A 39-year-old woman arrives at the hospital after her third episode of dizziness. Her first episode was 6 months ago and her most recent episode occurred yesterday. She describes feeling as if the room was spinning around her. During each of these episodes she has experienced significant nausea, often accompanied by emesis. Upon further questioning she tells you that she has been hearing a low rumbling noise in her right ear.
What test is required to confirm your diagnosis?
Audiogram. This patient is experiencing vertigo and tinnitus as evidenced by her episodes of spinning sensation and low rumbling noise in her right ear. These are two of the three main clinical signs of Meniere disease, an autosomal dominant condition that is characterized by episodic vertigo, tinnitus, and sensorineural hearing loss. A definite diagnosis requires all three features, so the next step should be an audiogram to test for sensorineural hearing loss. (A, B) A CT or MRI head does not play a diagnostic role in the evaluation of Meniere disease. (D) A tilt table test may be used in the evaluation of suspected neurocardiogenic syncope.
A 56-year-old woman is hospitalized for an asthma exacerbation. She is treated with continuous nebulized ipratropium and albuterol. She recovers without complications and is discharged. Upon questioning she states that she currently uses an albuterol inhaler nearly every day and a daily low-dose inhaled corticosteroid. She states that she wakes up about one to two times per week in the middle of the night due to her asthma. Pulmonary function tests reveal a FEV1 of 75%.
What is the best pharmacologic addition for the management of her asthma?
Begin a long-acting b-agonist. This patient has moderate persistent asthma based on her frequency of symptoms and her FEV1. The best management option is to step up her asthma therapy, and there are two options: add a long-acting β-agonist to her regimen, or increase her low-dose inhaled corticosteroid to a medium-dose inhaled corticosteroid. (A) Oral corticosteroids are a last resort if symptoms fail to improve with a long-acting β-agonist and a high-dose inhaled corticosteroid. (C) The next step would be a medium-dose, not high-dose, inhaled corticosteroid. (D, E) Theophylline and omalizumab are used as alternative agents but are not first-line treatment options in step-up therapy.
A 38-year-old IV drug abuser comes to the Emergency Department with a 3-day history of low-grade fevers and pleuritic chest pain. On examination, he has nail bed hemorrhages, nontender ecchymotic lesions on the palms (Figure below), small petechiae on the palatal mucosa, and a right-sided diastolic murmur. He has no focal neurologic deficit.
Which of the following should be done urgently for this patient?
Begin vancomycin. This patient is presenting with acute bacterial endocarditis, which is often caused by gram-positive organisms (especially S. aureus in IV drug users). The figure above shows Janeway lesions as a result of septic emboli. The appropriate empiric treatment, after blood cultures are sent, is to immediately begin vancomycin since it will cover S. aureus (and MRSA). (E) Ceftriaxone and gentamicin are used empirically to treat subacute bacterial endocarditis. (B, C) This patient does not have liver or heart failure. (D) A CT chest with contrast may be used to diagnose pulmonary embolism. Septic emboli to the lungs may be present if the patient has a right-sided vegetation; however, this diagnostic test is not indicated as part of the workup.
A 59-year-old man is admitted for an acute flare of his chronic tophaceous gout and is found to be anemic with a hemoglobin of 8.9 g/dL. Additional studies show a mean corpuscular volume of 75 μm3 , a serum ferritin of 14 ng/mL, and a serum iron of 35 μg/dL. He is hemodynamically stable and denies any hematochezia or melena.
Which of the following is the best next step?
Outpatient colonoscopy. This patient has a microcytic anemia with low ferritin and low iron levels that is consistent with irondeficiency anemia. All patients should receive a screening colonoscopy at the age of 50; however, this patient has an additional reason for having a colonoscopy— all patients older than 50 with microcytic anemia in the absence of any obvious blood loss is a red flag for colorectal cancer. (A) The patient is hemodynamically stable without any signs of active GI bleeding and therefore does not require an emergent inpatient colonoscopy. (B) A conservative approach to blood transfusion is the best option in this stable patient, and his hemoglobin is not low enough to warrant transfusion. (C) While repeating a CBC to ensure that his hemoglobin is not rapidly dropping may be a good idea; there is no value in repeating iron studies in 1 week.
A 29-year-old Caucasian man presents with fever and foot pain 4 days after he stepped on a nail while exercising on an outdoor track. Examination reveals a deep tissue abscess at the puncture site. No crepitus is noted. Laboratory studies reveal leukocytosis and an ESR of 120 mm/h. The patient is up-to-date on all vaccinations.
After surgical debridement of the injury, antibiotic therapy should be chosen to best cover which of the following pathogens?
Pseudomonas aeruginosa. Pseudomonas aeruginosa is a common cause of osteomyelitis following nail puncture, especially in people wearing tennis shoes. (A) The patient is not exhibiting symptoms of tetanus (muscle spasms, trismus, risus sardonicus, opisthotonos, etc.), which is primarily managed with tetanus immune globulin in unvaccinated patients. (C) The patient examination and mechanism of injury is less suggestive of S. pyogenes infection, though this is a common cause of cellulitis. (D) MAC infection is associated with HIV and is unlikely to be the cause of this patient’s osteomyelitis. (E) Salmonella osteomyelitis is associated with sickle cell disease.
Click to expand