Trauma/Emergencies — MCQs

A 62-year-old man is brought to his primary care physician by his wife because she is concerned that he has become more confused over the past month. Specifically, he has been having difficulty finding words and recently started forgetting the names of their friends. She became particularly worried when he got lost in their neighborhood during a morning walk. Finally, he has had several episodes of incontinence and has tripped over objects because he "does not lift his feet off the ground" while walking. He has a history of hypertension and diabetes but has otherwise been healthy. His family history is significant for many family members with early onset dementia. Which of the following treatments would most likely be effective for this patient?

A 22-year-old male presents to the emergency department after a motor vehicle accident. The patient is conscious and communicating with hospital personnel. He is in pain and covered in bruises and scrapes. The patient was the driver in a head-on motor vehicle collision. The patient's temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 120/70 mmHg, respirations are 18/min, and oxygen saturation is 99% on room air. A full trauma assessment is being performed and is notable for 0/5 strength in the right upper extremity for extension of the wrist. The patient is started on IV fluids and morphine, and radiography is ordered. The patient has bilateral breath sounds, a normal S1 and S2, and no signs of JVD. His blood pressure 30 minutes later is 122/70 mmHg. Which of the following fractures is most likely in this patient?

A 24-year-old 70 kilogram African-American man with epilepsy refractory to valproic acid, phenytoin, and levetiracetam undergoes magnetic resonance imaging of his brain under monitored anesthetic care. He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg. He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn. Overnight, the nurse continues to increase the patient's midazolam infusion rate, but she also notices that his left toes are cold to touch with significant edema. His temperature is 100°F (37.8°C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula. No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity. A delta pressure of 25 mmHg is obtained in the left leg. What is the best next step in management?

A 58-year-old woman comes to the physician because of headaches for 1 month. She describes them as 7 out of 10 in intensity. She has no nausea. Two years ago, she was treated for invasive lobular carcinoma of the left breast. She underwent a left mastectomy and multiple cycles of chemotherapy. She has been in good health since this treatment. Her temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 118/72 mm Hg. There is a well-healed scar on the left side of the chest. There is no lymphadenopathy. The abdomen is soft and nontender; there is no organomegaly. Neurologic examination shows no focal findings. An MRI of the brain shows a 4-cm temporal hyperintense mass near the surface of the brain. Which of the following is the most appropriate next step in management?

A 66-year-old man presents to the emergency department for a 1-hour history of right arm weakness. He was having breakfast this morning when his right arm suddenly became weak, causing him to drop his coffee mug. He also noticed that he was slurring his speech and had some additional weakness in his right leg. He had no symptoms prior to the onset of the weakness and noted no other unusual phenomena. These symptoms lasted for about 30 minutes, but they resolved completely by the time he arrived at the emergency department. His medical history is notable for hypertension and hyperlipidemia, but he does not receive close follow-up from a primary care physician for these conditions. The patient currently is not taking any medications. His pulse is 75/min, the blood pressure is 160/95 mm Hg, and the respiratory rate is 14/min. Physical exam is remarkable for a high-pitched sound heard on auscultation of the neck, the remainder of the exam, including a complete neurological exam, is entirely unremarkable. CT angiography of the head and neck shows no active hemorrhage and 80% stenosis of the left internal carotid artery. Which of the following is the next best step in the long-term management of this patient?

Paramedics are called to a 35-year-old man who had accidentally amputated his left index finger tip with a knife. He has no significant past medical history. His temperature is 37.2°C (99°F), pulse is 96/min, and blood pressure is 112/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. His left index finger is amputated distal to the distal interphalangeal joint at the level of the nail bed, and exposed bone is visible. There is profuse bleeding from the wound site. His ability to flex, extend, abduct, and adduct the joints is preserved and sensation is intact. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step prior to transporting this patient to the emergency department?

A 23-year-old male presents to his primary care physician after an injury during a rugby game. The patient states that he was tackled and ever since then has had pain in his knee. The patient has tried NSAIDs and ice to no avail. The patient has no past medical history and is currently taking a multivitamin, fish oil, and a whey protein supplement. On physical exam you note a knee that is heavily bruised. It is painful for the patient to bear weight on the knee, and passive motion of the knee elicits some pain. There is laxity at the knee to varus stress. The patient is wondering when he can return to athletics. Which of the following is the most likely diagnosis?

A 29-year-old man is brought to the emergency department 20 minutes after sustaining a gunshot wound to the abdomen. On arrival, he is awake and oriented to person, place, and time. He appears agitated. His pulse is 102/min, respirations are 20/min, and blood pressure is 115/70 mm Hg. The pupils are equal and reactive to light. Abdominal examination shows an entrance wound in the right upper quadrant above the umbilicus. There is an exit wound on the right lower back next to the lumbar spine. Breath sounds are normal bilaterally. There is diffuse mild tenderness to palpation with no guarding or rebound. Cardiac examination shows no abnormalities. Intravenous fluid therapy is begun. Which of the following is the most appropriate next step in management?

A 28-year-old man is admitted to the emergency department with a gunshot wound to the abdomen. He complains of weakness and diffuse abdominal pain. Morphine is administered and IV fluids are started by paramedics at the scene. On admission, the patient’s blood pressure is 90/60 mm Hg, heart rate is 103/min, respiratory rate is 17/min, the temperature is 36.2℃ (97.1℉), and oxygen saturation is 94% on room air. The patient is responsive but lethargic. The patient is diaphoretic and extremities are pale and cool. Lungs are clear to auscultation. Cardiac sounds are diminished. Abdominal examination shows a visible bullet entry wound in the left upper quadrant (LUQ) with no corresponding exit wound on the flanks or back. The abdomen is distended and diffusely tender with a rebound. Aspiration of the nasogastric tube reveals bloody contents. Rectal examination shows no blood. Stool guaiac is negative. Which of the following is the next best step in management?

A 68-year-old woman presents with shortness of breath and left-sided chest pain for a week. She says that her breathlessness is getting worse, and the chest pain is especially severe when she takes a deep breath. The patient denies any similar symptoms in the past. Her past medical history is insignificant except for occasional heartburn. She currently does not take any medication. She is a nonsmoker and drinks alcohol occasionally. She denies the use of any illicit drugs including marijuana. Vital signs are: blood pressure 122/78 mm Hg, pulse 67/min, respiratory rate 20/min, temperature 37.2°C (99.0°F). Her physical examination is remarkable for diminished chest expansion on the left side, absence of breath sounds at the left lung base, and dullness to percussion and decreased tactile fremitus on the left. A plain radiograph of the chest reveals a large left-sided pleural effusion occupying almost two-thirds of the left lung field. Thoracentesis is performed, and 2 L of fluid is drained from the thorax under ultrasound guidance. Which of the following patient positions and points of entry is the safest for performing a thoracentesis in this patient?