Management In A 40 Year Old Man With Acute Pain In the Ankle

A 40-year-old man complains of exquisite pain and tenderness in the left ankle. There is no history of trauma. The patient is taking hydrochlorothiazide for hypertension.
On examination, the ankle is very swollen and tender. There are no other physical examination abnormalities.
Which of the following is the best next step in management?

a. Begin colchicine and broad-spectrum antibiotics.
b. Perform arthrocentesis.
c. Begin allopurinol if uric acid level is elevated.
d. Obtain ankle x-ray to rule out fracture.
e. Apply a splint or removable cast.

Answer And Discussion:

A Patient Presents To ED Complaining Of Shortness of Breath And Cough Of 10 Days Duration

A 33-year-old male presents to the ED complaining of shortness of breath and cough of 10 days duration. He must sleep in a chair due to orthopnea. He has severe fatigue and a mild, diffuse headache. Four days ago, he was seen in an urgent care clinic and diagnosed with bronchitis. He reports no medical problems or surgeries. He quit smoking 1 year ago and denies alcohol and drug use. He has a strong family history of hypertension. The review of systems is otherwise negative.
On physical examination, his vitals are T 36.8◦C, P 104, RR 16, and BP 200/118. There are bibasilar
crackles with dullness to percussion at the lung bases. The heart, abdomen, and extremities are unremarkable. His chest x-ray shows cardiomegaly, mild CHF, and bilateral small pleural effusions. An ECG shows sinus tachycardia with left atrial enlargement and left ventricular hypertrophy. Lab results: troponin-T negative, hemoglobin 9.1 g/dL, WBC count and platelets normal, Na 136 mEq/L, K 4.4 mEq/L, Cl 96 mEq/L, HCO3 19 mEq/L, BUN 108 mg/dL, Cr 11.9 mg/dL, glucose 104 mg/dL, calcium 7.8 mg/dL, albumin 4.0 g/dL.

Which of the following is the most appropriate next step?
A) Prescribe levofloxacin and discharge patient with follow-up the next day.
B) Prescribe furosemide and discharge patient with follow-up the next day.
C) Administer a bolus of normal saline intravenously and admit the patient.
D) Administer furosemide intravenously and admit the patient.
E) Perform thoracentesis for diagnostic purposes.

Answer And Discussion:

A Case Of Fetal Bradycardia Upon Artificial Rupture Of Membranes

A 22-year-old G3P2 woman at 40 weeks’ gestation complains of strong uterine contractions. She denies leakage of fluid per vagina. She denies medical illnesses. Her antenatal history is unremarkable.
On examination, the blood pressure (BP) is 120/80 mm Hg, heart rate (HR) is 85 beats per minute (bpm), and temperature is 98°F (36.6°C). The fetal heart rate is in the 140 to 150 bpm range. The cervix is dilated at 5 cm and the vertex is at –3 station. Upon artificial rupture of membranes, fetal bradycardia to the 70 to 80 bpm range is noted for 3 minutes without recovery.

What is your next step in management of this case?

Answer And Discussion:

A Patient Presents With Fever, Sore Throat And Difficulty Breathing

A 30-year-old male patient complains of fever and sore throat for several days. The patient presents to you today with additional complaints of hoarseness, difficulty breathing, and drooling. On examination, the patient is febrile and has inspiratory stridor.

Which of the following is the best course of action?
a. Begin outpatient treatment with ampicillin.
b. Culture throat for β-hemolytic streptococci.
c. Admit to intensive care unit and obtain otolaryngology consultation.
d. Schedule for chest x-ray.
e. Obtain Epstein-Barr serology.

Answer And Discussion:

A Case Of Acetaminophen Overdose

A young female is brought to the emergency department after a suicidal attempt with acetaminophen overdose. Which of the following statements about acetaminophen overdose is correct?

A) Symptoms include extremity pain with physical findings of peripheral neuropathy.
B) Toxic effects rarely occur with ingestion of greater than 140 to 150 mg per kg of acetaminophen.
C) Elevations in liver tests peak 3 to 4 hours after ingestion.
D) Blood levels obtained 4 hours after ingestion determine treatment.
E) Treatment involves the use of deferoxamine.

Answer And Discussion:

Treatment Options For A 48 Year Old Woman With Rheumatoid Arthritis

A 48-year-old woman complains of joint pain and morning stiffness for 4 months. Examination reveals swelling of the wrists and MCPs as well as tenderness and joint effusion in both knees. The rheumatoid factor is positive, antibodies to cyclic citrullinated protein are present, and subcutaneous
nodules are noted on the extensor surfaces of the forearm. Which of the following statements is correct?

a. Prednisone 60 mg per day should be started.
b. The patient has RA and should be evaluated for disease-modifying antirheumatic therapy.
c. A nonsteroidal antiinflammatory drug should be added to aspirin.
d. The patient’s prognosis is highly favorable.
e. The patient should receive a 3-month trial of full-dose nonsteroidal anti-inflammatory agent before determining whether and/or what additional therapy is indicated.

Answer And Discussion:

A 45 Year old Woman Presents With Thrombocytopenia

A 45-year-old woman presents to your office with petechiae noted on the lower extremities. A platelet count is obtained and noted to be 10,000. Which of the following conditions would not be associated with her thrombocytopenia

A) Epistaxis
B) Hemarthrosis
C) Vaginal bleeding
D) Mucosal bleeding in the mouth
E) Ecchymosis at the site of minor trauma

Answer And Discussion:

A 5 Year Old Dehydrated Boy Needs Fluid Resustication

A 5-year-old boy presents to the paediatric surgery department with a 24-hour history of abdominal pain. His history and examination findings are consistent with a diagnosis of acute appendicitis. He is dehydrated with an estimated fluid deficit of 15%.
Which of the following is the most appropriate resuscitation fluid?

A:  Packed red blood cells
B:  5% dextrose and 0.45% sodium chloride
C:  10% dextrose and 0.18% sodium chloride
D:  0.9% sodium chloride
E:  3% sodium chloride

Answer And Explanation:

A Patient Presents With An Injury And An Extradural Hemorrhage On CT Scan

A 25-year-old man, a football player, presents to the emergency department after having lost consciousness during a game. He is very drowsy, with a Glasgow Coma Score of 13. A CT scan shows an extradural haemorrhage.

Which blood vessel is the patient bleeding from?
A Internal carotid artery
B Middle cerebral artery
C Middle meningeal artery
D Superficial temporal artery
E Superior sagittal sinus