A diabetic patient has a deep 2x3 cm dorsal foot ulcer, and you are concerned about the presence of osteomyelitis.
Which one of the following would be most cost-effective for evaluating this problem?
Correct Answer D: A recent study of foot ulcers in diabetics showed that finding palpable bone at the base of an ulcer with no intervening soft tissue had a higher positive predictive value than any type of imaging study, and correlated highly with the presence of underlying osteomyelitis. Other tests listed are less likely to be diagnostic and are much more expensive than simple probing of a wound.
Which of the following statements regarding epistaxis is true?
Correct Answer D: Epistaxis is nose bleeding, which occurs from the anterior or posterior portion of the nasal septum. Diagnosis is by direct visualization. Treatment varies by site of bleeding but includes cautery and various types of packing. The bleeding point may then be cauterized with electrocautery or silver nitrate on an applicator stick.
Six days following a hemicolectomy for colorectal carcinoma, a 54 year old woman experiences calf pain unilaterally. On physical examination, the affected side has a greater diameter than the other, and there is tenderness to palpation.
Which of the following investigations would be the next step?
Correct Answer B: Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. DVT can occur after a surgery. On average around day 7 post operatively. DVT results from conditions that impair venous return, lead to endothelial injury or dysfunction, or cause hypercoagulability. DVT may be asymptomatic or cause pain and swelling in an extremity. Diagnosis is by history, physical examination, and duplex ultrasonography, with d-dimer or other testing as necessary. Treatment is with anticoagulants.
Which one of the following procedures carries the highest risk for postoperative deep venous thrombosis?
Correct Answer E: Neurosurgical procedures, particularly those with penetration of the brain or meninges, and orthopedic surgeries, especially those of the hip, have been linked with the highest incidence of venous thromboembolic events. The risk is due to immobilization, venous injury and stasis, and impairment of natural anticoagulants. For total knee replacement, hip fracture surgery, and total hip replacement, the prevalence of DVT is 40%-80%, and the prevalence of pulmonary embolism is 2%-30%. Other orthopedic procedures, such as elective spine procedures, have a much lower rate, approximately 5%. The prevalence of DVT after a coronary artery bypass graft is approximately 5%, after transurethral prostatectomy < 5%, and after abdominal hysterectomy approximately 16%.
A 72-year-old white female is scheduled to undergo a total knee replacement for symptomatic osteoarthritis. She is otherwise healthy, with no history of vascular disease or deep vein thrombosis. She takes no routine medications.
Which one of the following is most appropriate for prophylaxis against deep vein thrombosis?
Correct Answer E: Prophylaxis is indicated with total knee or hip replacements. The two regimens recommended are low-molecular-weight heparin and adjusted-dose warfarin. These may be augmented by intermittent pneumatic compression.
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