A 42-year-old nurse presents with pain in her right foot. Six hours ago, she stepped in a hole and fell, twisting her foot while her weight was on it. She is unable to bear weight due to the pain. On examination, there is moderate swelling and tenderness to palpation over the dorsum of the midfoot.
The most likely diagnosis is:
Correct Answer D: A careful history, physical examination, and diagnostic studies usually lead to appropriate treatment of foot and ankle injuries. However, Lisfranc fracture/dislocation can be difficult to detect both clinically and radiographically. To help ensure that a Lisfranc injury is not missed, and foot with pain and swelling resulting from trauma must be examined radiographically. A fracture of the base of a metatarsal bone indicates a possible Lisfranc injury. Furthermore, if soft tissue edema persists after an injury to the foot, a Lisfranc injury should be ruled out.
Of the other conditions, only the cuneiform fractures affect the midfoot; these are extremely uncommon, and usually result from a direct blow to the foot rather than the twisting injury described in this case.
A 64-year-old white male smoker presents after an episode of numbness over the left side of his face and left arm that resolved within approximately 1 hour. Results of a workup include an LDL cholesterol level of 4.1 mmol/L (161 mg/dL), a normal CT brain scan, and carotid ultrasonography showing 40% stenosis of the right carotid artery and 60% stenosis of the left carotid artery.
Which one of the following would be least appropriate at this point?
Correct Answer A: Typical symptoms of carotid artery disease are contralateral weakness or sensory disturbance, ipsilateral blindness, and (if the dominant hemisphere is involved) Dysphasia, aphasia or speech apraxia. Cognitive impairment and decline are associated with asymptomatic high-grade stenosis of the left internal carotid artery.
This patient’s symptoms suggest right carotid artery disease; therefore, the left carotid stenosis should be considered an asymptomatic lesion not requiring surgery (endarterectomy).
Other studies should be performed to find the cause of this patient’s reversible ischemic neurologic deficit (RIND) or transient ischemic attack (TIA), including Echocardiography, cardiac rhythm monitoring, and additional laboratory studies. Risk factors should be addressed, including discontinuing tobacco, treating hypertension, and lowering the LDL level to below 2.6 mmol/L (100 mg/dL). Treatment would include antiplatelet therapy with aspirin, clopidogrel, ticlopidine, or aspirin with dipyridamole.
A 73-year-old black male being treated with warfarin (Coumadin) for chronic atrial fibrillation has been scheduled by his podiatrist for a bunionectomy. He has no history of a previous thromboembolic event, and his most recent INR was 2.5. The patient consults you regarding the preoperative and postoperative management of his anticoagulation.
You plan to stop his regular daily warfarin dose 3-4 days prior to his scheduled operation and restart it the day after.
Which one of the following would be most appropriate during the 4-5 days he is not taking his regular warfarin?
Correct Answer A: Guidelines have been established for the management of anticoagulation during invasive procedures. Patients with lone atrial fibrillation without previous thromboembolic events are at low risk (<1% annualized thrombotic risk) for a thrombotic event in the absence of anticoagulation. They can be safely managed with cessation of warfarin 3-4 days preoperatively, and resumption of warfarin postoperatively when the surgeon indicates it is safe to do so.
If the operative procedure is associated with a high risk of thrombosis, then prophylactic, rather than therapeutic, doses of unfractionated or low-molecular-weight heparin can be used as a postoperative bridge to restarting warfarin.
Patients at high risk for a thrombotic event in the absence of anticoagulation, such as those with prosthetic heart valves, should be managed by stopping warfarin 3-4 days preoperatively, beginning fully therapeutic doses of low-molecular weight heparin or intravenous unfractionated heparin when the INR decreases below the therapeutic range, stopping therapy briefly for surgery, and then resuming the heparin bridge postoperatively until warfarin is resumed. Dental procedures do not generally require interruption of anticoagulation therapy with warfarin.
A 55-year-old male with coronary artery disease undergoes coronary artery bypass grafting (CABG). The operation is uneventful, but 2 hours after the surgery he suddenly spikes a fever to 40.0˚C (104.0˚F). The patient’s pulse rate is 110 beats/min and his blood pressure is 140/85 mm Hg. He remains on the ventilator and does not awaken during the episode. The physical examination is otherwise unremarkable except for his surgical incisions. He has no history of recent infection prior to the surgery and his WBC count is not elevated. Apart from hypertension and coronary artery disease, his past medical and surgical histories are negative.
The most likely explanation for this patient’s fever is:
Correct Answer D: Malignant hyperthermia is an inherited myopathy in which abnormalities of skeletal-muscle sarcoplasmic reticulum cause an increase in intracellular calcium levels, resulting in sustained muscular contraction and a hypermetabolic state. This condition is most often triggered by inhalational anesthetics (e.g., halothane) or by succinylcholine, used for muscle paralysis. It results in a sudden rise in temperature, tachycardia, increased muscle tone, and eventual muscle rigidity. If unrecognized and untreated, there is a downward spiral with rhabdomyolysis, acidosis, renal failure, cardiovascular instability, and death. It usually presents in the operating room or the recovery room, and prompt recognition and treatment with dantrolene, along with cooling the patient, reduces morbidity and mortality risks.
While urosepsis, pneumonia, and bacteremia are possible complications of the surgery, none of these is the most likely cause of fever in this scenario. Post-pericardiotomy syndrome (Dressler’s syndrome) occurs at least 2 weeks postoperatively and is manifested by low-grade fever and chest pain.
A 35-year-old white female presents to your office with a history of three episodes of intense right upper quadrant pain over the last few weeks. Each attack developed a few hours after her evening meal, lasted 1-2 hours, and was accompanied by nausea. Between episodes she feels fine. She went to the emergency department after the third episode, and blood tests and a sonogram of the gallbladder were negative.
Which one of the following would you recommend?
Correct Answer C: This patient has biliary colic but does not have gallstones. Most such patients have biliary dyskinesia, which can be assessed well by a nuclear scan of the gallbladder with injection of cholecystokinin. Although some controversy exists with regard to this problem, confirmed cases tend to have a good response to cholecystectomy.
Click to expand