Question 1

A 79-year-old man is found poorly responsive in his apartment by a neighbor in the middle of July.  The apartment is not air conditioned and the last few days have been extremely hot.  The patient's neighbors state that he lives alone and appeared fully functional in their interactions with him.  No additional medical history is available.
On physical examination, he appears obtunded and responds slowly to commands.  His temperature is 42.2° C (108° F), blood pressure is 90/60 mm Hg, pulse is 104/min, and respirations are 16/min.  The patient's pulse oximetry shows 96% on room air.  Mucous membranes are dry.  His neck is supple, and jugular veins are flat in the supine position.  Cardiopulmonary examination is within normal limits.  There are no skin rashes.  Deep tendon reflexes are 2+ and symmetrical.  There is no muscular rigidity.
An electrocardiogram demonstrates sinus rhythm with nonspecific ST-segment changes.  A chest film shows no significant abnormalities.  Laboratory workup is pending.
In addition to volume resuscitation, which of the following is the best initial therapy for this patient?

Accepted Answer

This patient's presentation is consistent with classic (nonexertional) heat stroke. Nonexertional heat stroke is more common in the elderly and those with chronic medical conditions. Exertional heat stroke is more common in young healthy athletes exercising heavily in high ambient temperature and humidity. Heat stroke mortality is reported as 20%-60%. Hyperthermia management includes supportive measures (eg, airway protection, circulatory support), rapid evaporative cooling, cold IV normal saline boluses for hypotension or volume depletion, cooled oxygen and blankets, and temperature monitoring via rectal or esophageal probes. Evaporated cooling is safe, noninvasive, effective, and does not interfere with other treatment and monitoring. The technique involves spraying mists of water with fans blowing air over moist skin. Ice water immersion is also quick and effective in reducing the body temperature. However, it interferes with monitoring and is associated with increased mortality in elderly patients with classic (nonexertional) heat stroke. Younger patients with exertional heat stroke can better tolerate this technique (Choice E). (Choice A) Alcohol sponge baths should be avoided because large amounts of alcohol may be absorbed through dilated cutaneous blood vessels and lead to systemic toxicity. (Choice B) Antipyretics (eg, acetaminophen, aspirin) are not helpful in heat stroke as the mechanism is not regulated by the hypothalamus. Aspirin may even exacerbate complications such as renal failure or disseminated intravascular coagulation. (Choice C) Dantrolene is effective for treating hyperthermia associated with neuroleptic malignant syndrome but is ineffective in other hyperthermic disorders. The absence of muscular rigidity makes neuroleptic malignant syndrome unlikely. Educational objective: Management of classic (nonexertional) heat stroke includes cooling methods (eg, evaporative cooling), circulatory support (with intravenous fluid boluses), airway management, and treatment of complications. Antipyretics and dantrolene are not useful in the management of heat stroke. __________ References: Hot on the inside. (http://www.ncbi.nlm.nih.gov/pubmed/12889421) Successful treatment of severe heatstroke with therapeutic hypothermia by a noninvasive external cooling system. (http://www.ncbi.nlm.nih.gov/pubmed/21982153)

Question 2

A 43-year-old woman is seen in the hospital following a laparoscopic cholecystectomy.  The patient had no significant operative complications but was observed overnight due to nausea during recovery from anesthesia.  The nausea has resolved and she is tolerating a regular diet.  The patient reports continuous moderate incisional pain with occasional spikes of increased pain with movement.  Medical history is unremarkable and she takes no chronic medications.  She does not use tobacco, alcohol, or illicit drugs.
Vital signs are normal.  Examination shows intact abdominal incisions with normal bowel sounds and no significant abdominal tenderness.  The remainder of the examination is normal.
Which of the following is the most appropriate prescription for home pain control for this patient?

Accepted Answer

Overprescribing of opioid analgesics is associated with risk for abuse and diversion. Even when the initial indication for opioid therapy is appropriate, excess pills can be misused by patients and others, leading to overdose and dependence. Strategies to reduce overprescribing include: Using non-opioid medications (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) for mild pain (eg, low back pain, headache)For patients with moderate to severe pain who require opioid therapy, prescribing limited quantities and providing frequent follow-up to reassess opioid requirements Using non-opioid medications (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) for mild pain (eg, low back pain, headache) Using non-opioid medications (eg, acetaminophen, nonsteroidal anti-inflammatory drugs) for mild pain (eg, low back pain, headache) For patients with moderate to severe pain who require opioid therapy, prescribing limited quantities and providing frequent follow-up to reassess opioid requirements For patients with moderate to severe pain who require opioid therapy, prescribing limited quantities and providing frequent follow-up to reassess opioid requirements This opioid-naive patient has moderate postoperative incisional pain. Short-acting opioids (eg, hydrocodone, oxycodone) are appropriate and can be combined with acetaminophen or a nonsteroidal anti-inflammatory drug (eg, ibuprofen) to reduce opioid requirements (short-acting hydrocodone is available in the United States only in combination with acetaminophen or ibuprofen). However, most patients with uncomplicated laparoscopic cholecystectomy have a significant reduction in pain within the first 3 days. Therefore, the most appropriate care for this patient is to provide a short-term (3-5 days) opioid prescription with availability for office follow-up if pain persists beyond that time. (Choices B and C) The analgesic effect of codeine is more variable than that of other opioids. Oxycodone or hydrocodone are more appropriate for postoperative patients, but a 7-day supply is more than is needed for most patients. (Choice D) Tramadol can provide relief of mild to moderate pain, including postoperative pain, and may be associated with a reduced risk of abuse compared to other opioids. However, the risk of misuse of tramadol is still substantial, and a 14-day supply is excessive. (Choice E) A fentanyl transdermal patch can provide relief of chronic pain for up to 72 hours. However, long-acting opioids are associated with increased risk of respiratory depression and are not recommended for acute pain in opioid-naive patients. Educational objective: Strategies to reduce overprescribing of opioid medications include using non-opioid medications for mild pain and prescribing limited quantities of opioid medications for moderate to severe pain. For most patients with moderate postoperative pain, a short-term (3-5 days) prescription of an opioid analgesic is appropriate. __________ References: Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. (http://www.ncbi.nlm.nih.gov/pubmed/25233168)

Question 3

There has been a continuous increase in the number of urinary tract infections among residents of a local long-term care facility over the last 5 years.  Due to comorbidities, many residents are incontinent of urine and have indwelling urinary catheters.
Which of the following measures will most likely decrease the frequency of urinary tract infections in these patients?

Accepted Answer

It is estimated that 25%-50% of all hospitalized patients have an indwelling catheter placed sometime during their stay. The most common inappropriate use of indwelling catheters is to manage urinary incontinence. Catheters also should not be used to measure residual urine volume. A portable ultrasound unit can be used for this purpose as it accurately measures residual urine volume > 50 mL. Common appropriate indications for placement of catheters include: Management of acute urinary retention Measurement of urine output in critically ill patients Management of neurogenic bladder Management of hematuria with clots During surgery to assess volume status End-of-life care Management of acute urinary retention Measurement of urine output in critically ill patients Management of neurogenic bladder Management of hematuria with clots During surgery to assess volume status End-of-life care Measures to avoid complications of urinary catheters include: Using catheters only when appropriately indicated Prompt removal of catheters when no longer required Using alternatives to catheters (eg, condom catheters for male patients, diapers) Not routinely replacing or irrigating catheters Using catheters only when appropriately indicated Prompt removal of catheters when no longer required Using alternatives to catheters (eg, condom catheters for male patients, diapers) Not routinely replacing or irrigating catheters The only measure that has been shown to reduce risk of catheter-associated bacteriuria is removal of indwelling catheters as soon as they are not required. (Choices A, B, C & E) Acidification of urine is not recommended to decrease the incidence of catheter-associated urinary tract infections. Administration of prophylactic systemic antibiotics should be avoided due to risks of antimicrobial resistance. There is insufficient evidence to suggest that routine catheter change in patients with long-term indwelling catheters will reduce the risk of bacteriuria. Catheter replacement is indicated only for specific clinical indications such as infection and obstruction. Catheter irrigation with antimicrobials is not recommended. Educational objective: Urinary incontinence is not an indication for indwelling catheters. When not required, indwelling catheters should be removed promptly to avoid the risk of catheter-associated urinary tract infection. __________ References: Factors associated with catheter-associated urinary tract infections and the effects of other concomitant nosocomial infections in intensive care units. (http://www.ncbi.nlm.nih.gov/pubmed/22200187) Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/20175247)

Question 4

A 72-year-old woman is sent to the hospital after 2 days of agitation and combative behavior.  The patient has Alzheimer dementia and lives in a skilled nursing facility.  The nursing staff at the facility report that she is calm at baseline and spends most of her time in bed or in a wheelchair.  She is normally minimally interactive with staff members but reportedly brightens when her son comes to visit.  The patient has a history of generalized anxiety disorder but is currently not taking any medications for it.
In the emergency department, the patient is anxious and agitated.  She is disoriented to place and time and frequently tries to get out of bed.  She intermittently mumbles to herself and accuses the nurse of stealing her handbag.  Urinalysis is both leukocyte esterase and nitrite positive and contains 100 white blood cells/high-power field.  A urine culture has been sent to the laboratory.
In addition to empiric antibiotics for urinary tract infection, which of the following is the most appropriate management for this patient?

Accepted Answer

11ec193a_970b_e75c_853d_ef54e543e4a6_MD0002_00 This patient's acute presentation of worsening confusion and agitated behavior in the setting of a urinary tract infection is consistent with delirium. Initial management of delirium involves the treatment of reversible causes, followed by nonpharmacologic measures such as frequent verbal orientation, reassurance, and touch by someone familiar to the patient (eg, family member) or by a trained sitter at the bedside. Pharmacotherapy is reserved for situations in which nonpharmacologic strategies fail or the patient poses a significant risk of harm to self or others. Preferred agents include first- and second-generation antipsychotics (eg, haloperidol, olanzapine, quetiapine, risperidone) (Choice A). Short-term use is advised as these agents are associated with increased mortality in patients with dementia. Physical restraints are a last resort as they can lead to worsening agitation and result in impaired mobility and pressure ulcers (Choice C). (Choice B) Benzodiazepines (eg, lorazepam) can worsen confusion and cause paradoxical agitation. They are reserved for patients in alcohol withdrawal or those who have contraindications to antipsychotics. (Choice E) During the day, the patient's room should be well lit as darkness can contribute to worsening confusion. Educational objective: Initial management of delirium is aimed at treatment of reversible causes, patient orientation, and environmental modification. A cautious trial of antipsychotics is reserved for patients who fail conservative measures and pose a significant risk of harm to themselves or others. Restraints are a last resort and can worsen agitation. __________ References: Delirium in older persons: evaluation and management. (http://www.ncbi.nlm.nih.gov/pubmed/25077720) Delirium in elderly people. (http://www.ncbi.nlm.nih.gov/pubmed/23992774)

Question 5

An 84-year-old man with a long history of obesity, diabetes, and peripheral artery disease is hospitalized for an extensive gangrenous ulcer on his right foot.  A surgical consultant recommends urgent below-the-knee amputation as a life-saving procedure.  The patient refuses, saying, "I've had a long life.  Most of my friends are dead and all I have left are memories."  He does not want to undergo any type of surgical procedure and prefers to be treated with medications only.  His primary care provider is uncomfortable with this decision as the patient seems forgetful.
On evaluation and record review, there is no evidence of delirium or psychosis.  The patient is sad about the death of several friends over the past year.  His appetite is normal and he reports no changes in sleep.  He is able to provide a summary of his medical condition and acknowledges that refusing surgery may result in his death.  His score on a Montreal Cognitive Assessment is 24/30.
Which of the following is the most appropriate course of action?

Accepted Answer

11ec193a_970d_6dff_853d_7943ab4fa4cc_MD0002_00 Determination of patients' capacity to make medical decisions requires establishing a balance between respecting patient autonomy and protecting those with cognitive impairment. Patients who refuse treatment should be assessed for decision-making capacity according to the criteria in the table. The physician does not have to agree with a patient's decision provided the patient demonstrates consistent, logical reasoning. This patient has decision-making capacity. He is able to articulate reasons for his decision and shows no signs of delirium, psychosis, or severe depression that could interfere with his ability to understand the information and appreciate the risks of refusing surgery. He has the right to refuse treatment and his decision should be respected. Although he may have mild cognitive impairment, as evidenced by his Montreal Cognitive Assessment (MoCA) score of 24/30, there is no evidence that his ability to understand the specific consequences of his decision is impaired. MoCA scores <26/30 generally indicate mild cognitive impairment; however, there is no single score with high sensitivity and specificity to assess capacity. (Choice A) This patient expresses sadness associated with the loss of his friends but does not exhibit other symptoms of depression. There is no evidence that his mood has impaired his decision-making capacity regarding surgery. (Choice B) There is no evidence of impairment in decision-making capacity. Furthermore, there is limited evidence for significant benefit of cholinesterase inhibitors in mild cognitive impairment. (Choice C) Psychiatric consultation regarding capacity would be appropriate for complex cases in which the physician suspects that the patient's decision-making is compromised due to psychosis, depression, or cognitive impairment. (Choice E) This patient has decision-making capacity. If it were determined that he does not have decision-making capacity, the next step would be to contact a family member for surrogate decision-making regarding the surgery. Educational objective: Capacity to consent to or refuse treatment requires the ability to express a choice, understand the relevant medical information, appreciate the consequences of treatment options, and offer a rationale for the decision. Patients with decision-making capacity have the right to refuse medical treatment. Physicians must adhere to these decisions regardless of what they believe to be the best choice. __________ References: Assessment of decisional capacity: prevalence of medical illness and psychiatric comorbidities. (http://www.ncbi.nlm.nih.gov/pubmed/25355466) Assessment of capacity for medical decision making. (http://www.ncbi.nlm.nih.gov/pubmed/20349850)

Question 6

A 40-year-old woman is seen 48 hours after an uncomplicated repeat caesarean delivery at 39 weeks gestation.  She reports sudden-onset shortness of breath and a nonproductive cough.  The patient has no fever, chills, nausea, vomiting, or chest pain.  Her prenatal course was uncomplicated.  She has no chronic medical conditions.  The patient's previous pregnancy was uncomplicated; she had a term caesarean delivery for breech presentation.
On examination, the patient appears distressed.  Blood pressure is 196/112 mm Hg, pulse is 120/min, and respirations are 32/min.  Pulse oximetry is 86% on room air.  Auscultation of the lungs shows diffuse inspiratory crackles bilaterally.  Jugular venous pressure is normal.  Cardiac sounds are normal and there are no murmurs or additional sounds.  Abdominal examination is normal.  There is 2+ pedal edema to the bilateral mid-calves.
Laboratory results are as follows:
 Chest x-ray reveals bilateral diffuse alveolar infiltrates.  ECG shows sinus tachycardia and upsloping ST-segment depressions in the inferior lateral leads.
Which of the following is the most likely diagnosis in this patient?

Accepted Answer

11ec193a_970c_d1be_853d_6ff459395f14_MD0002_00 This patient with respiratory distress and crackles associated with new-onset hypertension and significant (3+) proteinuria has postpartum preeclampsia complicated by pulmonary edema. Preeclampsia typically presents from 20 weeks gestation and commonly manifests in the third trimester. However, it can occur after delivery and up to 6 weeks postpartum; the majority of cases occur within 48 hours of delivery. During pregnancy, common clinical features include headache, epigastric/right upper quadrant pain, and visual changes. In the postpartum period, pulmonary edema is a common presentation, likely due to preeclampsia-induced renal changes (eg, proteinuria) exacerbating physiologic postpartum fluid shifts. Other causes of postpartum pulmonary edema include capillary leak, left heart failure (eg, peripartum cardiomyopathy), and iatrogenic volume overload. Treatment of postpartum preeclampsia includes blood pressure control and administration of magnesium sulfate for seizure prophylaxis. Fluid restriction, oxygen support, and diuretics can be considered for patients who have preeclampsia complicated by pulmonary edema. (Choice A) Acute coronary syndrome can cause hypertension, dyspnea, and nonspecific ECG changes; however, the presence of significant proteinuria, absence of chest pain, and normal cardiac examination make preeclampsia, rather than acute coronary syndrome or its complications (eg, papillary rupture), a more likely cause of this patient's findings. (Choice B) Amniotic fluid embolism can cause an acute onset of dyspnea; however, the majority of patients have hypotension (eg, cardiogenic shock) and disseminated intravascular coagulation (eg, bleeding, bruising). (Choice C) Aspiration presents with acute-onset dyspnea, hypoxia, and diffuse crackles on auscultation; however, chest x-ray typically shows segmental rather than diffuse infiltration. Significant hypertension and proteinuria are not typical findings. (Choice D) Peripartum cardiomyopathy can present with dyspnea, cough, pedal edema, and hypertension in the third trimester or postpartum period. Proteinuria is not a characteristic finding, and this patient has no jugular venous distension or S3 to suggest heart failure. Educational objective: Preeclampsia, defined as new-onset hypertension and proteinuria, can present from 20 weeks gestation to 6 weeks postpartum and can be complicated by pulmonary edema. Treatment includes blood pressure control and seizure prophylaxis (ie, magnesium sulfate). __________ References: Cardiopulmonary complications of pre-eclampsia. (http://www.ncbi.nlm.nih.gov/pubmed/19464506) Etiology and management of postpartum hypertension-preeclampsia. (http://www.ncbi.nlm.nih.gov/pubmed/21963308)

Question 7

An 81-year-old man is transferred from a skilled nursing facility to the hospital due to lethargy and poor oral intake over the last 24 hours.  For the past 2 days, he has had increased urinary frequency and dysuria.  A urinalysis showed evidence of urinary tract infection, and he was started on oral ciprofloxacin.  He was recently hospitalized with acute ischemic stroke, and his hospital course was complicated by pneumonia requiring intravenous antibiotics.  He also had an episode of urinary retention requiring Foley catheter placement for 5 days.  His other medical problems include mild cognitive impairment, hypertension, and type 2 diabetes mellitus.  He has no known drug allergies.
His temperature is 38.9° C (102° F), blood pressure is 92/58 mm Hg, and pulse is 112/min.  Lungs are clear to auscultation.  His extremities are warm and well perfused.
Foley catheter placement yields 230 mL of cloudy urine.
Laboratory results are as follows:

Urine culture obtained at the nursing facility 2 days earlier showed extended spectrum beta-lactamase-producing Klebsiella.
Which of the following is the best initial antibiotic regimen for this patient?

Accepted Answer

Extended spectrum beta-lactamase (ESBL)-producing organisms lead to infections that result in increased virulence and mortality, longer hospital stays, and higher hospital expenses. Although ESBL-producing organisms are often the cause of nosocomial infections, community-acquired infections are becoming more common. Risk factors for acquiring ESBL-producing organisms include the following: Length of hospital or intensive care unit stay Presence of urinary catheter Presence of central venous or arterial catheters Presence of feeding tube Prior antibiotic administration Residence in long-term care facility (eg, nursing home) Ventilator usage Length of hospital or intensive care unit stay Presence of urinary catheter Presence of central venous or arterial catheters Presence of feeding tube Prior antibiotic administration Residence in long-term care facility (eg, nursing home) Ventilator usage Although ESBL-producing organisms may show in vitro susceptibility to penicillins with beta-lactamase inhibitors or cephalosporins, these drugs show an inoculum effect, resulting in decreased susceptibility as the size of inoculum is increased from 10⁵ to 10⁷ organisms. Similarly, treatment with fluoroquinolones, aminoglycosides, and aztreonam is also likely to fail due to higher resistance (Choices A, B, and D). Current guidelines recommended carbapenems (eg, imipenem, meropenem, doripenem, and ertapenem) for treating severe infections due to ESBL-producing organisms. Imipenem and meropenem have the best outcomes, but meropenem is preferred in this patient due to easier dose adjustment in renal failure. (Choice C) Daptomycin is used for treating skin and soft-tissue infections caused by Gram-positive organisms, Staphylococcus aureus (both methicillin-sensitive and methicillin-resistant) bacteremia and endocarditis, and vancomycin-resistant enterococci. It is not indicated for treatment in this patient, who has urosepsis due to Gram-negative organism. Educational objective: Although extended spectrum beta-lactamase-producing organisms may show in vitro susceptibility to penicillins with beta-lactamase inhibitors, cephalosporins, aminoglycosides, fluoroquinolones, and aztreonam, treatment with these agents is likely to result in high failure rates. Carbapenems (eg, imipenem, meropenem, doripenem, and ertapenem) are the only recommended treatment option for these organisms. __________ References: Epidemiology and genetic characteristics of extended-spectrum ß-lactamase-producing Gram-negative bacteria causing urinary tract infections in long-term care facilities. (http://www.ncbi.nlm.nih.gov/pubmed/22865381) Carbapenems versus alternative antibiotics for the treatment of bacteraemia due to Enterobacteriaceae producing extended-spectrum ß-lactamases: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22915465)

Question 8

A 75-year-old woman with stage 4 breast cancer with brain metastases is admitted to hospice with a life expectancy of 2-4 weeks.  She responded poorly to her last chemotherapy treatment and decided with her family that palliative care was best.  Although her pain is fairly well controlled, the patient has very poor appetite, little energy, and sleeps for most of the day.  She often does not get up for meals and has lost 3.6 kg (8 lb) in the past week.  During a family visit, the daughter notices that the patient is quieter than usual and appears very depressed; she says, "She barely responds to us anymore and just cries softly."
Physical examination is unchanged.  The patient is alert and oriented.  When the physician asks the patient about her mood she says, "Of course I am depressed given my situation.  I'm just so hopeless and tired."
In addition to providing support, which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Major depression in terminally ill patients is under-recognized and undertreated as physicians may assume that depression is a normal part of the grieving process. After ensuring adequate pain control and providing support, physicians should have a low threshold for pharmacological treatment with the goal of alleviating patient and family distress and facilitating emotional connection in the last weeks of life. The patient's anticipated life expectancy should guide medication selection. First-line treatments for depression such as selective serotonin reuptake inhibitors (eg, escitalopram) typically require several weeks to take effect and would be appropriate for patients with a life expectancy of several months (Choice B). In patients whose life expectancy is only 2-4 weeks, psychostimulants (eg, methylphenidate, dextroamphetamine, modafinil) are preferred due to their faster onset of antidepressant action. Stimulants may also be useful in counteracting general fatigue and opioid-related sedation. They are generally well tolerated, and improvement in mood and energy can be seen within 1-2 days. (Choice A) Electroconvulsive therapy (ECT) can achieve a more rapid response in severely depressed patients compared to medication. However, this patient's brain metastases are a relative contraindication to ECT, and its use would be inconsistent with palliative care's goal of providing nonintrusive comfort care. (Choice D) Mirtazapine is a first-line antidepressant that is particularly helpful in patients with anorexia and insomnia due to its appetite-stimulating and sedating properties. However, like other antidepressants, it typically requires weeks to take effect. (Choice E) Although it can be difficult to differentiate grief from major depression in terminal illness, this patient's severely depressed mood, withdrawal from family, and despondency are concerning for depression. A rapid antidepressant response could alleviate her suffering and improve quality of life in the weeks she has left. Patients, families, and physicians should not underestimate the impact of depression under the assumption that anyone in the same situation would be depressed. Educational objective: Depression in terminally ill patients is undertreated. Due to their rapid onset of action, psychostimulants should be considered for treating depressed palliative care patients with a life expectancy of days to weeks. __________ References: Managing grief and depression at the end of life. (http://www.ncbi.nlm.nih.gov/pubmed/22962989) Effects of methylphenidate on fatigue and depression: a randomized, double-blind, placebo-controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/22208450)

Question 9

A 63-year-old man with recent elective right inguinal hernia repair comes to the emergency department with pain and swelling of the right thigh.  The pain began the night before and he could not sleep well despite taking oxycodone and acetaminophen.  The patient has mild hypertension and type 2 diabetes requiring daily long-acting insulin.  He also suffers from resistant fungal infection of the toenails.
His temperature is 38.4° C (101° F), blood pressure is 110/72 mm Hg, and pulse is 124/min and regular.  His lungs are clear to auscultation.  A faint systolic murmur is heard at the base.  His abdomen is soft and nontender.  The surgical incision looks clean with minimal amount of gray discharge.  The right inner thigh has a large area of erythema and swelling that is very tender on superficial palpation.  Several small vesicles containing pink fluid with surrounding purpura are also present.
Laboratory results are as follows:

Which of the following is the best next step in management of this patient?

Accepted Answer

This patient's abrupt onset of thigh/groin pain with erythema and bullae after recent abdominal or pelvic surgery suggests necrotizing fasciitis (NF). NF is seen predominantly in patients with diabetes, immunosuppression, or recent surgery/trauma. Necrotizing fasciitis involves destruction of the muscle fascia and overlying subcutaneous fat. Infection initially spreads along the fascia due to the poor blood supply of muscle fascia before it involves subcutaneous fat. As a result, early identification is difficult. Early findings include erythema spreading across muscle fascia, swelling, and exquisite tenderness out of proportion to its appearance. Infection spreads rapidly and the patient appears ill; tender areas become anesthetic due to impairment of the blood supply. At this stage, examination shows skin discoloration, crepitus, and hemorrhagic blisters. The swelling and edema can lead to compartment syndrome. Most infections are polymicrobial, with cultures typically yielding a mix of aerobic and anaerobic pathogens. Initial antibiotic therapy should cover Streptococcus species, Gram-negative aerobes, and anaerobes. NF is a surgical emergency that requires immediate consultation. Despite broad-spectrum antibiotics, aggressive debridement of necrotic tissue is required to prevent local necrosis and systemic toxicity. Delaying surgical intervention can increase morbidity and mortality. (Choice A) Lower-extremity duplex ultrasound can diagnose deep venous thrombosis, which can present with leg swelling and pain. However, this patient's exquisite tenderness and vesicles suggest myonecrosis. (Choice B) Penicillin G does not effectively treat most Gram-positive, Gram-negative, or anaerobic organisms. Metronidazole can treat anaerobic infection but does not cover other organisms well. A preferred therapy is carbapenem or beta-lactam/beta-lactamase inhibitor plus coverage for methicillin-resistant Staphylococcus aureus (eg, vancomycin). (Choice D) Although this patient has a murmur on examination, he does not have other findings (eg, Osler nodes, Roth spots, splinter hemorrhages) to suggest endocarditis. (Choice E) Valacyclovir treats herpes zoster, which can present with vesicular lesions. However, the systemic findings (eg, fever, tachycardia, and leukocytosis) and erythema after recent surgery make necrotizing fasciitis more likely. Educational objective: Early findings of necrotizing fasciitis include erythema spreading across muscle fascia, swelling, and exquisite tenderness out of proportion to its appearance. Infection spreads rapidly and the patient appears ill. Tender areas become anesthetic, and examination shows skin discoloration, crepitus, and hemorrhagic blisters. Early aggressive surgical debridement of necrotic tissue is of utmost importance to prevent local necrosis and systemic toxicity. __________ References: Necrotizing soft tissue infections. (http://www.ncbi.nlm.nih.gov/pubmed/17599015) The diagnosis of necrotizing fasciitis. (http://www.ncbi.nlm.nih.gov/pubmed/15735411)

Question 10

A 69-year-old man is admitted to the hospital due to 2 days of high fevers, chills, headache, nausea, and diarrhea.  He has also had intermittent abdominal pain associated with 4 nonbloody bowel movements over the past 24 hours.  The patient has a history of rheumatoid arthritis and takes infliximab and hydroxychloroquine.  He lives with his wife in Florida and has had no sick contacts or recent travel outside of the state.  He is the primary caretaker of a domesticated bird.
Temperature is 39.4 C (103 F), blood pressure is 118/80 mm Hg, pulse is 112/min, and respirations are 16/min.  The patient is ill-appearing.  Pulmonary examination is normal.  Bowel sounds are hyperactive, and the abdomen is soft and mildly tender.  Neurological examination shows no focal abnormalities.
Laboratory results are as follows:
 Chest x-ray reveals no focal infiltrate.  Intravenous empiric antibiotics and fluids are administered.  Blood cultures sent on admission grow Gram-positive rods in all 4 bottles after 12 hours.
Which of the following is the most likely etiology of this patient's illness?

Accepted Answer

11ec193a_96fc_7dfe_853d_9b7162188ddf_MD0002_00 This patient has acute febrile gastroenteritis, underlying immunosuppression (infliximab), and bacteremia with Gram-positive rods, raising suspicion for Listeria monocytogenes infection. Listeria is found in soil and decaying vegetation and is often a low-level contaminant of food (eg, fruit, unpasteurized milk, soft cheeses). Healthy individuals who ingest large inoculums are at risk for self-limited (<48 hours) febrile gastroenteritis. Those with advanced age or underlying immunosuppression can also develop invasive disease (eg, bacteremia, sepsis, pneumonia, meningitis). Listeriosis is usually suspected clinically and confirmed by fluid (eg, blood, cerebrospinal fluid) cultures. Gastroenteritis does not typically require antimicrobial treatment, but ampicillin is the first-line therapy for invasive infection. (Choice B) Contact with respiratory secretions can lead to viral infections (eg, influenza). Listeria is primarily spread through food ingestion, not respiratory secretions. (Choice C) Exposure to antibiotics is associated with Clostridium difficile colitis, but bacteremia is very rare. In addition, this patient has no recent history of antibiotic use. Gram-positive bacteremia is more suggestive of Listeria or Clostridium perfringens. (Choice D) Exposure to bird feces is associated with psittacosis due to Chlamydia psittaci and cryptococcosis due to Cryptococcus neoformans. Neither of these infections is associated with febrile gastroenteritis or Gram-positive bacteremia. (Choice E) Bacterial overgrowth usually causes bloating, flatulence, and abdominal discomfort, not acute febrile gastroenteritis. In addition, most cases arise due to Gram-negative organisms and anaerobes. Educational objective: Listeriosis usually occurs due to the ingestion of contaminated food. Healthy individuals are at risk for self-limited febrile gastroenteritis, but those with immunosuppression or advanced age can also develop invasive disease (eg, bacteremia, sepsis, pneumonia, meningitis). Ampicillin is the first-line treatment for invasive infection. __________ References: Listeriosis: a resurgent foodborne infection. (http://www.ncbi.nlm.nih.gov/pubmed/20002687) Gastroenteritis due to Listeria monocytogenes. (http://www.ncbi.nlm.nih.gov/pubmed/15825036)

Question 11

A 36-year-old man is brought to the emergency department after waking up with dyspnea, nonproductive cough, fever, and malaise.  He had been feeling well prior to these symptoms and has no chronic medical problems.  The patient and his wife are on vacation in Florida and are staying in an "old and dusty" rental house.  Last night they went to a bar and then relaxed in a hot tub.
Temperature is 38.9 C (102 F), blood pressure is 144/89 mm Hg, and pulse is 104/min.  Pulse oximetry is 89% on room air.  Chest examination reveals bilateral fine crackles.  There are no skin rashes.
Laboratory results are as follows:
 Liver function tests are normal.  Chest x-ray reveals mildly increased interstitial markings in the middle and lower lung fields bilaterally.
Which of the following is most likely responsible for this patient's current symptoms?

Accepted Answer

Mycobacterium avium complex (MAC) is a group of free-living nontuberculous mycobacteria that are ubiquitous in the environment. Humans acquire the organism primarily via inhalation of aerosolized municipal water, but transmission can also occur through contaminated soil, food, and animals (eg, birds). Most healthy individuals exposed to MAC have little risk of infection. However, disseminated disease can occur in patients with severe immunodeficiency (eg, AIDS), and chronic pulmonary infections can occur in those with underlying lung disease or in nonsmoking women age >50. MAC can also induce a hypersensitivity pneumonitis ("hot tub lung"), particularly in those with recent exposure to contaminated hot tub water. Manifestations include an acute, flu-like illness with dyspnea, cough, malaise, and fever. Most cases are self-limited and resolve with close observation, supportive care, and avoidance of hot tub exposure. However, if symptoms worsen or persist, a short course of prednisone is often indicated. (Choice A) Although infection with Chlamydia psittaci can cause similar manifestations, most patients have severe headaches and a history of close contact with birds, making the diagnosis less likely in this patient. (Choice C) Pseudomonas infections associated with hot tub use usually present as folliculitis, not pneumonia. In addition, Pseudomonas pneumonia would be more likely to develop over days (not hours) and be associated with a lobar infiltrate (not patchy interstitial infiltrate). folliculitis (Choice D) Pneumonia caused by Staphylococcus aureus occurs primarily after influenza infection. Most cases are marked by lobar (or multilobar) consolidation, not interstitial infiltrates. (Choice E) Although Streptococcus pneumoniae is the most common cause of community-acquired pneumonia, patients typically have productive cough and a lobar (not interstitial) infiltrate. Educational objective: Patients with hot tub/spa exposure are at risk for Mycobacterium avium complex infection and can present with hypersensitivity pneumonitis ("hot tub lung"). Manifestations are often acute and resemble an influenza infection. Most cases are self-limited and resolve with supportive care; a short course of prednisone can be used if symptoms do not resolve. __________ References: Hot tub lung mimicking classic acute and chronic hypersensitivity pneumonitis: two case reports. (http://www.ncbi.nlm.nih.gov/pubmed/17885696) Hypersensitivity pneumonitis-like granulomatous lung disease with nontuberculous mycobacteria from exposure to hot water aerosols. (http://www.ncbi.nlm.nih.gov/pubmed/17384775)

Question 12

A 46-year-old woman is seen in the emergency department for severe headache accompanied by nausea since she awoke this morning.  She was diagnosed with hypertension 7 years ago and took medications for 2 years.  The patient stopped the medications and did not follow up with doctors as she felt fine.  She has a history of remote but not active intravenous drug use.  She is a current smoker with a 25-pack-year history.
Her temperature is 37.8° C (100.1° F), blood pressure is 176/105 mm Hg, and pulse is 100/min.  She appears lethargic with mild neck stiffness.  Cardiac auscultation shows an apical 2/6 holosystolic murmur.  Lungs are clear to auscultation bilaterally.  Deep abdominal palpation shows bilateral firm flank masses.  There is no peripheral edema or skin rash.  There is no focal muscle weakness or cranial nerve deficit.
ECG shows sinus tachycardia with left ventricular hypertrophy and secondary ST-segment and T-wave changes.
Laboratory results are as follows:

Which of the following is the most likely cause of this patient's headache?

Accepted Answer

This patient's presentation of hypertension, hematuria, proteinuria, renal insufficiency, and bilateral flank masses suggests likely autosomal dominant polycystic kidney disease (ADPKD). Major extrarenal complications of ADPKD are: Intracranial aneurysms Hepatic and pancreatic cysts Cardiac valve disease and aortic root dilatation Diverticulosis Intracranial aneurysms Hepatic and pancreatic cysts Cardiac valve disease and aortic root dilatation Diverticulosis Nearly 5% of young adults and 20% of patients > age 60 with ADPKD develop intracranial aneurysms that can rupture causing intracerebral or subarachnoid hemorrhage. This risk is higher in patients with family history of ruptured aneurysms. Patients typically present with "thunderclap" headache, nausea, and vomiting. Computed tomography (CT) scan usually diagnoses subarachnoid hemorrhage but can sometimes miss small bleeds. Lumbar puncture is indicated in patients with negative CT scan and usually shows xanthochromia. Angiography is recommended for patients with positive CT scan or lumbar puncture. Screening for intracranial aneurysms in ADPKD is controversial. This is because routine screening can identify small aneurysms (< 7 mm) that are at low risk for rupture, but the surgical intervention of these aneurysms can result in severe neurologic complications. Guidelines recommend screening patients with previous aneurysm rupture, family history of intracerebral bleed or aneurysm, and high-risk occupations (eg, pilots). (Choice A) Uncontrolled hypertension, sudden-onset headache, and neck stiffness suggest possible subarachnoid hemorrhage. Bilateral flank masses in this situation indicate underlying ADPKD rather than renal cell carcinoma with metastasis. (Choice B) Although this patient may be at risk for hypertensive encephalopathy, her low-grade fever and neck stiffness indicate subarachnoid hemorrhage. Low-grade fever in general is common with intracranial hemorrhage. Her blood pressure is also not severe enough to cause hypertensive encephalopathy (>180/120 mm Hg). (Choice C) Obstructive or non-communicating hydrocephalus is usually caused by space-occupying lesions. (Choice E) Although this patient's fever and neck stiffness can be due to viral meningitis/encephalitis, the bilateral flank masses, hematuria, and renal insufficiency make ADPKD more likely. Educational objective: Intracranial aneurysms occur in up to 20% of individuals with autosomal dominant polycystic kidney disease. However, routine screening for aneurysms is controversial. If chosen, screening is best performed with time-of-flight magnetic resonance angiography, which does not require gadolinium contrast and can be done at any glomerular filtration rate level. Computed tomography angiography is an alternate screening method. __________ References: Extended follow-up of unruptured intracranial aneurysms detected by presymptomatic screening in patients with autosomal dominant polycystic kidney disease. (http://www.ncbi.nlm.nih.gov/pubmed/21551026) Follow-up of intracranial aneurysms in autosomal-dominant polycystic kidney disease. (http://www.ncbi.nlm.nih.gov/pubmed/15086900)

Question 13

A 25-year-old man sustained a head injury during a motor vehicle accident. He is currently comatose and intubated in the intensive care unit. He has no significant medical problems except for mild asthma. His urine drug screen was negative; however, his blood alcohol level was above the legal limit. He works as a bartender and frequently binges on hard liquor and beer. A non-contrast head CT at the time of admission revealed a hyperdense, extra-axial, space-occupying, right-sided lesion, which was subsequently drained. He was sedated with a propofol infusion, but it was discontinued 12 hours ago. His temperature is 37 C (98.6 F), pulse is 80/min, blood pressure is 130/85 mm Hg, and respirations are 18/min. He is currently on volume assist-control ventilation with an FiO₂ of 40%, tidal volume of 500 cc, and PEEP of 5 cm H₂O. He is not triggering the ventilator. The general physical examination is unremarkable except for a hemi-craniectomy along the right side of the head. He is comatose on neurological examination. Cranial nerve and motor responses are absent. His arterial blood gas analysis shows a pH of 7.42, PaCO₂ of 36 mm Hg, and PaO₂ of 101 mm Hg. Which of the following is essential in establishing the diagnosis of brain death in this patient?

Accepted Answer

When clinical criteria suggest brain death, the best next step is apnea testing. Patients must be hemodynamically stable with a body temperature > 36 C (97 F), normal pH, and normal PaCO₂/PaO₂ levels. Apnea testing objectively confirms brainstem failure if the patient cannot generate spontaneous breaths or trigger the ventilator in response to elevated PaCO₂ levels > 10 minutes after disabling control mode (Choice E). clinical criteria 11ec193a_9709_2838_853d_197f40e05156_MD0002_00 Patients are first pre-oxygenated with 100% oxygen for 10 minutes using existing ventilatory support, and then mechanical ventilation is discontinued. However, they should continue to passively receive 100% oxygen while the chest and abdomen are observed for spontaneous respirations for approximately 10 minutes. If spontaneous respirations are observed, the apnea test is negative and the patient is not brain dead. A positive test is defined as no spontaneous respirations and requires another clinical brain death examination for confirmation. In addition, repeat ABG must confirm that the PaCO₂ was > 60 mm Hg or that it increased > 20 mm Hg from the baseline ABG. Patients who cannot tolerate apnea testing or have inconclusive results require ancillary diagnostic tests to confirm brain death. (Choice A) The atropine response test involves administering atropine and observing for an increase in heart rate (> 3%). Although the vagal nucleus in the medulla may be one of the last functions lost in brain death, the atropine response test provides a limited assessment and has not been well validated for confirming brain death. (Choice C) Cerebral blood flow testing (e.g., cerebral angiogram or cerebral scintigraphy) is the gold standard test for brain death confirmation, but it is highly invasive and not used routinely as the initial step for diagnosing brain death. Cerebral blood flow testing may be used in patients with an unreliable clinical examination or bedside apnea test. (Choice D) Current guidelines do not recommend EEG with ECI protocol for brain death confirmation, as it is susceptible to excessive artifact from other electrical devices in the ICU that make it less reliable. In addition, EEG is very sensitive to the effects of sedative medications and metabolic derangements, and therefore can be easily confounded by those variables. Educational objective: Brain death can be suggested by clinical criteria (e.g., coma, absent cranial nerve reflexes and motor responses, CT/MRI brain imaging consistent with a devastating CNS event, etc.). Two clinical brain death examinations and apnea testing are recommended and considered appropriate for brain death diagnosis. Every attempt should be made to remove all confounding variables that can interfere with obtaining a reliable clinical examination and bedside apnea test. __________ References: An update on brain death criteria: a simple algorithm with complex questions. (http://www.ncbi.nlm.nih.gov/pubmed/21881464) The diagnosis of brain death. (http://www.ncbi.nlm.nih.gov/pubmed/19881172)

Question 14

A 66-year-old woman is hospitalized for the worst headache of her life.  CT scan of the head without contrast shows diffuse subarachnoid hemorrhage with intraventricular extension and hydrocephalus.  Because of the patient's deteriorating mental status and agitation, her trachea is cannulated and a central venous catheter is placed.
Which of the following is the most effective strategy to decrease this patient's risk for developing catheter-related infection?

Accepted Answer

11ec193a_9700_ead2_853d_9b5c8ce2d8f3_MD0002_00 Measures to prevent catheter-related infection include proper hand hygiene, sterile catheter insertion using chlorhexidine skin disinfection, and maximal sterile barrier precautions. Catheters inserted without these techniques should be removed within 24-48 hours. Infection rate also depends on the site of insertion, with lower risk in subclavian compared to internal jugular and femoral catheters (Choice B). Fewer ports and antimicrobial-impregnated catheters also reduce infection (Choice E). Peripheral catheters inserted with sterile technique should be removed after 72-96 hours to reduce risk of infection. However, there is no definitive replacement time for central catheters, and routine replacement is not recommended as it increases mechanical complications without decreasing infection risk (Choice D). Replacement is indicated in suspected catheter infection (eg, purulence, fever, and hemodynamic instability). Guidewire technique for replacement increases infection risk and is not recommended. Daily chlorhexidine baths in the intensive care unit also reduce central catheter-related infection. Prophylactic topical and systemic antibiotics are not recommended as they promote fungal infections and antibiotic resistance (Choice C). Catheters should be monitored regularly and removed if tenderness or erythema is present or if they are no longer needed. Educational objective: Prevention of catheter-related infections includes maximal sterile barrier precautions with insertion, chlorhexidine skin disinfection, and the use of antibiotic-impregnated catheters. Femoral insertion site, routine replacement of central catheters, and prophylactic antibiotics are not recommended. __________ References: Summary of recommendations: Guidelines for the prevention of intravascular catheter-related infections. (http://www.ncbi.nlm.nih.gov/pubmed/21467014) Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability. (http://www.ncbi.nlm.nih.gov/pubmed/22482848) Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. (http://www.ncbi.nlm.nih.gov/pubmed/12233868)

Question 15

A 46-year-old man comes to the emergency department complaining of severe headache for the last 3 hours.  He took ibuprofen without much relief.  He suffers from tension headaches but says that this headache is nothing like those.  He feels nauseated and wants to move to a quiet, dark room.
His temperature is 36.5 C (97.7 F), blood pressure is 160/90 mm Hg, and pulse is 108/min.  Examination shows pain and mild stiffness with neck flexion.  There are no cranial nerve deficits or muscle weakness.
A noncontrast head computed tomography scan reveals subarachnoid hemorrhage with no evidence of hydrocephalus.  The patient is admitted to the intensive care unit.  A few hours later, he complains of increasing headache and has 2 episodes of vomiting.  Soon after, he develops cardiac arrest with pulseless electrical activity.
Which of the following interventions would have been the most effective in preventing this outcome?

Accepted Answer

11ec193a_970b_240b_853d_d7770d0925d5_MD0002_00 This patient has a subarachnoid hemorrhage (SAH) in the setting of severe headache and meningismus. SAH has a mortality rate of nearly 10% before patients reach the hospital and 25% within the first 24 hours of presentation. Rebleeding is the major cause of death within the first 24 hours, particularly within the first 6 hours. The initial step in managing suspected SAH is conventional angiogram as soon as possible with an endovascular approach (eg, coiling and/or stenting) to stabilize the aneurysm. (Choice A) Anti-fibrinolytic therapy (eg, tranexamic acid, epsilon aminocaproic acid) has not been shown to be effective in preventing rebleeding in patients with SAH. (Choices C and D) Hyperdynamic therapy (modest hemodilution, induced hypertension, hypervolemia) and nimodipine can effectively reduce the risk of vasospasm. However, this usually does not occur until after day 3. This patient's clinical course within the first 24 hours of SAH is most likely due to rebleeding. (Choice E) Ventricular drain placement is helpful in reducing intracranial pressure and increasing cerebral perfusion pressure. However, this patient's catastrophic event is likely due to rebleeding. Educational objective: In patients with subarachnoid hemorrhage, rebleeding is the major cause of death within the first 24 hours of presentation. Vasospasm usually does not occur until day 3. __________ References: How we do it: acute management of subarachnoid hemorrhage. (http://www.ncbi.nlm.nih.gov/pubmed/23452572)

Question 16

A 56-year-old man with a past medical history of hypertension and diabetes mellitus is hospitalized after sustaining a mild concussion following a motor vehicle accident.  His daily medications include aspirin, metformin, and lisinopril.  He has smoked one pack of cigarettes daily for 20 years.  He does not drink alcohol.  He is married and works as an accountant.  His family history is significant for coronary artery disease and diabetes mellitus.
His blood pressure is 143/95 mm Hg and pulse is 90/min with regular rhythm.  His general physical and neurological examinations are unremarkable.
An MRI of the brain without contrast reveals a chronic infarct in the right basal ganglia without any evidence of intracranial bleeding.
This patient is at the highest risk for which of the following?

Accepted Answer

This patient's brain MRI shows a silent, chronic lacunar infarct in the right basal ganglia related to his hypertension and diabetes mellitus. Given his vascular risk factors, he is at risk of having additional ischemic events. These events can accumulate over time and cause significant damage to the surrounding white matter tracts and subcortical grey matter, which are essential for proper cognitive function. One study found that patients with silent infarcts with positive brain imaging have double the risk of developing dementia over the subsequent 5 years, compared to normal controls with normal brain imaging. Multiple silent infarcts were associated with an even higher risk than single infarcts. Therefore, this patient is at risk for developing vascular (Binswanger's) dementia in the future. (Choice B) Migraine headaches are a common primary headache disorder typically afflicting patients between the ages of 15-50 years. Migraine headaches (especially those associated with prolonged negative aura) can lead to migrainous cerebral infarction from headache-induced changes in vascular tone or caliber. However, vascular risk factors and stroke have not been linked to a higher future risk of developing migraine headaches. (Choice C) Multiple sclerosis is an autoimmune demyelinating disease that predominantly affects the central white matter of the brain and spinal cord. Vascular risk factors and stroke have not been linked with an increased future risk of developing multiple sclerosis. (Choice D) Normal pressure hydrocephalus is a disorder characterized by ataxia, dementia, and urinary incontinence. This condition develops as a result of impaired cerebrospinal fluid absorption at the arachnoid granulations and has no causal relationship with ischemic events in the brain. (Choice E) The risk of developing seizures following an acute stroke is approximately 5-10% if the stroke involves the cortex. Subcortical strokes typically do not increase the risk of seizures. Severe concussions (e.g., associated with loss of consciousness or amnesia) can lead to a high risk of developing epilepsy later in life. However, this patient only had a mild concussion, and therefore has a low risk for epilepsy. Educational objective: Elderly people with silent brain infarcts have an increased risk of developing dementia than those without such lesions. __________ References: Silent brain infarcts and the risk of dementia and cognitive decline. (http://www.ncbi.nlm.nih.gov/pubmed/12660385)

Question 17

A 23-year-old woman with known type 1 diabetes mellitus and systemic lupus erythematosus is admitted with low-grade fever, nausea, and headache.  She takes prednisone, hydroxychloroquine, and multiple daily injections of insulin.  She also uses decongestants for seasonal allergies and omeprazole for acid reflux disease.
Initial laboratory results are as follows:

Lumbar puncture shows protein of 23 mg/dL and no white blood cells.  Chest x-ray is normal.  Urinalysis shows no evidence of infection.  The patient is treated with IV fluids and insulin infusion.  On the second day of hospitalization, she complains of worsening headache and blurry vision.  On physical examination, she appears mildly lethargic.  There is right-sided periorbital swelling and tenderness over the maxilla.  There is no lymph node enlargement and the neck is supple.  Chest examination is unremarkable.  The abdomen is soft and nontender.  There are no skin rashes.
Repeat laboratory results are as follows:

This patient would most likely require which of the following?

Accepted Answer

11ec193a_96fe_a0e1_853d_9dabe406909b_MD0002_00 This immunocompromised patient with diabetic ketoacidosis most likely developed rhino-orbital-cerebral mucormycosis, a devastating mold infection. The Mucorales species (eg, Rhizopus, Mucor, and Rhizomucor) are the most common pathogens found in soil and decaying vegetable matter. These organisms thrive in high-glucose, acidic conditions. Angioinvasion leading to tissue infarction is the hallmark of mucormycosis. Infection usually begins in the nasal turbinates through spore inhalation and presents with acute sinusitis (eg, fever, sinus pain, purulent nasal discharge, and congestion). The disease usually progresses rapidly, as patients develop symptoms due to invasion of the eye structures and brain. Imaging may reveal edematous mucosa and destruction of facial bone and periorbital tissues. Diagnosis is made by biopsy and tissue examination that show hyphae with irregular branching without septations. Aspergillus also affects immunocompromised patients; it has hyphae with regular branching and many septations. Treatment includes immediate, thorough surgical debridement and IV amphotericin B. (Choice A) Gram-negative rod infections (eg, Pseudomonas aeruginosa) are common in diabetics. They usually cause skin and soft-tissue infections instead of the combined sinus and periorbital disease seen in this patient. (Choice B) MRI would be less useful in this patient, who has a supple neck, normal lumbar puncture results, and no evidence of invasion into the soft tissues of the neck or carotid artery (eg, acute motor or sensory deficits). (Choice C) Although this patient has slightly altered mentation, the initial lumbar puncture showing no WBCs makes meningitis unlikely. A repeat lumbar puncture would therefore be less useful. (Choice E) Cardiac mucormycosis is extremely rare, and transesophageal echocardiography would not be useful in the management of rhino-orbital-cerebral mucormycosis. Infective endocarditis is unlikely in this patient. Educational objective: Rhino-orbital-cerebral mucormycosis is an uncommon but devastating infection in diabetic patients with poor glucose control and frequent episodes of ketoacidosis. Diagnosis is made by histology and culture revealing irregular branching hyphae without septations. Surgical intervention combined with IV amphotericin B is needed to achieve cure. __________ References: Epidemiology and clinical manifestations of mucormycosis (http://www.ncbi.nlm.nih.gov/pubmed/22247442) Mucormycosis and entomophthoramycosis: a review of the clinical manifestations, diagnosis and treatment (http://www.ncbi.nlm.nih.gov/pubmed/14748801)

Question 18

A 55-year-old man comes to the physician with an intensely pruritic rash under his left arm.  He has used an old prescription of 1% triamcinolone cream for the past 2 weeks without relief and believes that the rash is expanding.  The patient was diagnosed with Sjögren's syndrome 6 months ago when he developed dry eyes, dry mouth, and positive anti-SS-A and anti-SS-B antibodies.  Labial salivary gland biopsy at that time showed lymphocytic infiltration of salivary glands, confirming the diagnosis.  He was treated with hydroxychloroquine, topical moisturizing eye drops, and artificial saliva.  His other medical problems include type 2 diabetes mellitus, which has been well controlled with metformin.  Physical examination findings are shown in the image below.

Complete blood count and comprehensive metabolic panel are unremarkable.  His hemoglobin A1C is 6.1%.
After confirming the diagnosis, which of the following is the most appropriate next step in management of this patient?

Accepted Answer

11ec193a_9707_efb7_853d_bbbe8ff646ec_MD0002_00 This patient's presentation is consistent with tinea corporis. Tinea corporis is a dermatophyte infection that begins as a pruritic and scaly patch or plaque with erythema in a circular or oval pattern. It can involve the flexural areas or the axilla. The rash has irregular margins that develop central clearing and expand into an annular (ring-like) shape. Multiple lesions can coalesce to form a flower petal shape. Risk factors for tinea corporis include contact with infected humans, animals, or inanimate objects. Mild-to-moderate disease can occur in otherwise healthy patients. However, more extensive disease suggests possible underlying immunocompromised states (eg, HIV, uncontrolled diabetes). Outbreaks have occurred in athletes who have had skin-to-skin contact with infected athletes. flower petal shape Diagnosis is usually confirmed by potassium hydroxide (KOH) preparation of skin scrapings showing the characteristic segmented hyphae and arthrospores seen in dermatophytes. Mild-to-moderate disease usually responds to 2-4 weeks of topical antifungals (eg, clotrimazole). However, topical nystatin is ineffective against dermatophytes and is not recommended. Oral/systemic therapy is indicated for patients with severe or widespread disease, underlying immunocompromised states, or who fail topical therapy. Oral terbinafine, fluconazole, and itraconazole are preferred over griseofulvin due to greater efficacy and fewer side effects. (Choice A) Increasing the dose of oral hydroxychloroquine is indicated for treatment failure of Sjögren's syndrome. Refractory disease usually presents with worsening exocrine (eg, xerostomia) or extraglandular (eg, palpable purpura with cutaneous vasculitis, peripheral neuropathy) disease. However, tinea corporis does not suggest treatment failure of underlying Sjögren's syndrome. (Choice B) Topical steroids are effective against inflammatory skin conditions that can mimic tinea corporis, such as granuloma annulare. However, granuloma annulare has erythematous or violaceous annular plaques without scaling. Increasing the potency of the steroids may also worsen the tinea corporis. granuloma annulare (Choice C) Calcipotriene is a topical vitamin D analogue used to treat moderate-to-severe plaque psoriasis, which usually occurs on the extensor surfaces on the elbows, knees, hands, and feet. However, it is not effective for either Sjögren's syndrome or tinea corporis. plaque psoriasis (Choice E) Topical tacrolimus is an immunosuppressive agent approved for treating inflammatory skin conditions such as atopic dermatitis and discoid lupus. However, it is not effective for dermatophytosis and may worsen the condition. atopic dermatitis discoid lupus Educational objective: Tinea corporis is a dermatophyte infection that begins as a pruritic and scaly patch or plaque with erythema in a circular or oval pattern. The rash has irregular margins that develop central clearing and expand into an annular (ring-like) shape. Mild-to-moderate disease usually responds to 2-4 weeks of topical antifungals. Oral agents are reserved for severe or widespread disease, immunocompromised patients, and failure with topical therapy. __________ References: Superficial fungal infections. (http://www.ncbi.nlm.nih.gov/pubmed/22474120) Topical treatment of common superficial tinea infections. (http://www.ncbi.nlm.nih.gov/pubmed/12046779) Dermatophyte infections. (http://www.ncbi.nlm.nih.gov/pubmed/12537173)

Question 19

A 53-year-old woman is brought to the emergency department due to severe headaches, vomiting, and muscle weakness. The patient's medical problems include hypertension and obesity. Her body mass index is 34.2 kg/m². Temperature is 38 C (100.4 F), blood pressure is 185/105 mm Hg, pulse is 110/min, and respirations are 24/min. Pulse oximetry is 99% on room air. The patient is oriented to person and place only, and has a throbbing headache and paralysis of her left side. CT head scan without contrast reveals a right hemisphere hemorrhagic stroke. What is the best next step in preventing deep-vein thrombosis in this patient?

Accepted Answer

Deep-vein thrombosis (DVT) is a significant problem in patients with acute stroke, occurring in up to 15% of patients within the first 30 days, with pulmonary embolism (PE) accounting for up to 25% of all early deaths following stroke. DVTs can develop as soon as 24 hours after the acute event, with peak incidence at days 2-7. Risk factors in stroke patients include hemiparesis (with the risk proportionate to the degree of hemiparesis), atrial fibrillation, immobility, and advanced age. Pharmacologic DVT prophylaxis is recommended for ischemic stroke but is contraindicated for hemorrhagic stroke in the acute setting. Intermittent pneumatic compression (IPC) initiated within 72 hours of an acute stroke prevented DVT in the open-label CLOTS 3 trial. Patients who have been immobilized for more than 72 hours should not be started on IPC without first ruling out DVT due to possible clot dislodgement associated with IPC. (Choices A and E) Graduated compression stockings have not been shown to reduce the risk of proximal lower-extremity DVT after stroke. DVT was more common in stroke patients wearing below-knee-high compared with thigh-high graduated compression stockings in the CLOTS 2 trial. In contrast, thigh-high graduated compression stockings may be harmful (eg, skin breaks, blisters, skin necrosis) in stroke patients, according to the CLOTS 1 trial. (Choice B) D-dimer surveillance is not recommended as primary screening prophylaxis for DVT in patients with acute stroke. (Choice D) Pharmacologic DVT prophylaxis with low-molecular-weight heparin may be considered 1-4 days following hemorrhagic stroke in immobile patients as long as repeat imaging rules out further bleeding. Educational objective: In patients with hemorrhagic stroke, intermittent pneumatic compression started within 72 hours of the acute event is effective in preventing deep-vein thrombosis (DVT). Pharmacologic DVT prophylaxis may be considered 1-4 days following stroke in immobile patients as long as repeat imaging rules out further bleeding. __________ References: Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicenter, randomised controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/23727163) Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/22315263) Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. (http://www.ncbi.nlm.nih.gov/pubmed/19477503) Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. (http://www.ncbi.nlm.nih.gov/pubmed/20651276)

Question 20

A 35-year-old woman comes to the emergency department with progressively worsening dyspnea and generalized weakness.  She has had a month of double vision and difficulty swallowing that are significantly worse toward the end of the day.  Over the past 2 weeks, she has had difficulty raising her arms above her head and walking up and down stairs.  The patient has no headache, speech difficulty, muscle aches, numbness, or paresthesias.  She also has no rash, insect bites, recent travel, or illness.
On physical examination, the patient has fatigable horizontal binocular diplopia in the primary position and bilateral ptosis.  Strength is 4 on a scale of 5 in the proximal muscles of the upper and lower extremities.  Sensory examination and reflex testing are unremarkable.
Complete blood count, comprehensive metabolic panel, and chest x-ray are normal.  Vital capacity obtained at the bedside is 500 mL.  The patient's respiratory status decompensates, requiring endotracheal intubation and admission to the intensive care unit.
Which of the following therapies is the most appropriate for rapidly improving this patient's current condition?

Accepted Answer

11ec193a_970a_87ca_853d_ebb1d9c4dde2_MD0002_00 This patient's presentation is consistent with myasthenic crisis, defined as severe weakness from myasthenia gravis (MG) requiring intubation. Patients in myasthenic crisis can have generalized weakness, respiratory symptoms, or severe oropharyngeal weakness that results in dysphagia and aspiration. Common precipitants include infection and surgery. Patients should be monitored in the intensive care unit, with respiratory status checks every 2-4 hours using vital capacity and maximal inspiratory force. Plasma exchange or intravenous immunoglobulin (IVIG) are mainstays in initial therapy due to their relatively rapid onset of action, although benefits are transient: These therapies exert their effects within days and have a maximal effect at 3 weeks. Glucocorticoids are added to provide longer-term symptom relief as their onset of action occurs later, at 2-3 weeks, with a peak effect at 5.5 months. However, treatment with high-dose glucocorticoids alone is associated with a transient worsening of MG symptoms and should be initiated only with plasma exchange or IVIG (Choice A). Patients who cannot tolerate glucocorticoids can be started on azathioprine, mycophenolate mofetil, or cyclosporine, although these drugs have a delayed time of onset compared with glucocorticoids. (Choice B) Trials for using methotrexate as a corticosteroid-sparing agent in generalized MG are ongoing. However, it is not indicated for myasthenic crisis. (Choice D) Anticholinesterase inhibitors (eg, pyridostigmine) should be stopped while the patient is on mechanical ventilation to minimize secretions and aspiration risk. They can be restarted after extubation. (Choice E) Rituximab is useful for refractory MG, especially in patients who have MG with muscle-specific tyrosine-kinase (MuSK) antibodies. However, it is not used in the management of myasthenic crisis. Educational objective: Treatment for patients with myasthenic crisis includes plasma exchange or intravenous immunoglobulin due to their rapid onset of action and peak effect. High-dose glucocorticoids are used to maintain symptom control, but onset is delayed; glucocorticoids alone are not recommended as they are associated with a transient worsening of symptoms. Acetylcholinesterase inhibitors (eg, pyridostigmine) should be stopped temporarily during mechanical ventilation to minimize oral secretions. __________ References: Progress in the treatment of myasthenia gravis. (http://www.ncbi.nlm.nih.gov/pubmed/21180568)

Exam 2: In-patient Facilities