Quiz 53 Flashcards
Which one of the following physical examination findings would be pathognomonic for slipped capital femoral epiphysis? (check one)
A. Excessive forward passive motion of the tibia with the knee flexed
B. Lateral displacement of the patella with active knee flexion
C. Limited internal rotation of the flexed hip
D. Reduced hip abduction with the hip flexed
E. Inability to extend the hip past the neutral position
Limited internal rotation of the flexed hip
Physical activity, obesity, and male gender are predisposing factors for the development of this condition, in which the femoral head is displaced posteriorly through the growth plate.
The hallmark of SCFE on examination is limited internal rotation of the hip. Specific to SCFE is the even greater limitation of internal rotation when the hip is flexed to 90°. No other pediatric condition has this physical finding,
Orthopedic consultation is advised if SCFE is suspected.
A 74-year-old male presents with a 4-day history of diarrhea that he had initially thought was “a 24-hour virus.” He states that the onset of his illness included nausea, one episode of vomiting, and profuse diarrhea.
He does not recall eating anything unusual and has not traveled recently. He has lost 4 kg (9 lb) since his last visit 2 months earlier. His abdomen is soft, with hyperactive bowel sounds and mild diffuse tenderness on palpation. A CBC and basic metabolic profile are normal.
Which one of the following is the most likely cause of this patient’s illness? (check one)
A. Norwalk-like virus (Norovirus)
B. Shigella
C. Campylobacter
D. Escherichia coli O157:H7
E. Staphyloccocus aureus
Campylobacter
Campylobacter jejuni is one of the most common causes of bacterial foodborne illnesses, estimated to affect 1 million Americans annually. Undercooked or improperly handled chicken is most often implicated as the source.
occurs more frequently at the extremes of age, is most common during the summer months, and affects males disproportionately.Symptoms typically begin 2–5 days following exposure. Diarrhea is the predominant symptom, with a lesser degree of nausea and vomiting. Up to 10 days is required for full recovery.
While Escherichia coli O157:H7 and Shigella may cause a similar illness, both generally present with bloody diarrhea. E. coli O157:H7 is most often transmitted in contaminated undercooked beef, and Shigella is usually spread in a fecal-oral pattern or via contaminated water. The peripheral WBC count is typically increased substantially in shigellosis. Staphylococcus aureus produces an enterotoxin in food that causes the onset of nausea, vomiting, and diarrhea within hours of ingestion and clears within 24–48 hours. Norovirus is a very common cause of acute viral gastroenteritis, usually with more vomiting than diarrhea. It spreads person to person, and patients usually recover within 24 hours.
A 50-year-old female with significant findings of rheumatoid arthritis presents for a preoperative evaluation for planned replacement of the metacarpophalangeal joints of her right hand under general anesthesia. She generally enjoys good health and has had ongoing medical care for her illness.
Of the following, which one would be most important for preoperative assessment of this patient’s surgical risk? (check one) A. Resting pulse rate B. Resting oxygen saturation C. Erythrocyte sedimentation rate D. Rheumatoid factor titer E. Cervical spine imaging
While all of the options listed may have some value in evaluating the preoperative status of a patient with long-standing rheumatoid arthritis, imaging of the patient’s cervical spine to detect atlantoaxial subluxation would be most important for preventing a catastrophic spinal cord injury during intubation. In many cases, cervical fusion must be performed before other elective procedures can be contemplated. Although rheumatoid arthritis may influence oxygen saturation and the erythrocyte sedimentation rate, these tests would not alert the surgical team to the possibility of significant operative morbidity and mortality. Resting pulse rate and rheumatoid factor are unlikely to be significant factors in this preoperative scenario.
A 68-year-old white male with diabetes mellitus is hospitalized after suffering a right middle cerebral artery stroke. A nurse in the intensive-care unit calls to advise you that his blood pressure is 200/110 mm Hg. You should: (check one)
A. continue monitoring the patient
B. administer labetalol (Trandate)
C. administer nicardipine (Cardene)
D. administer nitroprusside (Nitropress)
E. administer nitroglycerin
Current American Heart Association guidelines for blood pressure control in stroke patients advise monitoring with no additional treatment for patients with a systolic blood pressure <220 mm Hg or a diastolic blood pressure <120 mm Hg. The elevated blood pressure is thought to be a protective mechanism that increases cerebral perfusion, and lowering the blood pressure may increase morbidity.
Which one of the following is the most likely cause of chronic unilateral nasal obstruction in an adult? (check one) A. Nasal septal deviation B. Foreign-body impaction C. Allergic rhinitis D. Adenoidal hypertrophy
The most common cause of nasal obstruction in all age groups is the common cold, which is classified as mucosal disease. Anatomic abnormalities, however, are the most frequent cause of constant unilateral obstruction, with septal deviation being most common.
Which one of the following is most consistent with a diagnosis of iron deficiency anemia? (check one)
A. Low iron-binding capacity
B. An elevated methylmalonic acid level
C. Increased serum ferritin
D. Reticulocytosis about 1 week after administration of iron
In iron deficiency anemia, serum iron is low but iron-binding capacity is high. Serum ferritin is one-tenth of normal. Bone marrow iron stores are depleted. Oral replacement, which is safer than parenteral administration and more acceptable to patients, should raise the hemoglobin level by 0.2 g/dL/day. A reticulocyte response should be seen in a week to 10 days unless factors such as a concomitant folic acid deficiency prevent a full response to therapy.
Which one of the following is the best INITIAL management for hypercalcemic crisis? (check one)
A. Intravenous furosemide
B. Intravenous pamidronate (Aredia)
C. Intravenous plicamycin (Mithramycin)
D. Intravenous saline
Intravenous saline
The initial management of hypercalcemic crisis involves volume repletion and hydration. The combination of inadequate fluid intake and the inability of hypercalcemic patients to conserve free water can lead to calcium levels over 14–15 mg/dL. Because patients often have a fluid deficiency of 4–5 liters, delivering 1000 mL of normal saline during the first hour, followed by 250–300 mL/hour, may decrease the hypercalcemia to less than critical levels (<13 mg/dL). If the clinical status is not satisfactory after hydration alone, then renal excretion of calcium can be enhanced by saline diuresis using furosemide. Intravenous pamidronate, a diphosphonate, reduces the hypercalcemia of malignancy and is best used in the semi-acute setting, since calcium levels do not start to fall for 24 hours. The same is true for intravenous plicamycin.
A healthy 24-year-old male presents with a sore throat of 2 days’ duration. He reports mild congestion and a dry cough. On examination, his temperature is 37.2°C (99.0°F). His pharynx is red without exudates, and there are no anterior cervical nodes. His tympanic membranes are normal, and his chest is clear.
You would do which one of the following?
(check one)
A. Treat with analgesics and supportive care
B. Treat with azithromycin (Zithromax)
C. Perform a throat culture and begin treatment with penicillin
D. Perform a rapid strep test
Treat with analgesics and supportive care
The Centers for Disease Control and Prevention (CDC) assembled a panel of national health experts to develop evidence-based guidelines for evaluating and treating adults with acute respiratory disease. According to these guidelines, the most reliable clinical predictors of streptococcal pharyngitis are the Centor criteria. These include tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever. The presence of three or four of these criteria has a positive predictive value of 40%–60%, and the absence of three or four of these criteria has a negative predictive value of 80%. Patients with four positive criteria should be treated with antibiotics, those with three positive criteria should be tested and treated if positive, and those with 0–1 positive criteria should be treated with analgesics and supportive care only. This patient has only one of the Centor criteria, and according to the panel should not be tested or treated with antibiotics.
A 28-year-old male is seen for follow-up of acute low back pain. He has a past history of substance abuse. Ibuprofen and acetaminophen have helped some, but he is experiencing muscle spasms. It is best to avoid which one of the following when treating this patient’s problem? (check one) A. Chlorzoxazone (Parafon Forte DSC) B. Metaxalone (Skelaxin) C. Cyclobenzaprine (Flexeril) D. Methocarbamol (Robaxin) E. Carisoprodol (Soma)
Carisoprodol (Soma)
There is limited data regarding the effectiveness of muscle relaxants in musculoskeletal conditions, but strong evidence regarding their toxicity. Because the evidence for comparable effectiveness is weak, drug selection should be based on patient preference, side-effect profile, drug interactions, and abuse potential. Carisoprodol is metabolized to meprobamate, which is a class III controlled substance. It has been shown to produce both physical and psychologic dependence.
