A 55-year-old overweight male presents with a complaint of pain in the left big toe. He recently started jogging 2 miles a day to try to lose weight, but has not changed his diet and says he drinks 4 cans of beer every night. The pain has developed gradually over the last 2 weeks and is worse after running. An examination shows a normal foot with tenderness and swelling of the medial plantar aspect of the left first metatarsophalangeal joint. Passive dorsiflexion of the toe causes pain in that area. Plantar flexion produces no discomfort, and no numbness can be appreciated.
Which one of the following is the most likely diagnosis?
Correct Answer A: Pain involving the big toe is a common problem. The first metatarsophalangeal (MTP) joint has two sesamoid bones, and injuries to these bones account for 12% of big-toe injuries. Overuse, a sharp blow, and sudden dorsiflexion are the most common mechanisms of injury.
Gout commonly involves the first MTP joint, but the onset is sudden, with warmth, redness, and swelling, and pain on movement of the joint is common. Morton’s neuroma commonly causes numbness involving the digital nerve in the area, and usually is caused by the nerve being pinched between metatarsal heads in the center of the foot. Cellulitis of the foot is common, and can result from inoculation through a subtle crack in the skin. However, there would be redness and swelling, and the process is usually more generalized.
Sesamoiditis is often hard to differentiate from a true sesamoid fracture. Radiographs should be obtained, but at times they are nondiagnostic. Treatment, fortunately, is similar, unless the fracture is open or widely displaced. Limiting weight bearing and flexion to control discomfort is the first step. More complex treatments may be needed if the problem does not resolve in 4-6 weeks.
A 32-year-old farmer comes to your office because of an upper respiratory infection. While he is there he points out a lesion on his forearm that he first noted approximately 1 year ago. It is a 1-cm asymmetric nodule with an irregular border and variations in color from black to blue. The patient says that it itches and has been enlarging for the past 2 months. He says he is so busy that he is not sure when he can return to have it taken care of.
In such cases the best approach would be to:
Correct Answer D: Despite this individual’s busy schedule, he has a potentially life-threatening problem that needs proper diagnosis and treatment. Though an excisional biopsy takes longer, it is the procedure of choice when melanoma is suspected. After removal and diagnosis, prompt referral is essential for further evaluation and therapy. A shave biopsy should never be done for suspected melanoma, as this is likely to transect the lesion and destroy evidence concerning its depth, thus making it difficult to assess the prognosis. A punch biopsy should be used only with discretion when the lesion is too large for complete excision, or if substantial disfigurement would occur. Since this may not actually retrieve cancerous tissue from an un-sampled area of a large lesion that might be malignant, it would be safest to refer such patients. Neither cryotherapy nor electrocautery should be used for a suspected melanoma.
An absolute contraindication for diagnostic laparoscopy is:
Correct Answer D: Diagnostic laparoscopy is a surgical procedure used to evaluate intra-abdominal or pelvic pathology (eg, tumor, endometriosis) in patients with acute or chronic abdominal pain and operability in patients with cancer. It is also used for lymphoma staging and liver biopsy. Absolute contraindications include a coagulation or bleeding disorder, poor patient cooperation, peritonitis, intestinal obstruction, and infection of the abdominal wall. Relative contraindications include severe cardiac or pulmonary disease, large abdominal hernias, multiple abdominal operations, and tense ascites.
One day after an orthopedic procedure to fix a femoral bone fracture by trauma, a 36-year-old white woman develops tachycardia, tachypnea, dyspnea, and hypoxia.
What is the most likely diagnosis?
Correct Answer D: Fat embolism can cause acute respiratory failure after long-bone fractures. It is thought to be caused by deposition of embolic fat within the pulmonary capillaries, resulting in a capillary leak within the lung.
The source of the embolic fat appears to be marrow fat. Alterations in circulating free fatty acids, increases in fibrin split products, and increases in platelet adhesiveness have been observed to occur in this syndrome and probably play an important part in the production of the pulmonary lesion.
The signs and symptoms of the syndrome are hypoxemia, tachypnea, petechiae, fever, altered sensorium, and chest Xrays similar to signs of the adult respiratory distress syndrome (ARDS).
Early recognition is facilitated by monitoring of arterial blood gas levels for hypoxemia. Treatment is directed at ARDS using graduated oxygen therapy and steroids.
Following surgery for a left hemi-thyroidectomy the patient is found to have persistent hoarseness.
Which one of the following nerves is most likely to have been injured?
Correct Answer D: Recurrent laryngeal nerve paralysis is caused by neck or thoracic lesions trauma and thyroidectomy.
Vocal cord paralysis results in loss of vocal cord abduction and adduction. Paralysis may affect phonation, respiration, and deglutition, and food and fluids may be aspirated into the trachea. In recurrent laryngeal nerve paralysis, the cord may move with phonation but not with inspiration. In unilateral paralysis, the voice may be hoarse and breathy, but the airway is usually not obstructed because the normal cord abducts sufficiently.
Click to expand