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The Quizzes about Ultrasound in the Emergency Department (22 test)

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1.A 35-year-old woman presents to the ED via ambulance after being involved in an automobile EMS reports the patient was a restrained front seat passenger in a car struck on the front passenger door with significant cabin intrusion. The patient was nonambulatory on scene and required prolonged extraction from the vehicle. The vital signs on scene after extrication were blood pressure (BP) 105/80 mm Hg, heart rate (HR) 115 beats per minute, respiratory rate (RR) 22 breaths per minute, and oxygen saturation 100% on a non-rebreather mask. Two larger-bore IVs were established with 2 L of normal saline infused during extrication and transport. On arrival in the emergency department (ED), the patient does not remember what happened. She complains of pain in the right forearm and abdomen. In the ED her vital signs are BP 90/65 mm Hg, HR 140 beats per minute, temperature 98.9°F, RR 35 breaths per minute, and oxygen saturation 100% on a non-rebreather mask. Physical exami- nation reveals a diaphoretic patient who responds to painful stimuli. She answers questions but is confused. On examination, her abdomen is non- distended, soft, and tender along the right upper and lower quadrants on moderate palpation. Her dorsal forearm has a 4-cm laceration with active oozing of blood. She is neurovascularly intact in the right extremity, and no deformities are noted. There is no other evidence of trauma. A second liter of normal saline is started, type O–negative blood is ordered, and the type and cross match is sent to the laboratory. Chest and pelvis radiographs are negative for acute injury. You obtain a focused assessment by sonography for trauma (FAST) examination, shown in the following image. What is the next best step in the management of the patient?

  1. Continue intravenous (IV) fluids and obtain a computed tomographic (CT) scan of her head.
  2. Continue IV fluids and obtain a CT scan of her abdomen and pelvis.
  3. Wait for the hemoglobin result and, if low, administer 2 units of packed red blood cells (RBCs).
  4. Transport the patient to the operating room for emergent therapeutic laparotomy.
  5. Place interlocking stitches to close the forearm laceration to control bleeding and prevent her BP from dropping even further.

2. A 16-year-old girl present to the ED complaining of severe sudden- onset sharp pain located in the right lower quadrant (RLQ). The pain started suddenly 1 hour before The pain is associated with a single epi- sode of nonbloody emesis; however, no diarrhea, vaginal bleeding, vaginal discharge, frequency, or burning with urination was reported. The patient denies any sexual activity in her past. She states she is G0P0 and her last normal menstrual period was 3 weeks ago. Her BP is 130/75 mm Hg, HR is 115 beats per minute, temperature is 99.3°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a very uncomfortable appearing patient holding her RLQ. Her abdomen is tender in the RLQ with mild voluntary guarding but no rebound tender- ness, Rovsing sign, psoas, or obturator signs. Pelvic examination shows right adnexal tenderness, with no masses, cervical motion tenderness, or discharge. Laboratory results reveal a urinalysis with 1+ leukocyte esterase, negative qualitative b-human chorionic gonadotropin (b-hCG), white blood cell (WBC) count 8000/mL, hematocrit 46%, and platelets 270/mL. Which of the following ultrasound findings helps to rule out ovarian tor- sion as this patient’s diagnosis?

  1. Unilateral enlarged ovary secondary to edema
  2. Venous and arterial blood flow detected with Doppler sonography of the right ovary
  3. Free fluid in the pouch of Douglas
  4. Normal-sized ovary with no surrounding ovarian mass
  5. Presence of right adnexal mass measuring 5 cm at largest diameter

3. A 23-year-old woman presents to the ED with abdominal discomfort located in the left lower quadrant (LLQ) for the past 3 The pain is intermittent, nonradiating, with no alleviating or aggravating factors. She denies vomiting, diarrhea, dysuria, vaginal bleeding, or vaginal discharge. The patient states she is sexually active with one partner and her last menstrual period (LMP) was 2 weeks ago. Her BP is 115/70 mm Hg, HR is 75 beats per minute, temperature is 98.6°F, RR is 15 breaths per minute, and oxygen saturation is 100% on room air. Physical examination is unre- markable. Urinalysis shows no evidence of hematuria or infection. Qualita- tive b-hCG is positive. Bedside transvaginal pelvic ultrasound is obtained as seen below.

Which of the following is the earliest ultrasound finding confirming intra- uterine pregnancy (IUP)?

  1. Gestational sac with visualized endometrial stripe
  2. Gestational sac containing yolk sack and embryonic pole with visualized endo- metrial stripe
  3. Blighted ovum with visualized endometrial stripe
  4. Intradecidual sign with visualized endometrial stripe
  5. Gestational sac containing yolk sac with visualized endometrial stripe

4. Emergency medical service (EMS) was called to the scene of an unconscious 38-year-old man with labored EMS intubated the patient, placed two large-bore IVs, and began a normal saline infusion. On arrival in the ED, his BP is 70/30 mm Hg, HR is 140 beats per minute, temperature is 98.9°F, and oxygen saturation is 100% on a non-rebreather. Physical examination reveals a diaphoretic male, moving all four extremi- ties spontaneously, but he is not following commands. The neck exami- nation reveals elevated jugular venous pressure and a midline trachea. A single puncture wound is noted just below the xiphoid process; however, no abdominal distension is appreciated on abdominal examination. Your FAST examination is as shown in the following the ultrasound image. What is the next best step in the patient’s management?

  1. ED resuscitative thoracotomy after placement of a chest tube.
  2. Immediate transfer to the operating room for emergent laparotomy and pelvic binding.
  3. Immediate transfer to operating room for emergent thoracotomy.
  4. Stat CT scan of the abdomen and pelvis to evaluate for hollow viscus injury.
  5. Perform a stat bedside pericardiocentesis.

5. A 42-year-old woman presents to the ED complaining of abdominal pain that is located in her right upper quadrant (RUQ). The pain started 5 hours before presentation after a She describes the pain as sharp, radiating around the right flank and into the back. The pain never com- pletely goes away but waxes and wanes in intensity. This pain is associated with nausea and vomiting, but no diarrhea or fever has been noted. Her review of systems reveals that she has been getting sharp pains in her RUQ after meals for the past year. Her BP is 145/75 mm Hg, HR is 110 beats per minute, temperature is 100.3°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. The physical examination shows a non- distended abdomen with tenderness to palpation in the RUQ. There is no rebound or guarding. When the patient tries to inhale during deep palpation of the RUQ, she is forced to pause during inspiration because of extreme pain. Laboratory results reveal WBC 16,000/mL, hematocrit 48%, platelets 250/mL, aspartate aminotransferase (AST) 45 U/L, alanine aminotransferase (ALT) 40 U/L, alkaline phosphatase 75 U/L, amylase 50 U/L, lipase 40 U/L, sodium 140 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbon- ate 24 mEq/L, blood urea nitrogen (BUN) 9 mg/dL, creatinine 0.5 mg/dL, and glucose 85 mg/dL. You obtain a bedside ultrasound scan as seen below and find the following image showing a gallbladder wall thickness of 7 mm. Which of the following is a later finding of cholecystitis?

  1. Cholelithiasis
  2. Sonographic Murphy sign
  3. Mucosal sloughing
  4. Gallbladder wall thickening
  5. Pericholecystic fluid

6. A 25-year-old man presents to the ED after being shot in the face with a shotgun at long The patient complains of pain generally across his face; however, the pain is greatest around his right eye. He is not sure if he can see out of the eye because the right eyelid is swollen shut. His BP is 140/80 mm Hg, HR is 105 beats per minute, temperature is 98.4°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physi- cal examination shows multiple pellet marks across the face. The right eyelid has a grouping of pellet marks and is swollen shut with surround- ing ecchymosis and edema. The eyelid cannot be pried open secondary to pain limitation and further attempts at direct visualization of the eye where deferred for concern of manually increasing intraocular pressure. The rest of the physical examination was unremarkable. Bedside ocular ultrasound was obtained as seen below. Which of the following is the most likely diagnosis?

  1. Intact globe
  2. Retinal detachment
  3. Lens dislocation
  4. Globe rupture
  5. Retrobulbar hematoma

7. A 70-year-old man presents to the ED complaining of pain in his left back and He describes the pain as dull and aching. The pain started 1 day before presentation while watching TV. The pain is constant and does not radiate. He has no history of trauma or heavy lifting, and nothing seems to make the pain worse or better. His BP is 170/95 mm Hg, HR is 88 beats per minute, temperature is 97.6°F, RR is 17 breaths per minute, and oxygen saturation is 100% on room air. The physical examination and laboratory studies are unremarkable. A bedside ultrasound is obtained as seen below with the transverse and sagittal views of the aorta. Which of the following is the most accurate way to measure abdominal aortic aneurysm diameter?

  1. While viewing the aorta in a sagittal plane, measure anterior to posterior diameter from inner wall to inner wall.
  2. While viewing the aorta in a transverse plane, measure anterior to posterior diameter from inner wall to inner wall.
  3. While viewing the aorta in a transverse plane, measure anterior to posterior diameter from outer wall to outer wall.
  4. While viewing the aorta in a sagittal plane, measure the anterior posterior diameter from outer wall to outer wall.
  5. While viewing the aorta in a transverse plane, measure anterior to posterior diameter from outer wall to inner wall.

8. A 55-year-old woman is brought to ED after being struck by an auto- mobile. Per EMS, she was crossing an intersection when an automobile ran a stop sign striking her on the left The patient was found lying supine in the street alert and oriented to person, place, and time. Prehospital vital signs were BP 100/85 mm Hg, HR 120 beats per minute, RR 22 breaths per minute, and oxygen saturation 95% on room air. Intravenous access was established with normal saline being infused during transfer to your ED. On arrival in the ED, the patient complains of pain in the left hip and pelvic region. Vital signs in the ED are BP 95/60 mm Hg, HR 135 beats per minute, temperature 97.5°F, RR 28 breaths per minute, and oxygen saturation 100% on a non-rebreather. Physical examination reveals a pale diaphoretic patient. The breath sounds are clear bilaterally and her abdomen is soft and nondistended. Her pelvis appears stable, but exquisite pain is elicited with rocking of the pelvis. Her extremity examination reveals no leg length or temperature discrepancies, and she is neurovascularly intact throughout the lower extremities. The examination of her perineum reveals ecchymosis on the perineum and blood at the urethral meatus. You obtain a FAST examination as seen below and a pelvic radiograph that shows markedly widened view of the pubic symphysis. After pelvic binding is applied, what is the next best step in the management of this patient?

  1. CT scan of the abdomen and pelvis with intravenous contrast
  2. Transport to operating room for emergent laparotomy
  3. Transport to the interventional radiology suite for embolization
  4. Foley catheter to evaluate for hematuria
  5. CT thorax with intravenous contrast

9. A 30-year-old man presents to the ED complaining of severe pain in the left side and He states that the pain started suddenly 5 hours before presentation and describes the pain as stabbing. The patient has never experienced the pain previously and states the pain comes and goes in intensity but never completely goes away. The pain radiates to his left groin and denies any alleviating or aggravating factors. The patient denies any hematuria, burning with urination, fever, vomiting, changes in bowel habits, recent trauma, or heavy lifting. His BP is 155/80 mm Hg, HR is 105 beats per minute, temperature is 99.5°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a patient in obvious pain who cannot seem to find a position of comfort. The only remarkable finding was costovertebral angel tenderness on the left side. Laboratory results reveal sodium 142 mEq/L, potassium 4.0 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 12 mg/dL, creatinine 0.7 mg/dL, and glucose 100 mg/dL. Urinalysis shows 2+ blood and RBC 20 to 50/hpf. A bedside renal ultrasound is obtained. Which of the following findings on ultrasound is consistent with severe  hydronephrosis?

  1. Anechoic collections around the renal pelvis with dividing segments of renal cortex
  2. Prominent anechoic renal calyces
  3. Prominent anechoic renal pelvis and calyces
  4. Prominent anechoic renal pelvis and calyces with cortical thinning
  5. Prominent renal pelvis and calyces with echogenic structure at ureteropelvic junction casting clean shadowing in the background

10. A 48-year-old man was reroofing the second story of his house when he slipped and fell to the ground, landing on his right EMS arrived at the scene, placed the patient in spinal precautions, and established an IV. On arrival to the ED, he complains of pain along the right costal margin going to his right lateral chest and in his RUQ. He states it hurts to breathe but has not other complaints. His BP is 130/80 mm Hg, HR is 110 beats per minute, temperature is 98.9°F, RR is 25 breaths per minute and shallow, and oxygen saturation is 100% on room air. Physical examination reveals the patient taking rapid shallow breaths and holding his right hemithorax. His neck examination shows no elevated jugular venous pressure and his trachea is midline. His chest wall is tender down the right lateral wall. You do not palpate crepitus. His breath sounds are equal to auscultation bilateral. His abdominal examination reveals a nondistended abdomen, but there is tenderness in the RUQ. A 2-L bolus of normal saline is started and you obtain a FAST examination, as shown in the following image. What is the next best step in the management of this patient?

  1. Chest tube thoracostomy
  2. Rapid sequence intubation
  3. CT scan of the thorax with intravenous contrast
  4. CT scan of the abdomen and pelvis with intravenous contrast
  5. Transport to the operating room for emergent laparotomy

 

11. A 55-year-old man presents to the ED complaining of epigastric abdominal He describes the pain as gradual in onset, burning in nature, and radiates through to his back. It is associated with vomiting and diarrhea. His BP is 180/90 mm Hg, HR is 100 beats per minute, temperature is 98.9°F, RR is 20 breaths per minute, and oxygen saturation is 100% on room air. On physical examination, his abdomen is soft and nondis- tended, but there is marked tenderness in the epigastrium. The remainder of his examination is normal. Laboratory results reveal WBC 12,000/mL, hematocrit 48%, platelets 250/mL, AST 500 U/L, ALT 600 U/L, alkaline phosphatase 450 U/L, amylase 1500 U/L, lipase 2000 U/L, total bilirubin 3.0 mg/dL, sodium 150 mEq/L, potassium 4.4 mEq/L, chloride 90 mEq/L, bicarbonate 20 mEq/L, BUN 9 mg/dL, creatinine 0.5 mg/dL, and glucose 110 mg/dL. You obtain a bedside ultrasound scan that reveals as shown in the following image. Which of the following findings is consistent with extrahepatic biliary obstruction?

  1. Mickey Mouse sign
  2. Increased echogenicity with irregular texture of the liver
  3. Playboy bunny sign
  4. Double barrel shotgun sign or parallel channel sign
  5. Antler signs

 

12. A 25-year-old woman with a history of pelvic inflammatory disease presents to the ED with abdominal The pain is located in the RLQ and has been sharp, constant, and nonradiating for the last 2 days. The pain is associated with some vomiting and vaginal spotting. The patient denies fever, change in bowel habits, or vaginal discharge. Her LMP was 4 weeks ago and has been having unprotected sex with two partners. Her BP is 110/75 mm Hg, HR is 80 beats per minute, temperature is 99.1°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination reveals a tender abdomen in the RLQ with no rebound or guarding. Pelvic examination shows a closed cervical os with scant vaginal bleeding. There was right adnexal tenderness without fullness and no cervical motion tenderness. Urinalysis shows no evidence of hema- turia or infection. Qualitative b-hCG is positive. The following ultrasound images are obtained of the uterus and left ovary, respectively. Which of the following confirms an ectopic pregnancy?

  1. Free fluid in the cul-de-sac posterior to the cervix
  2. Gestational sac with yolk sac in the adnexa
  3. Complex adnexal mass
  4. Tubal ring
  5. Ring of fire sign

 13. A 30-year-old, 8 weeks’ pregnant woman presents to the ED with vomiting 10 to 20 times a day for the past 5 The patient also noticed some vaginal spotting over the last day, with no discharge, no urinary com- plaints, no abdominal pain, and no diarrhea. Her BP is 135/75 mm Hg, HR is 100 beats per minute, temperature is 97.9°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows dry mucous membranes and a nontender abdomen with a gravid uterus extending half way between the pubic symphysis and umbilicus. Pelvic examination shows scant blood in the vaginal vault with a closed cervical os. Laboratory results reveal serum sodium 143 mEq/L, potassium 3.9 mEq/L, chloride 95 mEq/L, bicarbonate 19 mEq/L, BUN 15 mg/dL, creatinine 1 mg/dL, and glucose 105 mg/dL; urinalysis shows a specific gravity greater than 1.030 g/mL and 3+ ketones; and quantitative b-hCG is 1,500,000 mIU/mL. Which of the following ultrasound findings confirms the diagnosis?

  1. Thin-walled unilocular anechoic cystic structure measuring 4 cm in diameter on the ovary
  2. Cluster of grapes in the uterine cavity
  3. Hypoechoic stripe between the endometrium and chorionic membrane
  4. Multiple thin-walled multilocular cystic masses on each ovary measuring approximately 6 cm in diameter
  5. Hypoechoic solid spherical mass in the uterine wall

14. A 60-year-old woman presents to the ED stating that she is turning Her husband first noticed her skin turning yellow 2 weeks ago. The patient has no other complaints and is otherwise healthy. Her BP is 130/70 mm Hg, HR is 80 beats per minute, temperature is 97.4°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. On physical examination, her abdomen is soft without any tenderness, orga- nomegaly, or masses. Her skin examination reveals jaundice. Laboratory results reveal WBC 10,000/mL, hematocrit 48%, platelets 250/mL, AST 400 U/L, ALT 450 U/L, alkaline phosphatase 500 U/L, amylase 50 U/L, lipase 40 U/L, direct bilirubin 15.2 mg/dL, total bilirubin 16.5 mg/dL, sodium 140 mEq/L, potassium 3.5 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 10 mg/dL, creatinine 0.6 mg/dL, and glucose 85 mg/dL. Which of the following is an abnormal common bile duct (CBD) diameter?

  1. 40-year-old man postcholecystectomy with 9-mm-diameter CBD
  2. 75-year-old woman with 7-mm-diameter CBD
  3. 50-year-old man with 4-mm-diameter CBD
  4. 40-year-old  postcholecystectomy  with  10-mm-diameter CBD
  5. 60-year-old man with 9-mm-diameter CBD

15. A 58-year-old-woman presents to the ED with the complaint of left- sided back pain, fever, vomiting, and The patient states all of her symptoms started 15 days ago with low abdominal pain associated with burning on urination that has progressively worsened with migration of pain up her right side. She said that the pain was consistent with her previ- ous urinary tract infections (UTIs), so she tried home remedies before com- ing to the hospital 4 days ago. Chart review shows the patient was started on ciprofloxacin for pyelonephritis. She has been compliant with her medica- tions since they were started, but she seems to be getting worse. Her history is significant for multiple UTIs and diabetes. Her BP is 150/85 mm Hg, HR is 110 beats per minute, temperature is 100.5°F, RR is 18 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows a nontoxic-appearing patient with mild left-sided costovertebral angel tender- ness and left upper quadrant (LUQ) tenderness. Her examination shows no peritoneal signs or masses. Laboratory results reveal WBC 15,000/mL, hematocrit 48%, platelets 250/mL, sodium 135 mEq/L, potassium 4.5 mEq/L, chloride 110 mEq/L, bicarbonate 23 mEq/L, BUN 20 mg/dL, crea- tinine 1.2 mg/dL, and glucose 250 mg/dL. Urinalysis shows 1+ leukocyte esterase, 1+ blood, 1+ bacteria, 5 to 10 RBC/hpf, and 5 to 10 WBC/hpf. A bedside left renal ultrasound is obtained as shown in the following image. Which of the following is most suggestive of renal abscess?

  1. Solitary anechoic cystic structure with internal septations and areas of echogenic debris
  2. Solitary anechoic smooth cystic structure with no internal echoes
  3. Prominent echolucent renal pelvis and calyces
  4. Multiple anechoic smooth cystic structures with no internal echoes
  5. An irregular heterogeneous solid structure that is hyperechoic relative to sur- rounding parenchyma

16. A 35-year-old man presents to the ED complaining of pain and swell- ing in his left lower The patient states the pain started when he woke up this morning. With further questioning, the patient states he was aboard a transatlantic flight from England yesterday. There is no history of trauma, he has never experienced leg pain like this in the past, and cur- rently has no chest pain or shortness of breath. He has no history of medical problems. His BP is 130/75 mm Hg, HR is 75 beats per minute, temperature is 99.3°F, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Physical examination shows his left leg is larger in circumference compared to his right. The left leg is slightly red and warm to touch with soft compartments, symmetric pulses, and intact sensation. The left calf is tender with palpation and dorsiflexion of the ankle. Which of the following ultrasound findings is consistent with deep venous thrombosis (DVT)?

  1. Noncompressible anechoic cystic structure in the popliteal fossa
  2. Noncompressible superficial femoral vein
  3. Noncompressible spherical echogenic structure superficial to femoral   artery
  4. Noncompressible middle section of the great saphenous vein
  5. Semicompressible cystic structure with fluid dissecting into the soft tissue planes of the calf

17. A 35-year-old woman presents to the ED complaining of a The patient states the headache has been coming and going for months. The headache is not maximal or sudden in onset and today it is not really different from previous episodes. The patient decided to come to the ED today because she was experiencing periods where her vision seemed dim. With further questioning, the patient states she gets periodic whooshing sound in her ears. Her BP is 145/75 mm Hg, HR is 93 beats per minute, temperature is 97.9°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Her physical examination is unremarkable; however, the fundi were not clearly visualized on funduscopic examination. Ultra- sound evaluation of the eye is obtained as shown in the following image. Which of the following further suggests the most likely diagnosis?

  1. Ribbon-like echogenic structure in the vitreous chamber that is free floating with eye movement
  2. Optic nerve sheath diameter of 6 mm
  3. Loss of globe volume with echogenic matter in the vitreous chamber
  4. Optic nerve sheath diameter of 4 mm
  5. Color Doppler flow of the optic disk showing only blood flow exiting the globe

18. A 27-year-old woman, G2P1, currently 20 weeks’ gestation, presents to the ED complaining of right-side and back The pain was sudden in onset 2 hours before presentation and described as stabbing in nature. The pain radiates to the right groin and is not associated with any alleviat- ing or aggravating factors. The patient does complain of some vomiting but no other associated symptoms. Her previous pregnancy was uncompli- cated. Her BP is 120/70 mm Hg, HR is 90 beats per minute, temperature is 97.9°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination shows her in pain, and she cannot seem to find a position of comfort. There was mild right-sided costovertebral angle tenderness. The abdominal examination shows a gravid uterus palpable at the level of the umbilicus but no tenderness or peritoneal signs. Labo- ratory results reveal sodium 138 mEq/L, potassium 4.0 mEq/L, chloride 110 mEq/L, bicarbonate 24 mEq/L, BUN 15 mg/dL, creatinine 0.6 mg/dL, and glucose 105 mg/dL. Urinalysis shows 2+ blood and RBC 20 to 50/hpf. Which of the following ultrasound findings is suggestive of pathologic obstructive hydronephrosis in this patient?

  1. Bilateral prominence of the renal collecting system with full bladder
  2. Prominence of the right renal collecting system in the supine pregnant patient
  3. Bilateral anechoic collections around the renal pelvis with dividing segments of renal cortex
  4. Unilateral prominent renal pelvis located outside the medial margin of the renal cortex and no calyceal dilation
  5. Prominence of the right renal collecting system while in the left lateral decubitus position

19. A 27-year-old man presents to your ED by ambulance after being involved in an automobile The patient was a restrained rear seat passenger in T-bone–style accident striking the patient’s rear passenger side door. EMS reports there was significant cabin intrusion of the car. The patient was able to climb out of the other side of the car and was ambula- tory on scene. Now, he complains of neck and right chest pain. The chest pain is sharp and worse with breathing. He has no other complaints. His BP is 135/70 mm Hg, HR is 110 beats per minute, temperature is 98.2°F, RR is 20 breaths per minute, and oxygen saturation is 100% on room air. Physical examination reveals clear breath sounds bilaterally and marked tenderness of the right lateral thorax with no crepitus or ecchymosis. The abdomen is soft, nondistended, and nontender. A supine AP chest radio- graph is normal. You place the ultrasound on the patient’s anterior chest wall and obtain the following images. Which of the following diagnoses does the ultrasound finding support?

  1. Pulmonary contusion
  2. Chest wall contusion
  3. Rib fracture
  4. Pneumothorax
  5. Hemothorax

20. A 28-year-old woman presents to the ED with vaginal The patient found out she was pregnant 7 weeks ago but was never able to follow up in the OB clinic for prenatal care. She is G3P2. The patient says the bleeding started 1 hour before presentation and was not associated with any trauma, abdominal pain, abdominal cramping, or a gush of clear fluid from the vagina. The patient is a smoker but denies using any drugs of abuse. Her BP is 120/70 mm Hg, HR is 85 beats per minute, tempera- ture is 98.2°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. Physical examination is only remarkable for a gravid uterus extending approximately 30 cm above the pelvic brim and blood dripping from the introitus. Bedside transabdominal pelvic ultrasound is performed. Which of the following ultrasound findings would make a digital examina- tion of the cervix contraindicated?

  1. Placenta implanted in the lower portion of the uterus
  2. A cervix 4 cm in length
  3. Hyperechoic fluid collection between the placenta and uterine wall
  4. Placenta implanted high and posterior on the uterine wall
  5. Breach fetus with foot as presenting part

 

21. A 58-year-old woman presents to the ED with abdominal She reports that the pain is in the RUQ and has been getting progressively worse over the last month. The pain is now a sharp, constant, and non- radiating. The pain is worse when she lays on her right side. She denies any urinary complaints. Her BP is 125/75 mm Hg, HR is 75 beats per minute, temperature is 96.9°F, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. On physical examination, her abdomen is nondis- tended and soft. She does have pinpoint tenderness to palpation under the right costal margin. Laboratory tests are within normal limits. You obtain a bedside ultrasound of the RUQ that revealed the following. Which of the following findings is suggestive of malignancy?

  1. Heterogeneous mass with irregular boarders
  2. Phrygian cap present in the mass
  3. Well-defined smooth mass margins with no internal echoes
  4. Homogenous echogenicity throughout the mass
  5. Riedel lobe present in the mass

22. A 45-year-old man presents to your ED after a fall from standing The patient states he was not watching where he was going when he tripped on a rug and fell into the coffee table. The patient hit his left side on the edge of the table. He denies loss of consciousness. He complains of pain in the left flank and pain in his left shoulder when he takes a deep breath. On examination his vital signs include a BP of 140/75 mm Hg, HR of 95 beats per minute, temperature of 98.9°F, RR of 16 breaths per minute, and oxygen saturation of 100% on room air. The lungs are clear to auscultation bilaterally and the abdomen is tender in the LUQ. There is no rebound, guarding, or organomegaly. There is no ecchymosis noted in the left flank. You obtain a bedside FAST examination, shown in the following image. What is the next best step in the management of this patient?

 

  1. Transfuse 2 units of type O-negative blood and start cross-matched blood once available.
  2. Perform CT scan of the abdomen and pelvis with intravenous contrast.
  3. Perform  emergent laparotomy.
  4. Upright chest radiograph to rule out free air under the diaphragm.
  5. If his pain resolves, prescribe ibuprofen for pain control and have him follow up with his primary care physician in 5 days for a repeat abdominal examination.

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