Bootcamp Flashcards
(99 cards)
1
Q
A 63-year-old man presents with a skin lesion ,diagnosed as basal cell carcinoma. Which one of the following is the best treatment option?
radiotherapy curettage surgical excision Cryotherapy chemotherapy
A
Excision
2
Q
23-year-old man came with pain and swelling on the radial side of the wrist after a fall and he mentions point tenderness around the dorsal radial wrist and x-ray reveals no fracture. Which one of the following treatments is the most appropriate?
- plaster immobilization for 2 weeks and re-x-ray
- plaster immobilization for 6 weeks and reassess
- compression bandage for 2 weeks and re-x-ray
- reassurance and analgesics
- compression bandage for a few days and early active exercise
A
Plaster immobilization for 2k and re XR
MRI will Dx scaphoid #
3
Q
40 year old woman is brought to the ER, unconscious following a head injury in a MVA.
There is bruising over the upper abdomen. Blood pressure is 85 mm Hg systolic, pulse 130/minute. What is the most important initial step in the management of this patient?
perform emergency burr holes immediate laparotomy diagnostic peritoneal lavage(DPL) x-ray (three views) of abdomen draw blood sample and start IV fluids
A
draw blood and start IVF
4
Q
A continuous machinery murmur is heard on auscultation of a mass in the anterior thigh of a 40 year old man with high-output heart failure. The origin of this mass is most likely associated with which one of the following?
- mycotic aneurysm
- blunt trauma
- congenital malformation
- previous femoral artery bypass
- penetrating injury
A
penetrating injury.
5
Q
77-year-old woman came with a 11 month history of low-back pain, exacerbated by walking. She admits to gait disturbance with ambulation. Examination is unremarkable for symmetrically decrease in both ankle and Knee reflexes. X-rays of the lumbosacral area show degenerative changes. Which one of the following is the most likely diagnosis?
- Polymiositis
- acute lumbar disk herniation
- normal pressure hydrocephalus (NPH)
- cervical stenosis
- lumbar stenosis
A
lumbar stenosis (neurogenic claudication)
6
Q
type of hemorrhoids suitable for treatment by elastic-band ligation?
- external hemorrhoids with pruritus ani
- internal hemorrhoids with bleeding
- external hemorrhoids with thrombosis
- internal hemorrhoids with fecal soiling
- external hemorrhoids with ulceration
A
Internal hemorrhoids with bleeding
7
Q
25-year-old man sustains a blow-out fracture of his left orbit while playing squash. The possible finding would be
- blood behind the left tympanic membrane.
- retinal detachment.
- horizontal diplopia.
- left enophthalmos.
- depression of the zygomatic arch on the left side.
A
Left Enopthalmos
When something hits orbit it is most likely to hit the inferior orbital bone. In that space there is the inferior orbital nerve (numbness around cheek). Inferior rectus located inside the inferior orbit and therefore trap the inferioir rectus muscle.
THEREFORE get vertical diploplia and Enopthalmos
8
Q
37 year-old woman came with 10 days history of hemorrhoids that slightly prolapse and bleed with some bowel movements. She feels itchy. Which treatment you would recommend for this patient?
- hemorrhoidectomy
- acetaminophen suppositories
- laxatives
- hemorrhoid banding
- stool softeners and high fibre diet
A
Hemorrhoid banding
9
Q
After a collision 29-year-old man is admitted to the hospital with a fracture of the tenth rib on the left side. He is noted to be pale, restless, and sweating, and his bp is low. On examination there is pronounced guarding in the left upper quadrant of the abdomen. Which one of the following viscera is most likely damaged?
left kidney Spleen left lung Pericardium left diaphragm
A
Spleen
(fracture of lower ribs on L side = spleen, # of lower ribs on R side = liver)
(penetrating injury = Liver injury, Blunt abdo trauma = splenic injury)
10
Q
19 yo old man sustains a severe blow to the head. Skull x-rays show air in the cranial vault. This finding represents which one of the following?
- skull fracture
- severe contusion
- fracture of the nasal septum
- severe concussion
- subdural hematoma
A
Skull # (vault #/linear #)
Pneumocephalus (must have broken skull to get air)
Layers of skull; Skull – Dura (if penetrate dura = air) – Arachnoid – Pia
Know approach to skull fractures (vault and basilar skull #)
Basilar skull # = racoon eyes, hemotympanum, mastoid bruises)
11
Q
55 year-old woman has a 2.5 cm carcinoma in the upper outer quadrant of her left breast, with no palpable axillary nodes. Which one of the following is the most appropriate treatment?
- lumpectomy and axillary dissection
- lumpectomy, axillary dissection and radiotherapy
- lumpectomy and tamoxifen
- lumpectomy followed by radiotherapy
- modified radical mastectomy
A
-lumpectomy, axillary dissection and radiotherapy. This is Grade IIA
Management of Breast CA Grade I <2cm Grade IIa- 2-5cm (no lymph nodes palpable) Grade Iib 2 – 5cm (palpable lymph nodes) Grade III
12
Q
17 yo old boy presents with history of a football injury to the left flank .He mentions that at the time of injury he only had the wind knocked out of him and recovered in a few minutes. after 1 hour, he began to experience pain in the left upper quadrant and left shoulder and light-headedness on standing. Which is the most likely diagnosis?
- contusion of the left kidney
- left-sided pneumothorax
- dislocation of the left shoulder
- ruptured spleen
- broken rib on the left side
A
Ruptured Spleen
Kehr’s Sign from splenic rupture
13
Q
After collision, 25 yo old man presents with bruising of the eyelid and clear fluid is observed leaking from his nose. Which is the most likely cause?
- linear fracture of the vault of skull
- squamous temporal bone fracture
- anterior cranial fossa fracture
- petrous bone fracture
- foramen magnum fracture
A
Anterior cranial fossa # (is the base of the skull)
Basilar skull fractures involve at least one of the five bones that comprise the base of the skull: cribiform plate of the ethmoid, orbital plate of the frontal bone, petrous and squamous portion of the temporal bone, and the sphenoid and occipital bones.
14
Q
37 year-old female keyboard operator is having pain and numbness in her hands that radiates up her arms. Which of the following is most likely to have been injured?
axillary nerve radial nerve median nerve brachial plexus / triceps muscle ulnar nerve
A
radial
15
Q
After a collision, 25 yo old man has obvious blunt chest and abdominal injuries, but the striking feature is his marked restlessness. Which one of the following is the most important step to start?
Check for causes of hypoxia Give him a sedative Check him for head injury Catheterize his bladder Give him morphine
A
Hypoxia
Airway and C spine precautions
16
Q
After a severe motor vehicle accident, 30 year old man is having an unstable knee joint. Under anesthesia, it is possible to pull the tibia forward excessively on the femur. Which one of the following structures is mostly injured in this patient?
Anterior cruciate ligament Medial collateral ligament Ligamentum patellae Lateral meniscus Oblique popliteal ligament
A
ACL
17
Q
25 yo old basketball player presents with swelling of his left knee. The injury occurred while he was turning with his left knee slightly bent. Which one of the following is most likely injured?
- Medial collateral ligament
- Medial meniscus
- Ligamentum patellae
- Fibrous capsule of the knee
- Anterior cruciate ligament
A
Medial Meniscus
When land with knee extended then ACL tear
Meniscal injuries occur when knee is flexed
18
Q
77 year old woman with Alxheimer’s disease falls in the nursing home and hits her head. No fractures are noted on a skull radiograph. She has fluctuating levels of consciousness and complains of a several headache on the left side of her head. Mydriasis is noted in the left pupil. Which one of the following is the most likely diagnosis in this patient?
- Epidural hematoma
- Intracerebral hemorrhage
- Subdural hematoma
- Hemorrhagic infraction of the brain
- Subarachnoid hemorrhage
A
Subdural Hematoma
Epidural Hematomas; rarely see <2y or over 60y. Tend to be associated with skull #, lucid interval. Maintaining GCS within 2h then NO epidural. No headache they’re ok.
Subdural higher in Elderly pts; can cause intermittent confusion (bridging veins)
If GCS 15 2 hours after injury then NO epidural because
19
Q
65 year old man came with blood pressure is slightly elevated and a left flank mass is palpated. Which one of the following tests is most likely to confirm the nature of the mass lesion?
- Angiogram
- Retrograde ureteropyelogram
- Intravenous pyelogram
- Radioisotope renogram
- Computed tomography
A
CT
Approach to flank masses;
- US (cystic vs solid)
- CT
20
Q
T/F does renal cell Ca cause paraneoplastic syndrome
A
YAS
Stimulates erythropoietin so get polycythemia
21
Q
35 days after the removal of a cast from 57 yo old woman’s leg, she is unable to dorsiflex her foot, which one of the following nerve is most likely injured?
Sural Femoral Saphenous Common peroneal Tibia
A
Common peroneal. (wraps around the head of the fibula)
Make sure cast doesn’t touch head of fibula.
22
Q
After a collision, patient with a clear fluid leaking from his ear and bruising in the mastoid region (Battle’s sign). Which one of the following injuries is most likely?
Fracture of the supraorbital ridge Linear fracture of the vault of skull Middle cranial fossa fracture Ethmoid bone fracture Foramen magnum fracture
A
Ethmoid Bone
23
Q
25 yo old man presents with a wound on the front of his left wrist, at the level of the proximal transverse crease. There is diminished sensation over the lateral half of the palm of the hand and the palmar aspect of the lateral three and on half fingers. He is unable to oppose his thumb to the other figures. Which one of the following is likely to have been injured?
Ulnar nerve Musculocutaneous verve Radial nerve Brachial nerve Median nerve
A
MEdial Nerve
24
Q
A soccer player was struck on the left side of the head with the ball. The player fell to the ground, but did not lose consciousness. After a few hours he has seen to be confused and irritable. Which one of the following is the most likely diagnosis?
Subdural hematoma Intracerebral hemorrhage Subarachnoid hemorrhage Post-concussion syndrome Extradural hematoma
A
Extradural Hematoma
Hyperventilation done to decrease ICP
25
25 yo old woman came with damaged radial nerve due to fracture of the lower third of the humerus. Which one of the following will be patient experience?
A weakness in pronating the forearm
An inability to oppose the thumb
A loss of wrist extension, leading to wrist drop
A sensory loss over the ventral aspect of the base of the thumb
An inability to abduct the fingers
loss of wrist extension
26
After a car accident 55 yo old man came with chest pain, on examination, at the end of the expiration his blood pressure is 130/90 mmHg and at the end of inspiration it is 110/92 mmHg. Which one of the following condition is most likely?
- Pneumothorax
- Acute myocardial infraction
- Multiple rib fractures
- Aortic rupture
- Cardiac tamponade
tamponade (pulsus paradoxus)
27
3 hrs after application of the plaster cast for supracondylar fracture, a patient comes back with a complaint of severe pain in the hand, swelling of the fingers and cyanosis. Which one of the following is the best management?
-To administer vasodilators
-Cut open the plaster near the fingers
T-o administer analgesics
-Cut open the entire plaster cast immediately
-To observe the patient
cut open the entire plaster cast immediately
Brachial artery, median nerve and ulnar nerve can be injured.
28
33 year old male is admitted to the emergency department 1 hour after he sustained major burns to the thorax, the neck and the face. Aside from hypovolemic shock, the most immediate life threatening complication to anticipate is
- Hemorrhage secondary to a stress ulcer
- Gram negative sepsis
- Acute gastric dilation
- Secondary inhalation injury
- Acute renal failure
Secondary Inhalation Injury
Ringers Lactate Parkland Formula; 4cc/kg x % BSA burned
Singed eyebrows, soot in mouth - direct evidence of inhalation injury
29
25 year old woman who is breastfeeding presents to the ER with 2 day history of pain and redness in the right breast. Her temperature is 38 C. On examination there is a fluctuant 10cm diameter area of induration, redness and extreme localized tenderness. Which one of the following is the most appropriate step in management?
Discontinue breast-feeding (from both breasts)
Incise and drain the indurated area
Express milk from the right breast with pump and discontinue breast feeding (from the left)
Apply a hot compress and prescribe an anti-inflammatory (medication)
Prescribe a course of cloxacillin
Incise and Drain the indurated area
Mastitis vs Breast Abscess
- This is abscess re: fluctuating mass
Staph aureus is the bug (use clod)
30
63 year old woman is prescribed tamoxifen therapy following surgery for breast cancer. Which one of the following best described the mode of action of this drug on reducing the patient’s risk of recurrent disease?
It decreases secretion of FSH
It blocks the binding of estrogen to estrogen receptors
It enhances biliary excretion of estrogens
It has direct cytotoxic effects
It has progestational activity that limits the growth-promoting effects of estrogens
Blocks binding of estrogen to estrogen receptors
31
69 year old woman presents to your office with a lump in her breast. Which one of the following is the greatest risk factor for cancer?
```
Positive family history
Early menarche
Use of hormone replacement therapy
Advanced age
Nulliparity
```
Advanced age
Two most common RF is sex and age (greatest RF for BC)
32
62 year old woman with breast carcinoma was treated with a partial mastectomy. Which one of the following suggests a better prognosis?
- The primary tumor was 2.5 cm in diameter
- Presence of estrogen receptors
- Absence of metastasis in the liver
- Positivity of only 5 lymph nodes
- Recurrence-free in the first 6 months
Presence of ER
33
```
67 year-old previously healthy woman has palpable 1.5-cm mass in the upper outer quadrant of the left breast. Which one of the following is the most likely diagnosis?
acute mastitis
Carcinoma
fibroadenoma
Paget's disease of the breast
fibrocystic disease
```
Carcinoma
- Fibroadenoma (mobile and solid, no fluid on aspiration)
- Pagets (affects the skin, eczema, peau d'orange around nipple and areola)
- Fibrocystic Disease (common age 30 -50) menopause causes fibrocysts to shrink
34
29 year old male complains that for 7 weeks, food has been getting "stuck" in his throat. He says that he has difficulties swallowing liquids and solids. On further questioning, he confirms that he occasionally regurgitates undigested food that he ate several hours prior. Which of the following studies would you expect to yield abnormal results?
- Computed tomography of the chest without oral contrast
- Esophagogastroduodenoscopy
- Esophageal manometry
- Electrocardiogram
- Computed tomography of the chest with oral contrast
Esophageal Manometry
Zenkers Diverticulum; with foul smell, obstructive dysphagia
35
An elderly patient who underwent orthopedic repair of a hip fracture developed abdominal distention and dull diffuse abdominal pain. He denies fever or diarrhea. WBC count was 4.8. An abdominal plain film shows right sided colonic distention Colonoscopy revealed no obstruction or other abnormalities. Which is the likely inciting factor in the development of this condition?
```
Prior abdominal surgery
Narcotic administration
Recent exposure to antibiotics
Transmural inflammation
Colonic perforation during hip fixation
```
Ogilivies - constipation from narcotics.
36
A 14-year-old girl with persistent melena and chronic anemia undergoes colonoscopy. The findings are shown in the photograph. Which of the following correctly describes the nature of her disease? (polyps multiple on colonoscopy)
Mutation of an oncogene on chromosome 5
Mutation of a tumor suppressor gene on chromosome 2
Mutation of an DNA mismatch repair gene on chromosome 7
Mutation of a tumor suppressor gene on chromosome 5
None of the above
Mutation of tumour suppressor gene on chromosome 5
37
A 47-year-old male is brought to the emergency department for severe vomiting. He reports passing no flatus for 12 hours despite an increasingly distended abdomen. Which of the following represents the greatest risk factor for small bowel obstruction?
```
History of colon cancer
History of asymptomatic diverticulosis
History of colon resection
History of recent travel
History of fecal impaction
```
hx of colon resection (adhesions from prior surgery)
Any pelvic surgery can do that as well.
38
A 63-year-old male presents with lower back pain to his primary care physician. Physical examination shows a hard nodule on digital rectal examination. Prostate adenocarcinoma is suspected. Which lobe(s) of the prostate is most commonly affected by prostate adenocarcinoma?
```
Middle lobe
Lateral lobe
Anterior lobe
Posterior lobe
Lateral and middle lobes
```
Posterior lobe - prostate Ca
Medial lateral lobe = BPH
39
A 65-year-old man presents with increased frequency of urination, nocturia and difficulty starting and stopping his stream of urine. Laboratory work shows an increased level of free prostate-specific antigen. What is the mechanism of action of the drug used to treat this condition?
Inhibition of testosterone synthesis and interference with the fungal synthesis of ergosterol
Inhibition of 5-alpha-reductase
Nonsteroidal competitive inhibitor of androgens at the testosterone receptor
Antagonist of gonadotropin relasing hormone when used in continuous fashion
Inhibition of aldosterone by competing for intracellular aldosterone receptors
BPH and dihydrotestosterone (5 aplha reductase converts form testosterone)
Therefore 5 alpha reductase inhibitors used to treat bph
40
A 53-year-old male presents to the emergency room with abdominal pain. An X-ray reveals radiopaque kidney stones. Laboratory tests reveal hypercalciuria and normocalcemia. Treatment for such kidney stones may be initiated with which type of diuretic?
```
Furosemide
Mannitol
Acetazolamide
Thiazide
Spironolactone
```
Thiazide diuretics
41
Increased JVP, hypotension and decreased breath sounds in a trauma patient is what?
tension pneumo
42
Increased JVP, hypotension and normal breath sounds in a trauma patient is what?
cardiac tamponade
43
what meds can go through an ET Tube?
Narcan, atropine, epi, lidocaine, nebulizeres of ventolin
44
what do you worry about with nasal bone #
septal hematoma
45
what is the sign that racoon eyes (periorbital bruising) is due to basal skull fracture?
sparing of the tarsal plate
46
what do you see with globe injury?
teardrop sign
47
A 23 year old man is involved in a car crash after drinking and driving. At the ED, initial examination reveals his blood pressure is 140/80, heart rate is 74 and he has no evidence of chest or extremity injuries. He opens his eyes to pain and mumbles incomprehensible sounds. When you apply a painful stimulus to his supraorbital nerve, he reaches up, grabs your hand and pulls it away. What score would you give him on the Glasgow Coma scale?
```
12
65
3
9
15
```
9
48
A patient has been shot in the right groin. He is hypotensive and his right leg feels very cold. What is your immediate management?
```
Angiography
Insertion of intravenous lines
Antibiotics
Airway
Neurological assessment of the right leg
```
Airway
49
A 26-year-old man is brought to the emergency department after he sustained a gunshot wound to his left calf. On arrival, he is in severe pain. Temp is 36C, HR 90/min, RR 16/min, and BP is 110/76 mm Hg. Examination shows a 1 cm entrance wound over the medial aspect of his posterior right calf with no exit wound. The calf is tense and tender to palpation. Passive movement of the great toe exacerbates the patient’s calf pain. Peripheral pulses are normal and capillary refill time is 2 seconds. Sensation is intact. X-rays of the right lower extremity show a 1-cm bullet in the medial aspect of the posterior calf.
Which of the following is the next immediate step in the management?
```
MRI of the right lower extremity
Administration of antibiotics
Irrigation of the wound
Femoral arteriography
Doppler US of leg
```
Admin of Abx
- compartment syndrome and needs fasciotomy
50
A 35 year old woman presents with severe, upper abdominal pain associated with nausea and vomiting. Examination shows guarding and rebound of both right and left upper quadrants. Pulse is 120/minute and blood pressure is 90/60 mm hg. Labs reveal a white blood cell count of 25 x 10(9)/L and an amylase of 2000 U/L. Which one of the following is the most likely cause of this woman’s shock?
- Deleterious effects of trypsin and other toxic products on cardiac function
- Loss of whole blood into the peritoneal cavity
- Sepsis resulting from Gram-negative bacterial growth in necrotic pancreatic tissue
- Loss of fluid into the retroperitoneal space
- Disseminated intravascular coagulation
Loss of fluid into retroperitoneal space
51
Which of the following would least likely cause shock after trauma?
```
Ruptured spleen
Unstable pelvic fracture
Thoracic spinal cord injury
Cardiac tamponade
Epidural hematoma
```
E. Epidural hematoma
52
A 19-year old male hockey player is struck in the left side of the abdomen by an opponent’s hockey stick during a game. CAT scan of the abdomen shows a ruptured spleen and free intra-abdominal fluid. His heart rate is 125 bpm and his blood pressure is 80/60. Which of the following is the most appropriate fluid to initially treat this patient’s hypovolemic shock:
```
5% dextrose in 0.9% NaCl
0.45% NaCl
Ringer’s Lactate solution
3.33% dextrose in 0.33% NaCl
5% dextrose in water
```
A. Ringer’s Lactate solution
53
A 25-year old female has fallen while horseback riding and has suffered a cervical spinal cord injury. No other injuries are noted. Her blood pressure is 90/40 and heart rate is 40 bpm. What is the cause of her hypotension?
```
Systemic arteriolar dilation
Systemic venous dilation
Bradycardia
Decreased myocardial contractility
All of the above
```
All of the above
54
Which of the following does not characterize neurogenic shock?
```
Severe head injury
hypotension
Bradycardia
Spinal cord injury
Oliguria
```
Head injury
55
what is kehrs sign
shoulder pain post splenic rupture.
56
What does seatbelt sign make you think of?
duodenal hematoma/intraperitoneal injury
57
A 29 y.o. female is brought to the ED with severe LUQ abdominal pain and nausea, after an MVA. She had no loss of consciousness and states her last meal was 4 hours ago. She uses marijuana occasionally, consumes alcohol daily and states her LMP was 4 weeks ago.Vital signs show tachycardia only.
whats your DDX?
splenic injury
hemothorax
rib #
58
An 18-year-old man is brought to the emergency department complaining of pain in the right hip and flank after a motor vehicle accident. He is alert and stable. On examination he has abrasions, ecchymoses, and tenderness over the right iliac crest, as well as abrasions on the right flank. Urinalysis shows gross blood and x-ray of the cervical spine is normal.
Which of the following is the most appropriate next step in the diagnosis?
```
CT scan of the abdomen with contrast
MRI of the pelvis
Radionuclide renal scan
Selective renal angiography
Cystoscopy
```
if possible kidney injury
| - gross hematuria in trauma pt = bladder injury
59
A 23-year-old woman c/o pain in the left shoulder, 12 hours after falling down the stairs. Examination reveals diffuse abdominal tenderness. Hb is 100g/L, and WBC is 11,000/mm3. Which of the following is the most likely diagnosis?
```
Acute traumatic pancreatitis
Diaphragmatic tear
Ruptured spleen
Shoulder separation
Supracondylar fracture
```
spleen (KEHRS SING)
60
A 20 year old man was involved in a motor vehicle collision. He was in the passenger seat and had been wearing his seat belt. His only complaint at presentation to the ER, was vague abdominal pain at the site of a seat belt. He was admitted for observation. Overnight, he developed increasing abdominal pain, fever, guarding and rebound. His vitals were stable and an abdominal series showed air fluid levels, with minimally dilated small bowel. Which one of the following is the most likely diagnosis?
- Diaphragmatic rupture
- Small Bowel Hematoma
- Ruptured spleen
- Bladder rupture
- Liver laceration
Small bowel wall hematoma (duodenal hematoma)
61
A 22-year-old university student twists his ankle while playing basketball. Which of the following would be the most likely injury?
```
Fracture of the medial malleolus
Sprain of the medial ligament complex
Sprain of the lateral ligament complex
Fracture of the lateral malleolus
Fracture of the base of the fifth metatarsal
```
Sprain of the lateral ligament complex
62
57 year old lawyer who has been your patient for several years. He comes to see you after a fall while skiing. His right knee is painful and swollen.
DDX
Anterior cruciate ligament tear
Posterior cruciate ligament tear
Meniscus
Fracture
63
A 45 year old woman comes to the ER via ambulance after being an unrestrained passenger in a MVA. She complains of severe hip pain. On exam, she is noted to hold her hip in flexion and adduction. What is her most likely injury?
```
Psoas muscle disruption
Pelvic fracture
Femoral neck fracture
Sacro-iliac joint disruption
Posterior hip dislocation
```
Posterior hip dislocation
64
What do you send aspirate for when a ? septic joint
Gram stain and the three C's
Graim Stain, culture, cell count, crystals
65
What do you send aspirate for when a ? septic joint
Gram stain and the three C's
Graim Stain, culture, cell count, crystals
66
An older, overweight man c/o disabling, sharp heel pain every time his foot strikes the ground. The pain is worse in the mornings, preventing him from putting any weight on the heel. X-ray shows a bony spur matching the location of his pain, and physical examination shows exquisite tenderness on palpation over the heel spur. When the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation. Which of the following is the most likely diagnosis?
```
Epiphysitis of the calcaneus
Fracture of the posterolateral talar tubercle
Plantar fasciitis
Posterior Achilles tendon bursitis
Posterior tibial nerve neuralgia
```
plantar fasciitis
67
The driver of an automobile is brought to the emergency department following a head-on collision at 80 kph. He was wearing a seat belt and his only complaint is that of mild chest tenderness. All diagnostic tests are normal except for x-ray of the chest that shows a somewhat widened mediastinum.
Which of the following is the most appropriate next step in management?
- Bronchoscopy
- Discharge with a follow-up appointment in 24 hours
- Exploratory thoracotomy
- Observation in the hospital and another x-ray of the chest in 6 hours
- Chest CT angiography
CT angio
68
A tension pneumothorax is initially managed by which of the following?
```
Chest tube
Endotracheal intubation
Supplementary oxygen
Needle thoracostomy
Cricothyroidotomy
```
Needle Thoracostomy
69
A 20 year old male is involved in an altercation that results in him sustaining a knife stab wound to his left supraclavicular fossa. He has a large hematoma (not expanding) with a palpable thrill. Auscultation over the hematoma reveals a continuous bruit. What is your diagnosis?
Hematoma distorting subclavian artery and causing turbulence
Information maybe a red herring; patient actually has a congenital cardiac defect
Subclavian artery injury with A-V fistula
Vascular tumour
None of the above
AV Fistula
70
A 20 year old male is brought to the ER by ambulance. He was returning from a graduation party and was involved in a motor vehicle accident. He was the driver and was not wearing a seat belt. He smells of alcohol, and complains of chest pain.
After a primary survey of the patient , you discover that there is tracheal deviation to the right and bruising over the left anterior chest wall with tenderness. There is diminished air entry on the left with increased resonance and elevated JVP. His blood pressure is 80/50, pulse is 110, respiratory rate 36 and his breathing is very laboured.
What is your initial management?
```
Needle Thoracostomy
2 IVs with rapid fluid replacement
Cross-match blood
Oxygen- non rebreather
Close monitoring of his vital signs
ECG
Chest tube
0xygen by nasal prongs.----(wrong)
C-spine precautions
```
71
Initial Management of pericardial effusion?
Pericardiocentesis -subxiphoid approach
72
The most common cause of a hemothorax after blunt trauma is:
```
Lung injury
Laceration of intercostal vessel
Aortic rupture
Ruptured diaphragm
Ruptured right ventricle
```
Lac of intercostal vessel
73
Regarding penetrating torso trauma, which of the following statements is correct?
- All thoracic wounds require a thoracotomy
- Most thoracic wounds require a thoracotomy
- A minority of thoracic wounds require a thoracotomy
- Gunshot wounds to the abdomen are commonly managed non-operative
- A knife protruding from the abdomen of a patient should immediately be removed
A. A minority of thoracic wounds require a thoracotomy
74
A 23-year old man is stabbed in the epigastrium. On admission, his BP is 80/50 mm Hg, his neck veins are distended, and his heart sounds are muffled. The hypotension in this patient is most likely caused by which one of the following?
-Cardiac tamponade
-Hypovolemic shock from blood loss
-Neurogenic shock from transection of the spinal cord
-Gastric perforation resulting in septic shock
All of the above
TamponADE
75
A 21 year old man is involved in a motorcycle collision. On arrival to the ER, he is noted to have no movement of his legs, no sensation in his legs and loss of rectal tone. Which one of the following may be beneficial?
```
Opioid antagonists
High dose steroids
High dose antihistamines
Spinal cord cooling
Revascularization of the spinal cord
```
High dose steroids
76
A 35 year old male truck driver presents with severe lower back and leg pain after a fall, while carrying a heavy parcel. You diagnose intervertebral disc herniation. Which of the following should lead you to advise urgent investigations and possibly urgent surgery?
- Constipation and increase pain on straining stool
- Loss of sensation in the perineal and “saddle” areas
- Loss of sensation over the small toe and heel
- Loss of the ankle reflex on the side of the leg pain
- Paravertibral muscle spasm
-Loss of sensation in the perineal and “saddle” areas
77
The tissue MOST susceptible to prolonged periods of ischemia (i.e. vascular disruption in an extremity) is:
```
Bone
Nerve
Skin
Blood vessel
Muscle
```
Nerve
78
Patients with pre-gangrenous changes in their feet could have which of the following physical findings?
```
Palpable pulses
Pallor on dependency
Rubor on elevation
No motor function
None of the above
```
palpable pulses
- still will have pulses because its all pre gangrenous changes. Rubour on dependencing and pallor on elevation.
79
The most reliable diagnostic sign of an acute compartment syndrome in an awake patient would be?
Pain on passive stretch of muscles in the compartment
Pallor of the affected compartment
Pulselessness distal to the affected compartment
Swelling of the compartment
None of the above
Pain on passive stretch
80
A 79 year old male presents to the ER with the sudden onset pain in his right leg. His leg is pale and cool from the knee down, and his sensation is reduced in the foot. He is in atrial fibrillation. Pulses (femoral, popliteal, pedal) are normal in the left leg. On the right leg, he has a femoral pulse but absent pulses distally.
Which of the following would be your management at this stage?
non-invasive vascular lab (Doppler) studies
Arteriogram
2-D echo
IV heparin followed by urgent embolectomy
IV heparin, reassess in 2 hours
IV Heparin and urgent embolectomy
81
Which of the following findings is usually seen on physical examination, in a patient with an isolated zygoma fracture?
```
Loss of vision
Loss of taste sensation
Decreased sensation of the V1 distribution
Interruption of Stensen’s duct
Diplopia
Maxilla and Mandibular fractures.
```
Diploplia
82
A 25-year-old man sustains a blow-out fracture of his left orbit while playing soccer. You expect to find?
A.depression of the zygomatic arch on the left side.
B.horizontal diplopia.
C.retinal detachment.
D.left enophthalmos.
E.blood behind the left tympanic membrane.
Left Enopthalmos
83
A patient is referred to you complaining of “blurry vision”. Your examination reveals a Marcus Gunn phenomenon. Where is the lesion?
```
The parasympathetic supply to the pupil
The second cranial nerve
The sympathetic supply to the pupil
The third cranial nerve
The calcarine cortex
```
second cranial nerve
84
Twenty four hours after rod stabilization of a femoral shaft fracture, a 28-year-old homeless man has a sudden onset of combativeness and disorientation. His pulse is 120/min, respirations are 24/min, and blood pressure is 140/85 mm Hg. Examination shows petechiae over the axilla and review of other systems show no abnormalities.
Which of the following is the most likely cause of these findings?
```
Alcohol withdrawal
Aspiration pneumonia
Fat embolism
Intracranial hemorrhage
Pulmonary embolism
```
Fat embolism
85
A 56 yo old male sustains a displaced subcapital hip fracture which is treated with multiple pin fixations. He presents to your clinic 5 months after the operation with increasing hip pain. Radiographs demonstrate that the fracture has healed but there is narrowing of the joint space. What is the most likely diagnosis?
```
Osteomyelitis
Osteonecrosis
Pins backing out
Malunion
Septic arthritis
```
osteonecrosis
86
What mechanism of injury is most commonly associated with scaphoid fractures?
Extreme dorsiflexion of the wrist with compressive force to the radial side of the palm
87
A 69 year old man has suffered a pathological fracture of the proximal femur after a seemingly minor injury. He is most likely to have been previously diagnosed with which of the following?
```
Renal cell carcinoma
Alzheimer’s dementia
Gastric carcinoma
Osteoarthritis
Colon cancer
```
Renal Cell Ca
88
The treatment of open extremity fractures include each of the following EXCEPT:
```
Tetanus prophylaxis
Antibiotics
Management of the airway
Suturing of associated wound in the ER
Open reduction and fixation of fracture
```
D. Suturing of associated wound in the ER
89
A 47 year old man was tackled in a game of football 30 minutes ago. He presents to the ER c/o an injury to his right leg. Examination reveals an area of tenderness and swelling along the anterior surface of the lower leg as well as a 1 cm laceration. X-rays show a spiral fracture of the tibial shaft. Which of the following should not be performed?
- Remove gross debris and apply a sterile dressing
- Splint the leg after applying a sterile dressing, then call the O.R.
- Administer 1 gram of IV cefazolin
- Carefully debride the wound edges and probe for foreign bodies
- Inquire about the patient’s tetanus status
D. Carefully debride the wound edges and probe for foreign bodies
Lac to where compound # is therefore needs to go to OR
90
Which of the following statements about midshaft clavicle fractures is false?
- Most clavicle fractures occur in the midshaft
- Treatment of nondisplaced fractures with a figure eight dressing provides better patient satisfaction than a simple arm sling
- Immobilization of nondisplaced fractures often can be discontinued in one or two weeks
- Displaced fractures managed operatively have a lower rate of nonunion
- None of the above
-Treatment of nondisplaced fractures with a figure eight dressing provides better patient satisfaction than a simple arm sling
91
Which of the following is the most serious complication of a displaced supracondylar fracture of the humerus?
- A compartment syndrome of the forearm
- Failure to heal
- Healing in a non-anatomic position
- Injury to the median nerve
- Permanent restriction of elbow motion
A. A compartment syndrome of the forearm
Volkman ischemia
92
What are the knavel signs of flexor tendonitiis(4)
Finger held in passive flexion
Diffuse fusiform swelling
Passive extension = signif pain
Tenderness along flexor tendon sheath
(caused by cat bite on velar aspect of finger
93
swollen painful wrist in young woman DDX?
1. *** REACTIVE Arthritis
2. Septic Joint
Wrist sprain
Rheumatoid Arthritis
Gouty Arthritis
94
On clinical examination of a swollen painful wrist, which of the following features might aid in making the diagnosis?
- Bite wound from cat over base of thumb
- Blue sclear
- Deformity of hands
- Effusion in IP joints of fingers
- Hemotympanum
- Iritis
- Limitation of range of motion
- Pain on resisted extension wrist
- Pain on resisted flexion wrist
- Presence of swelling
- Tophi at elbow
```
Bite wound from cat over base of thumb
Deformity of hands
Effusion in IP joints of fingers
Iritis
Tophi at elbow
```
95
Which antibiotic is the first line drug of choice for an otherwise uncomplicated human bite infection of the hand?
```
Gentamicin
Amoxi/clav
Flagyl
Cephalexin
Erythromcyin
```
Amoxi-clav
96
You observe a serosanguinous discharge from the wound of a patient who underwent a sigmoid resection three days earlier. Which one of the following is the most likely diagnosis?
- Ureteric injury
- Anastomotic leak
- Wound infection
- Necrotizing fasciitis
- Fascial dehiscence
Fascial Dehisence
- Discharge can be from fascial dehiscence, sutures pull a bit (small amount of fluid and blood tinged; serosang)
- PURUlosangenous (wound infection re: pus)
- Anastomotic leak (SIRSy; dehydration
97
A 26 year old man from the local military base presents to your office complaining of severe pain over the tailbone. Physical examination reveals a swollen, indurated area over the natal cleft. Which one of the following is the most appropriate management at this time?
- Oral antibiotics
- Oral analgesics and rest
- Injection of steroids
- X ray of the sacrum
- Incision and drainage
Abscess (I&D)
Pilonidal cyst/dimple
- ischiorectal abscess - near ischium
98
A 70-yo hypertensive man on atenolol, is brought to the ER 20 mins after his wife found him unconscious in a pool of vomitus. On exam,Temp is 37°C, HR is 60/min, RR 10/min, and BP is 170/98 mm Hg. The patient withdraws the left extremities vigorously to painful stimuli, but there is no movement of the right arm or leg. He moans incomprehensibly and opens his eyes briefly to noxious stimuli.
The left pupil is 6 mm and nonreactive while the right pupil is 3 mm and reactive to light. The eyes deviate conjugately to the left but funduscopy is normal. Deep tendon reflexes are 2+ in the left extremities and absent in the right extremities. Babinski sign is present on the right.
Which of the following will most rapidly decrease this patient’s intracranial pressure?
```
Oral glycerol therapy through nasogastric tube
Trendelenburg (head down) positioning
Intubation and hyperventilation
Intravenous dexamethasone therapy
Intravenous mannitol therapy
```
Tube ot decrease ICP
Classic description of uncial herniation.
Bleed is in left side of brain where eye conjugation are going and where pupil is going. contralteral side has leg and arm Paralysis.
Ipsilateral CN defects. Contra Paralysis.
99
A 14 yo boy with hemophilia A is brought to the clinic c/o headaches and decreased school performance since falling 10 ft to the ground 2 wks ago. He states he did not lose consciousness with the fall and remembers striking his head. On exam, vital signs are within normal limits. He has bilateral papilledema and hyperreflexia of the left limbs. A CT scan of the head two weeks ago showed no abnormalities.
Which of the following is the most likely diagnosis?
```
Epidural hematoma
Post concussive syndrome
Subarchnoid hemorrhage
Subdural hematoma
Brain abscess
```
Subdural because of slow bleed
