A 45-year-old female presents with a 1-day history of left leg swelling. She notes that this has never happened to her before, and she denies any trauma to the leg. She underwent an appendectomy 10 weeks ago, and is otherwise healthy. A physical examination is normal except for 2+ pitting edema of the entire left leg.
The most appropriate next step would be:
Correct Answer A: No single clinical finding can be used to accurately diagnose deep venous thrombosis (DVT). Patients can be classified into low, moderate, or high-risk categories using a variety of risk factors. These include active cancer, paralysis, immobilization, local tenderness, swelling of the entire leg, a calf circumference 3 cm larger than that of the asymptomatic side, pitting edema, collateral superficial veins, a history of recent surgery, and previous DVT. The presence of three or more risk factors (in this case, swelling of the entire leg, pitting edema, and a history of recent surgery) places the patient into a high-risk category, which is an indication for ultrasonography (Doppler).
→ Observation only, or a trial of diuretics, would put the patient at risk of dying from an un-diagnosed pulmonary embolus.
→ Pelvic ultrasonography and Echocardiography are unlikely to reveal the source of the problem.
An 18-year-old motorcyclist presents in the emergency department following an accident. He has a compound (open) tibia and fibula fracture of the right leg and on examination the right leg has normal pulses.
Your immediate management of choice should be:
Correct Answer B: When examining a patient for a lower leg fracture one should first examine the patient for edema, ecchymosis, and point tenderness. Gross deformities should be noted and splinted. A careful neurovascular assessment should be performed, and an emergent fracture reduction should be performed if neurovascular deficits are present.
Immediate treatment of tibia and fibula fractures includes analgesics and, for suspected unstable fractures or fractures of long bones, splinting. Suspected open fractures require wound irrigation, sterile wound dressings, tetanus prophylaxis, and broad-spectrum antibiotics (eg, a 2nd-generation cephalosporin plus an aminoglycoside). Closed reduction (without skin incision) is done when possible; if not, open reduction (with skin incision) is done. In open reduction and internal fixation (ORIF), fracture fragments are aligned and held in place using hardware.
A 21-year-old female marathon runner presents to your office complaining of persistent “shin splints”. She reports that she has had to decrease her running because of this problem. On examination you note an area of localized tenderness over the distal medial tibia a few centimeters above the ankle.
Which one of the following is the most likely diagnosis?
Correct Answer C: Tibial stress fracture may present similarly to shin splints but tend to be persistent, and pain occurs with increasingly less activity. Athletes engaged in high-level repetitive training are at risk. Also at risk are patients with osteopenia, which may result from amenorrhea secondary to over training. Point tenderness helps differentiate tibial stress fractures from shin splints. Osgood-Schlatter disease and pes anserine tendinitis present as more proximal pain in the knee area. Tibialis posterior tendinitis causes pain that extends to the medial malleolus.
A patient with a subarachnoid hemorrhage from a ruptured aneurysm undergoes successful surgery 2 days after the hemorrhage. On the four post-op day, he shows right arm weakness and alterations in consciousness.
The most likely diagnosis is:
Correct Answer D: Vasospasm can develop several days (4 to 14) after an aneurysmal subarachnoid hemorrhage. Patients present with progressive weakness and alterations in consciousness. Early in the course, a computed tomography (CT) scan may not reveal an ischemic infarction.
→ Hydrocephalus can occur immediately after a SAH or weeks to months later. Symptoms are typically nonfocal and, if the hydrocephalus develops acutely, it is often accompanied by a depressed level of consciousness.
→ Bacterial meningitis can develop after a craniotomy. Typically, there is fever and impaired arousal. Focal signs can develop but are rarely the presenting feature.
→ Although a repeat hemorrhage can occur after clipping of an aneurysm if the aneurysm is not completely isolated from the circulation, it is unusual for this to happen and present with a focal deficit, as opposed to depressed consciousness.
→ Hyponatremia, which can develop after SAH, can cause an altered sensorium and seizures but not unilateral weakness.
An 83-year-old man has fallen while walking down stairs. He is brought to the emergency department with a 3 part intertrochanteric hip fracture. He is 167 cm tall and weighs 88 kg.
Which of the following procedures would you choose to perform?
Correct Answer E: There are two common types of hip fractures. Femoral neck or subcapital hip fractures occur in the neck of the femur. Intertrochanteric fractures occur in the large bony bumps (trochanters) where the powerful muscles of the buttocks and legs attach. When the fracture is not too severe, metal pins can be inserted surgically to support the femoral head. This surgical procedure preserves the person's own hip joint.
Most people with a hip fracture are treated with surgery. The type of surgery depends on the type of fracture. Treatment of severe femoral neck hip fractures involves removing the broken pieces surgically because the blood supply to the femoral head has been damaged. If damage to the femoral neck is incomplete (the break does not go all the way through), metal pins can be inserted surgically to support the femoral head (internal fixation). This is a smaller surgical procedure and the person's own hip joint is preserved.
Intertrochanteric hip fractures are treated with an implant, such as a sliding compression screw and side plate (choice E). This implant securely holds the bone fragments in their proper position while the fracture heals. The fixation is usually strong enough to permit the person to bear weight as tolerated. While the bone fragments generally heal in a couple of months, most people continue to improve in terms of comfort, strength, and walking ability for at least 6 months.
→ Hemiarthroplasty (choice A) involves replacement of the articular surface of the femoral head without surgical alteration to the acetabular articular surface. This may involve replacement of the femoral head and neck (unipolar hemiarthroplasty), replacement of the femoral head and neck with an additional acetabular cup that is not attached to the pelvis -also known as bipolar hemiarthroplasty (choice D), or replacement of the surface of the femoral head (resurfacing hemiarthroplasty).
→ Total hip replacement (choice B) is an arthroplasty that replaces the articular surfaces of both the acetabulum and femur. The above treatment options of arthroplasty are not the best for accidental intertrochanteric hip fracture in this patient with BMI>30.
→ Intramedullary nailing (choice C) used to an alternative management for intertrochanteric fractures but has been abandoned because it led to excessive external rotation and knee pain.
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