An 82 year old white male has a transient ischemic attack. A carotid duplex study reveals an 85% stenosis in the affected carotid artery.
Which one of the following would be the most appropriate management at this time?
Correct Answer E: Carotid endarterectomy is beneficial in patients with internal carotid artery stenosis of 70%-99% who have had a stroke or a transient ischemic attack attributable to the stenosis. The short-term risk of stroke is high among patients with severe stenosis of the internal carotid artery. Although data is lacking on the optimal timing of endarterectomy, when infarction is absent or limited, urgent endarterectomy is probably indicated for patients with internal carotid artery stenosis of 70%-99% and in selected patients with stenosis of 50%-69% who can be treated surgically with a low risk of complications.
A 69-year-old woman presents with the following toe nail infection.
She has had it for several months and would like to treat it because she hates the way it looks.
What is the most appropriate treatment?
Correct Answer D: Onychomycosis is fungal infection of the nail plate, nail bed, or both. Nails have asymptomatic patches of white or yellow discoloration and deformity. There are 3 characteristic presentations: (1) distal subungual, in which the nails thicken and yellow, keratin and debris accumulate distally and underneath, and the nail separates from the nail bed (onycholysis); (2) proximal subungual, a form that starts proximally and is a marker of immunosuppression; and (3) white superficial, in which a chalky white scale slowly spreads beneath the nail surface.
Diagnosis is by appearance and microscopic examination and culture of scrapings. Treatment is oral itraconazole or terbinafine. Itraconazole 200 mg bid 1 week/month for 3 months, or terbinafine 250 mg once/day for 12 weeks (6 weeks for fingernail), achieves a high cure rate.
A 62-year-old woman comes to the office because of pain in the left lower quadrant of her abdomen for the past 48 hours. The pain is associated with tenesmus, loss of appetite and a sensation of being febrile. She has a history of longstanding irritable bowel symptoms and has not taken any pharmacotherapy. Vital signs are: temperature 37.3°C (99.2°F), pulse 84/min and regular and respirations 12/min. On physical examination the abdomen is tender in the left lower quadrant; there is no rebound tenderness and bowel sounds are normal. Leukocyte count is 10.2 x10^9/L with 71% segmented neutrophils and 3% band forms. The patient is sent home on a liquid diet and amoxicillin-clavulanate therapy. Three days later she returns because the pain has become worse and she is now having chills.
Which of the following is the most appropriate next step?
Correct Answer A: The patient described has diverticulosis leading to diverticulitis. You must start antibiotics that cover the gram-positive cocci, gram-negative bacilli and anaerobes found in the abdomen. Cefoxitin (choice A) fits the bill. The severity of the inflammatory and infectious processes, as well as the underlying health of the patient, determines the appropriate treatment for patients with diverticulitis. Hospitalization is recommended if patients show signs of significant inflammation, are unable to take oral fluids, are older than 85 years, or have significant comorbid conditions. These patients should be placed on bowel rest and treated with intravenous fluids and intravenous antibiotics.
→ Immediate surgery (choice B) is too aggressive at this point. Most patients with acute diverticulitis respond to conservative inpatient medical management.
→The usual outpatient antibiotic regimen includes ciprofloxacin (500 mg PO twice daily) plus metronidazole (500 mg PO three times daily). For patients intolerant to metronidazole, clindamycin (choice C) may be an acceptable alternative.
→ Continuing the present therapy (choice D) is incorrect because the worsening pain and chills imply infection.
→ Colonoscopy (choice E) is dangerous in diverticulitis because it can lead to perforation.
Surgical indications for diverticulitis include all of the following, except:
Correct Answer D: Diverticulitis is inflammation of a diverticulum, which can result in phlegmon of the bowel wall, peritonitis, perforation, fistula, or abscess. The primary symptom is abdominal pain. Diagnosis is by CT scan. Treatment is with antibiotics (ciprofloxacin, or a 3rd-generation cephalosporin plus metronidazole) and occasionally surgery.
Surgery is required immediately for patients with free perforation or general peritonitis and for patients with severe symptoms that do not respond to nonsurgical treatment within 48 hours. Increasing pain, tenderness, and fever are other signs that surgery is needed. Surgery should also be considered in patients with any of the following: ≥ 2 previous attacks of mild diverticulitis (or one attack in a patient < 50); a persistent tender mass; clinical, endoscopic, or x-ray signs suggestive of cancer; and dysuria associated with diverticulitis in men (or in women who have had a hysterectomy), because this symptom may presage perforation into the bladder.
An overweight, 55-year-old man presents with left lower quadrant tenderness and a one week history of abdominal pain, loose non-bloody stools and worsening fever. Laboratory investigation yields leukocytosis with neutrophilia and left shift.
What is the diagnostic modality of choice?
Correct Answer A: Diverticulitis is inflammation of a diverticulum, which can result in phlegmon of the bowel wall, peritonitis, perforation, fistula, or abscess. The primary symptom is left lower quadrant abdominal pain. Diagnosis is by CT scan. Treatment is with antibiotics (ciprofloxacin, or a 3rd-generation cephalosporin plus metronidazole) and occasionally surgery.
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