A 28-year-old man is brought to the emergency department after being struck by a car an hour ago as he was crossing the street. He did not lose consciousness. He is complaining of pain in his right arm, forehead, and pelvis. He also has the urge to urinate, but has been unable to do so since the accident. He takes no medications. His temperature is 37.1°C (98.9°F), pulse is 72/min, respirations are 18/min, and blood pressure is 118/82 mm Hg. There are abrasions over his scalp and face and a 1x3 cm area of ecchymosis above his right eye. Abdominal examination shows suprapubic tenderness. There is a scant amount of blood at the urethral meatus. There is no cervical spinal tenderness. Musculoskeletal examination shows tenderness and ecchymosis over his right distal forearm. An x-ray of the pelvis shows a fracture of the pelvic ramus. A CT scan of the head and neck show no abnormalities. Which of the following is the best next step in the management of this patient?
Q42
A 77-year-old man is brought to the emergency department by his wife because of headache, nausea, and vomiting for 24 hours. His wife says that over the past 2 weeks, he has been more irritable and has had trouble remembering to do routine errands. Two weeks ago, he fell during a skiing accident but did not lose consciousness. He has coronary artery disease and hypertension. He has smoked one pack of cigarettes daily for 50 years. He has had 2 glasses of wine daily since his retirement 10 years ago. Current medications include atenolol, enalapril, furosemide, atorvastatin, and aspirin. He appears acutely ill. He is oriented to person but not to place or time. His temperature is 37°C (98.6°F), pulse is 99/min, respirations are 16/min, and blood pressure is 160/90 mm Hg. During the examination, he is uncooperative and unable to answer questions. Deep tendon reflexes are 4+ on the left and 2+ on the right. Babinski's sign is present on the left. There is mild weakness of the left iliopsoas and hamstring muscles. A CT scan of the head without contrast shows a high-density, 15-mm crescentic collection across the right hemispheric convexity. Which of the following is the most appropriate next step in the management of this patient?
Q43
A 27-year-old man is brought to the emergency department after a motor vehicle accident. He was the unrestrained driver in a head on collision. The patient is responding incoherently and is complaining of being in pain. He has several large lacerations and has been impaled with a piece of metal. IV access is unable to be obtained and a FAST exam is performed. His temperature is 98.2°F (36.8°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 13/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?
Q44
A 24-year-old man is brought by ambulance to the emergency department after a motor vehicle accident. He was the front seat driver in a head on collision. He is currently unconscious. The patient’s past medical history is only notable for an allergy to amoxicillin as he developed a rash when it was given for a recent upper respiratory infection 1 week ago. Otherwise, he is a college student in good health. The patient is resuscitated. A FAST exam is notable for free fluid in Morrison’s pouch. An initial assessment demonstrates only minor bruises and scrapes on his body. After further resuscitation the patient becomes responsive and begins vomiting. Which of the following is the most likely diagnosis?
Q45
A 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?
Q46
A 25-year-old man presents with pain and a limited range of motion in his right shoulder. He is a collegiate baseball player and says he has not been playing for approx. 1 week because his shoulder hurts when he throws. He also noticed trouble raising his arm over his head. He describes the pain as moderate, dull, and aching in character and worse when he moves his arm above his shoulder or when he lays in bed on his side. He denies any recent acute trauma to the shoulder or other joint pain. The medical history is significant for asthma, which is managed medically. The current medications include albuterol inhaled and fluticasone. He reports a 5-year history of chewing tobacco but denies smoking, alcohol, or drug use. The temperature is 37.0°C (98.6°F); blood pressure is 110/85 mm Hg; pulse is 97/min; respiratory rate is 15/min, and oxygen saturation is 99% on room air. The physical examination is significant for tenderness to palpation on the anterolateral aspect of the right shoulder. The active range of motion on abduction of the right shoulder is decreased. The passive range of motion is intact. No swelling, warmth, or erythema is noted. The sensation is intact. The deep tendon reflexes are 2+ bilaterally. The peripheral pulses are 2+. The laboratory results are all within normal limits. A plain radiograph of the right shoulder shows no evidence of fracture or bone deformities. An MRI of the right shoulder shows increased T1 and T2 signals in the rotator cuff tendon. Which of the following is the best initial course of treatment for this patient?
Q47
A 23-year-old man presents to the emergency department with testicular pain. His symptoms started 15 minutes ago and have not improved on the ride to the hospital. The patient’s past medical history is non-contributory, and he is not currently taking any medications. His temperature is 98.5°F (36.9°C), blood pressure is 123/62 mmHg, pulse is 124/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam is notable for a non-tender abdomen. The patient’s right testicle appears higher than his left and is held in a horizontal position. Stroking of the patient’s medial thigh elicits no response. Which of the following is the best treatment for this patient?
Q48
A 7-year-old child is brought to the emergency room by his parents in severe pain. They state that he fell on his outstretched right arm while playing with his friends. He is unable to move his right arm which is being supported by his left. On exam, his vitals are normal. His right extremity reveals normal pulses without swelling in any compartments, but there is crepitus above the elbow upon movement. The child is able to flex and extend his wrist, but this is limited by pain. The child has decreased sensation along his thumb and is unable to make the "OK" sign with his thumb and index finger. What is the most likely diagnosis?
Q49
A 56-year-old man presents to the emergency department with severe chest pain and a burning sensation. He accidentally drank a cup of fluid at his construction site 2 hours ago. The liquid was later found to contain lye. On physical examination, his blood pressure is 100/57 mm Hg, respiratory rate is 21/min, pulse is 84/min, and temperature is 37.7°C (99.9°F). The patient is sent immediately to the radiology department. The CT scan shows air in the mediastinum, and a contrast swallow study confirms the likely diagnosis. Which of the following is the best next step in the management of this patient’s condition?
Q50
A 26-year-old woman comes to the physician because of increasing pain and swelling in her right foot for the past 2 weeks. Initially, the pain was intermittent but it is now constant and she describes it as 8 out of 10 in intensity. She has not had any trauma to the foot or any previous problems with her joints. The pain has not allowed her to continue training for an upcoming marathon. Her only medication is an oral contraceptive. She is a model and has to regularly wear stilettos for fashion shows. She appears healthy. Vital signs are within normal limits. Examination shows swelling of the right forefoot. There is tenderness to palpation over the fifth metatarsal shaft. Pushing the fifth toe inwards produces pain. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
Trauma/Emergencies US Medical PG Practice Questions and MCQs
Question 41: A 28-year-old man is brought to the emergency department after being struck by a car an hour ago as he was crossing the street. He did not lose consciousness. He is complaining of pain in his right arm, forehead, and pelvis. He also has the urge to urinate, but has been unable to do so since the accident. He takes no medications. His temperature is 37.1°C (98.9°F), pulse is 72/min, respirations are 18/min, and blood pressure is 118/82 mm Hg. There are abrasions over his scalp and face and a 1x3 cm area of ecchymosis above his right eye. Abdominal examination shows suprapubic tenderness. There is a scant amount of blood at the urethral meatus. There is no cervical spinal tenderness. Musculoskeletal examination shows tenderness and ecchymosis over his right distal forearm. An x-ray of the pelvis shows a fracture of the pelvic ramus. A CT scan of the head and neck show no abnormalities. Which of the following is the best next step in the management of this patient?
A. IV pyelogram
B. Foley catheterization
C. Contrast-enhanced CT scan of the abdomen
D. Retrograde urethrogram (Correct Answer)
E. Retroperitoneal ultrasound
Explanation: ***Retrograde urethrogram***
- The presence of **blood at the urethral meatus**, **difficulty urinating**, and a **pelvic fracture** are highly suggestive of a **urethral injury**.
- A retrograde urethrogram is the appropriate diagnostic step to evaluate the integrity of the urethra before any attempt at catheterization.
*IV pyelogram*
- An IV pyelogram primarily assesses the **kidneys and ureters** for injury, which is not the immediate concern given the signs of urethral trauma.
- It would not provide the necessary detail to evaluate the **urethra** itself.
*Foley catheterization*
- Attempting Foley catheterization in the presence of suspected urethral injury is **contraindicated** as it can worsen the injury or create a false passage.
- The urethra needs to be assessed for integrity first to guide safe bladder drainage.
*Contrast-enhanced CT scan of the abdomen*
- While a CT scan of the abdomen might be performed later to assess other possible abdominal injuries, it is **not the primary imaging modality for urethral trauma**.
- A CT scan would not adequately visualize the **urethra** to rule out an injury.
*Retroperitoneal ultrasound*
- A retroperitoneal ultrasound evaluates for **fluid collections** or **organ injury** in the retroperitoneum, but it is not the most effective method for diagnosing **urethral tears**.
- It provides insufficient detail to assess the integrity of the urethra.
Question 42: A 77-year-old man is brought to the emergency department by his wife because of headache, nausea, and vomiting for 24 hours. His wife says that over the past 2 weeks, he has been more irritable and has had trouble remembering to do routine errands. Two weeks ago, he fell during a skiing accident but did not lose consciousness. He has coronary artery disease and hypertension. He has smoked one pack of cigarettes daily for 50 years. He has had 2 glasses of wine daily since his retirement 10 years ago. Current medications include atenolol, enalapril, furosemide, atorvastatin, and aspirin. He appears acutely ill. He is oriented to person but not to place or time. His temperature is 37°C (98.6°F), pulse is 99/min, respirations are 16/min, and blood pressure is 160/90 mm Hg. During the examination, he is uncooperative and unable to answer questions. Deep tendon reflexes are 4+ on the left and 2+ on the right. Babinski's sign is present on the left. There is mild weakness of the left iliopsoas and hamstring muscles. A CT scan of the head without contrast shows a high-density, 15-mm crescentic collection across the right hemispheric convexity. Which of the following is the most appropriate next step in the management of this patient?
A. Recombinant tissue plasminogen activator administration
B. Obtain an Electroencephalography
C. Obtain an MRI of the head
D. Surgical evacuation (Correct Answer)
E. Observation
Explanation: ***Surgical evacuation***
- The CT scan reveals a **high-density, crescentic collection**, strongly indicative of an **acute subdural hematoma**, which is causing significant neurological deficits and mass effect (e.g., increased intracranial pressure symptoms like headache, nausea, vomiting, and altered mental status, and focal neurological signs).
- Given the patient's **acute neurological decline**, significant mass effect from the 15-mm hematoma, and age, prompt **surgical evacuation** is the definitive treatment to relieve pressure and prevent further brain injury.
*Recombinant tissue plasminogen activator administration*
- **tPA** is indicated for **acute ischemic stroke**, not hemorrhagic stroke or subdural hematoma. Administering tPA in this context would be harmful, potentially worsening the hemorrhage.
- The patient's CT scan clearly shows a **hemorrhagic lesion**, not an ischemic event.
*Obtain an Electroencephalography*
- **EEG** is primarily used to evaluate **seizure disorders** or certain types of encephalopathy. While the patient has altered mental status, the primary issue identified on CT is a subdural hematoma requiring immediate intervention.
- EEG would not provide information relevant to the immediate management of an **acute subdural hematoma**.
*Obtain an MRI of the head*
- An **MRI** can provide more detailed imaging, but in the context of an **acute subdural hematoma** with significant neurological compromise, it would delay crucial and time-sensitive surgical intervention.
- The **CT scan** has already provided sufficient diagnostic information to warrant immediate surgical planning.
*Observation*
- **Observation** is not appropriate for a patient with a rapidly expanding **acute subdural hematoma** causing significant neurological deficits and a 15-mm collection, especially given the patient's age and clinical presentation.
- Delaying treatment would likely lead to further neurological deterioration, **herniation**, and potentially death.
Question 43: A 27-year-old man is brought to the emergency department after a motor vehicle accident. He was the unrestrained driver in a head on collision. The patient is responding incoherently and is complaining of being in pain. He has several large lacerations and has been impaled with a piece of metal. IV access is unable to be obtained and a FAST exam is performed. His temperature is 98.2°F (36.8°C), blood pressure is 90/48 mmHg, pulse is 150/min, respirations are 13/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?
A. Reattempt intravenous access
B. Obtain intraosseous access (Correct Answer)
C. Place a central line
D. Administer oral fluids
E. Exploratory laparotomy
Explanation: ***Obtain intraosseous access***
- The patient is in **hypotensive shock** (BP 90/48 mmHg, HR 150/min) after a severe trauma, and **IV access cannot be obtained**. **Intraosseous (IO) access** provides a rapid and reliable route for fluid and medication administration in emergent situations when peripheral IV access is difficult or impossible.
- While central line placement is also a viable option, **IO access is generally faster and easier to establish** in an emergency setting by a wide range of providers, making it the **best initial step** when peripheral IV fails.
*Reattempt intravenous access*
- Although obtaining IV access is critical, the question states that it "is unable to be obtained," implying initial attempts have failed or are proving too difficult/time-consuming given the patient's critical state.
- Persisting with repeated attempts risks significant delay in resuscitation, which is detrimental for a patient in shock.
*Place a central line*
- A central line provides reliable access for fluid and medication, but its placement is generally **more time-consuming** and technically challenging than IO access, especially in an agitated, unstable patient in a chaotic emergency setting.
- The immediate priority is rapid access for fluids to address the patient's shock, for which IO is superior in terms of speed of establishment.
*Administer oral fluids*
- The patient is **unstable**, **incoherently responding**, and likely has significant internal injuries given the mechanism of injury (head-on collision, impalement).
- Oral fluids would be **ineffective** and potentially dangerous (risk of aspiration) in this critical, hemodynamically unstable patient who requires immediate intravenous fluid resuscitation.
*Exploratory laparotomy*
- While the patient likely has significant internal injuries requiring surgical intervention (impalement, hypovolemic shock), an **exploratory laparotomy** is a definitive treatment step, not the *best next step in management* for immediate resuscitation.
- **Hemodynamic stabilization** with fluid resuscitation must occur *before* or *simultaneously with* definitive surgical intervention to improve survival chances.
Question 44: A 24-year-old man is brought by ambulance to the emergency department after a motor vehicle accident. He was the front seat driver in a head on collision. He is currently unconscious. The patient’s past medical history is only notable for an allergy to amoxicillin as he developed a rash when it was given for a recent upper respiratory infection 1 week ago. Otherwise, he is a college student in good health. The patient is resuscitated. A FAST exam is notable for free fluid in Morrison’s pouch. An initial assessment demonstrates only minor bruises and scrapes on his body. After further resuscitation the patient becomes responsive and begins vomiting. Which of the following is the most likely diagnosis?
A. Duodenal hematoma
B. Rupture of the inferior vena cava
C. No signs of internal trauma
D. Laceration of the spleen
E. Laceration of the liver (Correct Answer)
Explanation: ***Laceration of the liver***
- **Morrison's pouch** (hepatorenal recess) is located between the **liver and right kidney** in the **right upper quadrant**, making it the primary collection site for blood from **liver injuries**.
- The presence of **free fluid in Morrison's pouch** on FAST exam is the classic finding for **hepatic trauma** with intraperitoneal bleeding.
- **Vomiting** after resuscitation can occur with significant abdominal trauma and irritation from blood in the peritoneal cavity.
- Liver lacerations are among the most common solid organ injuries in blunt abdominal trauma from motor vehicle accidents.
*Laceration of the spleen*
- While splenic injuries are common in blunt abdominal trauma, free fluid from splenic laceration typically collects in the **left upper quadrant** (splenorenal recess) or **left paracolic gutter** first, not primarily in Morrison's pouch.
- Morrison's pouch is anatomically distant from the spleen, making this a less likely diagnosis with this specific FAST finding.
*Duodenal hematoma*
- A duodenal hematoma typically presents with **gastric outlet obstruction symptoms** like epigastric pain and persistent vomiting days after injury.
- This injury is **retroperitoneal** and rarely causes significant **intraperitoneal free fluid** that would be detected in Morrison's pouch unless there is an associated perforation.
*Rupture of the inferior vena cava*
- A ruptured IVC would cause **massive retroperitoneal hemorrhage** and result in rapid circulatory collapse with profound shock.
- This is a **retroperitoneal structure**, so bleeding would not typically present as free intraperitoneal fluid in Morrison's pouch.
- The patient's ability to become responsive after resuscitation makes this catastrophic injury unlikely.
*No signs of internal trauma*
- The presence of **free fluid in Morrison's pouch** on FAST exam is definitive evidence of **intraperitoneal bleeding**, indicating significant internal trauma.
- This finding directly contradicts the statement of no internal trauma, making this option clearly incorrect.
Question 45: A 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?
A. Exploratory laparotomy (Correct Answer)
B. Diagnostic peritoneal lavage
C. CT scan of the abdomen and pelvis
D. Exploratory laparoscopy
E. FAST exam
Explanation: ***Exploratory laparotomy***
- The patient presents with **multiple stab wounds** to the abdomen and signs of **hemorrhagic shock** (BP 74/54 mmHg, HR 180/min), which are clear indications for immediate surgical intervention.
- An exploratory laparotomy allows for direct visualization and repair of internal injuries, which is critical in this life-threatening situation.
*Diagnostic peritoneal lavage*
- While DPL can detect intra-abdominal bleeding, it is an **invasive procedure** and may delay definitive treatment in a hemodynamically unstable patient with obvious penetrating trauma.
- It is **less specific** than a laparotomy for identifying the exact location and nature of injuries, and it has largely been replaced by imaging studies or direct surgical exploration in unstable patients.
*CT scan of the abdomen and pelvis*
- A CT scan requires a **hemodynamically stable** patient and time for scanning and interpretation, which this patient does not have.
- Delaying definitive treatment for imaging in a patient with severe shock could lead to worse outcomes.
*Exploratory laparoscopy*
- Although less invasive, laparoscopy can be time-consuming and may not be feasible or safe in a patient with **profound hemorrhagic shock** and extensive injuries, especially if major vascular or visceral damage is suspected.
- Conversion to a **laparotomy** is often necessary in cases of significant injury, making immediate open exploration more efficient.
*FAST exam*
- A FAST exam can rapidly detect free fluid in the abdomen, suggesting internal bleeding, but it does **not provide specific information** about the source or extent of the injuries.
- While useful in the initial assessment, a positive FAST exam in a hemodynamically unstable patient with penetrating trauma directly points to the need for immediate surgical intervention, not further diagnostic delay.
Question 46: A 25-year-old man presents with pain and a limited range of motion in his right shoulder. He is a collegiate baseball player and says he has not been playing for approx. 1 week because his shoulder hurts when he throws. He also noticed trouble raising his arm over his head. He describes the pain as moderate, dull, and aching in character and worse when he moves his arm above his shoulder or when he lays in bed on his side. He denies any recent acute trauma to the shoulder or other joint pain. The medical history is significant for asthma, which is managed medically. The current medications include albuterol inhaled and fluticasone. He reports a 5-year history of chewing tobacco but denies smoking, alcohol, or drug use. The temperature is 37.0°C (98.6°F); blood pressure is 110/85 mm Hg; pulse is 97/min; respiratory rate is 15/min, and oxygen saturation is 99% on room air. The physical examination is significant for tenderness to palpation on the anterolateral aspect of the right shoulder. The active range of motion on abduction of the right shoulder is decreased. The passive range of motion is intact. No swelling, warmth, or erythema is noted. The sensation is intact. The deep tendon reflexes are 2+ bilaterally. The peripheral pulses are 2+. The laboratory results are all within normal limits. A plain radiograph of the right shoulder shows no evidence of fracture or bone deformities. An MRI of the right shoulder shows increased T1 and T2 signals in the rotator cuff tendon. Which of the following is the best initial course of treatment for this patient?
A. No further treatment is needed
B. Acromioplasty
C. Intra-articular corticosteroid injection
D. NSAIDs and conservative measures (Correct Answer)
E. Conservative measures (rest and ice)
Explanation: ***NSAIDs and conservative measures***
- The patient presents with symptoms and MRI findings consistent with **rotator cuff tendinitis**, common in overhead athletes. Initial treatment should focus on **reducing inflammation** and pain, and promoting healing.
- **NSAIDs** combined with conservative measures like **rest from inciting activities** and **ice application** are the mainstay of initial treatment for tendinitis, aiming to alleviate pain and improve function.
*No further treatment is needed*
- This option is incorrect because the patient is experiencing significant pain, limitation in his sport, and MRI findings of **tendinitis**, which warrants intervention.
- Doing nothing would likely lead to worsening symptoms and potentially chronic issues, especially given his athletic demands.
*Acromioplasty*
- **Acromioplasty** is a surgical procedure typically reserved for cases of **subacromial impingement syndrome** that have failed extensive conservative management, or for larger, more symptomatic tears.
- The patient's presentation suggests **tendinitis** without clear evidence of chronic impingement or a full-thickness tear requiring immediate surgical intervention.
*Intra-articular corticosteroid injection*
- **Corticosteroid injections** can provide temporary pain relief but are generally reserved for cases that have failed conservative therapy with oral NSAIDs and physical therapy.
- They also carry risks like **tendon weakening** and potential for rupture, which is particularly concerning in an athlete with tendinitis.
*Conservative measures (rest and ice)*
- While **rest and ice** are crucial components of conservative management, this option is incomplete as it omits the important role of **NSAIDs** in managing the inflammatory component of tendinitis.
- Simply resting and icing might not be sufficient for adequate pain control and inflammation reduction in an active individual with this degree of symptoms.
Question 47: A 23-year-old man presents to the emergency department with testicular pain. His symptoms started 15 minutes ago and have not improved on the ride to the hospital. The patient’s past medical history is non-contributory, and he is not currently taking any medications. His temperature is 98.5°F (36.9°C), blood pressure is 123/62 mmHg, pulse is 124/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam is notable for a non-tender abdomen. The patient’s right testicle appears higher than his left and is held in a horizontal position. Stroking of the patient’s medial thigh elicits no response. Which of the following is the best treatment for this patient?
A. Ceftriaxone
B. Ciprofloxacin
C. Manual detorsion
D. Bilateral surgical procedure (Correct Answer)
E. Surgical debridement
Explanation: ***Bilateral surgical procedure***
- This patient presents with classic signs of **testicular torsion**, including acute, severe testicular pain, an elevated and horizontally positioned testicle, and absence of the **cremasteric reflex**.
- **Surgical exploration** is the definitive treatment for testicular torsion, involving detorsion of the affected testis and bilateral orchidopexy to prevent recurrence in the affected testis and torsion of the contralateral testis.
*Ceftriaxone*
- **Ceftriaxone** is an antibiotic used to treat bacterial infections, often combined with doxycycline for sexually transmitted infections like **epididymitis**.
- Testicular torsion is a **surgical emergency** caused by twisting of the spermatic cord, not an infection, so antibiotics are not indicated as a primary treatment.
*Ciprofloxacin*
- **Ciprofloxacin** is a fluoroquinolone antibiotic used for various bacterial infections, including some urinary tract infections and epididymitis.
- Testicular torsion requires immediate surgical intervention; antibiotics are ineffective as the pathology is **mechanical**, not infectious.
*Manual detorsion*
- **Manual detorsion** can be attempted as a temporary measure while preparing for surgery, but it is not definitive because it doesn't prevent recurrence.
- Even if successful, **surgical exploration** and **fixation (orchidopexy)** are still required to confirm viability and prevent future episodes.
*Surgical debridement*
- **Surgical debridement** involves removing necrotic tissue, which might be necessary if testicular ischemia progresses to **necrosis**.
- However, initially, the goal is to **restore blood flow** via detorsion and fixation; debridement would only be considered if the testis is non-viable after attempts to salvage the testis.
Question 48: A 7-year-old child is brought to the emergency room by his parents in severe pain. They state that he fell on his outstretched right arm while playing with his friends. He is unable to move his right arm which is being supported by his left. On exam, his vitals are normal. His right extremity reveals normal pulses without swelling in any compartments, but there is crepitus above the elbow upon movement. The child is able to flex and extend his wrist, but this is limited by pain. The child has decreased sensation along his thumb and is unable to make the "OK" sign with his thumb and index finger. What is the most likely diagnosis?
A. Scaphoid fracture
B. Distal ulnar fracture
C. Supracondylar humerus fracture (Correct Answer)
D. Distal radius fracture
E. Midhumerus fracture
Explanation: ***Supracondylar humerus fracture***
- The classic presentation of a **fall on an outstretched arm** with **crepitus above the elbow** is highly indicative of a supracondylar humerus fracture.
- **Decreased sensation along the thumb** and inability to make an **"OK" sign** points to **anterior interosseous nerve (AIN)** palsy, a common complication of this fracture type due to compression or injury.
*Scaphoid fracture*
- This fracture typically presents with **pain in the anatomical snuffbox** and occurs at the wrist, not above the elbow.
- While it can result from a fall on an outstretched hand, it does not explain the crepitus above the elbow or the specific nerve palsy described.
*Distal ulnar fracture*
- This injury would cause pain and swelling at the **distal forearm/wrist**, not crepitus above the elbow.
- Nerve involvement, if present, would typically affect the **ulnar nerve**, not the anterior interosseous nerve.
*Distal radius fracture*
- Also known as a **Colles fracture** when dorsal displacement is present, this injury occurs at the wrist and presents with pain and deformity there.
- It does not account for the crepitus above the elbow or the specific AIN palsy symptoms.
*Midhumerus fracture*
- While a midhumerus fracture can occur from a fall on an outstretched arm and cause crepitus, it would be located in the **middle third of the upper arm**, not specifically above the elbow joint.
- The specific AIN palsy is less commonly associated with mid-shaft humeral fractures, which are more likely to involve the **radial nerve**.
Question 49: A 56-year-old man presents to the emergency department with severe chest pain and a burning sensation. He accidentally drank a cup of fluid at his construction site 2 hours ago. The liquid was later found to contain lye. On physical examination, his blood pressure is 100/57 mm Hg, respiratory rate is 21/min, pulse is 84/min, and temperature is 37.7°C (99.9°F). The patient is sent immediately to the radiology department. The CT scan shows air in the mediastinum, and a contrast swallow study confirms the likely diagnosis. Which of the following is the best next step in the management of this patient’s condition?
A. Ceftriaxone
B. Oral antidote
C. Dexamethasone
D. Surgical repair (Correct Answer)
E. Nasogastric lavage
Explanation: ***Surgical repair***
- The presence of **mediastinal air** on CT scan and confirmation of **esophageal perforation** by contrast swallow study indicate a surgical emergency.
- **Emergency surgical repair** is crucial to prevent widespread mediastinitis, sepsis, and potential mortality from corrosive ingestion.
*Ceftriaxone*
- While **antibiotics** like Ceftriaxone might be used as adjuncts to prevent infection, they are not the primary treatment for an established esophageal perforation.
- Antibiotics alone will not address the structural defect or contain the leakage of corrosive material into the mediastinum.
*Oral antidote*
- For corrosive ingestions, administering an **oral antidote** is contraindicated as it can worsen tissue damage or induce vomiting, leading to further esophageal injury.
- The immediate priority is managing the perforation, not neutralizing the corrosive agent internally.
*Dexamethasone*
- **Corticosteroids** like dexamethasone are sometimes considered in the management of corrosive ingestions to reduce stricture formation, but their role is controversial and they are not the initial treatment for an acute perforation.
- In an active perforation, corticosteroids would not address the immediate life-threatening issue of mediastinal contamination.
*Nasogastric lavage*
- **Nasogastric lavage** is contraindicated in corrosive ingestions, especially with suspected or confirmed perforation.
- Passing a tube could further injure the already damaged tissue and increase the risk of perforation or exacerbate an existing one.
Question 50: A 26-year-old woman comes to the physician because of increasing pain and swelling in her right foot for the past 2 weeks. Initially, the pain was intermittent but it is now constant and she describes it as 8 out of 10 in intensity. She has not had any trauma to the foot or any previous problems with her joints. The pain has not allowed her to continue training for an upcoming marathon. Her only medication is an oral contraceptive. She is a model and has to regularly wear stilettos for fashion shows. She appears healthy. Vital signs are within normal limits. Examination shows swelling of the right forefoot. There is tenderness to palpation over the fifth metatarsal shaft. Pushing the fifth toe inwards produces pain. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Acute osteomyelitis
B. Morton's neuroma
C. Stress fracture (Correct Answer)
D. Freiberg disease
E. Plantar fasciitis
Explanation: ***Stress fracture***
- The patient's presentation of worsening **forefoot pain** with activity (marathon training), tenderness over the **fifth metatarsal shaft**, and pain with pushing the fifth toe inwards strongly suggest a stress fracture. She is at high risk due to her frequent use of **stilettos** and intense physical activity.
- **Stress fractures** often present with insidious onset of pain that worsens with activity and improves with rest, and localized tenderness over the affected bone.
*Acute osteomyelitis*
- This typically involves signs of **infection** such as fever, warmth, and systemic symptoms, which are not present in this patient.
- While it can cause pain and swelling, the lack of an obvious portal of entry for infection and the activity-related nature of her pain make it less likely.
*Morton's neuroma*
- This condition is characterized by **neuropathic pain** in the forefoot, often described as burning or tingling, typically between the third and fourth toes.
- The pain is usually exacerbated by tight shoes and relieved by removing shoes, but localized tenderness over a metatarsal shaft is not typical.
*Freiberg disease*
- This is an **osteochondrosis** that primarily affects the **second metatarsal head**, causing pain and stiffness, especially during weight-bearing.
- The patient's pain is localized to the **fifth metatarsal shaft**, making Freiberg disease less likely.
*Plantar fasciitis*
- This condition causes pain on the **bottom of the heel**, particularly with the first steps in the morning or after a period of rest.
- The current patient's pain is located in the **forefoot** and on a metatarsal shaft, which is inconsistent with plantar fasciitis.
