line and instability with **varus stress testing**.
*Lateral meniscus*
- **Meniscal injuries** often present with mechanical symptoms such as clicking, locking, or catching, and pain that might worsen with specific movements like twisting or squatting.
- While a fall could potentially injure the meniscus, the specific finding of **posterior tibial translation** points more directly to a ligamentous injury.
Question 33: A 24-year-old woman presents to her primary care physician for unilateral breast pain. The patient states that she has been breastfeeding her son but has been experiencing worsening pain recently. Her pain is severe enough that she is now struggling to breastfeed her son with her left breast. The patient's past medical history is notable for gestational diabetes which was controlled with diet and exercise. Her temperature is 101°F (38.3°C), blood pressure is 137/69 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 97% on room air. Physical exam reveals an erythematous breast with a 3-cm tender and fluctuant mass of the left breast. Which of the following is the best next step in management?
A. No intervention necessary
B. Ultrasound and fine needle aspiration (Correct Answer)
C. Incision and drainage
D. Ice packs and breast pumping
E. Vancomycin and discharge home
Explanation: ***Ultrasound and fine needle aspiration***
- The presence of a **tender**, **fluctuant breast mass** with accompanying **fever** in a breastfeeding woman is highly suggestive of a **breast abscess**.
- **Ultrasound-guided needle aspiration** is the **first-line treatment** for breast abscess according to current guidelines (ACOG, WHO).
- This approach is **less invasive** than incision and drainage, allows for better cosmetic outcomes, and enables easier continuation of breastfeeding.
- Aspiration can be **repeated if necessary**, and most abscesses (80-90%) resolve with aspiration plus antibiotics.
*Incision and drainage*
- While this was historically the standard treatment, it is now considered **second-line therapy** for breast abscesses.
- Reserved for cases where **needle aspiration fails**, or for **complex/multiloculated abscesses**.
- More invasive with greater tissue disruption and potentially more difficult breastfeeding recovery.
*No intervention necessary*
- The patient presents with clear signs of **infection** (fever, pain, erythema) and a **palpable abscess**, indicating urgent need for intervention.
- Ignoring these symptoms could lead to worsening infection, systemic sepsis, or more complex surgical intervention.
*Ice packs and breast pumping*
- **Ice packs** and **breast pumping** are supportive measures for managing **mastitis** or engorgement but will not resolve a formed **abscess**.
- These interventions would delay appropriate treatment and potentially worsen the infection.
*Vancomycin and discharge home*
- **Antibiotics** like vancomycin are crucial adjunctive therapy for breast abscesses, especially considering potential **MRSA involvement**.
- However, for a **fluctuant abscess**, antibiotics alone are insufficient without **drainage** (aspiration or incision); discharging without drainage is inappropriate.
Question 34: A 40-year-old woman who works as a secretary presents to your office complaining of new pain and numbness in both of her hands. For the past few weeks, the sensation has occurred after long days of typing, but it now occasionally wakes her up from sleep. You do not note any deformities of her wrists or hands, but you are able to reproduce pain and numbness in the first three and a half digits by tapping the wrist. What is the best initial treatment for this patient's complaint?
A. Local steroid injections
B. Carpal tunnel release surgery
C. Splinting (Correct Answer)
D. A trial of gabapentin
E. Short-acting benzodiazepines
Explanation: ***Splinting***
- This patient's symptoms are highly suggestive of **carpal tunnel syndrome (CTS)**, given the **pain and numbness** in the distribution of the **median nerve** (first three and a half digits) that is exacerbated by repetitive wrist movements (typing) and reproduced by **Tinel's sign** (tapping the wrist).
- **Splinting** the wrist, especially at night, is the **first-line conservative treatment** for CTS, as it keeps the wrist in a neutral position, reducing pressure on the median nerve.
*Local steroid injections*
- While local steroid injections can provide **temporary relief** for CTS, they are typically considered if splinting and activity modification are unsuccessful.
- They are not the **initial treatment** of choice due to potential side effects and the less invasive nature of splinting.
*Carpal tunnel release surgery*
- **Carpal tunnel release surgery** is a definitive treatment for CTS but is reserved for cases that fail conservative management, show signs of **thenar atrophy**, or have objective evidence of severe nerve compression on **electromyography/nerve conduction studies**.
- It is an **invasive procedure** and not appropriate as a first-line intervention.
*A trial of gabapentin*
- **Gabapentin** is an anticonvulsant often used to treat **neuropathic pain**, but it is generally reserved for more generalized or refractory neuropathic conditions.
- It is not the primary treatment for localized nerve compression like CTS when less invasive and more targeted options are available.
*Short-acting benzodiazepines*
- **Benzodiazepines** are primarily used for anxiety, insomnia, or muscle spasms and have **no direct role** in treating the underlying nerve compression or symptoms of carpal tunnel syndrome.
- They do not address the pathology and carry risks of dependency.
Question 35: A 32-year-old man is brought to the emergency department 15 minutes after falling 7 feet onto a flat-top wooden post. On arrival, he is in severe pain and breathing rapidly. His pulse is 135/min, respirations are 30/min, and blood pressure is 80/40 mm Hg. There is an impact wound in the left fourth intercostal space at the midaxillary line. Auscultation shows tracheal deviation to the right and absent breath sounds over the left lung. There is dullness to percussion over the left chest. Neck veins are flat. Cardiac examination shows no abnormalities. Two large-bore intravenous catheters are placed and intravenous fluid resuscitation is begun. Which of the following is the most likely diagnosis?
A. Bronchial rupture
B. Cardiac tamponade
C. Flail chest
D. Hemothorax (Correct Answer)
E. Tension pneumothorax
Explanation: ***Hemothorax***
- The combination of **absent breath sounds**, **dullness to percussion** on the left, and **hypotension with flat neck veins** following trauma strongly suggests a massive hemothorax causing **hypovolemic shock** from significant blood loss into the pleural space.
- The injury site at the **left fourth intercostal space** (midaxillary line) is a common location for vascular injury. Dullness to percussion indicates fluid (blood) accumulation, not air.
- **Flat neck veins** are the key finding distinguishing hypovolemic shock (blood loss) from obstructive shock (tension pneumothorax or tamponade would cause distended neck veins).
- Tracheal deviation away from the affected side can occur with massive hemothorax due to mediastinal shift from fluid accumulation.
*Bronchial rupture*
- While possible with severe trauma, bronchial rupture typically presents with significant **air leak**, leading to subcutaneous emphysema and persistent pneumothorax, rather than **dullness to percussion** (which indicates fluid, not air).
- Usually causes **hyperresonance** on percussion, not dullness. Does not typically cause immediate massive hypovolemic shock with flat neck veins.
*Cardiac tamponade*
- Characterized by **Beck's triad**: hypotension, muffled heart sounds, and **distended neck veins** (due to impaired venous return).
- This patient has **flat neck veins**, which rules out tamponade. Additionally, cardiac examination shows no abnormalities (would expect muffled heart sounds in tamponade).
*Flail chest*
- Involves **paradoxical chest wall movement** due to multiple rib fractures creating a free-floating segment. While it causes pain and respiratory distress, it does not explain absent breath sounds, dullness to percussion, tracheal deviation, or hypovolemic shock.
- The primary issue is usually underlying pulmonary contusion, not massive blood loss into the pleural space.
*Tension pneumothorax*
- Classic presentation includes **absent breath sounds**, **hyperresonance to percussion** (air accumulation), **tracheal deviation** away from affected side, and **distended neck veins** (obstructive shock).
- This patient has **dullness to percussion** (fluid, not air) and **flat neck veins** (hypovolemic, not obstructive shock), making tension pneumothorax incompatible with the clinical picture.
Question 36: A 35-year-old man is brought into the emergency department by emergency medical services with his right hand wrapped in bloody bandages. The patient states that he is a carpenter and was cutting some wood for a home renovation project when he looked away and injured one of his digits with a circular table saw. He states that his index finger was sliced off and is being brought in by his wife. On exam, his vitals are within normal limits and stable, and he is missing part of his second digit on his right hand distal to the proximal interphalangeal joint. How should the digit be transported to the hospital for the best outcome?
A. In a sterile plastic bag wrapped in saline moistened gauze on ice (Correct Answer)
B. In a sterile bag of tap water
C. In the pocket of a coat or a jacket
D. Wrapped in a towel
E. In a sterile plastic bag wrapped in saline moistened gauze
Explanation: ***In a sterile plastic bag wrapped in saline moistened gauze on ice***
- The amputated digit should be wrapped in **saline-moistened gauze** to prevent tissue desiccation and then placed in a **sterile plastic bag**.
- This bag should then be placed on **ice** (indirect contact) to cool the tissue and minimize ischemic damage, preserving viability for potential re-implantation.
*In a sterile bag of tap water*
- Placing the digit directly in **tap water** can cause significant cellular damage due to osmotic differences, leading to cell lysis and making re-implantation less successful.
- Tap water is also not sterile, increasing the risk of **infection** for the amputated part.
*In the pocket of a coat or a jacket*
- Transporting the digit in a pocket provides no **temperature control** or **sterility**, leading to rapid tissue degradation and increased risk of bacterial contamination.
- This method offers no protection against **trauma or loss** of the amputated part.
*Wrapped in a towel*
- Wrapping the digit in a towel alone does not provide adequate **sterility** or **moisture**, leading to tissue desiccation and increased contamination risk.
- A towel offers no means of **cooling** the tissue, which is crucial for preserving cell viability.
*In a sterile plastic bag wrapped in saline moistened gauze*
- While wrapping in **saline-moistened gauze** and a sterile bag is a good start, the absence of **cooling** (ice) significantly reduces the time window for successful re-implantation.
- Without cooling, the **metabolic rate** of the tissue remains high, accelerating ischemic damage and tissue death.
Question 37: A 35-year-old man is brought to the emergency department 20 minutes after being involved in a motor vehicle collision in which he was a restrained passenger. The patient is confused. His pulse is 140/min and blood pressure is 85/60 mm Hg. Examination shows a hand-sized hematoma on the anterior chest wall. An ECG shows sinus tachycardia. Which of the following structures is most likely injured in this patient?
A. Papillary muscle
B. Left main coronary artery
C. Inferior vena cava
D. Aortic isthmus (Correct Answer)
E. Aortic valve
Explanation: ***Aortic isthmus***
- The **aortic isthmus** is the most common site of blunt **aortic injury** due to its relative immobility compared to the more mobile ascending aorta and arch. The deceleration forces experienced in a motor vehicle collision can cause a shearing injury at this location.
- The patient's **hypotension** and **tachycardia** are signs of significant hemorrhage, which is a common presentation of aortic injury. The chest wall hematoma also suggests significant trauma to the chest.
*Papillary muscle*
- Injury to the **papillary muscles** typically leads to severe **mitral regurgitation**, presenting with acute heart failure symptoms like pulmonary edema rather than primarily hypovolemic shock.
- While possible in trauma, the primary symptoms would involve a new significant murmur and rapid deterioration of cardiac function due to valve incompetence.
*Left main coronary artery*
- A **left main coronary artery** injury would likely lead to acute **myocardial ischemia** or infarction, manifesting as severe chest pain, ECG changes indicative of ischemia, and potentially cardiogenic shock, not hypovolemic shock.
- While trauma to the chest can cause coronary artery dissection, it is less common for blunt force to directly injure this artery without other, more widespread myocardial damage.
*Inferior vena cava*
- An injury to the **inferior vena cava (IVC)** would primarily cause severe internal bleeding, leading to hypovolemic shock. However, while possible, blunt force trauma to the chest is less likely to directly injure the retroperitoneal IVC without significant associated abdominal or lumbar spine injuries.
- The chest wall hematoma and focus on the chest suggests damage within the thoracic cavity, making an aortic injury more probable given the mechanism.
*Aortic valve*
- An injury to the **aortic valve** could cause acute **aortic regurgitation**, leading to acute heart failure and potentially cardiogenic shock with a new diastolic murmur.
- While possible, pure aortic valve injury from blunt trauma alone, without rupture of the aorta itself, is less common than aortic tear from shearing forces.
Question 38: A 52-year-old man presents to the emergency department because of fatigue, abdominal distension, and swelling of both legs for the last 3 weeks. His wife says that he lost some weight recently. He has had type 2 diabetes mellitus for 12 years, for which he takes metformin and sitagliptin. He has a history of Hodgkin’s lymphoma which was successfully treated with mediastinal radiation 20 years ago. He does not smoke or drink alcohol. He has a family history of type 2 diabetes in his father and elder sister. Vital signs include a blood pressure of 100/70 mm Hg, a temperature of 36.9°C (98.4°F), and a regular radial pulse of 90/min. On physical examination, there is jugular venous distension, most prominently when the patient inhales. Bilateral ankle pitting edema is present, and his abdomen is distended with shifting dullness on percussion. An early diastolic knocking sound is audible on the chest. His chest X-ray is shown in the exhibit. Which of the following is the best treatment for this patient?
A. Pericardiectomy (Correct Answer)
B. Percutaneous aspiration with high-flow oxygen
C. Pleurodesis
D. Ibuprofen, plus colchicine
E. Pericardiocentesis
Explanation: ***Pericardiectomy***
- This patient presents with signs and symptoms of **constrictive pericarditis**, including **fatigue**, **abdominal distension** (ascites), **bilateral leg swelling** (edema), **jugular venous distension** (Kussmaul sign), and an **early diastolic knocking sound**. The **chest X-ray** demonstrating **pericardial calcification** (arrows) is highly suggestive of this condition.
- As medical therapies are generally ineffective for constrictive pericarditis, **surgical pericardiectomy** (removal of the pericardium) is the definitive treatment to relieve the constriction and improve cardiac function.
*Percutaneous aspiration with high-flow oxygen*
- This treatment is typical for a **tension pneumothorax**, which involves air accumulation in the pleural space, compressing the lung and mediastinum.
- The patient's symptoms and imaging, especially the chest X-ray showing pericardial calcification, are inconsistent with pneumothorax.
*Pleurodesis*
- **Pleurodesis** is a procedure used to prevent recurrent **pleural effusions** or **pneumothorax** by adhering the parietal and visceral pleura.
- This patient's presentation points to pericardial, not pleural, pathology, and there is no mention of recurrent pleural effusions or pneumothorax.
*Ibuprofen, plus colchicine*
- This combination is the standard treatment for **acute pericarditis**, which is characterized by chest pain, pericardial friction rub, and EKG changes.
- The patient's chronic symptoms, signs of fluid overload, and pericardial calcification indicate **constrictive pericarditis**, not acute inflammation, making anti-inflammatory agents ineffective.
*Pericardiocentesis*
- **Pericardiocentesis** is indicated for **pericardial tamponade** or large, symptomatic **pericardial effusions** to relieve pressure.
- While fluid overload is present, the key underlying issue is chronic pericardial constriction due to calcification, not a large acute effusion amenable to simple drainage.
Question 39: A previously healthy 64-year-old man comes to the physician 3 days after noticing a lump in his right groin while he was bathing. He has no history of trauma to the region. He has hypercholesterolemia and hypertension treated with atorvastatin and labetalol. He has smoked 2 packs of cigarettes daily for 35 years. His vital signs are within normal limits. Examination shows a 4-cm (1.6-in), nontender, pulsatile mass with a palpable thrill at the right midinguinal point. On auscultation, a harsh continuous murmur is heard over the mass. Femoral and pedal pulses are palpable bilaterally. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Femoral lymphadenopathy
B. Femoral abscess
C. Femoral hernia
D. Arteriovenous fistula of the femoral vessels
E. Femoral artery aneurysm (Correct Answer)
Explanation: ***Femoral artery aneurysm***
- A **pulsatile mass** with a **palpable thrill** and a **harsh continuous murmur** heard over the mass in the groin is highly indicative of an aneurysm with turbulent flow.
- The patient's history of **smoking** and **hypercholesterolemia** are significant risk factors for **atherosclerosis**, which is the most common cause of peripheral aneurysms.
*Femoral lymphadenopathy*
- Lymphadenopathy typically presents as a **nontender, firm, rubbery mass** that is usually **non-pulsatile**.
- It would not typically be associated with a **thrill** or a **harsh continuous murmur**, which are signs of vascular flow.
*Femoral abscess*
- An abscess would present with signs of **inflammation**, such as redness, warmth, tenderness, and possibly fever, none of which are mentioned here.
- An abscess is typically a **non-pulsatile, fluctuant mass** and would not exhibit a thrill or a continuous murmur.
*Femoral hernia*
- A hernia is a protrusion of abdominal contents through a weakened area, often reducible and typically **non-pulsatile**.
- A hernia would not characteristically present with a **thrill** or a **harsh continuous murmur**, which are vascular findings.
*Arteriovenous fistula of the femoral vessels*
- While an AV fistula can cause a **pulsatile mass**, **thrill**, and **continuous murmur**, it typically arises from trauma or iatrogenic injury, which is not present in this case.
- An AV fistula would also likely involve more immediate symptoms and potentially distal ischemia or signs of venous congestion, which are not described.
Question 40: A 62-year-old man presents to the emergency department with sudden onset of severe left leg pain accompanied by numbness and weakness. His medical history is remarkable for hypertension and hyperlipidemia. His vital signs include a blood pressure of 155/92 mm Hg, a temperature of 37.1°C (98.7°F), and an irregular pulse of 92/min. Physical examination reveals absent left popliteal and posterior tibial pulses. His left leg is noticeably cold and pale. There is no significant tissue compromise, nerve damage, or sensory loss. Which of the following will most likely be required for this patient's condition?
A. Antibiotics
B. Warfarin
C. Fasciotomy
D. Amputation
E. Thromboembolectomy (Correct Answer)
Explanation: ***Thromboembolectomy***
- The sudden onset of severe leg pain, numbness, and weakness with absent pulses, a cold, pale limb, and an irregular pulse suggests **acute limb ischemia** likely due to an **arterial embolus**, which requires emergent surgical removal.
- Given the symptoms and history of an irregular pulse (suggesting possible atrial fibrillation), a thromboembolectomy is the most appropriate first-line treatment to restore blood flow and prevent permanent damage.
*Antibiotics*
- Antibiotics are used to treat **bacterial infections** and are not indicated for acute limb ischemia caused by a vascular occlusion.
- There are no signs of infection present, such as fever, redness, or purulent discharge, that would warrant antibiotic therapy.
*Warfarin*
- Warfarin is an **anticoagulant** used for long-term prevention of clot formation, particularly in conditions like atrial fibrillation or deep vein thrombosis.
- While anticoagulation may eventually be part of management to prevent future events, it is insufficient as immediate therapy for an acute, established arterial embolus causing critical limb ischemia.
*Fasciotomy*
- Fasciotomy is performed to relieve **compartment syndrome**, which occurs when increased pressure within a muscle compartment compromises circulation and nerve function.
- While compartment syndrome can be a complication of reperfusion after prolonged ischemia, it is not the primary treatment for the initial arterial occlusion; the first step is to restore blood flow to prevent the need for it.
*Amputation*
- Amputation is a last resort considered when the limb is **irreversibly ischemic** and non-viable, or when revascularization attempts have failed and there is extensive tissue necrosis or infection.
- In this case, there is no significant tissue compromise or nerve damage mentioned, indicating that the limb is still salvageable with timely intervention.
