TDM Examination sample case C
Get familiar with the multiple-choice and short-menu question types you will see on the TDM Examination.
A 74-year-old man is brought by ambulance to a rural emergency department after collapsing while sitting at a dinner table. He is awake and alert. He reports that he experienced sudden-onset left flank pain. The pain came and went, and he began to sweat and feel nauseated and dizzy. After a few minutes, he collapsed.
He takes the following medications:
On examination, he is diaphoretic and unable to find a comfortable position. He has mild left flank tenderness, and there are no signs of peritonitis. Cardiorespiratory examination findings are normal. The electrocardiogram shows sinus rhythm with no ischemic changes.
Which one of the following is the most appropriate immediate diagnostic test to perform? Select 1.
The results of the test in question 1 confirm the suspected diagnosis. Which of the following are the most appropriate next steps in managing this patient’s condition? Select 3.
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The combination of sudden-onset left flank pain, diaphoresis, nausea, dizziness, collapse, and marked hypotension raises immediate concern for a life-threatening vascular catastrophe, most notably a leaking or ruptured abdominal aortic aneurysm, rather than uncomplicated renal colic. In a patient whose condition is unstable, point-of-care ultrasonography (POCUS) rapidly answers the key bedside question—whether the aorta is enlarged and consistent with aneurysm—without moving the patient out of the resuscitation area. Abdominal computed tomography provides excellent anatomic detail but requires the patient to be hemodynamically stable, so it is not the best immediate test here. Chest radiography does not evaluate the abdominal aorta and would not explain flank pain with shock. Echocardiography and troponin levels target a primary cardiac cause of syncope, but the presentation is dominated by flank pain and shock without ischemic electrocardiogram changes. A kidney, ureter, and bladder (KUB) radiography or urinalysis may support nephrolithiasis, but neither would explain profound hypotension and would delay identifying a hemorrhagic cause that needs urgent action.
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If point-of-care ultrasonography (POCUS) confirms a ruptured abdominal aortic aneurysm, management priorities are resuscitation and rapid definitive repair. Starting intravenous fluid addresses hemorrhagic shock and helps maintain perfusion while preparing for operative management. Grouping and crossmatching blood is essential because this is a high-volume hemorrhage scenario where transfusion is likely and delays are dangerous. Consulting vascular surgery is the definitive next step because survival depends on urgent operative or endovascular control of bleeding. Tenecteplase IV and chewable acetylsalicylic acid (ASA) target acute coronary thrombosis and worsen hemorrhage in this case. Ciprofloxacin IV and ceftriaxone IV are not appropriate without evidence of infection or sepsis driving hypotension. Norepinephrine IV may be considered only after initial volume resuscitation, but it does not address the underlying hemorrhage and can worsen tissue ischemia if used prematurely. Cardiology and urology consultations do not align with the confirmed vascular diagnosis. A nasogastric tube is not routinely needed, and intubation is reserved for airway failure, respiratory compromise, or impending deterioration and is not performed automatically.