A patient who is scheduled for an elective surgery, is currently taking Coumadin.
What lab test is best for evaluating this patients current Coumadin (Warfarin) level?
Correct Answer A: International normalized ratio (INR), is a ratio of the patients PT to a control PT. All results are standardized using the international sensitivity index.
For example, a person taking the anticoagulant warfarin (brand name: Coumadin) might optimally maintain a prothrombin time (a "pro time" or PT) of 2 to 3 INR. No matter what laboratory checks the prothrombin time, the result should be the same even if different thromboplastins and instruments are used.
This international standardization permits the patient on warfarin to travel and still obtain comparable test results.
A 5-year-old male is scheduled for elective hernia repair at 11:00 am.
Which one of the following would be the most appropriate recommendation?
Correct Answer A: Recent guidelines recommend the following restrictions on diet prior to surgery for pediatric patients: 8 hours for solid food, 6 hours for formula, 4 hours for breast milk, and 2 hours for clear liquids. These changes have resulted in decreased numbers of canceled cases and pediatric patients who are less irritable preoperatively and less dehydrated at the time of anesthesia induction.
First time presentation of painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy are best treated by:
Correction Answer D: Excision of the lateral nail plate with lateral matricectomy (choice D) yields the best results in the treatment of painful ingrown toenails that display granulation tissue and lateral nail fold hypertrophy.
→ Antibiotic therapy (choice A) and cotton-wick elevation (choice B) are acceptable for very mildly inflamed ingrown toenails.
→ Permanent nail ablation (choice C) should be considered in patients with recurrent ingrown toenails.
→ All patients should be educated about importance of well-fitting shoes and proper nail trimming (choice E); the lateral nail plate should be allowed to grow well beyond the lateral nail fold before trimming horizontally. This patient should be taught about proper nail care, but the presenting condition should be treated with excision.
A 30-year-old white male visits your clinic after being in a bar fight. He describes hitting another man in the mouth with his closed fist. He reports a painful distal fifth metacarpal with a superficial abrasion.
After assessing tetanus status and copiously irrigating the wound, you should do which one of the following?
Correct Answer A: This presentation is consistent with a common injury called a “fight bite”. Radiographs are needed to determine if there is a distal metacarpal fracture so that it can be treated appropriately. Because human bites commonly cause infection, prophylactic antibiotics are recommended with any break in the skin. If the skin break is superficial, this is sufficient. Deeper wounds should be explored by a surgeon, but superficial wounds should not be probed indiscriminately.
An 80-year-old male presents with the chief complain of a “bone spur”, describing mid-heel pain that worsens as the day progresses. The pain is not relieved with ibuprofen. Examination reveals tenderness in the central aspect of the heel and a radiograph of the foot is unremarkable.
The most likely diagnosis is:
Correct Answer B: Fat-pad atrophy is a common cause of heel pain in the geriatric patient, and in contrast to plantar fasciitis, causes pain as the day progresses.
→ Plantar fasciitis classically presents as morning pain.
→ Tarsal tunnel syndrome causes neuropathic pain in the distribution of the posterior tibial nerve, radiating into the plantar aspect of the foot toward the toes.
→ Lumbar radiculopathy involves pain radiating down the leg into the heel, and is usually associated with weakness of dorsiflexion of the big toe and a decreased ankle reflex.
→ Multiple myeloma would be an extremely unusual cause of heel pain; heel pain associated with cancer more commonly presents nocturnally
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