$kin Things
A 71-year-old man is evaluated for erythema and tenderness of the left lower leg for 1 week's duration. This is the second similar episode of the left lower leg. The last episode was 2 months ago. He was previously treated successfully with antibiotics.
On physical examination, temperature is 38.1 °C (100.6 °F), blood pressure is 125/75 mm Hg, respiration rate is 16/min, and pulse rate is 85/min. There is a well-demarcated, warm and tender erythematous patch on the anterior lower left leg extending from dorsal foot to mid shin. There is tissue maceration and fissuring between second and third toe spaces bilaterally. The remainder of the physical examination is normal.
In addition to initiating antibiotic therapy, which of the following is the most appropriate management?
A. Following acute therapy, start prophylactic antibiotics
B. Obtain blood cultures
C. Obtain skin punch biopsy
D.Staphylococcal decolonization with intranasal mupirocin
E. Treat the interdigital intertrigo
E. Treat the interdigital intertrigo
Evaluation of the interdigital toe spaces and treatment of the maceration and fissuring in the web spaces and modification of other predisposing factors such as edema, obesity, eczema, and venous insufficiency can decrease the risk of recurrent cellulitis.
The sole use of this type of treatment is not recommended since it leads to large glucose fluctuations.
What is "sliding-scale insulin."
A 39-year-old woman is evaluated for new-onset nonproductive cough and dyspnea on exertion. She is pregnant at 32 weeks' gestation. Medical history is unremarkable. Her only medication is a prenatal vitamin.
On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 105/62 mm Hg, pulse rate is 100/min, and respiration rate is 22/min. Oxygen saturation is 86% breathing ambient air. Cardiopulmonary examination is normal. She has a gravid uterus and 1+ edema of the lower extremities without calf tenderness.
Laboratory studies:
Hemoglobin 12.1 g/dL (121 g/L)
Leukocyte count 4800/µL (4.8 × 109/L)
Platelet count 189,000/µL (189 × 109/L)
Urinalysis: Normal
Doppler ultrasonography of both legs is negative for deep venous thrombosis.
Which of the following is the most appropriate diagnostic test to perform next?
A. CT angiography
B. D-dimer assay
C. Magnetic resonance pulmonary angiography
D. Pulmonary function testing
E. Ventilation-perfusion lung scan
E. Ventilation-perfusion lung scan
In the presence of normal Doppler studies of the lower extremities, ventilation-perfusion lung scanning is the initial lung imaging study to evaluate for pulmonary embolism in pregnant patients; D-dimer testing has no diagnostic role.
A 25-year-old man is evaluated in the emergency department for fever, productive cough, dyspnea, and pleuritic chest pain that began several days ago. He reports no other symptoms. Intravenous ceftriaxone and oral azithromycin are initiated, and he is hospitalized. Medical history is significant for a recent diagnosis of HIV infection, for which he began antiretroviral therapy 1 month ago. Other medications are lamivudine, abacavir, and dolutegravir.
On physical examination, temperature is 39.2 °C (102.6 °F), blood pressure is 136/84 mm Hg, pulse rate is 110/min, and respiration rate is 20/min. Oxygen saturation is 90% breathing ambient air. Cardiac examination is normal, and the lungs are clear bilaterally.
Laboratory studies at the time of HIV diagnosis showed a viral load of 95,420 copies/mL and CD4 cell count of 256/µL. The interferon-γ release assay for tuberculosis was indeterminate because of inadequate response to the positive control. One week ago, HIV viral load was 1077 copies/mL and CD4 cell count was 313/µL.
A chest radiograph shows an infiltrate in the right middle lobe and bilateral hilar enlargement.
Sputum acid-fast bacilli smear shows acid-fast bacilli; culture results are pending.
Which of the following is the most appropriate management?
A. Await culture results
B. Pause antiretroviral therapy
C. Start prednisone
D. Start rifabutin, isoniazid, ethambutol, and pyrazinamide
D. Start rifabutin, isoniazid, ethambutol, and pyrazinamide
Immune reconstitution inflammatory syndrome is the return of a robust immune response resulting from treatment of HIV that may “unmask” a pre-existing infection; when this occurs, the underlying infection should be treated while antiretroviral therapy is continued.
A 36-year-old runner presents with pain associated with the anterior heel. The patient reports his symptoms are worse on awakening and improve as the day progresses.
What is the most likely diagnosis?
A. Achilles tendonitis
B. plantar fasciitis
C. calcaneal fracture
D. calcaneal bone spur
E. anterior talotibial impingement syndrome
B. plantar fasciitis
A 32-year-old man is evaluated for an intermittent pruritic rash of 8 years' duration. Medical history is significant for mild persistent asthma. His only medications are an albuterol inhaler and an inhaled glucocorticoid.
On physical examination, vital signs are normal. There is mild xerosis with erythematous plaques on the bilateral antecubital fossae, volar wrists, and anterior lower legs. Lichenification is present on the dorsal hands. Linear excoriations are found within many of the erythematous plaques on the arms.
Which of the following is the most appropriate treatment?
A. Oral cephalexin
B. Oral prednisone
C. Topical glucocorticoids
D. Topical ketoconazole
E. Topical mupirocin
C. Topical glucocorticoids
Atopic dermatitis
This is the initial stress test in patients who can exercise and have normal findings on a baseline ECG.
What is exercise electrocardiography?
A 67-year-old woman undergoes follow-up evaluation for an elevated globulin fraction of total serum protein level. She has no symptoms. Medical history is notable for hypertension treated with hydrochlorothiazide and atorvastatin.
On physical examination, vital signs are normal. No lymphadenopathy or hepatosplenomegaly is noted.
Laboratory studies:
Hemoglobin 14.5 g/dL (145 g/L)
Leukocyte count 7000/µL (7 × 109/L)
Platelet count 300,000/µL (300 × 109/L)
Calcium 9.1 mg/dL (2.3 mmol/L)
Creatinine 0.8 mg/dL (70.7 µmol/L)
Serum protein electrophoresis and immunofixation show an IgG monoclonal spike of 0.7 g/dL. Serum free light chain assay and 24-hour urine protein electrophoresis are normal.
Skeletal survey shows no lytic lesions.
Which of the following is the most appropriate management?
A. Kidney biopsy
B. MRI of the cervical, thoracic, and lumbar spine
C. Repeat laboratory studies in 6 months
D. Serum β2-microglobulin I measurement
C. Repeat laboratory studies in 6 months
In patients with IgG monoclonal gammopathy of undetermined significance, an M spike of less than 1.5 g/dL, and normal findings on serum free light chain assay and urine protein electrophoresis, the risk of progression is low, so extensive evaluation is not recommended.
A 66-year-old woman is evaluated in the emergency department with a 2-day history of fever and nonbloody diarrhea occurring several times a day. She recently completed a 10-day course of cephalexin for cellulitis of the leg.
On physical examination, temperature is 39.0 °C (102.2 °F), blood pressure is 98/60 mm Hg, pulse rate is 110/min, and respiration rate is 23/min. She appears uncomfortable but is not confused. Her abdomen is distended and bowel sounds are decreased. She has tenderness and abdominal guarding to palpation. Cellulitis has resolved.
Laboratory studies:
Leukocyte count
30,000/µL (30 × 109/L) (with 80% neutrophils, 15% band forms, and 5% lymphocytes)
Albumin
2.5 mg/dL (25 g/L)
Creatinine
2.5 mg/dL (221 µmol/L) (baseline 1.0 mg/dL [88.4 µmol/L])
Lactate
2.8 mEq/L (2.8 mmol/L)
Stool polymerase chain reaction assay is positive for Clostridium difficile toxin gene. Abdominal imaging reveals evidence of toxic megacolon.
The patient is admitted to the ICU, and a surgical consultation is requested.
Which of the following is the most appropriate medical treatment?
A. Fecal microbiota transplant
B. Oral metronidazole
C. Oral vancomycin
D. Oral vancomycin and intravenous metronidazole
E. Oral vancomycin and oral metronidazole
D. Oral vancomycin and intravenous metronidazole
Fulminant Clostridium difficile infections require oral vancomycin plus intravenous metronidazole; vancomycin enemas may also be added if ileus is present.
This opioid is not recommended for use due to toxic metabolite that casues CNS effects.
What is meperidine? (Demerol)
A 43-year-old woman is evaluated for painful wheals on the upper legs and back that have been present for 2 weeks. Individual lesions resolve with bruising in 3 to 4 days. The patient also reports some associated joint pain, particularly of the small joints in her hands. Medical history is unremarkable, and she takes no medications.
On physical examination, vital signs are normal. There are polycyclic edematous plaques on the back and upper legs. The remainder of the examination, including joint examination, is normal.
Which of the following is the most appropriate management?
A. Epicutaneous patch testing
B. Ice cube provocation test
C. Oral prednisone
D. Skin biopsies
E. Topical triamcinolone
D. Skin biopsies
Urticarial vasculitis.
Skin biopsies should be performed to evaluate for urticarial vasculitis when individual urticarial lesions are present for longer than 24 hours.
What is PPI therapy?
A 52-year-old woman undergoes perioperative evaluation. She has osteoarthritis of the right hip since sustaining injuries in a motor vehicle accident 15 years ago and is scheduled for elective hip arthroplasty in the next few months. Medical history is otherwise notable for type 2 diabetes mellitus. She is up to date on routine health care. Her last menstrual period was 5 weeks ago. Medications are ibuprofen and metformin.
On physical examination, vital signs are normal. She has painful and limited range of motion in the right hip.
Laboratory studies:Hemoglobin 10 g/dL (100 g/L)
Mean corpuscular volume 81 fL
Platelet count 223,000/µL (223 × 109/L)
Creatinine 1 mg/dL (88.4 µmol/L)
Hemoglobin A1c 7.5%
Which of the following is the most appropriate test to perform next?
A. Hemoglobin electrophoresis
B. Iron studies
C. Vitamin B12 level
D. No further evaluation
B. Iron studies
Patients scheduled for elective surgery who have anemia should be evaluated for iron deficiency; preoperative management of iron deficiency anemia includes oral iron replacement and evaluation to determine the source of blood loss.
A 72-year-old man undergoes preprocedural evaluation. He is scheduled to undergo cystoscopy and possible biopsy in follow-up for a previously diagnosed non–muscle invasive bladder cancer followed by an elective right total hip arthroplasty for chronic hip pain. He is otherwise asymptomatic. Medical history is significant for diabetes mellitus, hypertension, kidney transplantation, and osteoarthritis. Medications are metformin, amlodipine, pravastatin, prednisone, and tacrolimus.
On physical examination, vital signs are normal. External rotation of the right hip elicits pain. The examination is otherwise normal.
On microscopic urinalysis, leukocyte count is 20 to 40/hpf, erythrocyte count is 0 to 1/hpf, 2+ bacteria are present, and no squamous epithelial cells are seen. Urine culture grew 10,000 to 50,000 colony-forming units of Proteus mirabilis.
Kidney ultrasonography is unremarkable.
Which of the following is the primary indication for antimicrobial therapy in this patient?
A. Cystoscopy and biopsy
B. Diabetes mellitus
C. Kidney transplant
D. Total hip arthroplasty
A. Cystoscopy and biopsy
Screening for and possibly treating asymptomatic bacteriuria is supported by only two indications: pregnancy and medical clearance before an invasive urologic procedure.
A 38-year-old woman is evaluated for low back pain that began 7 days ago when she bent over to pick up a piece of paper. She describes the pain as moderate aching that is localized to the right lower back. A sharp pain intermittently radiates down the lateral aspect of the right leg. She has not had bowel or bladder dysfunction, fevers, leg weakness, night sweats, saddle anesthesia, or weight loss. She has no history of trauma, and she does not use intravenous drugs.
On physical examination, vital signs are normal. BMI is 21. Musculoskeletal and neurologic examinations are normal.
Which of the following is the most appropriate initial treatment?
A. Acetaminophen
B. Duloxetine
C. Nonpharmacologic modalities
D. Oxycodone
C. Nonpharmacologic modalities
First-line treatment of acute low back pain is nonpharmacologic therapy, including acupuncture, massage, spinal manipulation, and superficial heat; most patients will improve over time, regardless of the treatment chosen.
A 60-year-old woman is evaluated for follow-up treatment of long-standing psoriasis. Medical history is significant for hypertension and hypercholesterolemia. Family history includes multiple family members with psoriasis. She has no joint symptoms, and her medications are atenolol and simvastatin.
On physical examination, vital signs are normal. There is no joint swelling.
She has a total of 30% body surface area involvement with psoriasis without nail involvement.
Which of the following is the most appropriate treatment?
A. Methotrexate
B. Oral prednisone
C. Tacrolimus ointment
D. Topical calcitriol
A. Methotrexate
Moderate to severe psoriasis is best treated with systemic agents; avoid prednisone as a therapy for psoriasis.
Patients with this % cardiovascular risk (<1% risk for a perioperative major adverse cardiac event) may proceed to surgery without preoperative cardiac stress testing.
What is <1% risk for a perioperative major adverse cardiac event? (ASCVD)
A 45-year-old man is evaluated for shortness of breath with exertion and lower extremity edema of 6 months' duration. He reports no chest pain, fever, or cough. He takes no medications.
On physical examination, vital signs are normal. Jugular venous distention is noted. Cardiopulmonary examination reveals crackles at the base of the lungs. He also has 1+ lower extremity edema.
Laboratory studies are remarkable for eosinophilia, with an absolute eosinophil count of 2500/µL (2.5 × 109/L). A review of the medical record shows an eosinophil count of 2900/µL (2.9 × 109/L) 1 year ago.
An electrocardiogram shows sinus rhythm with low-voltage QRS and nonspecific ST changes. An echocardiogram shows findings compatible with a restrictive cardiomyopathy.
Which of the following is the most appropriate initial management?
A. Evaluation for helminth infection
B. Fat pad biopsy
C. Prednisone
D. Repeat laboratory evaluation in 3 months
A. Evaluation for helminth infection
Hypereosinophilic syndrome is characterized by moderate eosinophilia and end-organ damage commonly involving the skin, lungs, gastrointestinal tract, and heart; secondary causes of eosinophilia should be excluded.
A 33-year-old woman is evaluated after sustaining a needlestick puncture in an infusion clinic, where she works as a nurse. The needle was being placed for intravenous therapy and had blood on it; it is from a patient at the clinic who is known to have HIV infection and is taking antiretrovirals, but the recent viral load is unknown. The nurse has already cleaned her wound. Medical history is unremarkable, and she takes no medications.
On physical examination, vital signs are normal, and other examination findings are noncontributory.
Which of the following is the most appropriate immediate management?
A. Begin tenofovir and emtricitabine
B. Begin tenofovir, emtricitabine, and dolutegravir
C. Begin tenofovir, emtricitabine, and ritonavir-boosted darunavir
D. Determine source patient's viral load
B. Begin tenofovir, emtricitabine, and dolutegravir
Preferred HIV postexposure prophylaxis regimens include tenofovir disoproxil fumarate, emtricitabine, and either dolutegravir or raltegravir and are appropriate whether the exposure was occupational or nonoccupational.
A 49-year-old man is evaluated for a 2-day history of posterior neck stiffness and pain that radiates down his left arm and into the fourth and fifth fingers of his left hand. He is left-handed and works as a roofer. The pain worsens when he turns his head to the left and improves when he lies down, although he sometimes has pain when rising from a prone position. He has not had any arm or hand weakness or problems writing. He has no systemic symptoms.
On physical examination, vital signs are normal. On palpation, the pain is reproduced when the examiner applies downward pressure with the patient's head bent to the left and extended (Spurling test). Pain is relieved when the patient holds his left arm above the plane of his shoulder. Neck range of motion is limited with both left and right lateral rotation. There is no cervical spine tenderness to palpation. The neurologic examination is normal.
Which of the following is the most appropriate management?
A. Cervical collar
B. Cervical MRI
C. Electrodiagnostic testing
D. Gabapentin
E. Neck exercises
E. Neck exercises
Cervical radiculopathy, caused by nerve root compression, usually resolves within 2 to 3 months by using conservative measures; stretching and strengthening exercises of the neck muscles provide the best intermediate-term relief.
A 63-year-old man is evaluated for a skin eruption that is itchy and worsening for the past several weeks. Medical history is unremarkable, and he takes no medications.
On physical examination, vital signs are normal. There are tense bullae on an erythematous base and scattered erosions on the trunk and extremities.
Which of the following is the most appropriate diagnostic test to perform next?
A. Biopsy of lesional skin for direct immunofluorescence
B. Biopsy of lesional skin for histology
C. Biopsy of lesional skin for histology and perilesional skin for direct immunofluorescence
D. Biopsy of perilesional skin for histology and direct immunofluorescence
C. Biopsy of lesional skin for histology and perilesional skin for direct immunofluorescence
Autoimmune bullous disease
This treatment is the mainstay of treatment for travelers' diarrhea.
What is fluid replacement therapy?
A 61-year-old man is hospitalized after several days of productive cough, fatigue, and fever. He quit smoking 10 years ago. He takes no medications.
On physical examination, temperature is 39.2 °C (102.6 °F), blood pressure is 110/75 mm Hg, pulse rate is 110/min, and respiration rate is 24/min. Oxygen saturation is 90% breathing 2 L/min of oxygen through nasal cannula. Pulmonary examination reveals crackles in the right lower lung field. He has good performance status.
Chest radiograph shows right lower lobe pneumonia and a right hilar mass. CT scan of the chest and abdomen confirms an endobronchial lesion and right hilar mass, multiple lytic bone lesions, and a right adrenal mass. Bronchoscopy with biopsy confirms squamous cell carcinoma. Bone scan confirms multiple osseous metastatic lesions. Brain MRI shows no metastatic disease.
In addition to platinum-based chemotherapy, which of the following is most likely to improve outcome in this patient?
A. Palliative care consultation
B. PET/CT scan
C. Prophylactic cranial irradiation
D. Test for epidermal growth factor receptor mutation
A. Palliative care consultation
In patients with metastatic non–small cell lung cancer, early institution of palliative care has been shown to improve both quality of life and survival; palliative care does not preclude aggressive cancer treatment.
A 34-year-old man is evaluated for smallpox (variola) exposure. He feels wells. He is an Air Force surgeon and returned 2 days ago from a mission to the Middle East. Two others who accompanied him on his mission are being evaluated for a febrile illness characterized by headache, sore throat, and a vesicular rash on their faces, arms, and legs. The other men have been placed in airborne precautions because their clinical presentation is consistent with probable active variola infection. Medical history is notable for Crohn disease; he is up to date on all recommended immunizations. His only medication is infliximab.
On physical examination, vital signs are normal, and other physical examination findings are unremarkable.
A complete blood count and comprehensive metabolic profile are normal.
Which of the following is the most appropriate treatment?
A. Airborne precautions
B. Tecovirimat
C. Vaccinia immune globulin
D. Vaccinia immunization
D. Vaccinia immunization
Vaccinia immunization is appropriate in the event of possible exposure to smallpox (variola).
A 58-year-old woman is evaluated for a 4-week history of left lateral hip pain. She describes the pain as a moderate ache that intermittently radiates down the lateral aspect of the left leg. It began insidiously and has gradually worsened. The pain worsens when she is climbing stairs or lying on the affected side. She reports no previous trauma to the area. She has not had any leg weakness or swelling or any constitutional symptoms. She has not taken any analgesics for the pain.
On physical examination, vital signs are normal. On palpation, there is tenderness over the left greater trochanter. There is painless full range of motion with abduction, flexion, and external rotation of the left hip. The remainder of the examination is normal.
In addition to activity modification, which of the following is the most appropriate management?
A. Ibuprofen
B. Glucocorticoid injection
C. Hydrocodone/acetaminophen
D. Plain radiography of the left hip
A. Ibuprofen
Patients with greater trochanteric pain syndrome (trochanteric bursitis) typically have pain localized to the greater trochanter, which may radiate down the lateral leg to the knee, and pain to palpation over the greater trochanter; treatment includes avoiding painful activities, acetaminophen or NSAIDs, and muscle strengthening.