#4 -- 2014-09-12 SAEM Tests Practice Questions 2013 Flashcards
A 53 year old man with non-insulin dependent diabetes mellitus presents with pain, redness, and swelling of the right foot and lower leg, accompanied by a temperature of 102. X-rays reveal no subcutaneous gas and show no evidence of osteomyelitis. The patient has been admitted on three previous occasions for cellulitis of the right foot and notes that this episode is identical. Which of the following antibiotics is the most appropriate initial therapy for a presumed diagnosis of cellulitis? A. oral dicloxacillin B. intravenous nafcillin C. intravenous gentamicin D. intravenous ampicillin-sulbactam E. intravenous cefazolin
D. intravenous ampicillin-sulbactam
The answer is D. Gram-positive bacteria (Streptococcus species and S. aureus) most commonly cause cellulitis in non-diabetic hosts. Penicillinase-resistant penicillins (e.g. dicloxacillin, nafcillin, oxacillin) or 1st-generation cephalosporins (cephalexin, cefazolin) can effectively treat cellulitis. However, in diabetics with recurrent cellulitis, the infection is more likely to be polymicrobial and involve gram-negative organisms. A broader-spectrum antibiotic (e.g. ampicillin-sulbactam) with coverage of gram-positive and gram-negative bacteria is recommended. Gentamicin alone is not effective against gram-positive bacteria.
Which of the following is FALSE regarding the common skin disorder, seborrheic dermatitis?
A. characterized by erythema and waxy scaling
B. uncommon between infancy and puberty
C. differential diagnosis includes Tinea capitis, psoriasis of scalp, cutaneous lupus erythematosus
D. initial therapy often consists of high dose topical steroids
E. found in skin folds and hair-bearing of face scalp, chest and groin
D. initial therapy often consists of high dose topical steroids
The answer is D. Initial therapy for seborrheic dermatitis is application of anti-dandruff shampoo lathered onto the area and left on for 5-10 minutes. Shampoos can contain zinc pyrethrin (Head and Shoulders), selenium sulfide (Selsun Blue), salicylic acid (Neutrogena T-Sal) or tar (Polytar or Neutrogena T-Gel). The other answers are all correct regarding seborrheic dermatitis.
Of the following, which is most likely distributed in a Christmas-tree pattern on the posterior thorax? A. atopic dermatitis B. pityriasis rosea C. candidiasis D. eczema E. acanthosis nigrans
B. pityriasis rosea
A Wood’s light is an ultraviolet source that emits light of 365nm wavelength resulting in different fluorescent patterns when directed at different organisms. Which of the following correctly matches the organism to its fluorescent pattern?
A. Erythrasma – red or pink B. Tinea versicolor – green or yellow C. Pseudomonas – yellow or green D. Porphyria cutanea – urine color change to orange or yellow E. All of the above
E. All of the above
Which of the following is true regarding topical corticosteroid use?
A. Potency is measured by the ability to induce vasoconstriction.
B. To achieve large differences in potency, it is more effective to vary the dose of a particular steroid than to change the type of steroid.
C. Once initiating topical steroids, it is best to maintain the same application schedule without interruption until the symptoms no longer remain.
D. Hydrocortisone is the preferred agent for areas of the body characterized by thickened skin (e.g. palms and soles).
E. Fluorinated steroids should be used in pregnant woman.
A. Potency is measured by the ability to induce vasoconstriction.
The answer is A. Corticosteroids are classified into seven groups. (I is the strongest; VII, the weakest). Each steroid’s ability to cause vasoconstriction determines classification. To achieve large differences in potency, it is better to switch agents, as varying the dose of a particular agent does not affect potency as much. In general, vascoconstriction in response to corticosteroid use has been shown to decrease over time, a process known as tachyphylaxis. Therefore, interrupted application schedules are preferred (application for 2 weeks, then 1 week without application). Hydrocortisone is a relatively low potency steroid and does not adequately penetrate thickened parts of the skin such as the sole or palm. Fluorinated steroids are to be avoided in pregnant women.
A 19 year old male presents to the emergency department with allergic-mediated pruritis over large portions of his body. Which of the following is true regarding this condition?
A. H2 antagonists such as ranitidine or famotidine have never been shown to provide benefit.
B. Topical antihistamine agents should be encouraged to manage the pruritis.
C. There is no role for therapies such as Domeboro solution (1:10 diluted aluminum sulfate soaks), potassium permanganate baths, and oat-meal baths.
D. Oral doses of antihistamines should be encouraged initially.
E. Second generation antihistamines such astemizole, fexofenadine, and loratadine are more effective but cause increased levels of sedation and should be avoided if possible.
D. Oral doses of antihistamines should be encouraged initially.
The answer is D. Oral administration of diphenhydramine or hydroxyzine (25 to 50 mg po q6H) is an appropriate adult dose and is effective for pruritis. Intravenous administration can also be used. Topical antihistamines are quickly absorbed, making it difficult to predict the actual dosing if a patient aggressively applies the preparation. Thus, use over large areas of the body should be avoided especially if the patient is currently taking oral antihistamine. The bath or soaking therapies are also recommended to control large areas of pruritis. Second generation antihistamines, although more costly, have lower dosing frequency requirements and cause less sedation.
The rate at which a topical medication absorbs into the skin is determined in large part by the “vehicle,” or medication base. Which of the following is true regarding medication bases?
A. Creams are a mixture of oils, water and preservatives and are best used for acute rather than chronic conditions.
B. Ointments are greaseless mixtures of propylene glycol and are contraindicated for dry lesions.
C. Bases containing alcohol are best for dry scaly conditions or denuded areas.
D. Alcohol-free bases are best for exudative lesions such as poison ivy dermatitis.
E. Gels are composed of petroleum jelly and do not contain water.
A. Creams are a mixture of oils, water and preservatives and are best used for acute rather than chronic conditions.
A 45 year old male presents to the emergency department with sharp pains on the right side of the head. Upon exam, there are vesicular eruptions with crusting lesions on the patient’s right forehead terminating in the patient’s right eyebrow. The lesions are depicted in the figure below. The patient is extremely sensitive to light in his right eye. Which of the following is false regarding this patient?
[image]
Photo courtesy of eMedicine.com
A. The patient probably had chicken pox as a child
B. A Tzanck preparation can distinguish Herpes simplex virus from herpes zoster virus infection.
C. These lesions can occur anywhere on the body.
D. Acyclovir is an accepted treatment of this condition.
E. Treatment is most effective if given within 72 hours of when the eruption begins.
B. A Tzanck preparation can distinguish Herpes simplex virus from herpes zoster virus infection.
A 19 year old with eczema (atopic dermatitis) presents to the urgent care clinic demonstrating pustules within an area affected by his chronic eczema. A Tzanck preparation yields positive results, confirming the diagnosis of eczema herpeticum. Which of the following is FALSE regarding this condition?
A. It is often mistaken as an exacerbation or a superimposed impetigo infection.
B. Constitutional symptoms and adenopathy are often present.
C. Death from this condition is very rare.
D. It can be caused by either HSV or VZV.
E. Oral or, if necessary, IV acyclovir is used to treat this condition.
C. Death from this condition is very rare.
The answer is C. Mortality from this condition has been reported as high as 10%. If this diagnosis is suspected, immediate dermatology consultation should be obtained.
A 20 year old college female recently returned from spring break after hiking in the Virginia woods approximately two weeks prior to her presentation to the E.D. One day prior to presentation, she developed fever, chills, and anorexia. In the emergency department, she complains of headache, photophobia, and myalgias. On exam, one notices a disseminated, non-blanching, papular rash. Which of the following statements regarding this condition is FALSE?
A. It is caused by the tick borne parasite Rickettsia rickettsii.
B. 95% of patients develop symptoms between the period of April 1 and September 30.
C. Characteristically the rash begins on the trunk and spreads to the extremities.
D. A skin biopsy shows a necrotizing vasculitis.
E. If untreated, fatality rates range between 25-50%; however, treatment reduces the rate to 10%.
C. Characteristically the rash begins on the trunk and spreads to the extremities.
The answer is C. Rocky Mountain Spotted Fever characteristically begins on wrist, forearms, and ankles. Within 6-18 hours, the rash spreads centripetally to the arms, thighs, trunk, and face.
A 12 year old boy complains of a pruritic rash on his inner thighs and under his axilla. The rash is unresponsive to topical and oral antihistamines. On examination, one notes circular, raised nodules on an erythematous base. The rash appears as shown in Figure A below. (Figure B depicts a hand rash of identical etiology in an older patient.) Which of the following statements is FALSE regarding this rash?
[image]
Photo courtesy of eMedicine.com
A. The parasite is a mite known as Sarcopetes scabii.
B. Treatment is permethrin 5% cream applied to skin for 8-12 hours.
C. Often this condition occurs in young adults by sexual contact or in the elderly hospitalized population.
D. Antibiotic therapy is contraindicated because it may exacerbate the underlying condition.
E. The organism involved does not penetrate the dermis for it relies on oxygen for survival.
D. Antibiotic therapy is contraindicated because it may exacerbate the underlying condition
The answer is D. This condition is commonly associated with secondary bacterial infection and antibiotics may be indicated if signs of superinfection (i.e. surrounding erythema) are present.
A 42 year old male presents to the emergency department with a 5-day history of a pruritic vesiculobullous rash on his right forearm. The rash has spread to involve his left palm and elbow (see Figure). He reports that he developed the rash 48 hours after working in the woods last week with his brother, who developed a similar rash. Antihistamines have decreased the pruritis, but the rash has continued to spread. Appropriate management of this patient’s exposure can include all of the following EXCEPT:
[image]
A. careful washing of all clothing that was worn in the woods
B. avoidance of contact with the rash to reduce spreading of the oleoresin antigen
C. continued antihistamine therapy
D. drainage of large bullae for cosmetic purposes
E. oral steroid treatment
B. avoidance of contact with the rash to reduce spreading of the oleoresin antigen
The answer is B. This patient has developed allergic contact dermatitis, a type-IV hypersensitivity reaction, likely due to poison ivy or poison oak exposure. Although the rash can be expected to resolve on its own (i.e. without medical intervention) in 1-2 weeks, relief of this patient’s symptoms can be facilitated with continued antihistamine therapy and/or oral steroid treatment. The bullae can be drained for cosmetic purposes, but the tops should not be removed to avoid risk for bacterial superinfection. This condition is due to exposure to allergenic plant oleresins, which may remain on the clothing that the patient was wearing at the time of contact; thorough washing should therefore be recommended. The allergen is not present in the bullae of vesicles and so, after the initial washing of the involved site, contact with the rash does not cause it to spread.,
A 67 year old known alcoholic female is brought to the emergency department by EMS after being found somnolent with the odor of alcohol on her breath. After the primary survey is completed and she is stabilized, she is found to have scaly, sharply marginated, bright red eczematous plaques, vesicles and pustules in her perioral and anogenital areas (see Figure for a similar appearing rash). Consistent with this exam, she is also noted to have a red, glossy tongue and loss of her nails. With what nutritional deficiency are these findings associated? [image] A. potassium B. magnesium C. calcium D. phosphorus E. zinc
E. zinc
The answer is E. Low blood levels of potassium, magnesium, calcium, phosphorus, and zinc can occur as a consequence of dietary deficiency and/or acid-base imbalances in alcoholics. Hypokalemia can cause periodic muscle paralysis and areflexia. Hypocalcemia can cause tetany and weakness. Low phosphorus levels can contribute to myocardial dysfunction, CNS symptoms, muscle weakness and bleeding disorders. Hypomagnesemia can cause a clouded sensorium and other neurological deficiencies. Chronic zinc deficiency leads to the dermatologic consequences described in this patient, including patches and plaques of dry, scaly, sharply marginated and brightly red eczematous dermatitis evolving into vesiculobullous, pustular, erosive, and crusted lesions that initially involve the perioral and anogenital areas. Progression can involve the scalp, hands, feet, trunk and flexural regions. There may be diffuse alopecia and graying of remaining hair. Nail manifestations may include loss of nails or paronychia. A red, glossy tongue is common, and the oropharynx may reveal aphthous-like ulcers. Patients with zinc deficiency tend to be photophobic, irritable, and depressed. Treatment of zinc deficiency consists of dietary or intravenous zinc salt supplementation for 2-3 weeks.
For several conditions of internal malignancies there may be associated cutaneous manifestations. The conditions below all describe common dermatological conditions associated with malignancy EXCEPT: A. acanthosis nigricans B. erythema nodosum C. dermatomyositis D. pruritis E. pemphigus
E. pemphigus
The answer is E. Pemphigus is likely an autosomal condition involving antibodies directed at intercellular substance. Significant damage to the epidermis may subsequently lead to dehydration, sepsis, or even death. The other options are known to be associated with internal malignancy. For each condition, there may be several types of malignancy it can be associated with.
Dermatological anthrax may occur wherever spores come into contact with the skin. Of the following options, which statement is FALSE concerning dermatological anthrax:
A. Mortality rates are over 20-30% lower than for pulmonary anthrax.
B. Antibiotics do not affect the course of local disease.
C. Characteristic lesion is a black escar preceded by a vesiculopapular lesion 1 week prior.
D. Initial diagnosis is usually made by Gram’s stain analysis.
E. The organism most likely to cause dermatological anthrax is Bacillus anthracis.
D. Initial diagnosis is usually made by Gram’s stain analysis.
The answer is D. Diagnosis of cutaneous anthrax is usually made on a clinical basis, often after determining patient exposure while taking the history. In the future, PCR methods may become widely available and useful to make definitive diagnoses. Treatment for cutaneous anthrax is aimed at preventing the dissemination of a disease which is complicated by a significantly higher mortality.
Drug-induced urticaria is a common side effect of many drugs. Which statement about urticaria is FALSE?
A. Penicillins and opiates are the most common offenders.
B. Steroids should always be used in treatment to avoid possible anaphylaxis.
C. Nonimmunological urticaria may be caused by degranulation of mast cells.
D. Drug-induced urticaria may be immunological or nonimmunological.
E. Association with malignancy is not strong enough to investigate for possible cancer when urticaria of unknown origin exists.
B. Steroids should always be used in treatment to avoid possible anaphylaxis.
The answer is B. Precipitants of urticaria include food allergies, cold induced, malignancy, SLE, familial, exercise, excessive heat, etc. Drug-induced urticaria does not represent anaphylaxis or indicate its impending development so steroids are usually not indicated. Treatment may only include stopping the offending drug and administering antihistamines or other antipruritics as needed. Although penicillins and opiates are the most common precipitants, drug-induced urticaria has been demonstrated after use of an enormous number of medications.
A 50 year-old male presents with a chief complaint of chronic nasal itching and “a sore that won’t go away” over the past few months. Of the following choices, which is the most appropriate management?
[image nasty basal/scc looking thing]
A. prescription of topical steroid cream and follow-up in 5-7 days
B. provision of an antibiotic-soaked dressing and reassessment in the E.D. within 48 hours
C. urgent or next-day outpatient follow-up in Dermatology Clinic
D. CT scan of the face for signs of nasal or facial trauma
E. screening of the eyes for zoster opthalmicus
C. urgent or next-day outpatient follow-up in Dermatology Clinic
The answer is C. The patient’s history and presentation are highly suggestive of malignancy.
The patient depicted in the figures developed a rash on the face and chest, with subsequent sparse involvement of the extremities. Of the choices below, which is the most likely diagnosis for the patient depicted in the figures? [image shows peeling skin] [image] A. erythema multiforme minor B. meningococcemia C. cellulitis D. Rocky Mountain spotted fever E. Stevens-Johnson syndrome
E. Stevens-Johnson syndrome
The patient in the figure presents with findings of petechiae and mucosal lesions after beginning to take a sulfonylurea for diabetes. He is nontoxic, afebrile, and has no allergic symptoms. Based upon the most likely diagnosis, which of the following statements is true?
[image nasty black spots in mouth]
A. Platelet transfusions are indicated if platelet count is below 100,000/mm3.
B. Intracranial hemorrhage is not a major concern unless the platelet count falls below 2,500/mm3.
C. Steroids are usually indicated in adults.
D. Prothrombin time is usually twice normal.
E. Intra-articular bleeding is commonly seen with this patient’s condition.
C. Steroids are usually indicated in adults.
The answer is C. The patient’s presentation is most consistent with ITP (immune thrombocytopenic purpura). Platelet transfusions can induce inflammatory (autoantibody) response and worsen the patient’s condition by increasing platelet destruction. Intracranial hemorrhage is the most feared complication of ITP, and intracranial bleeding is a risk even if levels do not fall as low as 2,500/mm3 (20,000/mm3 is a commonly cited threshold for spontaneous intracranial bleeding). The PT is expected to be normal, and intra-articular bleeding is not a major feature of ITP.
All of the following are common non-infectious causes of fever EXCEPT: A. Trauma B. Thyroid storm C. Pulmonary embolism D. Neuroleptic malignant syndrome E. CVA
A. Trauma
The answer is A. There are many non-infectious causes of fever. PE, CVA, thyroid storm and NMS are all classic non-infectious causes. Trauma generally does not cause fever. Hypothermia (environmental) tends to be of more concern.
Which of the following statements regarding fever and WBC is TRUE?
A. WBC is specific for serious bacterial infection.
B. WBC is of no clinical value.
C. Elevated WBC indicates serious bacterial infection.
D. WBC is sensitive for serious bacterial infection.
E. WBC is a poor discriminatory predictor of serious bacterial infection.
E. WBC is a poor discriminatory predictor of serious bacterial infection.
The answer is E. WBC is a commonly ordered test in the setting of infection. However, it lacks the sensitivity and specificity to be a good discriminatory test for serious bacterial infection. It is more reflective of, and an important marker for, the body’s response to the infection
A 5 year old boy presents with fever and sore throat. On physical exam, the child has enlarged tonsils with exudates. Which of the following is true?
A. Treatment of choice is azithromycin
B. Vaccination prevents recurrence
C. The etiology of the infection is most likely bacterial
D. Viruses rarely cause exudative pharyngitis
E. If the infection is bacterial, the primary role of antibiotic therapy is to prevent complications
E. If the infection is bacterial, the primary role of antibiotic therapy is to prevent complications
The answer is E. Pharyngitis is a common infection in children. Viruses cause the majority of cases. The most common bacterial cause is Group A strep. It is very hard to distinguish bacterial versus viral infections based on clinical grounds. Antibiotics do not significantly alter clinical course; however, they reduce complications such as rheumatic fever and glomerulonephritis. Penicillin is the treatment of choice. There is no vaccine for Group A strep.
A 4 year old boy presents with fever, sore throat and stridor. Physical exam reveals T103 in an ill-appearing, drooling, stridorous child in mild respiratory distress. The next steps include: A. chest X-ray B. dexamethasone C. observation D. albuterol E. antibiotics and airway management
E. antibiotics and airway management
The answer is E. A child presenting to the emergency department with stridor most likely has croup, with epiglottitis being a less common – but more serious – etiology. Croup tends to be the etiology in younger, nontoxic-appearing children, who usually have a characteristic barking (“seal”) cough. Treatment of croup includes cool mist (though the literature supporting this is limited), racemic epinephrine (which is probably no better than nebulized l-epinephrine), and steroids. Epiglottitis is a true emergency. It presents in children who are older, with high fever, and who are ill appearing. One of the key clinical features is drooling, which indicates swelling and pain interfering with handling of secretions. Children with epiglottitis are at risk of airway obstruction and need early airway management, preferably while the problem is still urgent (as opposed to during catastrophic deterioration) and preferably in the operating room. A lateral soft tissue X-ray would most likely reveal signs of an inflamed epiglottic region (e.g. thumbprint sign). Epiglottitis is a bacterial infection treated with antibiotics.
All of the following are common pathogens in otitis media EXCEPT: A. viral agents B. Moraxella catarrhalis C. Strep pneumoniae D. Staph. aureus E. H. influenzae
D. Staph. aureus
A 22 year old male with IVDA presents to the emergency department with a fever and dyspnea. His physical exam reveals T 101.5, clear lungs and a murmur. Of the following, the correct treatment plan is?
A. blood cultures and admission
B. amoxicillin and discharge
C. surgery
D. blood cultures and discharge
E. blood cultures, vancomycin, and admission
E. blood cultures, vancomycin, and admission
The answer is E. Infective endocarditis has a very high morbidity and mortality if untreated. IVDA with a fever represent a special population at risk. Many emergency departments routinely admit IVDA with a fever even without other findings suggestive of endocarditis. Given the patient’s fever and murmur, he should receive blood cultures, IV antibiotics and admission.
A 28 year old female is 4 months pregnant and presents with dysuria. Her UA reveals leukocyte esterase and nitrates. Of the following, the best treatment is: A. Amoxicillin B. Macrodantin (nitrofurantoin) C. Ciprofloxacin D. Doxycycline E. Bactrim
B. Macrodantin (nitrofurantoin)
A 24 year old female presents with fever, vomiting, right flank pain, and dysuria. Her UA reveals leukocyte esterase. The correct diagnosis is: A. Choleycystitis B. Cystitis C. Right lower pneumonia D. Pyelonephritis E. Appendicitis
D. Pyelonephritis
A 16 year old male presents with a large swollen right knee. He denies any trauma. His physical exam reveals T101 and a swollen right knee. The knee is hot, and there is pain with motion. Also noted is a diffuse rash. The correct diagnosis is: A. Osgood-Schlatter B. Neisseria gonorrhea C. gout D. pseudogout E. juvenile rheumatoid arthritis
B. Neisseria gonorrhea
