The correct answer is 2.

A crescent-shaped hematoma is seen in acute subdural hematoma, whereas acute epidural hematoma produces a biconvex, lens-shaped collection. The diagnosis is therefore acute subdural hematoma, but the hematoma is not displacing structures, either clinically (pupils are of equal size) or radiologically. Evacuation is not a priority. The neurologic damage resulted from the initial blow and could be compounded by a subsequent increase in intracranial pressure. Therapy should therefore be directed at preventing such an increase, i.e., hyperventilation, diuretics, and fluid restriction.

(Choice 1) Immediate administration of high-dose steroids may result in a better long-term outcome in spinal cord injuries. Steroids also lower the elevated intracranial pressure caused by brain tumors; however, for reasons that we do not understand, these agents do not do so in cases of increased intracranial pressure caused by trauma.

(Choice 3) Vasodilators would increase intracranial pressure, whereas alpha blockers would produce systemic hypotension and further reduce brain perfusion.

(Choice 4) The patient does not have an epidural hematoma as evidenced by the lack of a biconvex, lens shaped collection on CT.

(Choice 5) Surgical evacuation of his subdural hematoma is not indicated if no damage has been caused by the hematoma, since there is no midline shift or anisocoria (inequality of pupils).

The correct answer is 3.

The chest x-ray above clearly demonstrates a nasogastric tube that is in the stomach and located above the normal level of the diaphragm. This finding is consistent with a diaphragmatic rupture. Image below is a CT scan that shows the stomach in the left chest, which is also consistent with a diaphragmatic rupture. Diaphragmatic rupture is a severe injury, and one that is seen most often with blunt trauma. The diagnosis is usually and easily made with a chest x-ray, with the bowel seen within the chest. The left hemidiaphragm is injured more often, as the liver is thought to offer some protection to the right hemidiaphragm.

(Choice 1) Pulmonary laceration is difficult to diagnose via chest x-ray alone. It would present with lung density due to parenchymal bleeding.

(Choice 2) Aortic dissection would show a widened mediastinum on chest x-ray in a hemodynamically labile patient.

(Choice 4) A gastric perforation should show free air on chest x-ray.

(Choice 5) A cardiac contusion would not be seen on chest x-ray.

The correct answer is 3.

Approximately 5-1 0% of unconscious patients who present to the ED as the result of a motor vehicle accident or fall, have a major injury to the cervical spine. One third of injuries occur at the level of C2, and one half of the rest occur at the level of C6 or Cl. Most fatal cervical spine injuries occur in upper cervical levels, either at craniocervical junction, C 1 or C2. This patient had head trauma as evidenced by nature of her injury and epistaxis. Patient with head trauma can have coexisting cervical spine injury, which should always be assessed before mobilizing the patient. Clinical evaluation of the cervical spine in a patient with blunt trauma is unreliable. Because of grave consequences of missing a cervical spine injury, it is important to rule out a fracture or dislocation of cervical spine as the first priority. In the Emergency room this can be done best with a lateral view x-ray of spine. It is 85-90% sensitive in diagnosing cervical spine injury. At the site of accident, when cervical spine injury is suspected, the patient should be transported with the neck stabilized with a collar. Tenderness on palpation of cervical spine is indicative of a spine injury.

(Choice 1) This patient has epistaxis suggestive of fracture of base of skull. However, a CT scan is indicated only after cervical spine injury is ruled out and patient is stable. An alternative could be to do a CT scan of head including the neck.

(Choice 2) Though the patient has an obvious fracture of her left tibia, cervical spine injury is potentially more dangerous and should be ruled out before looking for trauma to other body parts.

(Choice 4) Lumbar puncture has no significant role in assessment of head trauma and is rather contraindicated in head injury unless a CT scan rules out intracranial hypertension. (Choice 5) X-ray of head gives very little useful information and CT scan of head is a better alternative to assess head injury.

The correct answer is 4.

This patient has classic signs and symptoms of appendicitis. The pain of appendicitis typically begins as dull, vague periumbilical pain consistent with midgut visceral pain due to stretching of the appendiceal wall. As inflammation of the peritoneum in the right lower quadrant (RLQ) ensues, the pain localizes to that region and becomes sharp in quality. At this time pain is elicited upon palpation of McBurney’s point in the RLQ, and RLQ pain can be reproduced upon deep palpation of the left lower quadrant (Rovsing’s sign). Appendicitis is a clinical diagnosis. Patients with a classic presentation of appendicitis should be operated on immediately to remove the inflamed appendix and prevent appendiceal rupture.

(Choice 1) Ultrasound of the abdomen when appendicitis is suspected is utilized in women in whom other pathology, such as an ovarian process, may be the cause of disease. Ultrasound is also used in patients who are pregnant.

(Choice 2) CT scan of the abdomen is used in nonpregnant patients to confirm the diagnosis if the presentation is atypical.

(Choice 3) Conservative management with delayed appendectomy is employed in patients in whom an abscess of phlegmon has occurred. The focus of infection is treated with intravenous antibiotics and bowel rest is employed. The appendix is ultimately removed weeks later.

The correct answer is 4.

The surgical treatment for portal hypertension encompasses a variety of shunt operations. Shunt types include a portocaval shunt, mesocaval shunt, and the distal splenorenal shunt. Since the portal vein is formed by the superior mesenteric vein and the splenic vein, a distal splenorenal shunt reduces portal vein pressure (splenic vein blood is shunted into the renal vein) without bypassing the liver. Therefore, portal vein blood containing ammonia produced by colon bacteria is partially metabolized in the liver by the urea cycle; this reduces the risk for inducing hepatic encephalopathy. In contradistinction, portosystemic shunts reduce portal pressure but deprive the liver of portal blood flow, thus exacerbating hepatic encephalopathy by increasing serum ammonia levels.

(Choice 1) Mesocaval shunts are anastomoses between the superior mesenteric vein and vena cava, the portal vein and vena cava, and the mesenteric vein and renal vein. These are most often performed as an emergency procedure for active esophageal bleeding that is resistant to therapy. In general, these shunts decompress esophageal veins, control ascites, and have a high rate of patency.

(Choices 2 & 3) The side-to-side (portal vein-inferior vena cava) and the end-to-side (portal vein-inferior vena cava) shunts decompress sinusoidal pressure in the liver and relieve ascites in most patients by redirecting portal vein blood into the vena cava.

(Choice 5) A mesosplenal shunt is sheer nonsense.

The correct answer is 3.

Classic signs of posterior urethral injury include blood at the urethral meatus, inability to void and a high-riding prostate on digital rectal examination. Perineal or scrotal hematomas are also frequently seen and such an injury is most classically associated with a pelvic fracture. When a urethral injury is suspected clinically, the urethra should be assessed with a retrograde urethrogram prior to insertion of a Foley catheter. The procedure can be used both to determine whether damage to the urethra has occurred and to determine the location of such damage within the urethra. Blind insertion of a Foley catheter is contraindicated in patients suspected of having a urethral injury because it can cause infection of a periurethral hematoma and can increase the severity of the urethral tear. (Choice 1) An immediate surgical repair is occasionally done in cases of anterior urethral injury. Most cases of urethral injury are treated with urinary diversion via a suprapubic catheter while the primary injury and associated hematomas are allowed to heal. After healing is complete, residual damage, such as urethral stricture, is assessed and repaired.

(Choice 2) One should never attempt to pass a Foley catheter in a patient with a suspected urethral injury as it can cause seeding of periurethral or perivesical hematomas and can convert a partial urethral laceration into a complete laceration.

(Choice 4) The failure to void in this patient’s case is not a result of failure to produce an adequate volume of urine. In this setting, diuretics would only worsen the patient’s distress. (Choice 5) A retrograde cystogram with post void films is used for diagnosis of bladder injury. Bladder injury may occur following major trauma, especially pelvic fracture. Patients typically complain of gross hematuria.

The correct answer is 2.

This patient has developed a drop in her oxygen saturation, and blood gas analysis reveals hypoxemia with a borderline low pC0 2 . Her vital signs are otherwise normal, and she appears comfortable. Thus, the most likely cause of her hypoxemia is post-operative atelectasis. Atelectasis is one of the most common postoperative pulmonary complications, and is particularly common after abdominal and thoracoabdominal surgery. Following such surgeries, pain and changes in lung compliance can cause impaired cough and deep breathing. Shallow inhalations limit recruitment of alveoli at the lung bases and weak cough predisposes to small airway mucus plugging. Adequate pain control and use of incentive spirometry decrease the incidence of post-operative atelectasis by promoting lung expansion.

(Choice 1) General anesthesia impairs laryngeal defenses, predisposing to aspiration of gastric contents. Signs and symptoms of aspiration generally manifest within hours of surgery, and include dyspnea, cough, wheeze, hypoxemia, and tachypnea.

(Choice 3) Bronchospasm is common in the post-operative period, particularly in patients with underlying COPD or asthma. Wheezing and dyspnea would be expected in addition to hypoxemia.

(Choice 4) Diaphragmatic paralysis may occur as a consequence of phrenic nerve injury from thoracic surgery, cervical manipulation, or tumor compression but is less likely during abdominal surgery. Unilateral diaphragmatic paralysis is often asymptomatic, while bilateral diaphragmatic paralysis causes hypoxemia, rapid shallow breathing, orthopnea, and even respiratoryfailure.

(Choice 5) Ventilator associated pneumonia (VAP) may occur in patients who are on assisted ventilation for >48 hours, and is a result of impairments in the lung’s natural defenses. Fever and hypoxia are common, and Pseudomonas infection must be considered. This patient has not been ventilated >48 hours and is afebrile, making this diagnosis unlikely.

The correct answer is 3.

Cardiac tamponade is characterized by decreased cardiac output and increased central venous pressure owing to restriction of blood flow into and out of the heart as fluid in the pericardial sac restricts filling of all the cardiac chambers. An echocardiogram is the most sensitive and specific noninvasive test to establish the presence of fluid in the pericardial sac. After the diagnosis is established, pericardiocentesis should be performed to immediately reduce intrapericardial sac pressure. Surgery follows to locate the source of the tamponade in those cases that are associated with trauma. Distention of the neck veins on inspiration is called Kussmaul’s sign. Normally, the increase in negative intrathoracic pressure on inspiration sucks blood from the jugular venous system into the right side of the heart. However, if the right side of the heart is restricted by fluid in the pericardial sac, the blood regurgitates into the jugular veins on inspiration.

(Choice 2) A drop in the pulse or the blood pressure of more than 10 mm Hg on inspiration is called pulsus paradoxus. It reflects the drop in inflow of blood into the right side of the heart, which automatically decreases the outflow of blood from the left ventricle. An increase in central venous pressure without an increase in blood pressure further documents the inability of the heart to receive fluid and pump it out into the systemic circulation; therefore, giving additional fluid would exacerbate the condition.

(Choices 1,4 & 5) Inserting a chest tube into the left pleural cavity, decreasing venous pressure by administering a venodilator, and decreasing venous pressure by administering a loop diuretic would be incorrect steps in management, at least at this time.

The correct answer is 2.

A plain abdominal x-ray film is most likely to detect a stone in this patient, who manifests the typical symptomatology of renal colic, most commonly due to a urinary stone impacted in the ureter. Usually, gross or microscopic hematuria is present. Absence of fever is an important negative sign excluding coexistence of urinary tract infection. Most urinary stones consist of calcium phosphate or oxalate and thus contain enough calcium to be visible on plain x-ray films. However, some urinary calculi are radiolucent (especially uric and cystine stones), whereas others are so small as to be undetectable on plain x-ray films.

(Choice 1) is rarely necessary in patients with the typical presentation of renal colic.

However, NP becomes necessary when the diagnosis is uncertain. Frequently, this investigation will demonstrate dilatation of the ureter proximal to the site of stone blockage. (Choice 3) is useful when the stone is suspected to be located at the ureterovesical junction. The bladder should be full to allow ultrasonography.

(Choice 4) Serum calcium, phosphorus, electrolytes, and uric acid should be evaluated in patients experiencing a first urinary tract stone, but serum chemistry studies are not necessary as initial diagnostic investigations.

(Choice 5) Urine cultures are not necessary for uncomplicated urinary stone disease without clinical evidence of urinary tract infection. However, abnormal urinary pH should suggest participation of infectious agents in stone formation. Proteus infections result in alkaline pH because of urease production. On the other hand, a pH lower than 5.0 suggests rate or cystine stones.

The correct answer is 4.

The patient described is suffering from acute embolic mesenteric ischemia that has progressed to bowel infarction. The acute form of mesenteric ischemia typically presents with sudden-onset severe poorly localized (visceral) midabdominal pain accompanied by nausea and vomiting. In the early stages of ischemia, physical examination is typically unremarkable. When bowel infarction occurs, patients develop peritoneal signs on abdominal examination, such as tenderness to palpation with guarding and rebound tenderness. Bowel infarction is also characterized by the passage of bloody stool. The most common cause of acute mesenteric ischemia is embolic occlusion. Emboli typically originate in the heart. The patient described has atrial fibrillation (AF) based on her rapid irregular pulse and the absence of P waves on EKG. AF predisposes to thrombus formation within the fibrillating atria. This is typically prevented by anticoagulating all patients with AF, but some patients, such as those who have suffered a prior intracerebral hemorrhage or subdural hematoma, are not candidates for chronic anticoagulation.

(Choice 1) Though patients with diabetes may have “silent” myocardial infarctions (Ml), which do not produce chest pain, an Ml is unlikely in this setting due to the presentation with abdominal pain and the negative troponin value. T wave inversions in the above patient could be due to long standing hypertension.

(Choice 2) Severe acute necrotizing pancreatitis produces epigastric pain radiating to the back with a “boring” quality. It is possible but less likely given the patient’s age and other comorbidities that put her at risk for mesenteric thrombosis. Pancreatitis is classically associated with gall stones or chronic alcoholism.

(Choice 3) Patients with a ruptured AAA typically experience acute abdominal or back pain followed by syncope. Hypovolemic shock ensues and many patients do not survive long enough to receive medical care.

(Choice 5) Acute cholecystitis classically presents with acute right upper quadrant abdominal pain, fever, nausea and vomiting. Heme-positive stools are not typically seen.

The correct answer is 2.

This patient has peripheral artery disease (PAD) manifesting with left lower extremity claudication (exertion related pain relieved with rest). Though intermittent claudication can result from a number of etiologies, atherosclerotic vascular disease is the most common cause by far. Risk factors include increasing age, diabetes mellitus, cigarette smoking, hypertension, and hyperlipidemia. PAD affects up to 14 % of individuals over age 70, though

up to 50% of patients may be asymptomatic. In severe cases, limb ischemia and infarction can result. Measurement of the ankle-brachial index (ABI) is the first step in diagnosing PAD. The ABI is calculated by dividing the systolic blood pressure obtained by Doppler in the posterior tibial and dorsalis pedis arteries by that in the brachial artery. Ratios of 1 to 1 .3 are considered normal. An ABI less than 0.9 is highly sensitive and specific for greater than 50% occlusion in a major vessel. AB is less than 0 .4 are consistent with limb ischemia. After PAD is diagnosed by ABI, a number of different imaging studies may be performed to more accurately identify the occluded vessel.

(Choice 1) This high-risk patient with clinical claudication requires more than reassurance. (Choice 3) Arterial duplex ultrasonography is a non-invasive test helpful in determining the exact vessel(s) involved in PAD. It is actually less sensitive and specific than the ABI for diagnosing PAD but can help to identify the specific vessels responsible for symptoms once the diagnosis is made.

(Choice 4) Contrast arteriography is the gold standard for evaluating PAD as it is highly sensitive and specific for determining the specific vessels involved. However, because it is an invasive procedure requiring arterial puncture and the use of contrast dye, it is best reserved for instances when the diagnosis is unclear or when planning invasive interventions. (Choice 5) Endovascular stenting may be used in patients with claudication refractory to medical therapy and in patients with a single, hemodynamically significant lesion or limb ischemia who are not candidates for surgical intervention.

The correct answer is 2.

Patients suffering rapid deceleration blunt chest trauma are at high risk for aortic injury. Oftentimes in the setting of high energy aortic injury secondary to blunt chest trauma, aortic transection, circulatory collapse, and death are immediate sequelae. A minority of patients with aortic injury have an incomplete or contained rupture. There are no clinical findings specific for aortic injury, but hypotension, external evidence of trauma and altered mental status are common. Once stabilized with airway, breathing, and circulation secured, patients should be assessed with an upright chest x-ray. Findings suggestive of aortic injury include a widened mediastinum, large left-sided hemothorax, deviation of the mediastinum to the right and disruption of the normal aortic contour. In these cases, the diagnosis can be confirmed via CT scanning. Management of patients with established aortic injury includes antihypertensive therapy where appropriate and immediate operative repair.

(Choice 1) Esophageal rupture following blunt trauma is rare. Manifestations of esophageal rupture include pneumomediastinum and pleural effusion. The diagnosis is confirmed with water-soluble contrast esophagography. Circulatory collapse is not seen.

(Choice 3) In most instances of myocardial rupture, death is the immediate result. Occasionally, the rupture is contained by the pericardium resulting in cardiac tamponade, in which case muffled heart sounds, hypotension and distended neck veins will be noted on physical examination.

(Choice 4) Myocardial contusion classically causes tachycardia, new bundle branch blocks or arrhythmia. Sternal fracture is a commonly associated finding.

(Choice 5) Patients suffering diaphragmatic rupture may experience abdominal pain, pain referred to the shoulder, shortness of breath and vomiting. Radiographic studies will classically demonstrate abdominal viscera above the diaphragm and loss of the diaphragmatic contour.

The correct answer is 2.

In managing the patient with trauma, first priority should be to establish an airway followed by securing breathing and circulation (ABC of resuscitation). In a totally apneic patient like this, an appropriate airway should be restored as soon as possible. Orotracheal intubation is the best way to restore airway in this patient. Afacemask is not a mean to establish an airway.

An orotracheal intubation needs hyperextension of neck and should be done only after a cervical spine injury is ruled out or in case of apneic patient. Though this patient is apneic and is also at risk of having a cervical injury the benefits of orotracheal intubation outweighs the risk and so an orotracheal intubation should be done with care not to move the head. Another option would be to do a surgical cricothyroidotomy.

(Choice 1) Nasotracheal intubation is a blind procedure and it is necessary that patient should have a spontaneous breathing. Thus it is contraindicated in apneic patients.

(Choice 3) Needle cricothyroidotomy is an excellent field procedure to establish an airway especially in children. However, it is not suitable in adults due to risk of carbon dioxide retention especially in patients with head injury where hyperventilation can be required to prevent or treat intracranial hypertension.

(Choice 4) Intubation over a fiberoptic bronchoscope although very effective cannot be performed so rapidly to meet the needs of an apneic patient

(Choice 5) Tracheostomy is no longer a first option to establish an airway because of its complications. A surgical cricothyroidotomy is always preferred over surgical tracheostomy, however a cricothyroidotomy should be converted to formal tracheostomy in 5- 7 days if prolonged airway control is needed as cricothyroidotomy has high incidence of tracheal stenosis with prolonged use.

The correct answer is 4.

Legg-Calve-Perthes disease refers to idiopathic osteonecrosis of the femoral head. It classically affects children four to ten years of age and exhibits a predilection for males. Patients generally present with mild chronic pain of insidious onset in the hip or knee as well as an antalgic gait. Physical examination shows marked limitation of internal rotation and abduction at the hip joint. Proximal thigh atrophy may also be present. X-rays may be negative initially, but serial studies will show changes in the femoral head consistent with necrosis and recalcification. MRI and bone scans show findings suggestive of femoral head necrosis much earlier than standard x-rays and may be used o make the diagnosis months earlier. Treatment is aimed at maintaining placement of the femoral head within the acetabulum so that it may heal in the proper shape and position. This may be accomplished with splints or surgery.

(Choice 1) Slipped capital femoral epiphysis is seen classically in obese adolescent males. Patients present with hip or knee pain and an antalgic gait.

(Choice 2) Septic arthritis most commonly presents with acute-onset pain, swelling and warmth of a single joint accompanied by fever and leukocytosis.

(Choice 3) In children, hematogenous osteomyelitis most commonly affects the metaphysis of long bones such as the humerus, tibia and femur. Patients will be acutely ill with fever, chills and motion-limiting pain.

(Choice 5) Developmental dysplasia of hip is a congenital disorder typically diagnosed in infancy as all the infants are regularly screened for DOH.

The correct answer is 3.

This patient most likely has traumatic dissection of the thoracic aorta caused by a deceleration injury. Disruption of the aorta can occur at the root (the origin of the ligamentum arteriosum) or at the diaphragm. Prognosis is poor, with 85% of patients dying at the scene of the accident, and only 15% making it to the hospital. These patients have small tears or effective tamponding. The intima and media are fractured, leaving the adventitia intact. Blood collects subjacent to the adventitia, giving rise to a pseudoaneurysm, which is seen as a widened mediastinum on a posterior-anterior chest x-ray film. A widened mediastinum is the most consistent sign associated with traumatic disruption of the thoracic aorta and should immediately make one suspect this lesion. Approximately one-third of patients have no presenting clinical symptoms after traumatic disruption of the thoracic aorta.

(Choice 1) is usually seen in the elderly. The most common cause for this condition is atherosclerosis. There may be a longstanding history of hypertension and associated coronary artery disease. A palpable pulsatile mass is present in the epigastric region. Unlike traumatic disruption of the thoracic aorta, this is a true aneurysm.

(Choice 2) most often follows blunt chest injury. It is associated with elevated venous pressure, hypotension, and muffled heart sounds. These three signs compose Beck’s triad. Of these, hypotension is the most reliable symptom, because elevated venous pressure may not be seen in the presence of severe hypotension, and the heart sounds are not muffled on many occasions. Tachycardia is present, and the chest radiograph is noncontributory, as acute effusions are not discernible. Two-dimensional echocardiography is the best test to confirm the diagnosis. Treatment involves pericardiocentesis.

(Choice 4) follows blunt chest trauma. It mainly involves the right ventricle. Patients may not have symptoms at initial presentation. Presence of a new right bundle branch block on electrocardiogram should point to the diagnosis. Radionuclide angiography is the most sensitive test to detect this condition.

(Choice 5) may also follow blunt chest trauma. Patients may appear remarkably fit. Chest x- ray films may show a few patchy infiltrates that progress with time. Respiratory failure can develop rapidly. Therefore, one should have a high index of suspicion when confronted with a patient with vague symptoms after blunt chest injury.

The correct answer is 3.

The patient described has peripheral vascular disease. Peripheral vascular disease most commonly occurs in older men with diabetes, hypertension and hyperlipidemia. Patients commonly present with claudication, as described in the patient above, as well as erectile dysfunction and other signs of vascular insufficiency such as skin changes. Skin changes include atrophy, a shiny quality, loss of appendages such as hair follicles and a propensity for non-healing wounds and ulceration. The degree of vascular insufficiency is best assessed with the ankle-brachial pressure index (ABI or ABPI). This test is done by determining the ratio of ankle to brachial systolic blood pressures. The normal value is 1; numbers that approach zero are associated with more advanced disease.

(Choice 1) Amitriptyline is used in the treatment of pain in the context of postherpetic neuralgia, neurologic pain and painful paresthesias.

(Choice 4) Segmental volume plethysmography and doppler ultrasound may be used to aid in determining the location of a lesion causing peripheral arterial disease, but the diagnosis should first be established with ABI. Doppler ultrasound is also used in the diagnosis of DVT. (Choice 5) An MRI of the spine is useful in diagnosing disease of the soft tissue of the spine such as the spinal cord and intervertebral disks. It may be used in the evaluation of patients with radicular pain.

The correct answer is 3.

This patient endured major thoracic trauma and now has tachypnea and paradoxical thoracic wall movements that correct with positive pressure mechanical ventilation. These findings are consistent with a diagnosis of flail chest, a condition that occurs when multiple contiguous ribs are fractured in two or more locations, causing a segment of ribs to lose its continuity with the remainder of the thoracic wall. Because of the associated pain, patients with flail chest take shallow breaths and compensate for the resulting hypoxemia with hyperventilation. On examination, the isolated thoracic wall segment exhibits paradoxical inward motion on inspiration and outward movement on expiration. Pain control and supplemental oxygen are the most important early steps in managing this condition, but intubation with mechanical positive pressure ventilation is required in many patients with this injury. Positive pressure mechanical ventilation replaces the normal negative intrapleural pressure during spontaneous ventilation with positive intrapleural pressure. Because of the positive intrathoracic pressure induced by the ventilator, the previously paradoxically moving flail segment of the thoracic cage now moves out normally with the rest of the rib cage during inspiration.

(Choice 1) Tracheobronchial injury alone would not cause paradoxical motion of a segment of the thoracic cage. Signs of tracheobronchial injury include hemoptysis, pneumomediastinum, and air leak even after chest tube placement.

(Choice 2) Esophageal rupture secondary to blunt thoracic trauma would not alone cause paradoxical motion of a segment of the thoracic cage. Esophageal rupture can cause subcutaneous emphysema and potentially shock via mediastinitis and third spacing of intravascular fluid into the mediastinum.

(Choice 4) Without a chest tube, pneumothorax will worsen with positive pressure ventilation.

(Choice 5) A patient with an air embolism following major thoracic trauma might present with acute circulatory failure and neurologic signs. Air embolism would not alone cause paradoxical motion of a segment of the thoracic cage.

The correct answer is 1.

This patient has the classic symptoms of hypovolemic shock, namely, hypotension, tachycardia, tachypnea, oliguria, and peripheral vasoconstriction resulting in cold clammy skin. Hemoperitoneum, i.e., intraabdominal hemorrhage) is the most common cause of

shock in the first 24 hours following abdominal surgery. The most likely cause is a slipped ligature from an artery, for example, the cystic artery. The hematocrit will not fall until several hours after the primary event. Management involves restoration of blood volume and immediate surgical intervention to secure the vessel and arrest the hemorrhage.

(Choice 2) results in endotoxic shock. Toxins released by gram-negative bacteria lead to vasodilatation of blood vessels. As a result, the patient would have a bounding pulse and warm skin. Other features include high fever and hypotension.

(Choice 3) is associated with chest pain. Cardiogenic shock could result from a massive myocardial infarction. In that case, the patient would have hypotension, tachycardia, and a weak pulse. The skin would not be warm, and fever, if present, would be low grade.

(Choice 4) usually presents several days after surgery. It is seen in patients who have been lying immobile for a few days in bed and then develop deep vein thrombosis. There may be calf swelling and tenderness, but pulmonary embolus without clinical symptoms of deep venous thrombosis has been known to occur. The patient would have sudden chest pain, hemoptysis, hypotension, and tachycardia.

(Choice 5) is associated with stabbing chest pain, tachypnea, tachycardia, and, in the case of tension pneumothorax, hypotension. Physical findings will include absent breath sounds, hyperresonance to percussion, and a tracheal shift to the contralateral side. This could follow insertion of a line into the subclavian vein.

The correct answer is 5.

A woman of this age who is found to be anemic and have occult blood in the stool should be suspected of having a cancer on the right side of the colon. Thus, the colonoscopy that was initially planned was the appropriate study. However, the patient also has obstructive jaundice, which is most likely of malignant origin (she has the sonographic equivalent of a positive Courvoisier-Terrier sign). Good clinical thinking involves attempting to find one single disease that explains all of the concurrent findings. Therefore, assuming that the patient has colon cancer plus a cancer of the head of the pancreas is not a good bet. A single tumor that would bleed into the gastrointestinal lumen and obstruct the common duct is ampullary carcinoma, and upper gastrointestinal endoscopy should identify it.

(Choice 1) If we insist in ruling out colon cancer, colonoscopy could be done during the session in which upper gastrointestinal endoscopy is performed. Barium enema would be a less attractive alternative.

(Choices 2 & 3) The problem is not in the liver and, thus, a CT scan or a biopsy of the organ is a misguided effort. Dilated intrahepatic ducts and dilated extrahepatic ducts point to a low obstruction of the biliary tree. They are not suggestive of liver metastasis or liver pathology. The laboratory findings are also suggestive of biliary obstruction rather than hepatocellular disease.

(Choice 4) Further definition of the nature of biliary obstruction can be obtained with an endoscopic retrograde cholangiopancreatogram (ERCP) or a percutaneous transhepatic cholangiogram (PTC). However, if we suspect that the obstructing tumor grows out of the duodenal wall, performing the study via a liver puncture (i.e., PTC) will miss the pathology. ERCP would find it, but, in fact, the full study would not have to be completed: As soon as the endoscopist looks at the ampulla, the tumor will be discovered. Cannulation of the ducts and injection of dye would not be needed.

The correct answer is 5.

Prostatic hyperplasia results in partial obstruction of the proximal urethra, causing hesitancy and decreased force of stream. With increasing degrees of prostatic enlargement, the volume of urine remaining in the bladder after voiding increases progressively until complete urinary retention manifests with occasional overflow incontinence. Urinary retention leads to dilatation of the ureters and renal pelves (hydronephrosis).

(Choice 1) is the most common cause of urinary incontinence in the elderly. It manifests with an uncontrollable urge to urinate not triggered by stress maneuvers. It seems to be related to a deficiency in the descending pathways that inhibit the voiding reflex triggered by bladder distension. This condition does not lead to urinary retention.

(Choices 2 & 3) Urinary incontinence associated with Alzheimer disease and normal pressure hydrocephalus is similar to detrusor overactivity and results from failure to inhibit the contractions of the vesical detrusor muscle.

(Choice 4) may cause sphincteric damage, resulting in total incontinence, in which leakage of urine is continuous. Obviously, this condition will not result in hydronephrosis since there is no obstruction to urinary outflow.

The correct answer is 5.

This patient has a ruptured abdominal aortic aneurysm. The abdominal aorta is retroperitoneal. Rupture can be heralded by severe flank or back pain due to bleeding posteriorly into the retroperitoneal space. This is true in 80% of cases; however, in the remaining 20%, the aneurysm ruptures anteriorly into the peritoneal cavity. Hypotension due to blood loss and a pulsatile mass in the epigastrium are also found. Prior to rupture, patients may have a history of backache or a vague discomfort in the epigastric region. Some 95% of cases of abdominal aortic aneurysm are due to atherosclerosis (Choice 5). Other causes include Marfan syndrome, trauma, mycotic infection, and syphilis. Most aneurysms occur below the renal arteries, as the vasa vasorum are lacking here. Lack of inherent blood supply here leads to tissue hypoxia, atherosclerosis, and weakening of the aortic vessel wall. There may be associated atherosclerosis elsewhere, such as the iliacs, and coronaries.

(Choice 1) is involved in the pathogenesis of aortic dissections due to hypertension in elderly men or connective tissue disorders in younger individuals.

(Choices 2 & 3) CMD occurs in the middle and outer part of the aorta and is characterized by elastic tissue fragmentation and the presence of cleft like spaces containing acid mucopolysaccharides. CMD also occurs in Ehlers-Danlos syndrome, in which there is a defect in collagen (Choice 2) and Marfan syndrome, in which there is a defect in fibrillin (Choice 3). Aortic dissections are the most common cause of death in these connective tissue disorders.

(Choice 4) has been implicated in the pathogenesis of some cases of abdominal aortic aneurysms; however, it is rare.

The correct answer is 6.

The patient described is experiencing a fever acutely following surgery for an abdominal aortic aneurysm repair where two units of packed red blood cells were transfused. The time course of this fever is too acute to be attributable to DVT, infection, hematoma or drugs. The patient is most likely suffering an acute febrile nonhemolytic transfusion reaction (AFNTR). Acute transfusion reactions classically occur during or within a few hours of completion of the transfusion. Classically patients with AFNTR experience an increase in temperature of at least one degree Centigrade accompanied by rigors. AFNTR is an immune-mediated phenomenon mediated by host antibodies that bind to donor cells causing the activation of complement components and release of inflammatory cytokines. The condition worsens with continued transfusion of the offending blood product. Treatment is with discontinuation of the blood product transfusion and administration of antipyretics.

(Choice 1) Nosocomial pneumonia is unlikely as the patient is not tachypneic, the lungs are clear to auscultation and the onset of fever is acute.

(Choice 2) Drug fever most commonly occurs one to two weeks following initiation of therapy. It is more commonly associated with the use of anticonvulsants and trimethoprim/sulfamethoxazole, though the list of possible drugs is lengthy.

(Choice 3) Malignant hyperthermia is caused by inhaled anesthetics. Patients typically have fever, tachycardia, acidosis, rhabdomyolysis and are at high risk for cardiac arrest and death. (Choice 4) Patients with pulmonary embolism present with pleuritic chest pain, tachypnea, dyspnea and possibly hemoptysis.

(Choice 5) Surgical site infection is not likely to cause fever in the acute postoperative period. Additionally, on exam the patient wound is consistent with a normal postoperative wound.

The correct answer is 2.

This clinical presentation is a characteristic of anterior cord syndrome. Anterior cord syndrome is commonly associated with burst fracture of the vertebra and is characterized by total loss of motor function below the level of lesion with loss of pain and temperature on both sides below the lesion. MRI is the best investigation to study the extent of neurological damage.

(Choice 1) Central cord syndrome is characterized by burning pain and paralysis in upper extremities with relative sparing of lower extremities. It is commonly seen in elderly secondary to forced hyperextension type of injury to the neck.

(Choice 3) Brown Sequard syndrome is acute hemisection of cord and is characterized by ipsilateral motor and proprioception loss and contra lateral pain loss below the level of lesion. (Choice 4) Acute disk prolapse will be characterized by severe radicular pain with positive straight leg raising test.

(Choice 5) Cauda equine syndrome is characterized by paraplegia, variable sensory loss, urinary and fecal incontinence and it would not occur secondary to fracture of fourth thoracic vertebra.

The correct answer is 2.

The diagnosis is one of exclusion: the multiple dilated loops of small bowel rule out duodenal atresia or annular pancreas, leaving malrotation as a possibility. That was ruled out by the contrast enema, and the operative findings. The microcolon is the sign of an “unused” colon, i.e., nothing has been getting to it, which brings to mind intestinal atresia or meconium ileus, both of which have been ruled out as well. That leaves us with aganglionic colon (Hirschsprung disease), the extent of which can vary tremendously. If the entire colon is aganglionic, this exact clinical picture will result. The diverting ileostomy will take care of the functional obstruction, whereas the appendix provides the safest way to obtain tissue for the pathologist to confirm the absence of ganglia. Definitive repair will be done when the child is a little older.

(Choice 1) A diverting ileostomy alone would take care of the immediate problem, but would not help establish the diagnosis.

(Choice 3) Diversion at the transverse colon would leave a functionally obstructed segment in the circuit.

(Choice 4) will eventually be done, but not before establishing a diagnosis.

(Choice 5) Total proctocolectomy is not done for aganglionic megacolon. The denervated segment is removed, but the normal gut is then brought down to the anus or a portion of the distal rectum.

The correct answer is 3.

Diffuse axon al injury is the most significant cause of morbidity in patients with traumatic brain injuries. It is frequently due to traumatic deceleration injury and results in vegetative state as in this patient. Sudden acceleration-deceleration impact produces rotational forces that affect the brain areas where the density difference is the maximum, thus most of the diffuse axon al injury occur at gray white matter junction. Clinical features of patients with diffuse axon al injury are out of proportion with the CT scan findings. Patient loses consciousness instantaneously and later develops persistent vegetative state. CT scan characteristically shows numerous minute punctate hemorrhages with blurring of grey white interface. However, MRI is more sensitive than CT scan for diagnosing diffuse axonal injury. (Choice 1) Epidural hematoma will show as a biconvex hematoma on CT scan.

(Choice 2) Subdural hematoma will show as a lenticular hematoma on CT scan.

(Choice 4) Subarachnoid hemorrhage will present with acute severe headache and CT will show presence of blood within subarachnoid space.

(Choice 5) Multiple sclerosis (MS) is a progressive neurological disorder that can involve multiple foci of white matter. CT scan will not show MS lesions but MRI will show MS lesions in white matter in the periventricular areas.

The correct answer is 2.

In addition to the classic findings on a physical exam, patients with mesenteric ischemia often present with leukocytosis and metabolic acidosis (lactic acidosis). This acute condition is associated with a high mortality rate, and prompt diagnosis and treatment are imperative. (Choice 1) As a later sign of ischemic bowel, patients may develop gastrointestinal bleeding with a decrease in hematocrit, but only as a late finding, not as a presenting symptom. (Choice 3) Metabolic alkalosis may be due to overaggress ive diuresis, persistent emesis, exogenous bicarbonate loading, or a so-called contraction alkalosis. None of these findings would be expected with ischemic bowel.

(Choice 4) The sodium level is not usually directly affected by ischemic bowel.

(Choice 5) Decreased albumin is seen in states of chronic malnutrition, not acutely in ischemic bowel.

The correct answer is 4.

This critically ill young boy may be bleeding to death from his numerous injuries. Despite the severity of his injuries and the fact that he appears to be oxygenating well, the first step is to establish a secure airway. In a trauma situation, airway, breathing, and circulation take priority, and should be addressed in that order. Controlling the bleeding and giving red blood cells (RBCs) and fresh frozen plasma (FFP) are secondary to obtaining a secure airway. (Choices 1, 3 & 5) These steps are all important measures and need to be performed expediently, but only after the airway is secure.

(Choice 2) A tourniquet is not used in the trauma situaton. Direct pressure to the bleeding vessels is required.

The correct answer is 5.

Complications from central venous catheter (CVC) placement occur in 1-5% of cases and include arterial puncture, pneumothorax, hemothorax, thrombosis, air embolism, sepsis, vascular perforation and myocardial perforation leading to tamponade. Thus radiographic confirmation of the position of the catheter tip is required following CVC insertion. To avoid myocardial perforation, the catheter tip should be located proximal to the cardiac silhouette or proximal to the angle between the trachea and the right mainstem bronchus. Ideally, the

catheter tip should lie in the superior vena cava; tip placement in smaller veins like the subclavian, jugular, azygous or internal mammary predisposes to vascular perforation. Chest x-ray is also required to ensure the absence of iatrogenic pneumothorax and hemothorax. (Choice 1) CVC insertion via the jugular vein carries similar risks for pneumothorax and myocardial perforation as the subclavian approach. The femoral approach is less likely to cause pneumothorax but is significantly more prone to infection.

(Choice 2) There is no value to monitoring cardiac electrical activity during CVC insertion. (Choice 3) Aspiration of blood assures only that the tip of the catheter is within the vasculature. It does not determine the location of the catheter tip or negate the risk of pneumothorax.

(Choice 4) Cardiac ultrasound can detect fluid in the pericardium but cannot precisely determine the placement of the eve catheter tip or the presence of pneumothorax.

The correct answer is 4.

The patient has already sustained the neurologic damage due to the initial blow and is not threatened by a single large hematoma displacing the midline structures. However, she is still vulnerable to further neurologic impairment resulting from the development of increased intracranial pressure. If the intracranial pressure is medically prevented or minimized (with fluid restriction, diuretics, and hyperventilation), her chances of recovery are somewhat better.

(Choice 1) The patient has normal vital signs; therefore, infusing IV fluids would not help. If she had been in shock, the brain would have suffered from inadequate perfusion, and restoring intravascular volume would have been a good idea. In this case, the additional fluid would simply compound the problem of increased intracranial pressure.

(Choice 2) Systemic vasodilators would decrease intravascular pressure and work against the local vasoconstriction that hyperventilation would have offered. The end result would be less cerebral perfusion.

(Choice 3) Hyperbaric oxygen has no role in the prevention or treatment of increased intracranial pressure.

(Choice 5) Surgical evacuation is indicated for hematomas that are displacing the midline structures.

The correct answer is 1.

Complications are common following rhinoplasty, and up to one in four rhinoplasties may need revision. Common complications include patient dissatisfaction, nasal obstruction and epistaxis. Those that involve the nasal septum are less common but more serious. The septum is made up of cartilage and has poor blood supply contrasting sharply with the rich anastomosing blood supply of the nasal sidewall. The underlying cartilage relies completely on the overlying mucosa for nourishment by diffusion. Because of the poor regenerating capacity of the septa I cartilage, trauma or surgery on the septum may result in septa I perforation. The typical postoperative presentation is a whistling noise heard during respiration. Fallowing nasal surgery, septal perforation is typically the result of a septal

hematoma though a septal abscess may also be the cause. Additional conditions that can cause septal perforation are self-inflicted trauma (nose picking), syphilis, tuberculosis, intranasal cocaine use, sarcoidosis and Wegener granulomatosis.

(Choice 2) Nasal polyps are usually seen in patients with asthma and allergic disorders but may also occur in patients with other inflammatory conditions of the nasal mucosa. They may cause chronic nasal obstruction and should be surgically removed in symptomatic patients.

(Choice 3) Foreign bodies are common in children. On presentation, patients will have nasal obstruction and may have a foul odor, halitosis and nasal bleeding. Following surgery, a retained foreign body such as nasal packing most classically would cause toxic shock syndrome.

(Choice 4) Allergic rhinitis commonly presents with rhinorrhea, nasal pruritus, cough and occasionally dyspnea. On examination, the nasal mucosa is edematous and pale, and polyps may be present.

(Choice 5) Nasal furunculosis results from staphylococcal folliculitis following nose picking or nasal hair plucking. It is potentially life threatening as it can spread to the cavernous sinus. Patients complain of pain, tenderness and erythema in the nasal vestibule.

The correct answer is 3.

This patient has a recurrent parotid neoplasm. The two lobes of the parotid gland are separated by the facial nerve, which courses directly through the substance of the gland. From his history, it seems this patient initially had a superficial parotidectomy in order to

excise the tumor. Now, to completely excise this recurrent tumor, removal of the deep lobe of the parotid is required. This will necessitate dissection of the branches of the facial nerve from the parotid tissue. If the facial nerve (CN VII) is involved by the tumor, then it may need to be sacrificed in order to achieve a cure. The extracranial facial nerve carries motor innervation to the muscles of facial expression. Its destruction will cause a unilateral facial droop.

(Choice 1) Hoarseness can result from injury to the recurrent laryngeal branches of the vagus nerve. These nerves are vulnerable to damage during surgery on the thyroid or parathyroid glands.

(Choice 2) Tic douloureux (trigeminal neuralgia) manifests with short bursts of excruciating, lancinating pain lasting from seconds to minutes in the distribution of the second and third branches of the trigeminal nerve. The etiology is likely external compression of the trigeminal nerve.

(Choice 4) Hypoglossal nerve injury can cause tongue palsy. Surgery below the mandible, such as for a tumor of the submandibular salivary gland, would put one at risk for this type of injury.

(Choice 5) Jaw asymmetry can result from unilateral paralysis of the muscles of mastication, which are innervated by the mandibular division of the trigeminal nerve (V3). V3 exits the cranium via the foramen ovale and follows a deep course to innervate the muscles of mastication. Injury to this nerve before it reaches the muscles of mastication would require a very deep dissection.

The correct answer is 3.

Anatomic proximity to major vessels is the main criterion to suspect vascular injury in gunshot wounds of the extremities. Although absent pulses and an expanding hematoma make such an injury virtually certain (and dictate the need for surgical exploration), the presence of normal pulses and the absence of a hematoma do not rule out vascular injury. Noninvasive Doppler studies or, if necessary, an arteriogram can provide the necessary reassurance.

(Choice 1) Massive external bleeding might be currently prevented by clots. Disturbing them in the emergency department could lead to a lot of unnecessary excitement in a place ill- equipped to deal with the problem. When vascular injuries are explored in the operating room, proximal and distal control are obtained first, before the wound itself is probed. (Choice 2) If his vessels are indeed injured, sending him home would risk the development of complications, such as late bleeding, vascular occlusion from intimal flaps, or development of an AV fistula.

(Choice 4) Formal surgical exploration would be mandatory if he were exsanguinating, had no distal pulses, or had an expanding hematoma. When the only reason to suspect vascular injury is anatomic proximity, a less aggressive approach is indicated.

(Choice 5) Waiting for complications to develop would be expensive and lead to higher morbidity.

The correct answer is 2.

The patient has cirrhosis of the liver complicated by ascites (shifting dullness in the abdomen) and portal hypertension, the latter causing esophageal varices that have ruptured, producing hematemesis. The most common cause of portal hypertension is alcoholic cirrhosis. Approximately 50% of the deaths in cirrhosis are due to ruptured varices. The left gastric coronary vein, a branch of the portal vein, normally drains blood from the distal esophagus and proximal stomach to the portal vein for drainage into the liver. However, in portal hypertension, caused by blocked blood flow due to tissue scarring, as in alcoholic cirrhosis, blood backs up into the vein causing distention (varices) and the potential for rupture. Bleeding varices cannot be diagnosed on the clinical presentation alone and require an emergency endoscopy to localize the source of bleeding. Endoscopy also is useful in therapy with variceal ligation, banding, or sclerotherapy. Ancillary management may include the use of intravenous octreotide, which decreases splanchnic blood flow and portal vein pressure. Intravenous vasopressin plus nitroglycerin may also be used; the nitroglycerine reduces the cardiac afterload and coronary artery resistance induced by the vasopressin. In recalcitrant cases, a transjugular intrahepatic portosystemic shunt (TIPS) may be required to stop the bleeding. A metal stent is inserted that connects the hepatic vein with the portal vein. This reduces portal pressure; however, it increases the risk for developing hepatic encephalopathy by increasing blood ammonia levels. Other options include caval shunting, in which the portal vein is anastomosed to the inferior vena cava (side-to-side or endto-side), or a distal splenorenal shunt.

(Choices 1,3 & 5) Pyloric obstruction is associated with vomiting due to retention of food in the stomach. Hematemesis is not a feature of the disease. Although hematemesis is most frequently associated with peptic ulcer disease (most commonly duodenal ulcers followed by gastric ulcers), the endoscopic findings described are most compatible with bleeding varices.

(Choice 4) does not usually present with massive hematemesis. Dysphagia for solids, weakness, and weight loss are the usual presenting signs and symptoms.

The correct answer is 4.

This patient has an acute tear in his rotator cuff. The rotator cuff is formed by the tendons of the supraspinatus, infraspinatus, teres minor and subscapularis muscles. The supraspinatus is most commonly injured, due to repeated bouts of ischemia near its insertion on the humerus induced by compression between the humerus and the acromion. A common cause of acute rotator cuff tears is a fall on outstretched hands. Patients usually have severe shoulder pain and edema following the traumatic event and are unable to abduct the arm past 90 degrees. The drop arm test is a maneuver that can help to diagnose a rotator cuff tear. Here, the patient’s arm is abducted passively to greater than 90 degrees, and the patient is then asked to lower the arm slowly. With a complete rotator cuff tear, the patient will be unable to lower the arm smoothly and it will appear to drop rapidly from near the 90 degree position.

(Choice 1) Rupture of the tendon of the long head of the biceps produces a positive “Popeye sign” where the biceps muscle belly becomes prominent in the mid upper arm. Weakness with supination is prominent, and forearm flexion is typically preserved.

(Choice 2) Injury to the long thoracic nerve causes a winged scapula due to paralysis of the serratus anterior muscle. The most common cause is iatrogenic injury during axillary lymphadenectomy.

(Choice 3) The lower (inferior) trunk of the brachial plexus originates from the CS and Tl cervical roots. Injury to this trunk, which typically results from sudden upward pulling on the arm, produces Klumpke’s palsy. This palsy primarily affects muscles innervated by the ulnar nerve, which supplies most of the intrinsic muscles of the hand. Weakness and atrophy of the hypothenar and interosseous muscles characterize this palsy, and a “claw hand” deformity may also result.

(Choice 5) A humeral neck facture would be more likely to present with swelling, ecchymosis and crepitus over the fracture. Axillary nerve injury may be present.

The correct answer is 3.

The clinical picture is classic for a dissecting aneurysm of the thoracic aorta. The presentation resembles that of a myocardial infarction, but it happens in hypertensive patients who develop a wide mediastinum. At one time, only an arteriogram could establish the diagnosis (at considerable risk), but noninvasive imaging is currently preferred.

(Choice 1) ECG and cardiac enzymes are usually done on anyone with chest pain, but the results would have been negative here. They would have ruled out infarction but would not establish the alternate diagnosis.

(Choice 2) Studying the esophagus with Gastrografin swallow, followed by barium if negative, would have been a good idea if the patient had vomited repeatedly before developing the chest pain and if the x-ray film had shown mediastinal air rather than a wide mediastinum.

(Choice 4) Ventilation-perfusion scan would actually have been the best choice if a pulmonary embolus had been suspected.

(Choice 5) Pulmonary angiogram might have come to mind if he had been immobilized by recent surgery and had then developed signs suggestive of pulmonary embolus: pleuritic pain, shortness of breath, hemoptysis, and distended head and neck veins. Actually, although the angiogram is supposed to be the gold standard in such cases, it is seldom done. Less invasive diagnostic means, as suggested in (Choice 3), are preferred.

The correct answer is 5.

This patient has a left-sided tension pneumothorax. Physical examination findings that support this diagnosis include tachypnea, tracheal deviation away from the affected side, and neck vein distention. Additional findings classically seen in tension pneumothorax include decreased breath sounds and hyperresonance to percussion on the affected side. Tension pneumothorax results from injuries that create a one-way valve in the chest wall. Such wounds allow air to enter the thorax during inspiration but do not allow that air to escape during exhalation. Tension pneumothorax requires emergent treatment with needle thoracostomy. Subsequent tube thoracostomy may be performed to maintain lung expansion. In a patient who remains hemodynamically unstable following decompression of a pneumothorax, pericardial tamponade should be suspected.

(Choice 1) Tension pneumothorax is a clinical diagnosis requiring emergent treatment. Radiographic confirmation is not necessary; urgent needle decompression is more appropriate.

(Choice 2) Tamponade could cause tachycardia and jugular venous distention, but not mediastinal deviation.

(Choice 3) This patient is breathing spontaneously, indicating airway patency and no need for intubation.

(Choice 4) Cervical spine immobilization is done empirically in all trauma patients as part of the primary survey. After the patient is stabilized, the cervical spine can be cleared with radiographic studies.

The correct answer is 5.

Paget’s disease of bone, also known as osteitis deformans, is a disease of unknown etiology that is characterized by disordered bone remodeling. Specifically, osteoclast activity is increased leading to drastically enhanced bone resorption. This results in accelerated osteoblast activity in an effort to rebuild the degraded bone. The result is formation of structurally inferior woven bone at various sites throughout the body. The woven bone formed in Paget disease lesions is larger than normal bone and is prone to bowing and fracture. The most common presenting symptom in patients with this condition is pain resulting from bowing or fracture of the long bones that may result in secondary arthritis of the hip or knee. Laboratory testing in patients with Paget disease of bone will typically show an increase in alkaline phosphatase and normal serum calcium and phosphorus levels. Lesions may be identified radiographically with x-rays or by bone scanning. Enlargement of the bones of the skull in this condition may cause frontal bossing, increased head size (old hats no longer fit the patient), headaches and cranial nerve palsies. Classically, hearing loss may occur due to damage to the cochlear nerve resulting from enlargement of the temporal bone and impingement in the internal auditory meatus.

(Choice 1) An increased risk of subarachnoid hemorrhage is associated with various diseases including Marfan syndrome, Ehlers-Danlos syndrome and moyamoya disease. (Choice 2) Carpal tunnel syndrome occurs in people with occupations requiring repetitive wrist flexion as well as in acromegaly, amyloidosis and hypothyroidism.

(Choice 3) A predisposition for renal cell carcinoma is seen in Von-Hippel-Lindau syndrome. (Choice 4) A predisposition for pulmonary hemorrhage occurs in Goodpasture syndrome.

The correct answer is 4.

This patient presents with symptoms and signs suggestive of complicated appendicitis. Perforation with a localized inflammatory infiltration is likely to be present. Patients who present more than five days after the onset of symptoms, and have localized right lower quadrant findings, should be treated with IV hydration, antibiotics and bowel rest. Non- operative management is usually effective. CT scan may reveal an abscess that can be drained percutaneously. Antibiotics should cover enteric gram-negative organisms and anaerobes. A second/third generation cephalosporin or a fluoroquinolone plus metronidazole are usually used. Cefotetan has a good coverage of gram-negative organisms and anaerobes; therefore, this can be used as monotherapy in this case.

(Choice 1) Immediate surgery in these patients increases morbidity because it often requires extensive dissection, and causes injury to other organs; therefore, it is not recommended.

(Choices 2,3 & 5) Other antibiotic combinations given are not adequate. Although erythromycin and vancomycin are effective against gram-positive organisms, they do not cover gram-negative organisms or anaerobes.

The correct answer is 3.

This patient has anterior cord syndrome following spinal cord injury due to a motor vehicle accident. Anterior cord syndrome is characterized by selective damage to the corticospinal and spinothalamic tracts. These tracts course in the anterior portion of the spinal cord and transmit motor and pain I temperature sensation, respectively. Clinically, anterior cord syndrome is suggested by paralysis and loss of pain and temperature sensation below the level of injury while posterior column functions such as fine touch, vibration, pressure, and proprioception are preserved. All trauma patients should be evaluated for spinal injury. If the neurological examination is suggestive of blunt spinal cord trauma, immediate administration of high-dose intravenous steroids (methylprednisolone) is indicated.

(Choice 1) Immediate surgical intervention for spinal injuries is currently limited to relieving impingement on the spinal cord caused by foreign bodies, herniated disks, bony fracture fragments or an epidural hematoma.

(Choices 2 & 4) All patients with clinical evidence of a spinal cord injury should be imaged with CT scan to assess the bone and MRI to assess the cord and other soft tissues, such as the intervertebral disks. Treatment with intravenous corticosteroids should not be delayed for these imaging procedures.

(Choice 5) Watchful observation is not indicated in this patient with clinical evidence of spinal cord injury.

The correct answer is 5.

The differential diagnosis of severe postoperative chest pain with tachycardia and shortness of breath is between myocardial infarction and pulmonary embolus. Timing offers the first clue: Myocardial infarction typically occurs within the first 2 to 3 days, whereas pulmonary embolus is more commonly seen after 5 to 7 days. Although postoperative myocardial infarction often does not have the typical chest-pain pattern, this case presents with pain of a fairly typical nature and radiations. Both ECG and enzymes are used to confirm myocardial infarction, with enzymes being more reliable.

(Choice 1) would be the first step to build a case for pulmonary embolus, in which case they would show hypoxia and hypocapnia. However, the timing does not suggest pulmonary embolus, and the absence of distended veins almost completely excludes that diagnosis. (Choice 2) is nonspecific for either of the two diagnoses under consideration. Other problems that could be diagnosed with a chest x-ray film in this setting, such as atelectasis, pneumonia, or pneumothorax, could account for shortness of breath but not for chest pain. (Choice 3) is the ultimate, “gold-standard” test for pulmonary embolus. It is seldom done clinically (ventilation-perfusion scan is more commonly used), and, as noted above, it addresses a problem that clinically has already been excluded or made much less likely. (Choice 4) Transaminases would be very helpful in the differential diagnosis of jaundice, but they have no role in identifying the source of chest pain.

The correct answer is 4.

This patient has a fracture of the right scaphoid bone. Scaphoid is the most commonly fractured bone among all the carpals. It is commonly seen in young adults following a fall on the outstretched hand. Patient generally complains of pain at wrist joint. Tenderness in anatomical snuffbox is a very sensitive marker of scaphoid fracture. Fracture is most commonly located across the waist of scaphoid bone. Initial X rays may be normal or may show fine radiolucent line in non-displaced scaphoid fractures. Scaphoid views are necessary to avoid missing the scaphoid fractures. Cast immobilization is recommended in the treatment of all non-displaced scaphoid fractures (fractures < 2 mm displacement and no angulation).

(Choice 1) Open reduction and internal fixation is required if initial X ray shows fracture displacement.

(Choice 2) Percutaneous fixation is being used for non-displaced wrist fractures in certain centers as it has been shown to decrease the period of cast immobilization.

(Choice 3) It would have been an appropriate choice if the initial X ray shows no fracture. (Choice 5) Rest, Ice, Compression and Immobilization (RICE) are the treatment for minor ligament sprain but not for fracture.

The correct answer is 4.

This ileus is possibly due to a vagal reaction due to ureteral colic. Needle shaped crystals on urinalysis indicate uric acid stones. Uric acid stones, which are radiolucent, have to be evaluated by either CT of the abdomen or intravenous pyelography. CT of the abdomen is also useful to diagnose other pathology such as appendicular abscess etc. lies will be over when the ureterolithiasis is treated. Stones less than 0.6 cm may pass spontaneously with hydration and analgesia, otherwise instrumental intervention is needed.

(Choice 3) Colonoscopy is not indicated for the right-sided pathology and should not be performed in acute pathology of the bowel wall because of the risk of perforation.

(Choice 2) There is no left sided pathology suggestive to perform barium enema or sigmoidoscopy in this patient.

(Choice 5) Enteroclysis is used to diagnose small bowel tumors and other pathology, which can cause intestinal obstruction.

The correct answer is 5.

This patient is presenting with an acute abdomen, as indicated by his rebound tenderness and subdiaphragmatic free (intraperitoneal) air on abdominal x-ray, suggesting perforation of a hollow abdominal viscus. As mortality from peritonitis increases rapidly the longer treatment is delayed, this patient requires emergent laparotomy. In addition to pre-operative nasogastric tube decompression, IV fluids and antibiotics, his warfarin-induced

anticoagulation must be reversed. (While his INR of 2 .1 is appropriate for chronic management of atrial fibrillation, if not corrected pre-operatively, it will predispose the patient to intraoperative and post-operative bleeding complications.) The most rapid means of normalizing the prothrombin time is restoration of the vitamin K-dependent clotting factors through an infusion of fresh frozen plasma (FFP).

(Choice 1) The patient does have anemia, and the decision to transfuse patients pre- operatively is based on underlying risk factors for ischemic heart disease and anticipated blood loss during surgery. In general, tissue oxygen delivery does not become deficient until the hemoglobin drops below 7g/dl. Transfusion is often not required in patients with chronic anemia.

(Choice 2) Platelet counts greater than 50,000/mm 1 2 3 4 5 provide adequate hemostasis for most invasive procedures.

(Choice 3) Vitamin K administration will correct the coagulation time in warfarin-treated patients if the drug is also stopped, but this mode of anticoagulation reversal is not appropriate for emergency situations as vitamin K’s reversal effects depend on synthesis of new vitamin K-dependent clotting factors (II, VII, IX, and X) by the liver, which takes time. (Choice 4) Desmopressin (DDAVP) is given pre-operatively to patients with mild hemophilia A in order to prevent excessive bleeding. It indirectly increases factor VIII levels by causing vWF release from endothelial cells.

The correct answer is 4.

The victim described has sustained blunt thoracic trauma. He has tachycardia and hypotension that has not responded to a large bolus of IV fluid. His jugular venous distention indicates adequate intravascular volume status, thus severe hemorrhagic shock is an unlikely cause for the patient’s state. The patient is therefore most likely suffering from an injury to the heart, specifically one that is preventing adequate movement of blood through the heart and into the arterial circulation. Cardiogenic shock occurs when the heart is unable to generate sufficient cardiac output to meet the metabolic demands of the tissue. Causes of cardiogenic shock following trauma include cardiac tamponade, severe cardiac contusion, arrhythmia and myocardial infarction. Treatment of acute cardiac tamponade is by immediate decompression with pericardiocentesis or pericardiotomy.

(Choice 1) Blunt thoracic trauma may also cause a lung contusion. The amount of blood lost into the pleural space following a pulmonary contusion can vary from little to severe. Severe exsanguinating hemothorax is not evident on the patient’s chest x-ray, and severe blood loss would not cause jugular venous distention.

(Choice 2) Most patients with aortic rupture die in the field. Those that survive to the emergency department typically have suffered an injury of the aorta just distal to the left subclavian vein. Such injuries may be contained as hematomas within the mediastinum. This form of aortic rupture typically causes hypertension due to visceral afferent reflexes and a pseudocoarctation syndrome. An aortic rupture would not cause jugular venous distention. (Choice 3) An esophageal rupture does not cause massive blood loss or cardiac pump failure, and would therefore not acutely result in shock unresponsive to standard fluid resuscitation. Esophageal rupture typically presents with severe retrosternal chest pain and mediastinal free air on chest x-ray.

(Choice 5) Bronchial rupture can also result from blunt thoracic trauma and cause jugular venous distention (if responsible for a tension pneumothorax), but this condition would be evident on the patient’s chest x-ray.

The correct answer is 1.

Osteosarcoma is the most common primary malignancy of bone. The incidence of this malignancy is highest in the second decade of life, and it most commonly occurs at sites of rapid bone growth, such as the metaphyses of the distal femur, proximal tibia and proximal humerus. Patients typically present complaining of persistent bone pain that may be worse at night. Systemic manifestations are rare and pathologic fractures are uncommon. The ESR is normal while the serum alkaline phosphatase is elevated. X-ray shows a destructive lesion and periosteal new bone formation with periosteal elevation (Codman’s triangle). Aspiculated “sunburst” pattern within the tumor may also be seen radiographically.

(Choice 2) Ewing’s sarcoma is also most common in the second decade of life. It is a small, round, blue cell (neuroectodermal) malignancy classically associated with systemic features such as fever, malaise and weight loss. It typically affects the diaphyses of long bones as well as the spine and pelvis. X-ray shows an osteolytic lesion with onion-skin appearance. (Choice 3) Chronic osteomyelitis may present with painful swelling, fever and laboratory abnormalities including an elevated ESR and leukocytosis. Chronic osteomyelitis most commonly results from contiguous spread of infection from an adjacent site, such as the skin. This is commonly seen in diabetic foot ulcers.

The correct answer is 4.

Rubbery, movable breast masses in young women are fibroadenomas, and a rapidly growing variant is known to affect adolescents.

(Choice 1) Cancer is virtually unknown in this age group.

(Choice 2) Cystosarcoma phyllodes grows to very large size, but it does so over a period of several years. It starts in women in their early or mid twenties, and reaches large size by the time they are in their late twenties or early thirties.

(Choice 3) Mammary dysplasia is typically seen in women aged 20-40. It is characterized by painful breasts and recurrent formation of cysts.

(Choice 5) Intraductal papilloma is the least likely answer. Those tumors produce bloody nipple discharge, and their size is measured in millimeters.

The correct answer is 2.

This patient’s upper extremity sensory deficits and weakness are best explained by syringomyelia, a disease process in which CSF drainage from the central canal of the spinal cord is disrupted, leading to a fluid filled cavity that compresses surrounding neural tissue. Damage most often involves the crossing fibers of the spinothalamic tract (pain and temperature) and upper extremity motor fibers, due to their medial locations within the corticospinal tract. The most common causes of syringomyelia are Arnold Chiari malformations and prior spinal cord injuries (SCIs). In fact, 3-4% of SCI patients go on to develop syringomyelia. In cases of syringomyelia caused by SCI, the cervical level of the cord is most often involved. Symptoms develop months or years after the initial injury, and progression is gradual. Classically, the injury is a motor vehicle accident with whiplash. Characteristic physical exam findings include decreased strength and diminished pain and temperature sensation affecting the arms/hands or having a cape-like distribution, with preservation of dorsal column function (light touch, vibration, position sense).

(Choice 1) ALS causes upper and lower motor neuron deficits with no loss of sensory function. Twitching, muscle weakness, and cramping are common symptoms.

(Choice 3) Cervical spondylosis results from disc degeneration in patients over age 40.

Neck pain and stiffness are the most common symptoms. Patients may develop spinal stenosis, resulting in neurologic deficits.

(Choice 4) A herniated cervical disc may cause unilateral radiculopathy from compression of the nerve root. Unilateral pain and weakness in the distribution of the involved nerve is likely, but dissociated sensory findings will not occur.

(Choice 5) Multiple sclerosis is a demyelinating disease that presents with random, asymmetric white matter lesions. Nystagmus and scanning speech are common symptoms. A relapsing-remitting course is common, and at least two separate lesions are required for diagnosis. This patient’s symptoms are explained by one lesion.

The correct answer is 2.

Over 1 % of children in the Australia are victims of child maltreatment, which can take on many forms including physical or sexual abuse, psychological abuse, and neglect or Munchausen disease by proxy. Most cases of child abuse that present for medical evaluation will enter the medical system via the emergency department. Emergency physicians must maintain a high index of suspicion for abuse. To reinforce the need for reporting, many local authorities have implemented policies including fines or imprisonment for failing to report suspected abuse to child protective services. Factors that may indicate child abuse include but are not limited to the following:

1 . Patterned scalds and burns indicative of forceful immersion or the use of a hot object such as a cigarette or curling iron

2. Incoherent or improbable explanation of the injuries

3. Delay in seeking care after the injury

4. Fractures of the long bones or ribs, fractures in various stages of healing

5. Bruising on areas other than those overlying bony prominences

6. Suspicious bruises include those on the thighs, abdomen, cheeks and genitalia

7. Patterned bruising such as loops from a cord or belt or imprints of a hand

8. Subdural hematoma and retinal hemorrhages in very young infants

9. Inappropriate affect of the caregiver

In any case of suspected child abuse, the physician should do the following:

1. Perform a thorough physical examination and obtain a radiographic skeletal survey in order to identify and document any signs of abuse.

2. Report the case to child protective services

3. Admit the patient to ensure their safety

In the case described, the wounds are most consistent with an intentional immersion burn. These burns classically show a sharp demarcation between the burned and unburned skin and sparing of the bilateral gluteal regions because these are typically firmly pressed against the bottom of the tub thereby preventing burning. Additionally, the mother’s story is inconsistent with the injuries and she has delayed seeking medical care for 2 days.

(Choices 1 & 3) The child should never be sent home in cases of suspected child abuse. It is mandatory to report the case to child protective services and hold the patient in the hospital. Maintaining the water temperature below 140 °F helps prevents scalds in most of the cases.

(Choice 4) The caregiver should never be confronted in case of suspected child abuse.

They should simply be informed that abuse is suspected and will be investigated by the appropriate authorities. Accusations should not be made by the physician.

(Choice 5) Physicians are mandatory reporters for suspected child abuse or domestic abuse. It is illegal to not report such incidents.

The correct answer is 5.

Bloody urethral discharge in an old man is highly suspicious of urethral carcinoma. This is a rare cancer, but an early diagnosis allows a good chance of cure. If gross hematuria is the initial presentation, discrimination between upper tract, lower tract (vesical), and urethral sources may be obtained by evaluation of the timing of hematuria. A clean-catch urine is collected in separate aliquots. The last few milliliters are collected after performing prostatic massage to obtain prostatic secretions. Initial hematuria is characteristic of urethral lesions, midstream or total hematuria results from upper urinary tract and vesical sources, and terminal hematuria reflects prostatic disease.

(Choice 1) manifests with a yellow (purulent) discharge, which is most abundant in the early morning. The discharge contains numerous neutrophils with gram-negative diplococci. (Choice 2) results in chronic suprapubic pain or discomfort. Hematuria is usually absent. Microscopic examination of prostatic secretions reveals more than 1 0 leukocytes per high power field, but cultures are negative. The pathogenesis of this condition is probably noninfectious.

(Choice 3) is most commonly detected by digital rectal examination and/or abnormally elevated serum prostatic-specific antigen (PSA). If hematuria is present, it is of the terminal type, i.e., present in the last aliquot of a fractionated urine collection.

(Choice 4) does not manifest with bloody urethral discharge or hematuria. Its most frequent presenting sign is painless enlargement of the testis.

The correct answer is 3.

This patient complains of continued chest pain and dyspnea hours after a high-speed motor vehicle accident (MVA). An unrestrained driver, he most likely sustained significant blunt trauma to the chest secondary to impact with the steering wheel. His clinical presentation and x-ray findings are consistent with bilateral pulmonary contusions. Pulmonary contusion is often not clinically evident immediately following an injury and initial radiographic studies may be negative. Patients typically develop hypoxia and respiratory distress hours later as pulmonary edema sets in. Administration of large volumes of IV fluid may hasten this process. This patient’s respiratory alkalosis and hypocarbia are secondary to hyperventilation, itself driven by hypoxia. Pulmonary contusion complicates 30-75% of cases of severe blunt chest trauma. MVAs with associated rapid deceleration are a common cause. Management involves close monitoring and intubation with mechanical ventilation in severe instances.

(Choice 1) Aspiration of gastric contents is possible, but would be more likely if there was a history of the patient having vomited in the field. In aspiration, fluid challenge would not ordinarily exacerbate the hypoxia. Given this patient’s history, pulmonary contusion is more likely.

(Choice 2) The patient’s chest x-ray shows no sign of hemothorax.

(Choice 4) Myocardial contusion can occur secondary to blunt thoracic trauma, but is asymptomatic in most cases. In symptomatic cases, presenting complaints may include arrhythmia, heart failure and chest pain. Cardiac rupture is an uncommon manifestation. If myocardial contusion were the cause of this patient’s shortness of breath, the PCWP would have been increased to much higher levels.

(Choice 5) Radiographic signs of aortic rupture include mediastinal widening, depression of the left main bronchus, displacement of the trachea and esophagus to the right, and obliteration of the aortic knob shadow. These are not present in the x-ray described.