Dx
A 45-year-old diabetic man with cellulitis of the foot develops fever and crepitus. Imaging suggests gas in the tissue. What is the most appropriate next step?
A. Start oral clindamycin
B. Urgent surgical debridement and IV antibiotics
C. Increase to high-dose cephalexin
D. Apply topical antibiotics
Crepitus and gas suggest necrotizing fasciitis, a surgical emergency requiring urgent debridement and broad-spectrum IV antibiotics (e.g., vancomycin plus piperacillin-tazobactam), per IDSA guidelines. Oral or topical antibiotics are inadequate, and cephalexin does not cover anaerobic pathogens.
A 50-year-old woman presents with a 3-day history of erythema, warmth, and swelling of her right leg consistent with cellulitis. She has no fever, and the area is non-purulent. She has no drug allergies. What is the most appropriate antibiotic regimen?
A. Intravenous vancomycin
B. Oral cephalexin 500 mg four times daily
C. Oral clindamycin 300 mg three times daily
D. Intravenous ceftriaxone
Non-purulent cellulitis is typically caused by beta-hemolytic streptococci. Per IDSA guidelines, oral cephalexin is first-line for mild, outpatient-treated cellulitis in patients without systemic symptoms or MRSA risk factors. Vancomycin and ceftriaxone are reserved for severe or MRSA-suspected cases. Clindamycin is an alternative but not first-line.
A 55-year-old otherwise healthy woman presents with fever, cough, and a right lower lobe infiltrate on chest X-ray, consistent with community-acquired pneumonia (CAP). She is hemodynamically stable and will be treated as an outpatient. What is the most appropriate antibiotic regimen?
A. Azithromycin 500 mg on day 1, then 250 mg daily for 4 days
B. Levofloxacin 750 mg daily for 5 days
C. Amoxicillin 1 g three times daily
D. Ceftriaxone 1 g intramuscularly daily for 7 days
Per ATS/IDSA guidelines, azithromycin is a first-line option for outpatient CAP in healthy patients with no recent antibiotic exposure or comorbidities. Levofloxacin is reserved for patients with comorbidities or risk of resistant organisms. Amoxicillin does not cover atypical pathogens. Ceftriaxone is typically inpatient therapy.
A 60-year-old man with cirrhosis presents with confusion and asterixis. His ammonia level is elevated. What is the most appropriate initial treatment?
A. Rifaximin 550 mg twice daily
B. Lactulose titrated to 2-3 bowel movements daily
C. Neomycin 1 g four times daily
D. Branched-chain amino acids
Lactulose is the first-line treatment for hepatic encephalopathy, titrated to achieve 2-3 bowel movements daily, per AASLD guidelines. Rifaximin is an adjunct for recurrent encephalopathy. Neomycin is rarely used due to toxicity. Amino acids are not standard therapy.
A 55-year-old man with alcohol-related cirrhosis presents with new-onset ascites. He has no fever, abdominal pain, or altered mental status. His serum albumin is 2.8 g/dL, and serum creatinine is 1.0 mg/dL. What is the most appropriate initial management for his ascites?
A. Start furosemide 40 mg daily
B. Initiate spironolactone 100 mg daily
C. Perform large-volume paracentesis
D. Prescribe a low-sodium diet and spironolactone 100 mg daily
Per AASLD guidelines, first-line treatment for new-onset ascites in cirrhosis includes a low-sodium diet (2 g/day) and aldosterone antagonists like spironolactone (starting at 100 mg daily). Furosemide may be added later if needed, but spironolactone is preferred initially. Large-volume paracentesis is reserved for refractory ascites or symptomatic relief.
A 72-year-old man develops fever and cough 5 days after admission for a hip fracture. Chest X-ray shows a new left-sided infiltrate. What is the most appropriate empiric antibiotic regimen?
A. Azithromycin and ceftriaxone
B. Vancomycin and piperacillin-tazobactam
C. Levofloxacin alone
D. Clindamycin and doxycycline
Hospital-acquired pneumonia (HAP) requires broad-spectrum coverage for gram-positive (including MRSA) and gram-negative organisms, per ATS/IDSA guidelines. Vancomycin and piperacillin-tazobactam are appropriate empiric choices. Azithromycin and ceftriaxone are more suited for CAP. Levofloxacin may not cover MRSA adequately.
A 62-year-old woman admitted for pneumonia has a blood pressure of 162/92 mmHg on two readings. She is asymptomatic, with no history of hypertension. Her heart rate is 88 bpm, and she has no neurologic deficits. What is the most appropriate management?
A. Start IV labetalol
B. Start Amlodipine 5 mg PO
C. Observe and recheck BP
D. Initiate IV hydralazine
Asymptomatic hypertension in the inpatient setting (BP <180/110 mmHg) without end-organ damage does not require immediate pharmacologic intervention per JNC 8 and AHA guidelines. Observation and addressing underlying conditions (PNA, pain) are appropriate. Rechecking BP later guides further management.
A 70-year-old woman admitted for sepsis develops oliguria and a serum creatinine of 2.5 mg/dL (baseline 0.8 mg/dL). Her urine output is 0.4 mL/kg/h. What is the most likely cause of her acute kidney injury (AKI)?
A. Hypovolemia
B. Acute tubular necrosis (ATN)
C. Glomerulonephritis
D. Urinary tract obstruction
Sepsis is a common cause of ATN, the most likely etiology of AKI in this setting, per KDIGO guidelines. ATN results from ischemic or toxic injury to renal tubules. Hypovolemia is possible but less likely if sepsis is the primary issue. Glomerulonephritis and obstruction are less common in this context.
A 45-year-old man presents to the ED with a BP of 210/120 mmHg, headache, and blurred vision. Fundoscopic exam reveals papilledema. His serum creatinine is 1.8 mg/dL (baseline 1.0 mg/dL). What is the most appropriate initial treatment?
A. Oral clonidine 0.1 mg
B. Intravenous nitroprusside
C. Intravenous labetalol
D. Sublingual nifedipine
Per ACC/AHA guidelines, intravenous labetalol is a first-line agent for rapid BP reduction (target 10-20% reduction in first hour). Nitroprusside is an alternative but requires intensive monitoring. Sublingual nifedipine is contraindicated due to unpredictable BP drops. Oral clonidine is inappropriate for acute management.
A 65-year-old man with type 2 diabetes is admitted for acute pancreatitis. His home regimen includes metformin and insulin glargine. His blood glucose is 220 mg/dL. What is the most appropriate inpatient glycemic management?
A. Continue metformin and insulin glargine
B. Stop metformin, continue insulin glargine, and add sliding-scale insulin
C. Stop all diabetes medications and monitor glucose
D. Start insulin infusion
Per ADA guidelines, metformin should be held in hospitalized patients due to the risk of lactic acidosis, especially in acute illnesses like pancreatitis. Long-acting insulin (glargine) should be continued, with sliding-scale insulin added for glycemic control (target 140-180 mg/dL). Insulin infusion is reserved for critical]... DKA or critical illness.
A 35-year-old woman rescued from a fire has persistent hypotension and lactic acidosis despite oxygen therapy. Cyanide poisoning is suspected. What is the most appropriate treatment?
A. Sodium bicarbonate infusion
B. Hydroxocobalamin 5 g IV
C. Hyperbaric oxygen
D. Methylene blue 1 mg/kg IV
Hydroxocobalamin is the first-line treatment for cyanide poisoning, binding cyanide to form non-toxic cyanocobalamin, per ABA guidelines. Sodium bicarbonate addresses acidosis but not the underlying cyanide toxicity. Hyperbaric oxygen is for CO poisoning. Methylene blue is used for methemoglobinemia.