Post Op and Surgical Care

Post Op and Surgical Care Case 1 A 60-year-old female presents to your office for severe abdominal pain. She reports that she developed vague left lower quadrant abdominal pain yesterday. This morning she awoke from her sleep with severe, diffuse abdominal pain, anorexia, and vomiting. On examination she is lying very still. Temperature is 38.4 C, pulse 106, respirations 16, blood pressure of 100/62. She has dry mucous membranes. Her abdomen has diminished bowel sounds and is rigid with involuntary guarding and rebound tenderness greatest in the left lower quadrant. On pelvic examination, she is exquisitely tender on the left with a palpable mass. There are no masses on rectal examination, and her stool is negative for occult blood. Laboratory tests include a negative urine pregnancy, WBC 25,500/mm3, HCT 32%, platelets 450,000/mm3, Na 142 meq/L, K 3.2 meq/L, BUN 24 mg/dL, and Cr 1.0 mg/dL. Abdominal x-ray demonstrates free air under the diaphragm. Based on the information available, the most likely diagnosis in this patient is: A) Diverticulitis. B) Pelvic inflammatory disease. C) Appendicitis. D) Ovarian torsion. E) Abdominal aortic aneurysm. Answer: A Discussion The correct answer is A. The most likely cause of this patients symptoms is diverticulitis. Answer B, pelvic inflammatory disease (PID), is unlikely in a 60-yearold female. Also, the clinical presentation and pelvic exam findings are more consistent with diverticulitis than PID. Answer C, appendicitis, is unlikely because the pain is present on the left side as opposed to the right side, as one would expect with appendicitis. Answer D, ovarian torsion, is unlikely in a postmenopausal female unless there is a malignancy. Additionally, the pain of ovarian torsion should be colicky rather than constant and there should be no peritoneal signs (at least until the ovary is necrosed). Answer E, abdominal aortic aneurysm, is unlikely because of the exam findings here: there is no pulsatile mass, the patient is normotensive, there is fever, and you can palpate a left lower quadrant mass. However, in older patients presenting with abdominal pain, you must always keep the diagnosis of abdominal aortic aneurysm in mind.

Which of the following is true regarding this patients underlying disease process?A) The majority of patients with this disease will develop symptoms at some time. B) The condition is associated with a high malignant potential. C) The condition has a peak incidence of occurrence in the sixth, seventh, and eighth decades of life. D) The condition primarily affects the ascending colon. Answer: C Discussion The correct answer is C. Diverticulosis is an acquired disease that peaks in the sixth, seventh, and eighth decades, with about 50% of octogenarians having the condition. Answer A is incorrect. Most are asymptomatic from the disease process with only 1020% going on to develop symptomatic diverticulitis. Acute diverticulitis has a variety of presentations. Peridiverticular inflammation occurs when a fecalith becomes entrapped in a diverticular wall, resulting in a localized contained microperforation. Pain is typically acute and located in the left lower quadrant. Examination reveals only a mildly tender abdomen without any masses. Peridiverticular abscess and phlegmon result in worsening left lower quadrant abdominal pain, and often a mass is palpable. All of the following physical exam findings indicate peritonitis EXCEPT: A) Murphys sign. B) Rovsings sign.

C) Involuntary guarding. D) Rebound tenderness. Answer: A Discussion The correct answer is A. Peritonitis, as the name implies, is inflammation of the peritoneum. It can be aseptic, bacterial, or viral. Most commonly, peritonitis results from bacterial contamination of the peritoneum after injury to an abdominal viscus. In this patients case, generalized peritonitis occurs because either an inflamed section of the colon ruptured or a phlegmon ruptured. Pain due to peritonitis is usually severe and associated with anorexia and emesis. The patient will often have fever, tachycardia, leukocytosis, signs of dehydration, and electrolyte abnormalities. Answer A, Murphys sign, is tenderness to palpation of the right subcostal region during deep inspiration and is associated with biliary colic and cholecystitis but does not indicate peritonitis. Answer B, Rovsings sign, is pain at the disease site when palpating another site, classically a finding in appendicitis; the area of peritoneal inflammation has increased pain when palpating elsewhere on the abdomen. Answers C and D, involuntary guarding and rebound tenderness, are classic findings in peritonitis. You have identified free air on x-ray, indicating a ruptured viscus. The best film for identifying free air in the abdomen is: A) A flat plate abdomen. B) An upright abdomen. C) A left lateral decubitus film of the abdomen. D) An upright chest radiograph. Answer: D Discussion The correct answer is D. An upright chest radiograph is the one best x-ray film for identifying free air in the abdomen. CT is more sensitive but is not available in all situations and is expensive. While you are waiting for the local surgeon to arrive, which of the following is the LEAST important part of appropriate preoperative management? A) Maintaining the patient in an NPO state. B) Administration of antibiotics to cover gram-negative bacteria. C) Administration of antibiotics to cover gram-positive bacteria. D) Administration of antibiotics to cover obligate anaerobic bacteria. Answer: C Discussion The correct answer is C. The treatment of gram-positive organisms is the least important part of treatment for this patient. Initial treatment of perforated diverticuli should include fluid replacement, electrolyte correction, and, if the patient is vomiting, placement of an NG tube. A urinary catheter can be placed in order to monitor fluid balance if appropriate. Antibiotic therapy should be empirically provided based on the most likely pathogens. Perforations of the appendix, diverticuli, and other parts of the colon account for >80% of the causes of acute bacterial peritonitis. Distal small bowel and colonic perforations should include coverage for gram-negative bacteria, such as E. coli, and obligate anaerobe pathogens, such as B. fragilis. Various antibiotic regimens can be used. Each has benefits and risks that must be tailored to the individual patient. Examples of possible regimens include single-agent treatment with secondgeneration cephalasporin versus an aminoglycoside with metronidazole. Your patient undergoes exploratory laparotomy with removal of a segment of the sigmoid colon and colostomy. On postoperative day 2, the pathologist reports presence of an adenoma in the removed segment. Which of the following is true regarding adenomas and colon cancer? A) Of polyps, tubular adenomas have the highest potential for malignancy.

B) Polyps associated with Peutz-Jeghers have a high probability for malignant conversion. C) Most colon cancers occur in the lower right side. D) Colon (as opposed to rectal) cancer is more common in women. Answer: D Discussion The correct answer is D. There are several types of polyps. Inflammatory polyps are common in inflammatory bowel diseases and have no malignant potential. Hamartomas are often associated with Peutz-Jeghers syndrome and have very low malignant potential. Adenomatous polyps include villous, tubulovillous, and tubular. Villous tend to be sessile or flat while the others are more pedunculated. Approximately 7% of tubular, 20% of tubulovillous, and 33% of villous adenomas become malignant. Colon cancer most often occurs on the lower left side where the rectum begins. It peaks in the seventh decade. While rectal cancer is more common in males, colon cancer is more common in females. Following bowel rest for several weeks, your patient undergoes a colonoscopy. Several more polyps are noted during examination, as well as multiple diverticuli extending from the remaining sigmoidal colon to the splenic flexure. Biopsy results show adenocarcinoma. Which of the following tumor markers is elevated in colorectal cancer? A) PSA. B) CEA. C) Beta-HCG. D) CA-125. E) None of the above. Answer: B Discussion The correct answer is B. CEA, carcinoembryonic antigen, may be elevated in colon cancer. It is not useful as a primary screening tool due to low sensitivity and specificity. However, it is helpful in surveillance for recurrence of colon cancer after initial treatment. PSA will be elevated in prostatic cancer, beta-HCG in testicular cancer, and CA125 in ovarian cancer. However, CA-125 is not helpful in premenopausal women, in whom it is often found in the blood in low levels. Finally, AFP (alpha fetoprotein) is elevated in liver and testicular cancer. Note that beta-HCG and AFP are generally not elevated in testicular seminomas (although beta-HCG may be mildly elevated in up to 20%). Because of the cancer, hemicolectomy is indicated. Three weeks following your patients hemicolectomy, she presents complaining of abdominal pain. The pain is crampy and intermittent. Further history reveals a 24-hour history of vomiting, abdominal bloating, and low-grade fever. She reports her last bowel movement was 2 days ago and denies any flatus over the last 24 hours. On examination, her temperature is 37.1 C, pulse 95, respirations 12, and blood pressure 158/60. Her abdomen is slightly distended, diffusely tender to palpation without rebound or guarding, and has hyperactive bowel sounds. On flat-plate and upright views of the abdomen, there are dilated loops of small bowel and multiple air fluid levels. Which of the following is true regarding this patients current disease process? A) She most likely has a closed-loop small bowel obstruction. B) She most likely has an extramural source of obstruction. C) Dilated loops of bowel are defined as bowel loops 3 cm in diameter) on the flat plate and air-fluid levels on the upright or decubitus film. CT scan is more sensitive for obstruction than are plain films and will often reveal the source of the obstruction. However, CT should be reserved for patients in whom the diagnosis is unclear. Patients with a complete small bowel obstruction will lack air in the colon on plain film. However, remember that air can be introduced into the rectum during a rectal exam. Which of the following is NOT a cause of ileus? A) Burns. B) Spinal cord injury. C) Hypokalemia. D) Pneumonia. E) All of the above can cause an ileus. Answer: E Discussion The correct answer is E. All of the above can cause an ileus. Additional causes include: peritonitis, pancreatitis, uremia, narcotics, etc. You diagnose small bowel obstruction, which you believe is most likely related to adhesion formation after hemicolectomy. Which of the following is INCORRECT regarding the management of bowel obstruction? A) Initial treatment orders should include NPO, nasogastric decompression, intravenous fluid resuscitation, and electrolyte replacement as needed. B) This patient should undergo emergent surgical intervention. C) If she has fever or leukocytosis, she should undergo surgical intervention. D) If she requires surgery, broad-spectrum antibiotics to cover anaerobes and gram-negative aerobes should be administered perioperatively. Answer: B Discussion The correct answer is B. Peritoneal adhesions account for more than half of all small bowel obstructions. Approximately 5% of postabdominal laparotomy patients require adhesion takedown. Up to 80% of episodes of small bowel obstruction caused by adhesions resolve without surgical intervention. Initial treatment for all patients with mechanical bowel obstruction includes restricting oral intake, intravenous fluid resuscitation with Ringers lactate or normal saline, and electrolyte correction. Almost all patients require nasogastric decompression to relieve pain and prevent passage of swallowed air. Patients can be safely observed if all of the following conditions are met: no fever, no leukocytosis, no tachycardia, and no localized abdominal pain. Indications for surgery include rapidly progressing abdominal pain or distention, development of peritoneal findings, fever, diminished urine output, leukocytosis, hyperamylasemia, metabolic acidosis, and persistent obstruction. Complete bowel obstruction should always be treated surgically. Also, patients with de novo obstruction (e.g., no history of laparotomy) usually require surgical intervention. If surgery is necessary, broad-spectrum antibiotics that cover

anaerobes and gram-negative aerobes should be administered perioperatively to reduce wound infection and abdominal sepsis rates. Which of these patients with a small bowel obstruction can be safely observed? A) A patient with a fever and a partial small bowel obstruction. B) A patient with localized abdominal pain and a partial small bowel obstruction. C) An afebrile patient with a closed loop obstruction. D) All of the above. E) None of the above. Answer: E Discussion The correct answer is E, none of the above. See the answer to the question above for an explanation.

Case 2 A 52-year-old female presents to your office as a new patient and requests a 100,000 mile tune-up. She has not seen a physician in over 10 years and has one complaint today. She has a bulge in her right groin that occurs when she lifts heavy objects and when she coughs. She denies any episodes of severe, persistent pain, redness in the area, fever, or abdominal pain. On physical examination, she is an obese female with normal vital signs. When you ask her to perform a Valsalva maneuver, you can palpate a bulge in the right groin. Which of the following is true regarding this bulge? A) Since she is a female, it most likely represents a femoral hernia. B) Surgery is required in all such cases as soon as possible. C) The larger the bulge, the more likely it is to become incarcerated. D) Hernias are the most common cause of bowel obstruction in someone without prior abdominal surgeries. Answer: D Discussion The correct answer is D. Among patients who have not had abdominal surgery, hernias are the most common cause of bowel obstruction. When patients with a history of abdominal surgery are included, hernias are the second most common cause of bowel obstruction overall. Answer A is incorrect. Hernias in the groin can be direct, indirect, or femoral. In both men and women, the most common type is an indirect hernia, though femoral are more common in women than men. Direct hernias are rare among women. Answer B is incorrect because the surgical repair of hernias is elective. Surgery is absolutely indicated in cases of incarceration, but the incarceration rate is 5% initially and drops to 1% per year after 46 months. A risk/benefit analysis is recommended, especially in older patients with comorbid conditions. Answer C is incorrect. Larger hernias are less likely to incarcerate. Incarceration is defined as a loop of bowel slipping into a hernia and becoming entrapped. Strangulation occurs when the incarceration is so severe that it results in a compromised blood supply. To reduce her chances of having recurrent herniation after surgery, you advise her to: A) Be on bed rest before the operation. B) Lose weight before the operation. C) Burst and taper steroids before the operation. D) Pursue an aggressive weight loss program after the operation. Answer: B Discussion The correct answer is B. Obesity is associated with recurrent herniation after hernia repair, so obese patients should be instructed to lose weight before surgery. Other factors associated with hernia recurrence are smoking, steroid use,

and infection. Answers A, C, and D are all incorrect because they may increase the risk of hernia recurrence after repair. Your patient mentions that her 6-month-old grandson has a bulge at his navel. Regarding hernias in infants and children, which one of the following statements is most accurate? A) Umbilical hernias in infants require repair if not closed by 1 year of age. B) A scrotal sac that is translucent with a bright light is likely a hydrocele. C) Omphaloceles occur to the right of the umbilicus. D) Caucasian infants have the highest rate of umbilical hernias. Answer: B Discussion The correct answer is B. A scrotal sac that is translucent is generally a hydrocele. A hydrocele is a fluid collection in the tunica vaginalis of the scrotum or processus vaginalis in the inguinal canal. Hydroceles can either be present at birth or develop later. Clinically, a hydrocele illuminates with a bright light. However, it is important to remember that this finding can also be observed with an incarcerated inguinal hernia. Answer A is incorrect. Most umbilical hernias close spontaneously within the first 23 years of life. Because of this, operative repair is not recommended before the age of 2 years. Answer C is incorrect. An omphalocele is a defect in the anterior abdominal wall through which intraabdominal contents are extruded. It is seen at the base of the umbilicus (not to the right), and the organs are covered with a membrane. A neonate with a herniation of intraabdominal contents to the right of the umbilicus may have gastroschisis. Needless to say, omphalocele and gastroschisis require surgical repair. Answer D is incorrect. Umbilical hernias occur in 49% of Caucasians and 2550% of black infants. They rarely pose any threat to the infant. Case 3 A 24-year-old male presents to your clinic with a 5- day history of rectal bleeding. For several years, he has had constipating stools but has developed rectal bleeding in the last few days. In addition, he has severe, intermittent, crampy abdominal pain (presumably from constipation). He reports a mild fever. On examination, temperature is 37.9 C, pulse 95, respirations 12, and blood pressure 108/78. His abdomen is nontender. He has no guarding or rebound tenderness. Anoscopy reveals gross blood and 2 internal hemorrhoids. Regarding hemorrhoids in general, which of the following is true? A) Patients with hemorrhoids most commonly complain of perianal burning, itching, swelling, and pain. B) A grade III hemorrhoid can be reduced manually. C) If a patient under the age of 50 with rectal bleeding is found to have hemorrhoids on examination, further studies are not indicated. D) Because they are above the dentate line, strangulated internal hemorrhoids are not painful. Answer: B Discussion The correct answer is B. Grade III hemorrhoids can be reduced manually. Hemorrhoids are normal vascular structures in the anal canal; however, the venules can become engorged and symptoms such as pain, bleeding, and itching may result. Two types of hemorrhoids exist: external hemorrhoids derive from the inferior hemorrhoidal plexus below the dentate line, and internal hemorrhoids derive from the anal cushions above the dentate line. Internal hemorrhoids occur on the left lateral, right anterior, and right posterior anal walls and are classified into Grades IIV. Grade I hemorrhoids slide below the dentate with straining but not through the anus. Grade II protrude from the anus but spontaneously reduce, whereas Grade III hemorrhoids must be manually reduced. Grade IV internal hemorrhoids cannot be reduced. Answer A is incorrect because most patients with symptomatic hemorrhoids present with painless rectal bleeding. Answer C is incorrect. You should consider further evaluation (e.g., flexible sigmoidoscopy, colonoscopy, etc.) in patients under the age of 50 presenting with rectal bleeding, even if hemorrhoids are present and are the likely source of bleeding. In patients older than 50 with rectal bleeding, a full

colonoscopy is routinely recommended to rule out any cancerous process. Answer D is incorrect. Although most internal hemorrhoids do not cause pain, strangulated internal hemorrhoids are very painful and can become necrotic and gangrenous, requiring emergent surgery. Which of the following would you NOT consider as a treatment for this patients hemorrhoids? A) Psyllium. B) Dicyclomine. C) Warm sitz baths. D) Short course of topical hydrocortisone. E) Increased water intake. Answer: B Discussion The correct answer is B. Dicyclomine (Bentyl, Antispas) is not indicated. Dicyclomine is an anticholinergic and will contribute to constipationexactly what you want to avoid in patients with hemorrhoids. Answers A and E are the primary modes of treatment. Psyllium, as well as a diet high in fiber and water, will reduce straining and thus reduce intra-abdominal pressure. Answer C, warm baths or showers, have been shown to reduce anal canal pressures (40 C). Answer D, a short course of topical hydrocortisone (e.g., Anusol HC), may be of benefit. Long-term topical steroids are contraindicated. Finally, good hygiene and analgesia should be prescribed as needed. Which of the following is TRUE about treating hemorrhoids surgically? A) Irritable bowel syndrome is a relative contraindication to hemorrhoid surgery. B) It is best to ligate all hemorrhoids in a single office visit. C) Band ligation results in sloughing of hemorrhoids in about 12 weeks. D) Following excision, thrombosed external hemorrhoids should be closed to prevent bleeding. Answer: C Discussion The correct answer is C. Rubber-band ligation generally results in the sloughing of the hemorrhoid in 12 weeks. Answer A is incorrect. Inflammatory bowel diseasenot irritable bowel syndromeis a relative contraindication to the surgical treatment of hemorrhoids. Other contraindications to office-based hemorrhoidectomy procedures include bleeding diathesis, pregnancy, postpartum period, anorectal fissures, active anorectal infections, AIDS or other immunodeficient states, portal hypertension, rectal wall prolapse, and anorectal tumors. Complications of hemorrhoidectomy include pain, significant bleeding with sloughing, thrombosis of external hemorrhoids, and very rarely sepsis with pelvic cellulitis. Answer B is incorrect. Although evidence is scarce, standard of care dictates that only 1 hemorrhoid be ligated in a single office visit (due to concerns about excessive tissue necrosis). Answer D is incorrect. Patients who present with external hemorrhoids that are painful, tender, swollen, and with bluish discoloration have thrombosis. If the patient presents within 48 hours of thrombosis, the thrombus should be expressed. It is specifically important not to close the hemorrhoid once the clot is expressed. In fact, a small ellipse of the hemorrhoid should be removed to facilitate continued drainage to and prevent reaccumulation of clot. You prescribe conservative treatment for your patients hemorrhoids, and since he does not return for his next scheduled appointment, you assume he is doing well. You see him again 6 months later. He reports that he had indeed healed. Although he still takes psyllium, he began having painful bowel movements with blood-streaked stool 2 days ago. Upon examination of the anus, you find a fissure. All of the following findings would lead you to consider Crohns disease EXCEPT: A) Posterior midline fissure. B) Painless fissure. C) Multiple fissures. D) Nonhealing fissure. Answer: A

Discussion The correct answer is A. The posterior midline is where solitary fissures, unrelated to inflammatory bowel disease, are typically located. Fissures in any other location should raise suspicion for Crohns disease. Answers B, C, and D are also suggestive of Crohns. In a patient with an uncomplicated, initial anal fissure, what do you recommend for first-line therapy? A) Lords dilation. B) Botulinum toxin injections. C) Topical nitroglycerin. D) Oral psyllium. E) Oral nifedipine. Answer: D Discussion The correct answer is D. All of the options are employed for treating anal fissures. However, in patients with an uncomplicated, initial anal fissure, it seems prudent to initiate conservative therapy (e.g., psyllium, dietary fiber, water, warm soaks, etc.) prior to proceeding to more invasive measures. Most fissures will respond to conservative measures. Generally, healing takes 24 weeks. In addition to the treatments listed, topical diltiazem and topical nifedipine are also used, as are various surgical approaches. Lords dilation deserves special mention as a relatively arcane procedure for stretching the anal sphincter muscle (under anesthesia, we hope!). You note that this patients fissure is deep, ulcerating, and located at the left lateral aspect of the anus. Given this examination, you are concerned about Crohns disease. You briefly consider what you know about inflammatory bowel disease (IBD). Which of the following is true of IBD? A) Ulcerative colitis is primarily a diagnosis of young males. B) Crohns disease can be isolated to colonic disease. C) Ulcerations with cobblestone appearance are consistent with a diagnosis of ulcerative colitis. D) Crohns disease is more common in blacks, while ulcerative colitis is more common in whites. Answer: B Discussion The correct answer is B. Crohns disease can be isolated to the colon. Answer A is incorrect because ulcerative colitis is evenly distributed between men and women, with a similar incidence in each. Answer C is incorrect because ulcerations with a cobblestone appearance are more consistent with a diagnosis of Crohns disease. However, it is difficult to make a diagnosis on visual appearance alone; biopsy is required. Answer D is incorrect. In general, inflammatory bowel disease is more common in whites than nonwhites. Your patient undergoes a colonoscopy with biopsies. The initial results are consistent with Crohns disease. Which of the following treatment options should NOT be considered at this time? A) Oral sulfasalazine. B) Oral mesalamine. C) Partial colectomy. D) Oral prednisone. Answer: C Discussion The correct answer is C. Proceeding to surgery is premature. Answer A, oral sulfasalazine, can be used for the treatment of inflammatory bowel disease. Any of the other choices are reasonable as initial therapy in this patient. Other immunosuppressives (e.g., cyclosporine, 6-mercaptopurine) have also been used with success but are considered second-line drugs.

For what reason(s) might you refer this patient with Crohns disease for surgical intervention? A) Dependence on mesalamine to maintain remission. B) Annoying diarrhea. C) Prophylactic colectomy for extensive small bowel disease. D) Progression of symptoms despite maximal medical therapy. E) All of the above. Answer: D Discussion The correct answer is D. Of the potential indications listed, only disease progression despite maximal medical therapy is an accepted reason for surgical intervention in Crohns disease. Answer A is incorrect. Although dependence on steroids is sometimes considered an indication for surgery, dependence on mesalamine (with its more favorable side effect profile) should not be. Answer B is incorrect for obvious reasons. Answer C is incorrect. Although Crohns colitis is associated with an increased risk of colon cancer, Crohns disease of the small bowel is not. Which of the following is NOT a complication of Crohns disease? A) Spondyloarthropathy. B) Pyoderma gangrenosum. C) Uveitis. D) Amyloidosis. E) Hypercalcemia. Answer: E Discussion The correct answer is E. Hypocalcemia may occur as a result of malabsorption and can lead to tetany. All of the other options are complication of Crohns disease. Of particular note, amyloidosis can be secondary to chronic inflammation. Amyloid is an acute-phase reactant that is increased in inflammation and deposited in tissues. Case 4 An orthopedic colleague asks you to consult on a 64- year-old male prior to an elective total hip replacement. The surgery is scheduled for 3 months from now. The patient is a smoker with diabetes mellitus type 2 and has recently had a cardiac catheterization that showed significant, but non-bypassable, disease. He is asymptomatic and is able to walk stairs without difficulty. The surgeon would like some preoperative recommendations. You would recommend all of the following EXCEPT: A) The patient should stop smoking 4 weeks before surgery. B) The patient should have preoperative and postoperative beta-blockers if the pulmonary status allows it. C) The patient should have a chest radiograph done. D) The patient should have his hemoglobin/hematocrit drawn. E) The patient should have his creatinine measured. Answer: A Discussion The correct answer is A. Paradoxically, unless patients stop smoking 8 weeks or more before surgery, the risk of adverse pulmonary outcomes is increased. The cause of this phenomenon remains unclear but may occur because the cilia are able to mobilize material in the lungs. Answer B is true. The use of pre-, intra- and postoperative betablockers is well supported for patients with coronary artery disease. One of the most serious intraoperative events is a myocardial infarction. Beta-blockers have been shown in multiple studies to reduce this risk and to improve outcomes if the patient has an elevated risk for a myocardial infarction.

While answers C, D, and E are true, a lot of other routine preoperative assessment is not supported in the literature, but is recognized as the standard of care. You perform a physical examination on this patient. His vital signs are normal. He is mildly obese. You find a carotid bruit on the right. A carotid duplex examination shows 50% stenosis on the right and minimal stenosis on the left. Of the following, which is TRUE in regard to the treatment for carotid artery disease? A) This patient should undergo carotid endarterectomy immediately. B) Carotid endarterectomy should be used only in patients with symptomatic lesions with stenosis >80%. C) There is a 10% recurrence of lesions in patients who have undergone carotid endarterectomy. D) Morbidity and mortality of carotid endarterectomy approaches 10% for even the best of surgeons. E) Medical management in this patient would start with warfarin. Answer: C Discussion The correct answer is C. Lesions tend to recur in 10% of patients who have undergone endarterectomy. Answer A is incorrect. There is no indication for immediate surgery in this patient. Experienced surgeons have a morbidity and mortality rate of less than 2% with a recurrence rate around 10%. Medical treatments should always be instituted unless contraindicated. The focus is on controlling hypertension, hyperlipidemia, and other vascular risk factors. Medical management typically starts with antiplatelet agents, such as aspirin or clopidogrel, not with anticoagulant agents (e.g., warfarin). You now turn your attention to his diabetes. Regarding preoperative management of diabetic regimens, which of the following statements is FALSE? A) A type 2 diabetic who is diet-controlled should be given no insulin or glucose preoperatively. B) A diabetic patient taking only an oral hypoglycemic agent should be given no insulin or glucose preoperatively. C) Any oral hypoglycemic agents taken by a diabetic patient should be held 12 days prior to surgery. D) If a diabetic patient is on insulin, his or her shortacting insulin should be held entirely and twothirds of the NPH dose should be administered. Answer: D Discussion The correct answer is D. Currently, for type 2 diabetics who are controlled by either diet or oral hypoglycemics, no insulin or glucose is recommended before surgery. Instead, if glucose levels are >250 mg/dL, sliding scale shortacting insulin should be administered. Because of the prolonged effects of many oral hypoglycemic agents, they should be held 12 days prior to surgery. Type 1 diabetics and insulin-dependent type 2 diabetics should have their short-acting insulin held and one-third to one-half of their long-acting insulin given the morning of surgery. Glucose levels should be drawn every 12 hours thereafter, with appropriate sliding scale insulin administered in response. The patient undergoes his hip replacement and his postoperative EKG is normal. Four hours after surgery, he develops mild respiratory distress, a fever, and cough. On chest x-ray, there is a right lower lobe infiltrate. There is no evidence of fluid overload. Which of the following is the most likely cause of this patients fever and infiltrate? A) Pneumococcus. B) Gram-negative organisms. C) Atelectasis. D) Aspiration pneumonitis. E) Aspiration pneumonia. Answer: D

Discussion The correct answer is D. In the hours after surgery, an aspiration pneumonitis would be the most likely cause of this patients current findings. Aspiration pneumonitis occurs when there is aspiration of gastric contents with a pH of 25%, acidosis, cardiovascular disease, and age >60. Obviously, these are relative criteria. An otherwise normal 60year-old with a mild exposure need not have HBO. Pregnancy is an indication for HBO therapy because fetal hemoglobin has a high affinity for carbon monoxide and the fetus is highly susceptible to carbon monoxide. All of the following are well-established consequences of hyperbaric oxygen EXCEPT: A) Seizures. B) Psychosis. C) Myopia. D) Ear and pulmonary barotraumas. E) Direct pulmonary oxygen toxicity. Answer: B Discussion The correct answer is B. All of the rest are found as a result of hyperbaric oxygen. Answer C, myopia, is actually found in up to 20% of patients being treated with hyperbaric oxygen. It is due to direct toxicity of oxygen on the lens and usually resolves within weeks to months. Case 6 A 50-year-old immigrant from a country in the developing world is brought to your ED after being bitten by a stray dog. The bite was unprovoked and is on the abdomen. The patient has no other health history of note and has not taken antibiotics for over a year. You irrigate the wound and are deciding about closure. There is a 3-cm laceration on the abdomen. Which of the following is (are) true about dog bites? A) They tend to be primarily crush-type injuries. B) In general, the infection rate is similar to that for a laceration from any other mechanism (e.g., knife cut) except on the hands and feet. C) The primary organism in infected dog bites is Staphylococcus aureus. D) Primary closure of dog bite wounds is an acceptable option (except perhaps on the hands and feet). E) All of the above are correct. Answer: E Discussion The correct answer is E. All of the above are correct. Dog bites (except from very small dogs) tend to be crush injuries (as contrasted with cat bites, which are primarily puncture wounds). The infection rate is about the same as that for other lacerations. Bites on the hands and feet tend to have a higher rate of infection. Most dog bite infections

are polymicrobial, with S. aureus playing a large role and Pasteurella playing a smaller, but still significant, role. Other organisms include Streptococcus species and gram-negative species. You are concerned about rabies prophylaxis. Which of the following is (are) viable options? A) Isolating the suspect animal for 3 days. B) Euthanizing the suspect animal and examining its liver. C) Administering rabies immune globulin IM. D) Administering rabies immune globulin IV followed by rabies vaccination series. E) Administering rabies immune globulin by infiltrating it around the wound, followed by rabies vaccination series. Answer: E Discussion The correct answer is E. You should infiltrate rabies immune globulin around the wound and then begin the rabies vaccination series. As much of the immune globulin as possible should be infiltrated around the wound and the rest should be given IM. Answer A is incorrect because animals need to be isolated for 10 days, not 3. Answer B is incorrect. The animal can be euthanized but the brain should be examined and not the liver. Answers C and D are both incorrect methods of administering the vaccine/immune globulin. Which of the following require rabies prophylaxis in all cases? A) Stray rabbit bites. B) Stray rat bites. C) Stray bat bites. D) Stray squirrel bites. E) Stray snake bites. Answer: C Discussion The correct answer is C. All bats should be considered rabid unless available for observation and testing. Also see the CDC Web site for information about rates of infection in wild animals in your area. The question of tetanus prophylaxis is raised. The patient is unsure whether or not he has had a primary tetanus series. The correct course of action is to: A) Begin the patients primary series of DPT (diphtheria, pertussis, and tetanus). B) Give the patient tetanus immunoglobulin and begin the primary series of DPT (diphtheria, pertussis, and tetanus). C) Begin the patients primary series of DT (diphtheria and tetanus). D) Give the patient tetanus immunoglobulin and begin the patients primary series of DT (diphtheria and tetanus). E) Give the patient tetanus immunoglobulin and, since he is an adult, only a single dose of DT (diphtheria and tetanus). Answer: D Discussion The correct answer is D. Since this patient may not have had a primary series of tetanus vaccines, he should have tetanus immunoglobulin and should have a primary tetanus series started. DT is recommended because patients who have poor immunity to tetanus will generally also have poor immunity to diphtheria. Answers A and B are incorrect because adults should not be given the pertussis vaccine. It is not recommended for those 5 times the upper limit of normal, so you make the diagnosis of rhabdomyolysis. You decide to check additional lab tests. Which of the following would be typically found in rhabdomyolysis? A) Elevated calcium, decreased phosphate. B) Decreased potassium, elevated phosphate. C) Elevated phosphate, decreased calcium. D) Any of the above combinations may be seen. Answer: C Discussion The correct answer is C. In addition to an elevated CPK, other laboratory findings in rhabdomyolysis include: hyperphosphatemia, hyperkalemia, hypocalcemia, hyperuricemia, and hypoalbuminemia. Hypocalcemia is the most common laboratory abnormality, being present in approximately 70% of patients. The most common adverse consequence and greatest danger of rhabdomyolysis is: A) DIC. B) Acute renal failure. C) Seizure from hypocalcemia. D) Acute gout from hyperuricemia. E) Cardiac arrhythmia from hyperkalemia. Answer: B Discussion The correct answer is B. Myoglobin precipitates in the renal tubules causing acute renal failure. Answer A, DIC, can occur but is rare. Answer C, seizures from hypocalcemia, have not been reported in this condition, nor has answer D, gout. The potassium elevation from rhabdomyolysis generally does not reach a level sufficient to cause arrhythmias. The primary treatment for rhabdomyolysis is: A) Mannitol infusion. B) Saline infusion. C) Furosemide. D) Dialysis.

Answer: B Discussion The correct answer is B. The most important treatment for rhabdomyolysis is saline infusion with alkalinization of the urine. Answer A, mannitol, can be used to increase urine flow, but this is really a treatment that is secondary to good hydration and urine alkalinization. Answer C, furosemide, is not used in rhabdomyolysis. Loop diuretics will actually acidify the urine and are contraindicated. Answer D, dialysis, is what we are trying to avoid by using saline. The patient is able to maintain urine output after you institute saline. What treatment are you going to suggest for the underlying compartment syndrome? A) Fasciotomy. B) Immobilization and traction. C) Hot packs and elevation of the affected limb. D) Ice and elevation of the affected limb. Answer: A Discussion The correct answer is A. The treatment of compartment syndrome is fasciotomy. A rapid surgical or orthopedic consultation is critical in the treatment of compartment syndrome. The patient does well and everyone is happy. Case 12 A 52-year-old truck driver presents to your ED after being out in subzero (Fahrenheit) temperatures for several hours trying to repair his truck. He is hypothermic when you use a rectal thermometer with appropriate calibration. His initial core temperature is noted to be 28 C. He has a pulse of 24, blood pressure of 70/30, and slow mentation. He is awake, however. The appropriate first-line treatment for this patient is: A) Atropine. B) Epinephrine. C) Dopamine. D) Lidocaine. E) None of the above. Answer: E Discussion The correct answer is E. The hypothermic heart is generally resistant to drugs. Thus, the best treatment for this patient is rewarming. If the patient has poor perfusion, rapid rewarming with CPR if indicated is the treatment of choice. All of the following are acceptable methods of rewarming this patient EXCEPT: A) Active external rewarming (e.g., hot packs, etc.). B) Immersion in 40 C water. C) Passive external rewarming (e.g., blankets). D) Heated, humidified oxygen. E) Thoracic lavage with warm fluids. Answer: C Discussion The correct answer is C. Patients with a temperature of below 30 C generally do not have enough endogenous heat production to effectively rewarm themselves. Thus, external or internal active rewarming is indicated. All of the other options are correct methods of rewarming this patient. Extracorporeal blood warming is also effective. Heated

lavage fluids (e.g., gastric and rectal) are generally not very effective because of the limited surface area involved. Additionally, this type of lavage can potentially cause electrolyte abnormalities. Rapid rewarming of the extremities is associated with: A) Alkalosis, hypokalemia. B) Acidosis, hypokalemia. C) Acidosis, hyperkalemia. D) Alkalosis, hyperkalemia. E) None of the above. Answer: C Discussion The correct answer is C. Rewarming of the extremities can lead to return of cold blood to the core, leading to a paradoxical drop in body temperature. Additionally, hypothermia causes lactic acidosis with hyperkalemia in the extremities; as the peripheral blood is rewarmed and mobilized, systemic metabolic acidosis with hyperkalemia may result. Which of the following IS NOT associated with an increased risk of hypothermia? A) Diabetes mellitus. B) Obesity. C) Alcohol use. D) Old age. F) Chronic illness. Answer: B Discussion The correct answer is B. Obese patients have a smaller body mass to surface area ratio and do not have an increased risk of hypothermia. Answer C, alcohol use, causes patients to be relatively insensate to cold and also causes peripheral vasodilatation, increasing heat loss. Thermoregulation is impaired as we age. Thus, answer D, old age, is associated with a greater propensity toward hypothermia. Diabetes (answer A) and any chronic illness (answer D) can also predispose to hypothermia. The patients mental status clears and he complains that his fingers and toes, which were numb and cold, are now quite painful. You note that there is probably freezing of tissue (frostbite). The BEST method of rewarming the areas with frostbite is: A) Slowly in tepid water. B) Rapidly in the hottest water he can stand (tested by you, of course, to assure that there will be no burns). C) Using a hot air source such as a hair dryer. D) Using moist heat via a heating pad. Answer: B Discussion The correct answer is B. Frostbitten parts should be rewarmed as quickly as possible in hot water, between 37 and 40 C. Water cooler or hotter than this can lead to incomplete thawing and increased tissue loss. The other methods (answers A, C, and D) are not recommended. The patient has a lot of pain after thawing and reperfusion. You control the pain with morphine. Which of the following doses is the appropriate dose of morphine in this 100-kg male? A) 2 mg IV. B) 4 mg IV.

C) 6 mg IV. D) 8 mg IV. E) 10 mg IV. Answer: E Discussion The correct answer is E. The correct dose of IV morphine is 0.1 mg/kg or 10 mg in this 100-kg male. Similarly, the correct dose of meperidine (Demerol) is 100 mg (1 mg/kg). It is 2 days later. The patient is noted to have black eschar on multiple fingers and toes. There is no obvious perfusion to these areas. The best course at this point is: A) Debridement of the nonviable tissue. B) Skin grafting over open areas after debridement. C) Observation for a number of weeks despite the black eschar. D) Amputation of the nonviable distal digits. Answer: C Discussion The correct answer is C. It can take weeks for the proper demarcation line for debridement and grafting to become apparent. Thus, aggressive intervention at this point is counterproductive and may lead to additional tissue loss. For this reason answers A and D are incorrect. Skin grafting is also not appropriate at this time because debridement of the eschar is not appropriate. Case 13 A 19-year-old female presents to the ED with complaints of wheezing. She has a history of asthma and you have been following her since her eighth birthday. Generally, she has mild asthma not requiring an inhaled steroid. However, over the past several months things have accelerated so that she now uses her inhaler daily. On exam, she is tachypneic with a respiratory rate of 30 and wheezing in all fields. Her oxygen saturation is 95% and pulse is 110 with a normal blood pressure. Her blood gas is as follows: pH 7.40, CO2 40 mm Hg, O2 92 mm Hg, and HCO3 24 mEq/L (normal blood gas). A normal blood gas in this patient suggests that: A) This is a mild exacerbation and should respond well to therapy. B) She has respiratory acidosis. C) She has respiratory alkalosis. D) This is a severe exacerbation that will require aggressive therapy. E) None of the above. Answer: D Discussion The correct answer is D. A pH of 7.4 with a CO2 of 40 mm Hg in a patient who is asthmatic and tachypneic is a bad sign. The CO2 should be low in a tachypneic patient because she will be blowing off CO2. Thus, normal CO2 and normal pH indicate that the patient is retaining CO2. Answers B and C are both incorrect since the blood gas indicates neither acidosis nor alkalosis. Which of the following tests are indicated in routine evaluation of a patient with an asthma exacerbation? A) Chest x-ray. B) CBC. C) Arterial blood gas. D) A and C.

E) None of the above. Answer: E Discussion The correct answer is E. None of the above tests are indicated in the routine evaluation of an asthma exacerbation. A chest x-ray should be reserved for those patients in whom pneumonia or other pulmonary process is suspected (e.g., those with rales, an elevated temperature, etc.). A CBC is not going to change your therapy in the routine asthma exacerbation and is not indicated. Likewise, an ABG is unnecessary in most asthma exacerbations. It can be used to assist in your clinical evaluation to determine whether or not the patient is retaining CO2; however, even in the crashing patient, an ABG is not necessary because intubation is a clinical decision and should not be based solely on the blood gas. You decide to initiate therapy for this patient. Of the following options, the initial treatment of this patient is: A) Subcutaneous epinephrine. B) Albuterol MDI (metered-dose inhaler) with spacer. C) Nebulized ipratropium. D) Oral steroids. E) IV steroids. Answer: B Discussion The correct answer is B. The initial treatment for this patientand any patient presenting with an asthma exacerbationis a bronchodilator, in this case albuterol. It makes little difference whether this is via nebulizer or MDI, as long as one uses adequate doses. One albuterol nebulization is equal to about 810 puffs of an albuterol MDI with a spacer. Answer A is incorrect because subcutaneous epinephrine is the second or third line in the treatment of asthma. Answer C is incorrect. While ipratropium is effective in asthma, it is secondary to albuterol in the treatment of asthma. Answers D and E are incorrect. Steroids are indicated, but bronchodilator therapy is the primary treatment in acute asthma exacerbations. There is no albuterol MDI available to you in your ED, so the patient receives nebulized albuterol. However, she continues to wheeze. How many albuterol treatments can this patient safely be given? A) 1 every other hour. B) 1 an hour. C) 2 an hour. D) 3 an hour. E) Continuous nebulization of albuterol is OK. Answer: E Discussion The correct answer is E. Albuterol can be administered via nebulizer continuously if needed, even in the pediatric age group. Tachycardia, one of the main side affects of albuterol treatment, will often improve with continuous albuterol. This occurs because the patients tachycardia is often driven by hypoxia. Once the asthma is adequately treated, oxygenation improves, and the pulse comes down. The patient does not respond well to albuterol alone, so you request the addition of ipratropium. At this point you want to order steroids. Which of the following statements about steroids is true? A) IV steroids are superior to PO steroids in the treatment of asthma. B) Nebulized steroids are just as effective as oral steroids for the treatment of acute asthma exacerbations.

C) All patients who are steroid-dependent should have additional steroids even if they have already taken their dose for the day. D) The effective dose range for steroids in asthma is well established. E) Only patients requiring admission should have oral or parenteral steroids. Answer: C Discussion The correct answer is C. All patients who are steroiddependent should get steroids if they present to the ED with an acute exacerbation of asthma. Answer A is incorrect. Intravenous steroids and oral steroids have the same efficacy in acute asthma exacerbations. Thus, the choice of route depends mostly on convenience, cost, and physician preference. Answer D is incorrect. Multiple steroid dosing regimens and ranges of doses have been used in asthma with success. Answer E is incorrect. Discharged patients who have anything more than a minor asthma exacerbation should receive steroids. Which of the following is true about the role of theophylline in the treatment of acute asthma? A) Theophylline/aminophylline should be used in cases unresponsive to 23 doses of nebulized albuterol since it has added benefits when used with an inhaled beta-agonist. B) Patients who get theophylline/aminophylline have more side effects than do patients who get continuously nebulized albuterol and get no benefit from the drug. C) If you choose to use theophylline/aminophylline, the therapeutic goal is a serum level of 20 mcg/dl. D) None of the above is correct. Answer: B Discussion The correct answer is B. Patients who are treated with theophylline have more side effects, including tachycardia, nausea, and arrhythmias, than do patients who get continuously nebulized albuterol. Theophylline/ aminophylline have essentially no role in the treatment of acute asthma exacerbations. There is no benefit to theophylline or aminophylline over optimal beta-agonist therapy (e.g., continuous nebulized albuterol if required). Answer C is incorrect because, if used at all, the therapeutic goal for theophylline is a serum level of 15 mcg/dl. The patient responds to nebulizers and steroids. You decide to send her home. Which of the following is true? A) You should discharge the patient on 2 puffs of an albuterol MDI via spacer to be used PRN. B) You should place the patient on a steroid taper. C) You should discharge the patient on 810 puffs of an albuterol MDI via spacer to be used every 6 hours around the clock. D) You should start the patient on a steroid inhaler. E) None of the above. Answer: D Discussion The correct answer is D. The patient should be started on a steroid inhaler to prevent recurrent exacerbations. Overlapping this with oral steroids will give the inhaled steroids a chance to work while the patient is being covered with the oral steroids. Answer A is incorrect. The proper dose of albuterol via MDI is 610 puffs PRN. Answer B is incorrect because patients do not need a steroid taper if they are not on chronic steroids and will not be taking steroids for more than 10 days. You can simply treat the patient (e.g., with prednisone 40 mg PO QD) and then stop the steroids. No taper is needed. Note that this is not true for patients on chronic steroids who clearly do need a taper. Answer C is incorrect because scheduled albuterol is not as effective as PRN use. Additionally, albuterol can certainly be used more than every 6 hours.

Case 14 A 7-year-old presents to the ED with wheezing and hives after being stung by a bee. He was evidently throwing rocks at a yellow jacket nest when he was stung. On exam the patient has hives and wheezing with a normal blood pressure for his age. He is mildly tachycardic. Potentially useful treatments for this patient include all of the following EXCEPT: A) Intravenous diphenhydramine. B) Subcutaneous epinephrine. C) Subcutaneous diphenhydramine. D) Intravenous cimetidine. Answer: C Discussion The correct answer is C. Subcutaneous diphenhydramine can cause skin necrosis and is contraindicated. Either IV or IM diphenhydramine can be used. Of the others, subcutaneous epinephrine should be used in the patient with anaphylaxis who fails to respond to diphenhydramine and cimetidine or who has respiratory distress, hypotension, etc. Intravenous H2 blockers (e.g., cimetidine, ranitidine) are particularly effective in the treatment of anaphylaxis and should be used routinely in these patients. The family is concerned that the stinger may still be in the skin. The proper response is to: A) Remove the stinger with forceps. B) Remove the stinger using a double-edged razor or credit card. C) Leave the stinger embedded in the skin. D) Not worry about even looking for a stinger in this patient. Answer: D Discussion The correct answer is D. The only hymenopterans (bees, wasps, etc.) that leave the stinger in the skin are honeybees. Since this patient was stung by a yellow jacket, there will not be a stinger to find in this child. As for the other answers, either A or B would be appropriate treatment if a stinger was present. The only thing that seems to make a difference in the amount of venom injected is the length of time the stinger is in the skin and not the mechanism by which is removed. So, remove the stinger as quickly as possible by whatever means is available. The patient responds well to the therapy as noted above. You are going to discharge him and want to write his prescriptions. The patient should be discharged with which of the following? A) Diphenhydramine Q6 hours for the next 48 hours. B) Cimetidine for Q12 hours for the next 48 hours. C) An anaphylaxis (bee sting) kit. D) All of the above medications. Answer: D Discussion The correct answer is D. Patients can have biphasic reaction mediated by slow reacting substance of anaphylaxis, which is now believed to be a neutrophil chemotactic factor. This recurrence may occur up to 48 hours after the initial event. Thus, prescribing medications to prevent the recurrence is prudent. Also, the patient should have a bee sting kit available. The parents are concerned about this child who likes to play outside. They worry that he will get stung again.

You let them know that: A) Any sting should be treated as an emergency. B) He will continue to be allergic to bee stings in the future. C) He should take prophylactic medication before going out to play in the woods or other areas where he might get stung. D) None of the above. Answer: D Discussion The correct answer is D. Here is why. Patients who are allergic to one species of hymenopteran are not necessarily allergic to others. Generally, the allergy is species-specific. Thus, most stings will be benign in an allergic patient unless it is a sting from the offending species. Answer B is incorrect. Many children tend to outgrow bee sting allergies. This is in contrast to adults, in whom reactions tend to get worse over time. Answer C is incorrect. Obviously the child should be careful not to irritate yellow jackets, but prophylactic treatment is not routinely indicated. Case 15 A 14-year-old white male presents to the emergency department with acute-onset left testicular pain when running, 1 hour prior to presentation. His past medical history is negative, he is on no medications, and he has no allergies. He denies any trauma to the region. He states that his pain is severe and only on the left. The pain is increased with ambulation and movement. He denies nausea, vomiting, diarrhea, fever, chills, dysuria, hematuria, or penile discharge. His vital signs and physical exam are as follows: temperature 37.0 C, pulse 110, respirations 18, blood pressure 120/85. He is a well-nourished, well-developed white male in distress secondary to pain. Abdomen: Normal bowel sounds, nontender, soft, no masses. Genitourinary: Circumcised male, no penile lesions, no discharge. Left testicle tender to palpation but has a normal lay in the scrotum. The cremasteric reflex is normal bilaterally. What is the significance of the normal lay and cremasteric reflex? A) The cremasteric reflex should be abnormal in epididymitis. B) The presence of a cremasteric reflex effectively rules out testicular torsion. C) The normal lay of the testicle in the scrotum effectively rules out testicular torsion. D) The presence or absence of a cremasteric reflex is not helpful in ruling out testicular torsion. Answer: D Discussion The correct answer is D. The presence or absence of a cremasteric reflex is neither sensitive nor specific enough to confirm or rule out the presence of testicular torsion. Likewise, the lay of the testicle can be normal in patients with testicular torsion. An abnormal testicular lay and absence of the cremasteric reflex may point toward testicular torsion. However, you cannot rely on these findings to rule out testicular torsion. The LEAST likely diagnosis in this patient is: A) Torsion of testis. B) Epididymitis. C) Torsion of appendix testis. D) Torsion of appendix epididymis. E) Testicular tumor. Answer: E Discussion The correct answer is E. Testicular torsion is characterized by acute onset of unilateral testicular pain, often during activity such as running. It has a bimodal age distribution, during the first year of life and again during puberty. The differential diagnosis is dependent on the patients age. If the patient is 18,000 cells/mm3 is suggestive of septic hip but does not prove the diagnosis is septic hip. Likewise, a normal WBC count does not rule out septic hip. Seventy-one percent of patients with transient synovitis will have an effusion present, so the presence or absence of an effusion on ultrasound is not a good differentiator. You must have a high clinical suspicion for septic arthritis and consider the diagnosis in the appropriate patient. What is the most appropriate treatment for this patient with transient synovitis? A) Open fixation. B) Immobilization. C) Antibiotics. D) Surgical decompression. E) None of the above. Answer: E Discussion The correct answer is E. Conservative treatment is warranted: the appropriate initial treatment is rest and observation. Also, transient synovitis generally responds well to oral NSAIDs (e.g., ibuprofen). Home care is acceptable; however, admission is indicated if the diagnosis is equivocal or if significant pain management is required. For septic arthritis, prompt administration of an intravenous antibioticdirected at the most likely infecting pathogen and altered as necessary based on culture resultsis indicated. When septic hip is detected early, joint decompression by aspiration along with antibiotics may be sufficient. However, surgical decompression is often indicated to minimize the risk of osteonecrosis, and therefore prompt early orthopedic consultation is needed.

Case 2 Concept Review Legg-Calve-Perthes disease (LCPD) is avascular necrosis of the proximal femoral head resulting from compromise of the tenuous blood supply to this area. LCPD usually occurs in children aged 4-10 years. The disease has an insidious onset and may occur after an injury to the hip. In the vast majority of instances, the disorder is unilateral. Both hips are involved in less than 10% of cases, and the joints are involved successively, not simultaneously. Legg-Calv-Perthes disease usually occurs in children aged 4-10 years, with a mean age of 7 years. It occurs more commonly in boys than in girls, with a male-to-female ratio of 4:1. The condition is rare, occurring in approximately 4 of 100,000 children. The cause is not known, but children with Legg-Calv-Perthes disease (LCPD) have delayed bone age, disproportionate growth, and a mildly shortened stature. LCPD may be idiopathic, or it may result from a slipped capital femoral epiphysis, trauma, steroid use, sickle-cell crisis, toxic synovitis, or congenital dislocation of the hip. Rapid growth occurs in relation to development of the blood supply of the secondary ossification centers in the epiphyses, creating an interruption of adequate blood flow and making these areas prone to avascular necrosis. Interruption of the blood supply to the bone results in necrosis, removal of the necrotic tissue, and its replacement with new bone. Bone replacement may be so complete and perfect that completely normal bone may result. The adequacy of bone replacement depends on the age of the patient, the presence of associated infection, congruity of the involved joint, and other mechanical and physiologic factors. Necrosis may occur after trauma or infection, but idiopathic lesions can develop during periods of rapid growth of the epiphyses. The earliest sign of Legg-Calv-Perthes disease (LCPD) is an intermittent limp (abductor lurch), especially after exertion, with mild or intermittent pain in the anterior part of the thigh. LCPD is the most common cause of a limp in the 4- to 10-year-old age group, and the classic presentation has been described as a painless limp. The patient may present with limited range of motion of the affected extremity. The most common symptom is persistent pain. Hip pain may develop and is a result of necrosis of the involved bone. This pain may be referred to the medial aspect of the ipsilateral knee or to the lateral thigh. The quadriceps muscles and adjacent thigh soft tissues may atrophy, and the hip may develop adduction flexion contracture. The patient may have an antalgic gait with limited hip motion. Pain may be present with passive range of motion and limited hip movement, especially internal

rotation and abduction. Children with LCPD can have a Trendelenburg gait resulting from pain in the gluteus medius muscle. Laboratory studies and radiography may supplement medical history taking and physical examination in the assessment of a child with a limp. Case 2 A 6-year-old white male is brought in by his parents because he is complaining of pain in his hip and anterior thigh. He is walking much less than usual since the pain began about 4 weeks ago. You order a plain radiograph, which shows mild sclerosis with some increased density of the femoral head. An MRI is ordered, which the radiologist interprets as demonstrating osteonecrosis of the femoral head. What is the most likely diagnosis in this patient? A) Osteomyelitis. B) Septic arthritis. C) Slipped capital femoral epiphysis (SCFE). D) Legg-Calv-Perthes disease (LCPD). E) Sickle-cell anemia. Answer: D Discussion The correct answer is D. LCPD is idiopathic osteonecrosis of the femoral head. It is unilateral in 90% of cases, and the typical age range is 48 years, but 2- to 12-year-olds may present with the disease as well. Answer A is a possibility, although there should be evidence of osteomyelitis on MRI. Answer B is discussed in the previous case. Answer C, slipped capital femoral epiphysis, generally occurs in obese children (usually male) who are in early adolescence. Answer E, sicklecell anemia, can cause osteonecrosis of the femoral head also, but the disease is rare in white populations. Legg-Calv-Perthes disease is actually less common in blacks. Which of the following factors MOST affects the outcome in patients with Legg-Calv- Perthes disease? A) Age at onset of illness. B) Findings of subchondral fractures or fragmentation. C) Early appropriate treatment. D) Severity of pain and ability to bear weight. E) Bilateral involvement. Answer: A Discussion The correct answer is A. Compared to older children, younger children generally have a longer time for remodeling to occur via molding of the femoral head within the acetabulum; and therefore, younger children have less flattening of the femoral head. Which of the following is the best initial treatment for this patient? A) Joint replacement. B) Osteotomy. C) Rest and traction. D) None of the above. Answer: C Discussion The correct answer is C. The initial treatment for a patient with Legg-Calv-Perthes disease typically includes rest, traction, and the use of an abduction brace. The objectives are to increase ROM in the hip and to reduce the risk of significant deformity. In general, patients should be seen by a specialist. This is especially true for older children (>6 years) and those with very limited ROM (abduction 10. Patients should be advised that with angulations >1015 there will likely be a loss of MCP prominence, although there should be no loss of function. If this is unacceptable to the patient, referral is recommended. Case 8 A 65-year-old male presents with left shoulder pain and weakness that started after he put a new roof on his house. The pain came on gradually and is made worse with abduction and flexion of the shoulder joint. He describes

himself as active and healthy, and he only takes acetaminophen when needed for shoulder pain. You suspect that he may have a rotator cuff injury. If this is the case, what do you expect to find on exam? A) Tenderness to palpation of the greater tuberosity of the humerus. B) Limited active range of motion. C) Normal passive range of motion. D) Shoulder shrug with attempted abduction. E) Any of the above. Answer: E Discussion The correct answer is E. Okay, so this might fit under the category of trick question, but the shoulder exam can be normal in a patient with rotator cuff tear, or it can include any of the elements listed in A through D. Which of the following muscles is not a part of the rotator cuff? A) Supraspinatus. B) Infraspinatus. C) Subscapularis. D) Teres major. E) Teres minor. Answer: D Discussion The correct answer is D. The rotator cuff consists of the other four muscles listed, and functions to rotate the arm and stabilize the humeral head. Which of the following muscles is the most commonly torn in the rotator cuff? A) Supraspinatus. B) Infraspinatus. C) Subscapularis. D) Teres minor. Answer: A Discussion The correct answer is A. The supraspinatus is generally the point of origin for most tears. Based on your history and physical exam, you diagnose a rotator cuff injury. Appropriate initial management of this 65-yearold male should be: A) NSAIDs and physical therapy. B) Oral corticosteroids and physical therapy. C) Subacromial injection with corticosteroid and physical therapy. D) Surgical repair and physical therapy. E) None of the above. Answer: A Discussion The correct answer is A. For initial management in an individual >60 years of age, NSAIDs and physical therapy for 6 weeks are the best answer. If they have no improvement or inadequate response, a corticosteroid injection may be used judiciously. Injection will likely cause at least short-term pain relief but is thought to weaken the tendon and may accelerate extension of the tear. Oral steroid dosing may provide relief, but it is associated with a higher

incidence of systemic side effects. Patients with significant symptoms or failed therapy should be considered for MRI, orthopedic referral, and surgical management. Patients under the age of 60 with acute traumatic tears should be considered for surgery, with best results within 6 weeks of injury. Your patient is successful in rehabilitating his left shoulder, but then he returns 2 years later with right shoulder problems. The right shoulder has become progressively stiff and painful, and his ROM is now significantly limited in all directions. Your examination is consistent with frozen shoulder or adhesive capsulitis. Adhesive capsulitis is most commonly associated with which of the following? A) Diabetes mellitus type 1. B) Hyperthyroidism. C) Spondyloarthitis. D) Nondominant arm. E) Male gender. Answer: A Discussion The correct answer is A. Adhesive capsulitis has no clear predilection as to gender, race, arm dominance, or occupation. It is characterized by loss of ROM of the shoulder in all directions, with loss of both passive and active motion. It has a high incidence in patients with type 1 diabetes and tends to be more recalcitrant in those patients, of whom up to 50% will have bilateral involvementalthough not necessarily concomitantly. Adhesive capsulitis is not typically related to trauma, but it can be associated with disuse due to pain, osteoarthritis, sling use, etc. Other conditions that are associated with adhesive capsulitis include hypothyroidism, cervical disc disease, and Parkinsons disease. What initial treatment do you recommend for this patient? A) Arthroscopic debridement. B) Oral corticosteroids. C) NSAIDs and a sling for comfort. D) Extended progressive physical therapy. E) Mobilization under anesthesia. Answer: D Discussion The correct answer is D. A progressive stretching program with heat and NSAIDs to improve comfort is the most appropriate early treatment. A corticosteroid injection may be beneficial, but should be used cautiously in diabetic patients. Oral steroids have no greater benefit than NSAIDs. Answer C is incorrect because a sling will contribute to further immobilization and worsening of the problem. Mobilization under anesthesia may be a last resort in true adhesive capsulitis, but is more commonly used for posttraumatic or postoperative joint stiffness or adhesions that do not respond to conservative treatment. Case 9 A 24-year-old female presents to the clinic 24 hours after slipping on a patch of ice outside her home. She reports feeling a pop and immediate pain on the lateral aspect of the ankle. She reports significant swelling in the first few hours, with pain and inability to bear weight initially, but now she is able to walk with a significant limp. She reports no significant past injuries to the foot or ankle. On exam, you note edema/ effusion over the lateral ankle, some ecchymosis, tenderness, but no laxity on anterior drawer and inversion stress. There is no bony tenderness on palpation of the foot and ankle, but there is tenderness anterolaterally in the soft tissue. The most likely injury this patient has suffered is: A) Fracture of the distal tibia.

B) Fracture of the distal fibula. C) Sprain of the lateral ligament complex. D) Sprain of the medial ligament complex. E) Syndesmosis sprain. Answer: C Discussion The correct answer is C. A sprain is most likely because there is no bony tenderness. And, since she is tender laterally, the lateral ligament complex is most likely sprained. In this case, the most likely structure injured would be the: A) Anterior talofibular ligament. B) Distal fibula. C) Distal tibia. D) Deltoid ligament. E) Achilles tendon. Answer: A Discussion The correct answer is A. This is a sprain of the anterior talofibular ligament. This is the first ligament injured with an inversion ankle sprain. It is followed by the calcaneofibular ligament if enough force is involved. Answer E, Achilles tendon injury (specifically rupture), is of special note. First, this injury presents as pain in the Achilles tendon area. With a complete Achilles tendon tear, the patient will have marked weakness of plantar flexion. A diagnostic test (Thompson test) is to squeeze the posterior calf. In response, the foot should plantar flex. If this does not occur, consider Achilles rupture. Operative and nonoperative treatments have been used. Operative treatment carries a lower risk of re-rupture. Which of the following is the most appropriate management of this patients injury? A) Cast for 4 weeks followed by physical therapy. B) Crutches, non-weight-bearing for 2 weeks, and then progressive physical therapy. C) Rest, ice, elevation, and early mobilization using external support, crutches or cane if needed. Progress to activity as tolerated. D) Refer for orthopedic consultation. E) Immobilization, heat for comfort, analgesics or NSAIDs, and progress to activities as tolerated. Answer: C Discussion The correct answer is C. Treatment for most grade I and II sprains includes external support, such as an air or gel splint, ice application, and elevation; early mobilization is critical and will hasten recovery. NSAIDs or acetaminophen should be used for pain control. The patient should be allowed partial weight bearing as tolerated with crutches or a cane. Patients with recurrent problems of instability or an acute grade III sprain should be referred to an orthopedist for evaluation.

Ottawa Ankle Rules

Case 10 A 45-year-old female hospital clerk presents with bilateral aching pain in the forearms and thenar eminences. The pain is made worse with driving and typing. She also has intermittent numbness over the same areas. She tried to ignore the symptoms, but today she dropped her coffee mug on her computer keyboard and became alarmed at her loss of strength. She has hypothyroidism and is obese, but she reports that her health is otherwise good. Based on the history alone, which of the following is the most likely diagnosis? A) Carpal tunnel syndrome. B) Osteoathritis. C) Ulnar neuropathy. D) Diabetic neuropathy. Answer: A Discussion The correct answer is A. Carpal tunnel syndrome is due to median nerve entrapment in the carpal tunnel of the wrist. Typical symptoms include numbness, paresthesias, and pain at the palmar/radial aspect of the hand, quintessentially the thenar eminence. In more severe or long-lasting cases, you may see atrophy of the thenar eminence. Patients may also develop weakness of thumb opposition. Ostoearthritis of the wrists does not usually give the neurological symptoms of numbness and weakness; however, osteoarthritis of the cervical spine can cause spondylosis and nerve root impingement. Ulnar neuropathy involves the ulnar aspect of the arm, rather than the radial aspect, which is involved with carpal tunnel syndrome. Diabetic neuropathy typically presents in the feet, since they are innervated by the longest nerves in the body.

On exam, Tinels sign is positive (tapping over the median nerve at the wrist produces tingling in the first 3 digits and the radial half of the ring finger). Also, Phalens sign is positive (placing the wrists in a flexed position causes aching and numbness in the median nerve distribution). What is the best next step in the continuing evaluation and management of this patient? A) Nerve conduction studies. B) Radiograph of the wrist. C) MRI of the cervical spine. D) Orthopedic referral. E) Initiation of treatment. Answer: E Discussion The correct answer is E. In a clear-cut case of carpal tunnel syndrome, there is no need for further studies. If the diagnosis is in doubt, EMG/nerve conduction studies may be of benefit. If the ROM in the wrist is limited, x-rays may be helpful. At this point in time, MRI and orthopedic referral are not likely to add much. Which of the following is NOT associated with carpal tunnel syndrome? A) Hypothyroidism. B) Diabetes mellitus. C) Amyloid. D) Polycythemia vera. E) Rheumatoid arthritis. Answer: D Discussion The correct answer is D. All of the above are associated with carpal tunnel syndrome except for polycythemia vera. Polycythemia vera can cause a painful condition of the hands called erythromelalgia, which is a burning pain of the hands and feet associated with erythema, pallor, or cyanosis. It responds to aspirin. The point here is that patients with carpal tunnel syndrome should have a systemic cause ruled out either clinically or with labs. What is the most appropriate initial treatment? A) Thumb spica splint. B) Steroid injection. C) NSAIDs and neutral position wrist splints. D) Short arm casts. Answer: C Discussion The correct answer is C. Conservative therapy should be initiated first, unless there is some compelling reason for more aggressive therapy (e.g., severe weakness of the hands and loss of function). Most patients respond well to NSAIDs and the use of neutral position splints. The traditional cock-up splints are not as effective as neutral position splints. The splints should be worn at night. The patient may wear the splints during the day, too, but she should take them off for several hours per day to avoid disuse muscle atrophy. Answer A is incorrect; a thumb spica is not needed. Answer B, steroid injection, might be tried if initial conservative measures fail. If you choose to perform a steroid injection, avoid injecting steroids directly into the median nerve. Answer D is just wrongdont cast patients with carpal tunnel syndrome!