Quiz 46

Question 1

A 68-year-old male was seen in a local urgent-care clinic 6 days ago for upper respiratory symptoms and was started on cefuroxime (Ceftin). He presents to your office with a 2-day history of 4–5 watery stools per day with no blood or mucus. He is afebrile and has a normal abdominal and rectal examination. A stool guaiac test is negative, and a stool sample is sent for further testing.
What is the best initial management for this patient?

Answer 1

This patient is at high risk for Clostridium difficile–associated diarrhea, based on his age and his recent broad-spectrum antibiotic use. The initial management is to stop the antibiotics. Treatment should not be initiated unless the stool is positive for toxins A and B. The recommended initial treatment for C. difficileenteritis is oral metronidazole. Probiotics may be useful for prevention, but their use is controversial.

Question 2

Which one of the following is true regarding treatment of pressure ulcers? (check one)

Answer 2

Topical antibiotics should not be used for more than 2 weeks at a time

Trials have not definitively shown that nutritional supplements speed ulcer healing. The head of the bed should be elevated only as necessary, and should be kept to less than 30° to reduce shearing forces.Systemic antibiotics should only be used for cellulitis, osteomyelitis, and bacteremia. Topical antibiotics may be used for periods of up to 2 weeks (SOR C).

Question 3

The “Get Up and Go Test” evaluates for which one of the following?

Answer 3

The “Get Up and Go Test” is the most frequently recommended screening test for mobility. It takes less than a minute to perform and involves asking the patient to rise from a chair, walk 10 feet, turn, return to the chair, and sit down. Any unsafe or ineffective movement with this test suggests balance or gait impairment and an increased risk of falling. If the test is abnormal, referral to physical therapy for complete evaluation and assessment should be considered. Other interventions should also be considered, such as a medication review for factors related to the risk of falling.

Question 4

A 20-year-old male presents with a complaint of pain in his right testis. The onset of pain has been gradual and has been associated with dysuria and urinary frequency. The patient has no medical problems and is sexually active. On examination he has some swelling and mild tenderness of the testis. The area posterior to the testis is swollen and very tender. He has a normal cremasteric reflex, and the pain improves with elevation of the testicle.
Which one of the following would be the most appropriate management of this patient?
(check one)

Answer 4

This patient has epididymitis. In males 14–35 years of age, the most common causes are Neisseria gonorrhoeae and Chlamydia trachomatis. The recommended treatment in this age group is ceftriaxone, 250 mg intramuscularly, and doxycycline, 100 mg twice daily for 10 days (SOR C). A single 1-g dose of azithromycin may be substituted for doxycycline. In those under age 14 or over age 35, the infection is usually caused by one of the common urinary tract pathogens, and levofloxacin, 500 mg once daily for 10 days, would be the appropriate treatment (SOR C).

Question 5

An elevation of serum alkaline phosphatase combined with an elevation of 5'-nucleotidase is most suggestive of conditions affecting   (check one)
 A. bone 
 B. the liver 
 C. the placenta 
 D. the small intestine

Answer 5

Alkaline phosphatase is elevated in conditions affecting the bones, liver, small intestine, and placenta. The addition of elevated 5’-nucleotidase suggests the liver as the focus of the problem.

Question 6

A 60-year-old right-handed white male arrives in the emergency department with symptoms and signs consistent with a stroke. His past medical history is significant for tobacco abuse and chronic treated hypertension. He is alert and afebrile. His pulse rate is 100 beats/min, respirations 20/min, and blood pressure 190/95 mm Hg. He has a moderate right-sided hemiparesis and is aphasic. There are no other significant physical findings.

While appropriate tests are being ordered, immediate management in the emergency department should include which one of the following?

Answer 6

Maintaining adequate tissue oxygenation is an important component of the emergency management of stroke. Hypoxia leads to anaerobic metabolism and depletion of energy stores, increasing brain injury. While there is no reason to routinely administer supplemental oxygen, the potential need for oxygen should be assessed using pulse oximetry or blood gas measurement. Overzealous use of antihypertensive drugs is contraindicated, since this can further reduce cerebral perfusion. In general, these drugs should not be used unless mean blood pressure is >130 mm Hg or systolic blood pressure is >220 mm Hg. Antithrombotic drugs such as heparin must be used with caution, and only after intracerebral hemorrhage has been ruled out by baseline CT followed by repeat CT within 48–72 hours. Hypovolemia can exacerbate cerebral hypoperfusion, so there is no need to restrict fluid intake. Optimization of cardiac output is a high priority in the immediate hours after a stroke. Based on data from randomized clinical trials, corticosteroids are not recommended for the management of cerebral edema and increased intracranial pressure after a stroke.

Question 7

Which one of the following is the most common secondary cause of nephrotic syndrome in adults?

Answer 7

Diabetes mellitus

Question 8

loss of potassium,

Answer 8

leading to weakness, cardiac arrhythmias, and respiratory difficulty.