Assuming other appropriate measures are used (e.g., automatic anti-decubitus mattresses, local care, etc.), which one of the following represents the patient positioning most beneficial in the care of a sacral decubitus ulcer?
Correct Answer A: The 30° oblique position is well tolerated by elderly patients and can be used in almost any setting. The once common 90° lateral position leads to trochanteric ulcers. The supine position contributes to the already present sacral decubitus, and thus should be avoided, even as part of a regular turning schedule or pressure-reducing methods.
A 62 year old white female comes to see you for her annual pelvic examination. You find a nontender, cystic left adnexal mass. The patient is asymptomatic and otherwise in good health, and has no other pelvic abnormalities. Transvaginal ultrasonography demonstrates a 5-cm septated left ovarian cyst. Her CA-125 level is 120 U/mL (N <35).
The best management option is to:
Correct Answer E: A postmenopausal woman with an ovarian cyst > 3 cm in size associated with elevated CA-125, especially a level > 100 U/mL, should be referred to a surgeon for evaluation. Other benign conditions could cause elevation of CA-125, but usually to levels < 100 U/mL. The ultrasonography and CA-125 could be repeated periodically if the cyst were < 3 cm and the CA-125 level were normal. Repeat clinical examination would be inadequate, and reexamination following treatment with estrogen plus progestin would add no useful information. All of the other options would only delay the surgical evaluation, which is essential in this situation.
A 75 year old white female develops deep-vein thrombosis of the left leg 1 week after hip surgery. The patient is started on low-molecular-weight heparin (Lovenox). Daily monitoring while the patient is on low-molecular-weight heparin should include which one of the following?
Correct Answer D: Routine coagulation tests such as prothrombin time and partial thromboplastin time are insensitive measurements of Lovenox activity. Anti-factor Xa can be measured in patients with renal failure to monitor anti-coagulation effects.
The most common stress fracture in children involves which one of the following bones?
Correct Answer B: Tibial fractures are the most common lower extremity stress fractures in children, accounting for about half of all stress fractures.
A 25-year-old male presents with a 3-week history of gradually worsening foot pain. He does not recall any acute injury, but he is a recreational runner and admits to increasing his distance around the time the symptoms began. Findings on examination are consistent with a fracture of the neck of the second metatarsal.
Which one of the following would be most appropriate?
Correct Answer D: This patient has a classic stress fracture of the second metatarsal. This results from repetitive stress to the forefoot, in his case from increasing his running distance. Stress fracture usually begin as a gradual onset of pain in the forefoot, initially when active, but later also at rest. Radiographs may not be positive for 2-6 weeks after the onset of symptoms. The neck of the second metatarsal is most commonly involved.
Unlike acute fractures, a stress fracture does not require casting. It can be managed by limiting the stresses that cause it to happen, and which continue to cause discomfort. Activity can be continued as long as it does not cause discomfort. Limiting analgesic use allows the patient to know when he is overdoing it. NSAIDs may slow the healing process and most specialists recommend they not be used in this situation.
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