McQs Demo Flashcards
(21 cards)
A 62-year-old woman with a history of wrist and hand pain and stiffness presents with inability to straighten the end joint of her right thumb. Which one of the following conditions is most likely to be the cause of her thumb problem?
A. Aseptic necrosis of the lunate bone
B. Rheumatoid arthritis
C. Xanthoma of the tendon sheath
D. De Quervain tenosynovitis
E. Dupuytren contracture
The Correct answer is B.
The diagnosis is spontaneous rupture of the extensor pollicis longus tendon. In a woman with a history of the previous wrist and hand pain as outlined, rheumatoid arthritis (RA) would be the most likely primary diagnosis. RA is typically associated with inflammatory change involving joint and soft tissues, and spontaneous rupture of the long tendons of finger or thumb extensors is typical as they cross the wrist. The long tendon of the extensor pollicis longus (EPL), with its oblique course from the radial tubercle, is at significant risk.
Choice A is not correct:
Aseptic ischemic necrosis of the lunate is a rare complication of lunate dislocation and could predispose to overlying tendon rupture, but is a far less likely cause than RA.
Choice C is not correct:
Xanthoma of the tendon sheath usually presents as a firm nodule of the fibrous flexor tendon sheath of a finger and is not associated with spontaneous tendon rupture.
Choice D is not correct:
De Quervain tenosynovitis, a stenosing tenosynovitis involving the tendon sheath of the abductor pollicis longus (APL} and extensor pollicis brevis (EPB); the latter tendon extending the metacarpophalangeal joint of the thumb, not the (distal) interphalangeal joint. Spontaneous rupture of either APL or EPB in association with De Quervain disease is, in any event, rare.
Choice E is not correct:
Dupuytren contracture affects the palmar aponeurosis and can cause finger flexion deformities, but rarely affects the thumb.
Summarized Points:
RA is typically associated with inflammatory change involving joint and soft tissues, and spontaneous rupture of the long tendons of finger or thumb extensors is typical as they cross the wrist.
A 19-year-old woman comes to the office due to amenorrhea. Her menses were previously normal, with 4-5 days of moderate bleeding each month. However, over the past year, her periods have become increasingly irregular. She now has not had a period in 5 months. The patient has no chronic medical conditions. She is not sexually active and does not use contraception. She started a new job 6 months ago. Blood pressure is 100/70 mm Hg and pulse is 56/min. BMI is 18 kg/m2. Physical examination is normal. Laboratory results are as follows:
Follicle-stimulating hormone 3 IU/L (20-50)
serum Prolactin 5 µg/L (1-25)
Thyroid-stimulating hormone 2.7 mIU/L (0.4-5.0)
Urine pregnancy test negative
This patient is at greatest risk for which of the following long-term complications?
A. Osteoporotic fracture
B. Aortic root dilation
C. Bitemporal hemianopsia
D. Endometrial adenocarcinoma
E. Epithelial ovarian cancer
The correct answer is A.
This patient has functional hypothalamic amenorrhea (FHA), suppression of the hypothalamic-pituitary-ovarian axis due to increased stress (e.g., new job), excessive exercise, or relative caloric deficiency (e.g., anorexia nervosa, chronic illness, low BMI). The lack of hypothalamic function results in low FSH and estrogen levels.
Patients with prolonged FHA are at risk for long-term complications, including osteoporosis and infertility (e.g., anovulation). Low estrogen levels impair bone development in adolescents and decrease bone density in adults, resulting in osteoporosis and a higher risk of fracture. Therefore, patients with FHA who have been amenorrheic for >6 months require bone mineral density testing (e.g., DXA scan). Treatment is primarily with lifestyle changes (e.g., increase caloric intake, reduce exercise); those who cannot make lifestyle changes require combination hormonal contraception to restore bone density.
Choice B is not correct:
Aortic root dilation is a complication of Turner syndrome (45, XO). Amenorrhea in Turner syndrome is due to primary ovarian insufficiency, which leads to an elevated FSH.
Choice C is not correct:
Pituitary adenomas (e.g., prolactinomas) compress the optic chiasm, leading to bitemporal hemianopsia and diminished visual acuity. Prolactinomas may present with irregular menses, but this patient’s prolactin level is normal.
Choice D is not correct:
Endometrial hyperplasia and adenocarcinoma occur most commonly in patients with unopposed estrogen levels (e.g., postmenopausal estrogen therapy without progestin, obesity, chronic anovulation, polycystic ovary syndrome [PCOS]). Patients with FHA have low estrogen levels and are therefore at low risk for endometrial cancer.
Choice E is not correct:
Epithelial ovarian cancer is a long-term risk of PCOS. Patients with this syndrome exhibit oligomenorrhea and hyperandrogenism (e.g., hirsutism, acne) and are often obese. FSH is normal, but testosterone is usually elevated. This patient has no signs of hyperandrogenism and has a low-normal BMI, making PCOS unlikely.
Summarized Points:
Functional hypothalamic amenorrhea is due to suppression of the hypothalamic-pituitary-ovarian axis by stress, excessive exercise, or relative caloric deficiency. Long-term complications include infertility and osteoporosis due to estrogen deficiency.
An 11-year-old previously healthy boy comes to the physician with 3 days of worsening cough and fever. He is active in soccer and softball and attended a summer soccer camp 2 weeks ago. The patient is up-to-date on all of his vaccinations. His temperature is 38.3 C (101 F), blood pressure is 110/70 mm Hg, pulse is 68/min, and respirations are 24/min. Pulse oximetry shows 96% on room air. The patient is mildly tachypneic but does not have nasal flaring, retractions, or grunting. Examination shows decreased breath sounds and basilar crackles in both lower lobes. Diffuse wheezes and rhonchi are heard throughout. The remainder of his physical examination is unremarkable. Which of the following is the best next step in the management of this patient?
A. Amoxicillin
B. Azithromycin
C. Blood culture
D. Chest x-ray
E. Nasopharyngeal viral testing
The correct answer is B.
The history and examination in this previously well 11-year-old boy are consistent with uncomplicated atypical pneumonia. The bilateral lung findings and wheezing suggest an atypical process rather than lobar pneumonia. In children age, atypical pneumonia is most commonly due to Mycoplasma pneumonae.
The first-line treatment is oral azithromycin a 5-day course (10 mg/kg/day on day 1 followed by 5 mg/kg/day on days 2-5) is recommended for treatment.
Choice A is not correct:
M pneumoniae lacks a cell wall and is intrinsically resistant to amoxicillin. If lobar pneumonia (most commonly due to Streptococcus pneumoniae) cannot be excluded, then combination therapy with azithromycin and amoxicillin (to cover pneumococcal infection) is warranted.
Choice C and D are not correct:
Neither chest x-ray nor blood culture is recommended if pneumonia is likely and the patient can be managed as an outpatient. If the examination is equivocal, 2-view (posteroanterior and lateral) chest imaging can aid in clarifying the diagnosis and ruling out foreign body aspiration. Chest x-rays and blood cultures should be performed on ill-appearing patients to assess the severity of pneumonia and possible complications (e.g., empyema, effusion).
Choice E is not correct:
Children age <5 with bilateral pneumonia most frequently have a viral infection. Influenza, respiratory syncytial virus, metapneumovirus, and parainfluenza viruses account for >90% of lower respiratory tract infections in this age range. However, viral lower-respiratory tract disease is generally uncommon in children age >5 and during the summer. Selective viral testing may be useful when activity is high (e.g., fall, winter) but should not delay antibiotic therapy.
Summarized Points:
Mycoplasma pneumoniae is the most common cause of atypical pneumonia in children age ≥5. Azithromycin is the first-line treatment. Ancillary studies, such as blood cultures and chest radiographs, are not necessary in uncomplicated cases.
A 25-year-old woman complains that her left leg has become progressively stiff and clumsy over the last couple of weeks. She is worried as she has not been able to go to work for the last 4 days. On examination, tone is increased and there is a catch at the knee. She has six beats of clonus and an upgoing plantar. Power is reduced to 3-4/5 in the left leg flexors. There is no sensory involvement and the rest of the neurological exam is normal other than a pale disc on ophthalmoscopy. On further questioning, she admits that she has had two episodes of blurred vision in her right eye in the last two years. Each lasted a couple of weeks from which she fully recovered. What is the most appropriate initial treatment?
A. A non-steroidal anti-inflammatory drug (NSAID)
B. A course of oral steroids
C. Interferon-beta
D. Bed rest
E. Methotrexate
The Correct answer is B.
The subacute onset of upper motor neuron signs on a background of episodes of optic neuritis in a young woman makes relapsing–remitting Multiple Sclerosis (MS) the likely diagnosis. The diagnosis of MS hinges on the presence of multiple central nervous system (CNS) lesions separated by time and space. These manifest in either signs/symptoms or as enhancing white matter lesions on gadolinium-enhanced MRI. Oral steroids have been shown to be as effective as intravenous (IV) steroids, although patients tend to be admitted for IV treatment. They reduce the length of the relapse so the patient would recover quicker, but have no effect on the number of relapses or accumulation of disability.
Choice A is not correct:
There is no specific role for NSAIDs in MS. Even if the patient complained of pain, it would be important to ensure its origin. NSAIDs would not be appropriate for neuropathic pain.
Choice C is not correct:
This patient may be eligible for a disease-modifying drug such as interferon beta or glatiramer acetate, as she has a relapsing–remitting course and recent symptoms, but this would not be the most immediate treatment. These drugs reduce the number of relapses experienced by one third over two years and are expensive. Long-term effects on morbidity are currently unclear.
Choice D is not correct:
Bed rest alone is inappropriate as this patient would benefit from a course of steroids as she has disabling symptoms.
Choice E is not correct:
There is no evidence for methotrexate in relapsing–remitting MS.
Summarized Points:
For patients with acute multiple sclerosis (MS) exacerbation that results in neurologic symptoms and increased disability or impairments in vision, strength, or cerebellar function, best treated with glucocorticoids. Usually preferred regimen is intravenous methylprednisolone 1000 mg daily for five days without an oral taper. However, the data suggest that oral regimens are just as effective.
A 25-year-old female patient is evaluated for fetal loss for the third time in two years. Two weeks ago, she had a spontaneous abortion at 13 weeks’ gestation. Her medical history is significant for deep vein thrombosis. She takes no medication, although she did take folic acid until her pregnancy ended. She does not smoke, drinks, or use illicit substances. Vital signs are a temperature of 36.8 C (98.4 F), blood pressure 116/ 76 mm Hg, heart rate 76/minute, and respiratory rate of 16/minute. Exam reveals a well-developed well-nourished female in no acute distress. Her lungs are clear to auscultation and she has a regular rate and rhythm without murmur, rub, or gallop. Her abdomen is slightly distended and nontender. She has no lower extremity edema. Laboratory studies are within normal limits, including electrolytes, glucose, BUN, creatinine, and CBC. Which of the following is most likely to have contributed to her successive pregnancy losses?
A. Protein S deficiency
B. Factor V Leiden
C. Protein C deficiency
D. Anti-beta-2- glycoprotein antibodies
E. Lupus anticoagulant
The Correct answer is E.
The antiphospholipid syndrome should be considered in young patients with unexplained venous or arterial thrombotic events or in women with a history of adverse outcomes in pregnancy, including multiple embryonic losses, fetal death after 10 weeks gestation, or premature birth due to severe preeclampsia or placental insufficiency. Other clinical manifestations that should increase suspicion for antiphospholipid syndrome in this setting include a history of a false positive test for syphilis, a prolonged aPTT, mild thrombocytopenia, valvular heart disease, cognitive deficits related to white matter infarcts, or livedo reticularis.
Lupus anticoagulant is confirmed by demonstration of a prolonged aPTT (or abnormal hemostasis by another test that is phospholipid dependent); demonstrating the presence of antibodies by mixing patient plasma with normal plasma and failure to correct the aPTT; and, in a third step, correction of a PTT with the addition of excess phospholipids.
Patients who have had a thrombotic event and who have antiphospholipid antibodies should be treated indefinitely with a vitamin K antagonist. In select patient groups (arterial thrombosis, increased cardiovascular risk) aspirin should also be initiated. During pregnancy, patients with antiphospholipid syndrome should be treated with low molecular weight heparin (or unfractionated heparin in rare cases.) Warfarin is teratogenic and should be avoided. Direct oral anticoagulants cross the placenta and evidence of efficacy and safety is lacking, so they are no recommenced. Factor Xa inhibitors should also be avoided.
Choice A is not correct:
Protein S deficiency is inherited and can result in venous thromboembolism, including deep vein thrombosis and pulmonary embolism. It is not a likely cause of recurrent pregnancy complications, although the risk of venous thromboembolism (VTE) is increased above the risk already present in pregnancy.
Choice B is not correct:
Factor V Leiden renders both activated and inactivated Factor V unresponsive to the natural anticoagulant activated protein C, increasing the risk of venous thromboembolism. The mutation is common in the population and many individuals will never experience a thrombotic event.
Choice C is not correct:
Protein C deficiency is a minor cause of inherited thrombophilia. It is sometimes associated with rare warfarin-induced skin necrosis and neonatal purpura fulminans. There is a weak association with pregnancy loss.
Choice D is not correct:
Although both anticardiolipin antibodies and lupus anticoagulant are strongly associated with pregnancy loss, anti-beta-2- glycoprotein antibodies and other antiphospholipid antibodies do not have a strong association with increased risk. Lupus anticoagulant is the strongest predictor of increased risk of complications in pregnancy in women with antiphospholipid syndrome.
Summarized Points:
Antiphospholipid antibody syndrome is characterized by an episode of venous or arterial thrombosis or recurrent pregnancy loss and the presence of antiphospholipid antibodies, particularly lupus anticoagulant and anticardiolipin antibody. During pregnancy, anticoagulation with low molecular weight heparin is the first-line treatment, with aspirin for select patients. Long term anticoagulation with a vitamin K antagonist is indicated in patients who are not pregnant.
A 64-year-old woman with diabetes is hospitalized with left foot methicillin-resistant Staphylococcus aureus osteomyelitis complicated by sepsis and respiratory failure. She spends 3 days in the intensive care unit on mechanical ventilation but is now extubated and has resumed eating. She has generalized weakness, mild cough, and foot pain. The patient has no chest pain, abdominal pain, bleeding, or diarrhea. She has no prior history of pneumonia, heart failure, or coagulopathy. Her current medications include intravenous vancomycin, subcutaneous heparin, short- and long-acting subcutaneous insulin, and omeprazole. Her vital signs are within normal limits. Laboratory values show:
Hemoglobin 132 g/L (115–155)
Creatinine 123 µmol/L (50-90)
Albumin 25 g/L (35-50)
The coagulation profile is unremarkable. Which of the following should be strongly considered when transferring this patient to the medical floor?
A. Discontinuing omeprazole
B. Starting an albumin infusion
C. Starting oral diabetic medications
D. Switching from intravenous vancomycin to oral rifampin
E. Switching from pharmacologic to mechanical thromboprophylaxis
The correct answer is A.
Critically ill patients are at increased risk of gastrointestinal (GI) hemorrhage and may benefit from stress ulcer prophylaxis. Studies show that the incidence of bleeding in the intensive care unit (ICU) is approximately 1.5%-8.5% in patients receiving ulcer prophylaxis versus 15% in those not receiving prophylaxis. Nonetheless, ulcer prophylaxis may be associated with adverse effects (e.g., nosocomial pneumonia, Clostridium difficile infection) and higher costs and should consequently be limited to high-risk patients. High-risk features include:
History of GI bleeding in the past year
Evidence of coagulopathy
Mechanical ventilation >48 hours
Severe central nervous system injury
Severe burns
A combination of sepsis, prolonged ICU stay, or corticosteroid use
Acceptable options for ulcer prophylaxis include proton pump inhibitors (PPIs), histamine-2 receptor antagonists, and oral antacids. Although comparative trials are limited, oral PPIs may be preferred given their effectiveness and low cost. Ulcer prophylaxis should be discontinued once a patient no longer has an indication.
Choice B is not correct:
Albumin infusion can be considered in the setting of spontaneous bacterial peritonitis or large-volume paracentesis; however, hypoalbuminemia alone is not an indication.
Choice C is not correct:
Although this patient may need to be switched from subcutaneous insulin to an oral diabetic medication regimen prior to discharge, it is not necessary at the time of transfer from the ICU.
Choice D is not correct:
The optimal route of therapy (e.g., oral versus parenteral) for methicillin-resistant Staphylococcus aureus osteomyelitis is unclear. Intravenous regimens may consist of vancomycin or daptomycin. Antibiotics with oral and intravenous dosing can include trimethoprim/sulfamethoxazole in combination with rifampin, linezolid monotherapy, or clindamycin monotherapy. Oral rifampin alone is not appropriate due to the development of drug resistance.
Choice E is not correct:
Pharmacological thromboprophylaxis is preferred over mechanical thromboprophylaxis in patients who are not at risk for bleeding.
Summarized Points:
Stress ulcer prophylaxis may be beneficial in high-risk critically ill patients but should be discontinued once the patient leaves the intensive care unit and no longer has an indication. Unnecessary use of proton pump inhibitors may be associated with adverse effects (e.g., nosocomial pneumonia, Clostridium difficile infection) and higher costs.
A 40-year-old woman comes to the office to discuss sexual symptoms. The patient divorced 5 years ago and had not had sexual intercourse until 9 months ago when she became sexually active with a new partner. She enjoys spending time with her partner but has no desire for, and does not initiate, sexual activity, which causes significant stress on her relationship. The patent has no pain during sexual activity and no medical conditions. Her last menstrual period was a week ago. Pelvic examination is normal. Which of the following is the most appropriate treatment for this patent?
A. Oral ospemifene
B. Oral flibanserin
C. Oral sertraline
D. Pelvic floor physical therapy
E. Vaginal estrogen
The correct answer is B.
Sexual interest/arousal disorder (SIAD), a common sexual disorder in women, has a higher incidence with advancing age. DSM-5 criteria for SIAD include recurrence or persistence for ≥6 months, significant distress, and at least 3 of the following:
Reduced interest in sexual activity
Reduced sexual thoughts/fantasies
Reduced initiation of sexual activity/reduced receptiveness to partner initiation Reduced sexual pleasure during intercourse
Reduced arousal to sexual cues
Reduced genital and nongenital sensations during sexual activity
Flibanserin, a serotonin receptor agonist/antagonist, has been approved by the US Food and Drug Administration for the treatment of SIAD in premenopausal women to increase sexual desire. Studies also show a modest increase in the frequency of satisfying sexual events. However, flibanserin must be taken daily and can cause hypotension and syncope, especially when taken with alcohol and certain medications (e.g., fluconazole), which may limit its use. Postmenopausal women with SIAD may benefit from transdermal testosterone therapy; however, it is not recommended for premenopausal women because of minimal symptom improvement and potential for fetal virilization during pregnancy.
Choice A and E are not correct:
Ospemifene (a selective estrogen receptor modulator) and vaginal estrogen are used to treat dyspareunia due to vulvovaginal atrophy (i.e., genitourinary syndrome of menopause). This patient is premenopausal and has no pain during intercourse.
Choice C is not correct:
Sertraline, a selective serotonin reuptake inhibitor, is effective in the treatment of depression and anxiety; however, sexual side effects (e.g., decreased libido, anorgasmia) are common
Choice D is not correct:
Pelvic floor physical therapy is beneficial for patients with dyspareunia secondary to vaginismus or vulvodynia.
Summarized Points:
Sexual interest/arousal disorder, a common sexual disorder in women, is marked by persistent low sexual desire. Flibanserin has been approved for premenopausal women by the US Food and Drug Administration as it produces modest improvements in sexual desire.
A 38-year-old known asthmatic presents with sudden onset of breathlessness. The patient has no other significant medical history. The patient is unable to speak, unable to stand, has an RR >30/min, and has paradoxical thoracoabdominal movements. The patient has bradycardia. Little air movement is seen without wheeze. The peak expiratory flow rate (PEF) <50% is predicted. Arterial blood gas (ABG) analysis reveals SaO2 at room air 86%; PaO2 is 62 mm Hg, and PaCO2 is 45 mm Hg. What is the most likely diagnosis?
A. Mild asthma
B. Moderate asthma
C. Severe asthma
D. Impending respiratory failure
E. Congestive cardiac failure
The Correct answer is D.
PaO2 < 60 mmHg or PaCO2> 50mmHg are the arbitrarily established criteria for respiratory failure. The clinical picture in the above patient points to impending respiratory failure.
Choice A is not correct:
In mild asthma, the patient would probably be able to talk. Heart rate would be normal. Usually, there would be no use of accessory muscles. ABG would be essentially normal.
Choice B is not correct:
Moderate asthma would show a heart rate of about 100-120/min. There would be discomfort and the patient prefers sitting. The ABG would not be in the range for respiratory failure though would show changes.
Choice C is not correct:
Severe asthma patients would be uncomfortable and would have staccato speech and breath sounds as well as loud inspiratory and expiratory wheeze. The ABG would show changes similar to impending respiratory failure, but the heart rate would show tachycardia of >120beats/min.
Choice E is not correct:
Congestive heart failure (CHF) typically presents with a history of some cardiac disease, and there is always be a gradual onset of breathlessness. Patient would have increased jugular venous pressure and peripheral edema. Electrocardiograph (ECG) would indicate underlying myocardial infarction, arrhythmias, or left ventricular hypertrophy. Respiratory system examination would reveal normal breath sounds with crepitation, and S3 would usually be heard on cardiac auscultation.
Summarized Points:
Features of impending respiratory failure are:
Inability to speak
Feels disorientated and restless
Cyanosis of lips
Paradoxical thoracoabdominal movements
Bradycardia and absence of wheeze
Peak expiratory flow rate of less than 50%
Respiratory rate less than 10/min or > 30/min
A 60-year-old woman with known systemic sclerosis complains of abdominal distension, pain, and bloating accompanied by foul-smelling diarrhea for the past 6 months. She has lost 9 kg (20 lb) during this period. Her abdomen is distended and mildly tender diffusely. The liver and spleen cannot be felt. No synovitis or effusion is noted at any joints. Laboratory studies show macrocytic anemia. Barium enema shows multiple wide-mouthed diverticula in the colon. Small-bowel studies are pending. This patient’s abdominal symptoms will most likely be relieved by which of the following medications?
A. Extended-release nifedipine
B. Glucocorticoids and cyclophosphamide
C. Metoclopramide and erythromycin
D. Octreotide
E. Rifaximin
The correct answer is E.
Patients with systemic sclerosis (SSc) may develop small intestinal bacterial overgrowth syndrome (SIBO) due to reduced peristalsis, which leads to stasis and intestinal dilation. The most common initial symptoms are abdominal distension, bloating, constipation, and pain. Later, as fat malabsorption ensues, the patient may develop diarrhea, steatorrhea, and weight loss. Although the gold standard for the detection of SIBO is small-bowel aspiration, initial screening may be done with a glucose hydrogen breath test.
Most patients with SIBO will have symptomatic improvement following 7-10 days of antibiotics. The most commonly used empiric antibiotics are rifaximin, amoxicillin-clavulanate, and metronidazole combined with a cephalosporin. Recurrent SIBO is common, and patients often require repeated therapy. Some patients also may require longer courses of antibiotics and antibiotic rotation to achieve symptomatic remission.
Choice A is not correct:
Nifedipine is effective for the treatment of Raynaud’s phenomenon in patients with SSc. However, nifedipine may aggravate acid reflux symptoms and will not address bacterial overgrowth.
Choice B is not correct:
Glucocorticoids and cyclophosphamide are used most commonly in the treatment of SSc-associated interstitial lung disease and may be used to treat progressive skin disease.
Choice C is not correct:
Prokinetic agents such as metoclopramide and erythromycin are useful in the long-term management of gastroparesis in SSc but are not as effective in treating bacterial overgrowth and malabsorption. They can be added as adjuvants in patients who do not respond or are intolerant of antibiotics and have documented dysmotility.
Choice D is not correct:
Octreotide may help improve peristalsis and symptoms of SIBO in patients with intestinal scleroderma; however, it is currently not a recommended treatment as evidence is limited. Antibiotic therapy is more appropriate for this patient.
Summarized Points:
Patients with systemic sclerosis may develop small intestinal bacterial overgrowth due to reduced peristalsis, stasis, and intestinal dilation. Initial symptoms are abdominal bloating and pain; later symptoms include malabsorption with diarrhea, steatorrhea, and weight loss. Antibiotic therapy will usually alleviate the symptoms, but recurrent courses may be required.
A 61-year-old man with a history of type 2 diabetes mellitus comes to the office for a follow-up visit. Medical history also includes hypertension, hyperlipidemia, coronary artery disease, and osteoarthritis. He has diabetic nephropathy with a baseline creatinine of 176-221 µmol/L. The patient’s mobility is impaired due to right knee osteoarthritis and diabetic neuropathy. Medications include acetaminophen, insulin, metoprolol, valsartan, chlorthalidone, aspirin, and atorvastatin. Blood pressure is 159/102 mm Hg and pulse is 68/min. BMI is 36 kg/m2. Physical examination shows 2+ bilateral lower extremity edema. Laboratory results are as follows:
Serum creatinine 212µmol/L (70-120)
Serum potassium 5.4 mmol/L (3.5-5.0)
Hemoglobin A1c 7.5%
24-hour urine protein excretion 1.2 g/L
Which of the following is the best next step in the management of this patient?
A. Start lisinopril
B. Substitute amlodipine for metoprolol
C. Substitute furosemide for chlorthalidone
D. Substitute lisinopril for valsartan
E. Substitute spironolactone for metoprolol
The correct answer is C.
This patient has uncontrolled hypertension despite multiple antihypertensive medications. In addition, he is at increased risk for complications due to underlying diabetes and chronic kidney disease (CKD). Patients with CKD should have a target blood pressure of <140/90 mm Hg, and many experts recommend even more aggressive control. ACE inhibitors and angiotensin II receptor blockers (ARBs) (e.g., valsartan) are first-line antihypertensive agents in patients with proteinuric CKD (i.e., proteinuria >500 mg/day). For patients who have persistent hypertension despite first-line therapy, a diuretic or non-dihydropyridine calcium channel blocker (e.g., diltiazem, verapamil) may be added. Diuretics are especially useful for patients with edema (such as this patient) as euvolemia can increase the effectiveness of other antihypertensives. However, thiazide diuretics (e.g., chlorthalidone) are less effective in patients with creatinine clearance <30 mL/min/1.73m2; these patients should be transitioned to loop diuretics (e.g., furosemide). If loop diuretics alone are ineffective at improving edema, a thiazide may be added again to improve diuresis. The addition of furosemide would likely reduce this patient’s mild hyperkalemia as well.
Choice A and D are not correct:
This patient is appropriately on an ARB (valsartan). There is little benefit in substituting an ACE inhibitor (e.g., lisinopril) for an ARB beyond cost considerations and a slightly reduced rate of symptomatic hypotension. Adding an ACE inhibitor to an ARB is not recommended as combined therapy is associated with an increased risk of hypotension and hyperkalemia.
Choice B and E are not correct:
Calcium channel blockers (e.g., amlodipine) and aldosterone antagonists (e.g., spironolactone) are excellent options for third- or fourth-line therapy in proteinuric CKD. However, non-dihydropyridine blockers are preferred over dihydropyridines due to their effect on proteinuria. Also, aldosterone antagonists may worsen this patient’s hyperkalemia.
Summarized Points:
In patients with hypertension and proteinuric chronic kidney disease, diuretics can correct edema and increase the effectiveness of other antihypertensive medications. Loop diuretics are more effective than thiazide diuretics in patients with creatinine clearance <30 mL/min/1.73m2.
A 42-year-old man comes to the office for follow-up after a recent upper gastrointestinal endoscopy and small-bowel biopsy for suspected celiac disease. He initially presented 6 weeks ago with diarrhea and weight loss. The patient has followed a gluten-free diet since then and has noticed significant improvement in his bowel symptoms. He has no other medical problems and has started taking a multivitamin daily. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal, and examination shows no abnormalities. Laboratory results today show hemoglobin of 128 g/L (110 g/L 6 weeks ago) and mean corpuscular volume of 88 fL. Small-bowel biopsy results are consistent with celiac disease. Which of the following additional interventions is needed at this time?
A. Colonoscopy
B. Helicobacter pylori screening
C. Pneumococcal vaccination
D. Hepatitis A vaccination
E. Herpes zoster vaccination
The correct answer is C.
Patients with celiac disease are at risk of developing nutritional deficiencies, neuropsychiatric illness (e.g., peripheral neuropathy, headache, depression), and skin disorders (e.g., dermatitis herpetiformis). In addition, although the pathogenesis is unknown, hyposplenism has been reported and is believed to be relatively common. Therefore, pneumococcal vaccination is recommended in patients with celiac disease, regardless of age.
Most of the complications of celiac disease can be prevented by strict lifelong adherence to a gluten-free diet; however, nutritional deficiencies and bone loss (primarily due to vitamin D deficiency) should be screened for and treated appropriately.
Choice A is not correct:
Although upper gastrointestinal endoscopy with small-bowel biopsy is necessary to confirm the diagnosis of celiac disease and exclude other potential etiologies (e.g., intestinal lymphoma, bacterial overgrowth), colonoscopy does not have a role in establishing the diagnosis. In addition, celiac disease does not increase the risk of colorectal cancer.
Choice B is not correct:
Although Helicobacter pylori infection can lead to lymphocytic infiltration of the duodenum, as occurs in celiac disease, biopsy would frequently demonstrate the bacteria. In addition, given this patient’s gluten responsiveness, no further evaluation for H pylori is necessary.
Choice D and E are not correct:
Patients with celiac disease are not at increased risk for herpes zoster or hepatitis A; therefore, screening and vaccination guidelines for these conditions are similar to the general population. Herpes zoster vaccination is recommended for patients age Hepatitis A vaccine is recommended for adult patients at increased risk of infection or complications, such as those with liver disease or who travel to endemic areas.
Summarized Points:
Celiac disease is associated with hyposplenism; therefore, pneumococcal vaccination is recommended at the time of diagnosis, regardless of patient age. Other common complications of celiac disease include dermatitis herpetiformis and nutritional deficiencies leading to impaired bone metabolism and neuropathy. Strict adherence to a gluten-free diet can minimize or prevent many of these complications.
A 43-year-old woman with no significant medical history comes to the physician with episodic rectal pain for the past 8 months. About once a month she has severe rectal pain that lasts for minutes and resolves without intervention. She has no fever, diarrhea, anal trauma, rectal bleeding, or weight loss. She has 1 formed bowel movement every 3 days without any straining and does not associate the pain with bowel movements. She takes no medications. Her blood pressure is 110/60 mm Hg, pulse is 76/min, and respirations are 14/min. Physical examination reveals a soft, non-tender abdomen with normal bowel sounds. There is no hepatomegaly or splenomegaly. Rectal examination shows normal tone, no external hemorrhoids, and guaiac-negative brown stool. Pelvic examination is also unremarkable. Laboratory results are as follows:
Hemoglobin 126 g/L (115–155)
Mean corpuscular volume 84 fL (80–100)
Platelets 280 x 109/L (130–380)
Leukocytes 7.5 x 109/L (3.5–10.5)
Colonoscopy is notable for small internal hemorrhoids and mild diverticulosis. Which of the following is the most likely cause of this patient’s symptoms?
A. Endometriosis
B. Proctalgia fugax
C. Fibromyalgia
D. Irritable bowel syndrome
E. Somatization disorder
The correct answer is B.
This patient’s presentation suggests proctalgia fugax, a benign self-limited condition of recurrent and severe rectal pain occurring in up to 15% of the population. Proctalgia fugax is a functional disorder, and the diagnosis requires exclusion of other gastrointestinal causes of anal or rectal pain (e.g., hemorrhoids, cryptitis, ischemia, intramuscular abscess, anal fissures, rectoceles, or malignancy). The pathophysiology is possibly due to anal sphincter spasm/hypertrophy, pudendal nerve compression or neuralgia, or psychological factors.
Patients usually present with attacks of severe rectal pain lasting a few seconds to 2 hours. Anorectal and pelvic examination shows no abnormalities. Anorectal manometry may be normal or show elevated internal anal sphincter pressure. Colonoscopy is usually performed to exclude other diseases and is frequently normal.
The proposed diagnostic Rome Criteria for proctalgia fugax include:
Recurrent episodes of anal or rectal pain
Episodes lasting seconds to minutes
Absence of pain between episodes
Proctalgia fugax must also be differentiated from chronic proctalgia, which presents with chronic rectal pain (usually worse with sitting) lasting at least 20 minutes and not due to other diseases that cause rectal pain. Symptoms of chronic proctalgia must be present for at least 6 months prior to diagnosis.
Patients with mild proctalgia fugax require no specific treatment except reassurance and explanation of the condition. Patients with more debilitating symptoms may benefit from warm baths. Those with psychological dysfunction should be treated appropriately.
Choice A is not correct:
Endometriosis usually presents with chronic pelvic and/or lower back pain (mild to severe and crampy in nature), dysmenorrhea, dyspareunia, and bowel or bladder dysfunction (e.g., bloating, constipation or diarrhea, hematuria).
Choice C is not correct:
Fibromyalgia typically presents with tenderness in multiple soft-tissue areas of the body accompanied by musculoskeletal pain, fatigue, and mood disturbances.
Choice D is not correct:
Irritable bowel syndrome usually presents with chronic abdominal pain and altered bowel motility (constipation, diarrhea, or both). In addition, irritable bowel syndrome patients typically have decreased abdominal discomfort with defecation.
Choice E is not correct:
Somatization usually presents with a history of chronic, unexplained physical symptoms that are unrelated to physical examination findings and have no exacerbating or alleviating factors. These patients often have a history of psychiatric disorders.
Summarized Points:
Proctalgia fugax usually presents with severe and episodic rectal pain lasting seconds to minutes that is unrelated to bowel movements. Patients are usually asymptomatic between episodes. Diagnosis is made after excluding other gastrointestinal causes of anal and rectal pain.
A 38-year-old woman comes to the physician because of facial pain and fever. She developed a “cold” one week ago with symptoms consisting of mild malaise, sore throat, clear nasal discharge, and productive cough of small amounts of gray sputum. She felt that she was improving, but now has 1 day of fever, chills, purulent nasal discharge, and facial fullness with pain. Her pain is worsened by bending over. She also reports aching of her upper left molars. She is in good health, takes no medications, and has no HIV risk factors. She has no known drug allergies. Her temperature is 39.2 C (102.5 F), pulse is 90/min, and respirations are 14/min. She appears uncomfortable. There is pain to light tapping over her left maxillary region. There is swelling of her turbinates and purulent nasal discharge in her left naris. There are no nasal polyps. Her pharynx shows no erythema or exudates. Cardiopulmonary examination is within normal limits. Which of the following is the best next step in management?
A. Azithromycin
B. No antibiotic therapy
C. Sinus films
D. Amoxicillin-clavulanate
E. Trimethoprim-sulfamethoxazole
The correct answer is D.
This patient’s presentation is consistent with acute bacterial rhinosinusitis. Most acute sinusitis seen in the primary care setting is viral in origin and is associated with the common cold. There is no evidence that antimicrobial treatment is effective in treating viral sinusitis. However, differentiating between viral and bacterial sinusitis is difficult. Acute bacterial sinusitis should be considered in patients with symptoms > 10 days; severe symptoms with fever > 39 C (102 F), purulent nasal discharge or facial pain > 3 days; or worsening symptoms > 5 days after an initially improving viral upper respiratory infection.
Indications for antibiotic therapy for suspected rhinosinusitis
Persistent symptoms lasting more than 10 days
Severe symptoms, high fever (>39°C or 102°F), purulent nasal discharge or facial pain > 3 days
Worsening symptoms > 5 days after an initially improving viral upper respiratory infection
Current guidelines recommend amoxicillin-clavulanate for 5-7 days to treat acute bacterial sinusitis in non-penicillin allergic patients. Amoxicillin is not the drug of choice due to increasing resistance to respiratory pathogens (e.g., Streptococcus pneumonia and Haemophilus influenza).
Macrolides (e.g., azithromycin, clarithromycin), trimethoprim-sulfamethoxazole, and 2nd or 3rd generation cephalosporins are also not recommended as first-line agents due to increasing resistance involving the same respiratory pathogens. Doxycycline and respiratory quinolones (e.g., levofloxacin, moxifloxacin) are alternatives for penicillin-allergic patients. Quinolones or high-dose amoxicillin-clavulanate (2000 mg/125 mg) is recommended in patients who fail initial therapy.
Choice A and E are not correct:
Macrolides (e.g., azithromycin, clarithromycin), trimethoprim-sulfamethoxazole, and 2nd or 3rd generation cephalosporins are also not recommended as first-line agents due to increasing resistance of respiratory pathogens (e.g., Streptococcus pneumonia and Haemophilus influenza).
Choice B is not correct:
Most cases of rhinorrhea and nasal congestion are due to virus infections. Viral upper respiratory infections can be observed with follow-up. It is important to avoid excessive and unnecessary antibiotics due to increasing antibiotic resistance. However, if symptoms persist or worsen (as in this case), treatment for bacterial sinusitis should be initiated.
Choice C is not correct:
Sinus x-rays are not indicated in acute bacterial sinusitis. CT is preferred over sinus x-rays in patients with acute complicated sinusitis with vision abnormalities (e.g., decreased acuity, diplopia), periorbital edema, severe headache, or altered mental status. CT is also preferred in patients with uncomplicated bacterial sinusitis with persistent or worsening symptoms after antibiotic treatment to evaluate for air-fluid levels, which indicate chronic sinusitis.
Summarized Points:
Acute bacterial sinusitis usually presents with symptoms > 10 days; severe symptoms with fever > 39 C (102 F), purulent nasal discharge or facial pain > 3 days; or worsening symptoms > 5 days after an initially improving viral upper respiratory infection. Amoxicillin-clavulanate for 5-7 days is preferred in non-penicillin-allergic patients. Doxycycline and respiratory quinolones (e.g., levofloxacin, moxifloxacin) are alternatives in penicillin-allergic patients.
A 68-year-old man presents to the Emergency Deportment in distress with severe lower abdominal pain. He has been unable to void for the past twelve hours. Has been constipated for the past three days. and gives a two-year history of increasing difficulty passing urine with a poor stream. He has to get up 6-8 times at night to pass urine. Which one of the following is the most appropriate initial management?
A. Administer intramuscular neostigmine methylsulfate
B. Administer 10mg morphine and 10 mg of hyoscine butylbromide intramuscularly
C. Insert an indwelling urethral catheter into the bladder
D. Arrange suprapubic drainage of the bladder
E. Administer a rectal laxative suppository
The Correct answer is C.
Acute urinary retention (AUR) is the inability to voluntarily pass urine. It is the most common urologic emergency. In men (Age >60), AUR is most often secondary to benign prostatic hyperplasia (BPH); AUR is rare in women. It is typically associated with lower abdominal and/or suprapubic discomfort.
Initial management of AUR consists of prompt bladder decompression usually with an indwelling urethral catheter for the short term (i.e., <3 days). Hospitalization is indicated for patients with urosepsis, acute renal failure, or obstruction related to malignancy or spinal cord compression. In men with BPH or presumed BPH, initiate an alpha-1-adrenergic antagonist (e.g., alfuzosin 10 mg) at the time of initial catheterization to prevent recurrent urinary retention after catheter removal. BPH patients with AUR should be evaluated by a urologist.
Choice A is not correct:
Intramuscular neostigmine is contraindicated for mechanical obstruction. It is sometimes used for urinary retention associated with impaired detrusor muscle function without obstruction.
Choice B is not correct:
Hyoscine butylbromide, a smooth muscle relaxant, would worsen the retention and increase the pain.
Choice D is not correct:
Suprapubic drainage of the bladder would be reserved for the occasional patient in whom bladder neck obstruction cannot readily be relieved by urethral catheterization.
Choice E is not correct:
A rectal laxative suppository may be useful as a subsequent treatment for constipation but would not relieve urinary retention.
Summarized Points:
Acute urinary retention (AUR) is the most common urologic emergency and is seen more often in men than women. Benign prostate hyperplasia (BPH) is the most common underlying condition in men, but there are many possible etiologies. Medications are frequently implicated. The majority of patients can be managed as outpatients once bladder decompression is accomplished. Hospitalization is indicated for patients with urosepsis, acute renal failure, or obstruction related to malignancy or spinal cord compression.
A 67-year-old woman comes to the emergency department with 2 days of fever, fatigue, and progressive confusion. She underwent coronary catheterization 2 weeks ago with placement of an intracoronary stent and was discharged home within 24 hours. The patient’s temperature is 38.6 C (101.5 F), blood pressure is 122/70 mm Hg, and pulse is 114/min and regular. The lungs are clear on auscultation. No heart murmurs are appreciated. The abdomen is soft and non-tender. She is initially treated with vancomycin and piperacillin-tazobactam. Forty-eight hours later, blood cultures from admission grow methicillin-resistant Staphylococcus aureus. What is the best next step in the management of this patient’s infection?
A. Add gentamicin
B. Add rifampin
C. Echocardiogram
D. Colonoscopy
E. Ophthalmologic examination
The correct answer is C.
This patient has methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in the setting of a recent hospitalization and cardiovascular procedure. Even in the absence of a heart murmur, echocardiography is recommended for all patients with S aureus bacteremia due to the high risk of associated metastatic complications. A transthoracic echocardiogram (TTE) should be performed first, although a transesophageal echocardiogram is more sensitive in detecting valve vegetations and could be considered if there is no evidence of vegetations on TTE.
Choice A and B are not correct:
The routine addition of gentamicin or rifampin is not recommended in cases of MRSA bacteremia. Gentamicin is sometimes added to shorter courses of penicillin therapy for selected patients with native-valve endocarditis due to penicillin-susceptible strains. Some guidelines recommend adding rifampin to vancomycin in patients with a penicillin allergy who are being treated for methicillin-susceptible native-valve endocarditis.
Choice D is not correct:
Colonoscopy is recommended in cases of bacteremia caused by Streptococcus gallolyticus due to a strong association with colonic malignancy. There is no association between MRSA bacteremia and colonic lesions.
Choice E is not correct:
Although metastatic complications to the eye can occur with MRSA bacteremia, they are uncommon and ophthalmologic evaluation in a patient without visual symptoms is generally not recommended. In contrast, all patients with candidemia should undergo ophthalmologic evaluation.
Summarized Points:
Echocardiography should be performed in all patients with Staphylococcus aureus bacteremia regardless of the presence of clinical signs suggestive of endocarditis.
A 47-year-old female with a 22 year history of type 1 diabetes mellitus complains of burning pain in all her toes that wakes her up at night. Her blood pressure is 135/85 mmHg and his heart rate is 85/min. Cardiopulmonary examination is normal. Popliteal pulses are normal but dorsalis pedis pulses are decreased bilaterally. There is sensory loss over both feet with normal muscle strength. There is a small ulcer over the base of the right second toe. Which of the following might have prevented this wound?
A. Hypolipidemic therapy
B. ACE inhibitor therapy
C. Daily aspirin therapy
D. Tight glycemic control
E. Vascular surgery
The Correct answer is D.
Foot ulcers are a common complication of diabetes. There are two main factors contributing to foot ulcer development in diabetic patients, 1. diabetic neuropathy, which is likely present in this patient given his sensory loss and neuropathic pain, and 2. vascular disease, which is likely present here too given the weak dorsalis pedis pulses. Diabetic neuropathy impairs patients’ ability to recognize pain or trauma to their feet, so injurious factors (e.g. ill-fitting shoes) or injuries themselves (e.g. puncture wound from a nail) are allowed to persist and worsen over time without intervention. To worsen matters, poor blood flow impedes proper healing. The key to preventing diabetic foot ulcers is tight glycemic control, which slows the progression of both diabetic neuropathy and vascular disease.
Choice A is not correct:
Though patients with diabetes and vascular disease often have hyperlipidemia, hypolipidemic treatment alone would not likely have prevented this ulcer.
Choice B is not correct:
While this patient is at risk for having hypertension, elevated glucose levels are more likely to contribute to ulcer formation.
Choice C is not correct:
Daily aspirin therapy is likely indicated in this patient secondary to the increased risk of heart disease and stroke in patients with diabetes and vascular disease. However, aspirin has little effect on foot ulcer risk.
Choice E is not correct:
Ulcers due to vascular insufficiency tend to affect the tips rather than the bases of toes. Even though vascular insufficiency often contributes to diabetic foot ulcers, peripheral neuropathy is the primary factor. Vascular surgery alone would not likely have prevented this patient’s ulcer in the face of such dramatic diabetic neuropathy.
Summarized Points:
Foot ulcers are common in patients with diabetes due to both diabetic neuropathy and peripheral arterial disease. Optimal glucose control is considered the cornerstone for the treatment of diabetes and its complications. Intensive glucose control has been shown to prevent the development of peripheral neuropathy.
A 28-year-old woman comes to the clinic because of abdominal and pelvic pain. She experiences pain for 2 weeks each month for the past 4 years. She describes the pain as being most severe during each menstrual period; the pain is sometimes associated with nausea. She also tells you that she and her husband have been unable to conceive for the past 3 years. She has no significant past medical history. Her last menstrual period was 8 days ago. General physical and pelvic examinations are normal. A hysterosalpingogram performed as an outpatient demonstrates a normal uterus with normal fallopian tubes and spillage into the peritoneum. Which of the following is the best next step in management?
A. Laparoscopy
B. Chromosome analysis
C. In-vitro fertilization
D. Laparotomy
E. Trial of oral contraceptive pills
Submitted
The Correct answer is A.
This patient has a history of intermittent abdominal pain and infertility consistent with a diagnosis of endometriosis. Laparoscopy will reveal characteristic “powder-burn” lesions and filmy or dense adhesions. Symptoms associated with endometriosis occur mainly during the perimenstrual period: pain on bowel movements, pain during sexual intercourse, back pain and intestinal upset. The most likely cause of her pelvic pain is endometriosis, for which laparoscopy is diagnostic. Cauterization of ectopic endometrial implants may restore fertility in a number of patients.
Choice B is not correct:
A chromosome analysis would detect a genetic cause of infertility, but this is not likely in this patient.
Choice C is not correct:
In-vitro fertilization is reserved for women with severe endometriosis who are unable to become pregnant after laparoscopy and removal of ectopic implants fails. Keep in mind that many women with endometriosis eventually do conceive. Moreover, hormonal treatment of endometriosis can aid in conception.
Choice D is not correct:
A laparotomy would be a more surgically invasive procedure, which can be avoided by doing a laparoscopy.
Choice E is not correct:
Also, a trial or oral contraceptive pill (OCPs) is the least invasive method of treatment currently available, it is not appropriate in this patient because she wants to conceive. Many women note an improvement in symptoms with OCPs.
Summarized Points:
Laparoscopy is diagnostic in women with endometriosis. Endometriosis is suspected when abdominal or pelvic pain occurs during the perimenstrual period. If laparoscopic removal of ectopic endometrial implants does not improve fertility, in-vitro fertilization may be offered for women who wish to conceive.
A 39-year-old farmer presents with an open fracture of the tibia due to a rollover tractor injury. Which one of the following is the most important treatment modality for the prevention of infection?
A. Immediate broad-spectrum prophylactic antibiotics in large doses
B. Immediate and complete surgical debridement of the wound
C. Immediate anatomical reduction
D. Avoidance of the use of internal fixation
E. Limb elevation and adequate nutrition
Submitted
The Correct answer is B.
The aim with open (compound) fractures of bone is to convert them as expeditiously as possible to closed (simple) fractures. This requires, most importantly, adequate and early wound debridement (wound toilet), with excision of all dead or doubtfully viable tissue from the skin down to the fracture site, plus removal of any introduced foreign material.
Choice A, C, and D are not correct:
Antibiotics and maintained anatomical reduction are additionally helpful; the latter may require internal fixation to stabilise the fracture.
Choice E is not correct:
Limb elevation and adequate nutrition are also additionally helpful.
Summarized Points:
Open fractures are surgical emergencies. Prompt stabilization and meticulous debridement are the keys to operative management. For most open fractures, a broad-spectrum cephalosporin and an aminoglycoside are started in the emergency department and the patient’s tetanus status should be obtained.
A 4-year-old boy is admitted to the hospital with right eyelid swelling and redness. Approximately 3 days prior to admission he developed a nasal discharge, and fever, and then 24 hours prior, developed right eyelid swelling and erythema. He has a history of mild asthma and his vaccinations are up to date. His temperature is 38.9 °C (102 °F), blood pressure 124/78 mm Hg, and pulse is 89/min. There is mild proptosis on the right . The extraocular motor examination is remarkable for difficulty moving the right medially, pupils are equally round and reactive to light. No lymphadenopathy is present. Laboratory studies show:
Leukocyte count 18 x109/L (3.5–10.5)
Hemoglobin 126 g/L (125–170 )
Blood urea nitrogen 3.57 mmol/L (2.5‐8.0)
Creatinine 53.05 µmol/L(70‐120)
Sodium 135 mmol/L (135‐145)
Potassium 4.1 mmol/L (3.5‐5.0)
Intravenous cefuroxime therapy is initiated. Which of the following is the best next step in management?
A. Administer amphotericin B, intravenously
B. Discharge him after 24 hours of antibiotics
C. Order a CT scan of the orbits with intravenous contrast
D. Prepare him for surgical exploration of the right orbit
E. Prepare him for surgical exploration of the sinuses
The Correct answer is C.
This patient has cellulitis of the right eyelid. One of the most important things to find out in order to guide therapy is whether the infection is preseptal or postseptal. The orbital septum can be thought of as running along the anterior aspect of the bones of the orbit separating the superficial tissues from the orbital contents themselves. Some signs of postseptal infection that this patient has are ophthalmoplegia and proptosis. The risk of visual loss and spread to deeper structures such as the cavernous sinus are why this diagnosis is important to make, as opposed to superficial orbital cellulitis, which is fairly easily treated. It is also important to look for any abscesses that might need to be drained. CT scanning can help to elucidate many of these.
Choice A is not correct:
Amphotericin B is an important tool in the treatment of fungal infections such as mucormycosis. Infection with this fungus is extremely deadly and should be considered in the differential diagnosis of any patient with a severe sinus infection. There is often evidence of devitalized tissue and patients often have some sort of relative immune-suppressive diseases such as diabetes or chronic renal insufficiency. There is nothing, in this case, to suggest that amphotericin should be added at this point.
Choice B is not correct:
Discharge of the patient should be only after adequate treatment, which may take more than 24 hours. Intravenous antibiotics can be discontinued and switched to oral after the patient has been stable and afebrile for 24 hours.
Choice D and E are not correct:
Surgical exploration of the sinuses or orbit should not be performed prior to a CT scan. If an abscess or other signs of more severe infection are seen on the scan, then surgical debridement may be warranted.
Summarized Points:
Patients with suspected orbital cellulitis with any of the following features undergo a contrast-enhanced CT scan of the orbits and sinuses to confirm the diagnosis of orbital cellulitis and detect potential complications:
Proptosis
Limitation of eye movements
Pain with eye movements
Double vision
Vision loss
Edema extending beyond the eyelid margin
Absolute neutrophil count (ANC) >10,000 cell/microL
Signs or symptoms of central nervous system (CNS) involvement
Inability to examine the patient fully (usually patients less than one year of age)
Patients who do not begin to show improvement within 24 to 48 hours of initiating appropriate therapy
A 21-year-old woman comes to the office for contraception counseling. She has been using condoms with her boyfriend but would like a more reliable contraception method. The patient has Wilson disease and a seizure disorder that is well-controlled with carbamazepine. Which of the following is the best contraception method for this patient?
A. Combination oral contraceptives
B. Condoms plus spermicide
C. Copper-containing intrauterine device
D. Diaphragm plus spermicide
E. Depot medroxyprogesterone acetate
The correct answer is E.
All combined estrogen/progestin contraceptives, including the oral contraceptive pill, transdermal patch, and vaginal ring are less effective in patients taking hepatic enzyme-inducing antiepileptic drugs (AEDs). As a result, the use of AEDs (e.g., phenytoin, carbamazepine, phenobarbital) increases the risk of unintended pregnancy in these patients.
The most effective contraceptive options for patients taking AEDs are intrauterine devices (IUDs) and depot medroxyprogesterone acetate (DMPA) injections, as these are not affected by antiepileptics. However, this patient is not a candidate for the copper-containing IUD because she has Wilson disease (copper accumulation due to impaired transport); although this type of IUD acts primarily locally within the uterus, it is contraindicated in patients with Wilson disease because small amounts of copper may absorb systemically. The levonorgestrel IUD and DMPA injection are safe, effective options for patients who have Wilson disease and are on AED therapy.
Choice A is not correct:
In patients taking hepatic enzyme-inducing antiepileptic drugs (AEDs), all methods of estrogen/progestin contraception are ineffective, including the oral contraceptive pill, transdermal patch, and vaginal ring.
Choice B and D are not correct:
Barrier methods such as condoms and diaphragms, with or without spermicide, are less effective than depot medroxyprogesterone acetate in preventing pregnancy. They are also less effective than oral contraceptives, even in patients taking hepatic enzyme-inducing AEDs.
Choice C is not correct:
For patients taking AEDs, the best contraceptive method is an intrauterine device (IUD) or depot medroxyprogesterone acetate (DMPA) injection, as these are not affected by antiepileptic drugs. However, this patient with Wilson disease will not be a good candidate for a copper-containing IUD because even small amounts of copper will absorb into the body.
Summarized Points:
All combined estrogen/progestin contraceptives are less effective in patients taking hepatic enzyme-inducing antiepileptic drugs. These patients should be offered intrauterine devices or depot medroxyprogesterone acetate injection. The copper-containing intrauterine device is contraindicated in patients with Wilson disease.
A 35-year-old African American man is brought to the emergency department by his girlfriend stating, “I can’t swallow.” He tells you his symptoms started 2 hours ago with a feeling that his head was “pulled to the side” and his neck was “tight”. Since then he has had difficulty speaking and eating. His medical history is significant for a remote appendectomy and cholecystectomy. A chart review reveals that he has no allergies, was diagnosed with schizophrenia last year, and has been resistant to taking oral medications. He denies hallucinations and his girlfriend confirms the “voices” are controlled with the injections he receives each month. His last injection was yesterday. His temperature is 37.0 °C (98.6 °F), blood pressure is 130/70 mm Hg, pulse is 90/min, and respirations are 26/min. He is an anxious appearing man with excessive drooling. His head seems fixed in an unusual position and you palpate spasms in several neck muscles. Which of the following is the best next step in management?
A. Benztropine, orally
B. Benztropine, intramuscularly
C. Diphenhydramine, orally
D. Haloperidol, intramuscularly
E. Haloperidol, orally
The Correct answer is B.
This patient has acute dystonia, which is a brief or prolonged muscle spasm, usually of the head or neck muscles including the larynx and pharynx. He most likely received haloperidol or a similar high-potency neuroleptic in his injection yesterday and is experiencing acute dystonia as a medication side effect.
Choice A and C are not correct:
Oral benztropine and diphenhydramine are reasonable choices for dystonic reactions but this patient’s airway is compromised and he may aspirate his secretions. For this reason, he needs to be given benztropine intramuscularly and his symptoms will improve in about 30 minutes.
Choice D and E are not correct:
Haloperidol (choices D and E) is not indicated as his schizophrenic symptoms are controlled. He most likely received haloperidol or a similar high-potency neuroleptic in his injection yesterday and is experiencing acute dystonia as a medication side effect.
Summarized Points:
Acute drug-induced dystonia presents with abnormal tongue or jaw postures and neck dystonia, occurring within the first 3 days of starting a neuroleptic. The treatment is benztropine (Cogentin), intravenously or intramuscularly, or diphenhydramine (Benadryl) intravenously.
