The answer is C. The combination of wrist pain and grip weakness is characteristic of de Quervain’s tenosynovitis. Local tenderness is present over the distal portion of the radial styloid adjacent to abductor pocillis longus tendon. The pain is generally reproduced with direct palpation of the involved tendons. Pain is aggravated by passively stretching the thumb tendons over the radial styloid in thumb flexion (the Finkelstein maneuver).

Carpal tunnel syndrome will present with parathesia and/or weakness primarily in the distribution of the median nerves— thumb and index finger. A scaphoid fracture presents with mild, dull pain, deep in the radial wrist that is worsened when making a grip. On exam, there is tenderness to palpation in the anatomical “snuff box”—this is a sensitive, but not specific test. A boxer’s fracture refers to a fracture of the midshaft of the 5th metacarpal (typically following a blow with a closed fist). A hamate fracture presents with pain along the ulnar side of the hand and is frequently seen in sports that require swinging of bats or racquets.

Additional Reading: de Quervain’s tenosynovitis. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Musculoskeletal system

The answer is B. Controlled studies have not found patching to improve the rate of healing or comfort in patients with traumatic or foreign body abrasions. Patients should be treated with topical antibiotics to prevent superinfection. Antibiotics ointment is better than drops.

If a corneal foreign body is detected, an attempt can be made to remove it by irrigation. The topical anesthetics administration is controversial. Animal studies showed that it can delay corneal epithelial healing. In humans, some studies showed that dilute solutions of proparacaine 0.05% provide analgesia without impairing healing after several days of treatment.

Additional Reading: Evaluation and management of corneal abrasions. Am Fam Physician. 2013;87(2):114-120.

Category: Special sensory

The answer is D. Disruption of the flexor digitorum profundus tendon, also known as jersey finger, commonly occurs when an athlete’s finger catches on another player’s clothing, usually while playing a tackling sport such as football or rugby. The injury causes forced extension of the distal interphalangeal (DIP) joint during active flexion. The ring finger is the weakest finger and accounts for 75% of jersey finger cases. Acute pain and swelling over the volar aspect of the DIP joint and distal phalanx is characteristic. The characteristic finding of jersey finger is the inability to actively flex the DIP joint.

Additional Reading: Acute finger injuries: Part I. Tendons and ligaments. Am Fam Physician. 2006;73:810-816, 823.

Category: Musculoskeletal system

The answer is C. Injury to the extensor tendon at the DIP joint is also known as mallet finger. The condition is the most common closed tendon injury of the finger. Mallet finger is usually caused by an object (e.g., a ball) striking the finger, creating a forced flexion of an extended DIP. The extensor tendon may be strained, partially torn, or completely ruptured or separated by a distal phalanx avulsion fracture. Those affected with mallet finger complain of pain at the dorsal DIP joint; inability to actively extend the joint; and, often, with a characteristic flexion deformity. It is critical to isolate the DIP joint during the evaluation to ensure extension is from the extensor tendon and not the central slip. The absence of full passive extension may indicate bony or soft tissue entrapment requiring surgical intervention. Mallet finger most often involves the middle finger and the next.

Additional Reading: Common finger fractures and dislocations. Am Fam Physician. 2012;85(8):805-810.

Category: Musculoskeletal system

The answer is C. Morton’s neuromas are typically found between the metatarsal of the third and fourth toes or at the bifurcation of the four plantar digital nerve. The second and third common digital branches of the medial plantar nerve are the most frequent sites for development of interdigital neuromas. Morton’s neuromas develop as a result of chronic trauma and repetitive stress, as occurs in persons wearing tight-fitting or high-heeled shoes. Pain and paresthesias are usually mild at onset and are located in the interdigital space of the affected nerve. In some cases, the interdigital space between the affected toes may be widened as a result of an associated ganglion or synovial cyst. Pain is noted in the affected interdigital space when the metatarsal heads of the foot are squeezed together. Injection with 1% lidocaine can assist in confirming the diagnosis.

Additional Reading: Busconi BD, Stevenson JH. Approach to the athlete with Morton’s neuroma. Sports Medicine Consult: A Problem-Based Approach to Sports Medicine for the Primary Care Physician. Philadelphia, PA: Lippincott, Williams & Wilkins; 2009.

Category: Musculoskeletal system

The answer is D. A noncontrast helical CT can detect both stones and urinary tract obstruction and has become the gold standard for the diagnosis of the stone disease. The specificity of helical CT is nearly 100%. Ultrasonography is the procedure of choice for patients who should avoid radiation, including pregnant women and possibly women of childbearing age. It is sensitive for the diagnosis of urinary tract obstruction and can detect radiolucent stones mixed on KUB. Intravenous pyelogram (IVP) has a higher sensitivity and specificity than an abdominal pain film for the detection of stones and provides data about the degree of obstruction.

Additional Reading: Treatment and prevention of kidney stones: an update. Am Fam Physician. 2011;84(11):1234-1242.

Category: Nephrologic system

The answer is D. The overall incidence of laparoscopic cholecystectomy bile duct injuries range from 1.7% in the first case to 0.17% at the 50th case (0.4 to 0.6). The incidence is four times higher that an open cholecystectomy. Between 5% and 26% of patients undergoing elective laparoscopic cholecystectomy require conversion to an open procedure. A common reason for conversion is the inability to clearly identify the biliary anatomy.

Additional Reading: Cholelithiasis. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Gastroenterology system

The answer is E. Fractures of the proximal portion of the fifth metatarsal may be classified as avulsions of the tuberosity or fractures of the shaft within 1.5 cm of the tuberosity. The tuberosity, or styloid, is the most proximal portion of the fifth metatarsal. It protrudes in the lateral and plantar planes. Fracture of the tuberosity are among the most common lower extremities fractures. Tuberosity avulsion fractures cause pain and tenderness at the base of the fifth metatarsal. Bruising, swelling, and other injuries may be present. Nondisplaced tuberosity fractures are usually treated conservatively and heal without difficulty; however, orthopedic referral is indicated for (a) fractures that are comminuted or displaced, (b) fractures that involve more than 30% of the cubometatarsal articulation surface, and (c) fractures with delayed union. Management and prognosis of acute (Jones fracture) and stress fracture of the fifth metatarsal within 1.5 cm of the tuberosity depend on the type of fracture, on the basis of classification. Simple fractures are generally treated conservatively with a non-weight-bearing short leg cast for 6 to 8 weeks. Fractures with delayed union may also be treated conservatively or may be managed surgically, depending on patient preference and other factors. All displaced fractures and nonunion fractures should be managed surgically. Although most fractures of the proximal portion of the fifth metatarsal respond well to appropriate management, delayed union, muscle atrophy, and chronic pain may be long-term complications.

Additional Reading: Proximal fifth metatarsal fractures. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Musculoskeletal system

The answer is C. This lesion is suspicious for melanoma, on the basis of the asymmetry, irregular border, color variegation, and size larger than 6 mm. In addition, a history of evolution of the lesion, with changes in size, shape, or color, has been shown in some studies to be the most specific clinical finding for melanoma. The preferred method of biopsy for any lesion suspicious for melanoma is complete elliptical excision with a small margin of normal-appearing skin. The depth of the lesion is crucial to staging and prognosis, so shave biopsies are inadequate. A punch biopsy of the most suspicious-appearing area is appropriate if the location or size of the lesion makes full excision inappropriate or impractical, but a single punch biopsy is unlikely to capture the entire malignant portion in larger lesions. Electrodesiccation and curettage is not an appropriate treatment for melanoma. Mohs’ surgery is sometimes used to treat melanomas, but is not used for the initial diagnosis.

Additional Reading: Cutaneous malignant melanoma: a primary care perspective. Am Fam Physician. 2012;85(2):161.

Category: Integumentary

The answer is E. When there are two or more primary tumors located in different quadrants of the breast or there are associated diffuse microcalcifications that appear malignant, breastconserving therapy is not considered appropriate. Additionally, a woman with previous breast irradiation is also not a candidate for breast conservation treatment. Breast irradiation cannot be given during pregnancy, but it may be possible to perform breastconserving surgery in the third trimester and administer irradiation after delivery. Positive surgical margins are also an absolute contraindication.

Additional Reading: Treatment of breast cancer. Am Fam Physician. 2010;81(11):1339-1346.

Category: Integumentary

The answer is E. Antibiotic prophylaxis is warranted in the setting of uncomplicated appendicitis. Reasonable regimens include a cephalosporin with anaerobic activity: Cefoxitin or cefotetan. Complicated appendicitis consists of perforated or gangrenous appendicitis, including peritonitis or abscess formation.

Additional Reading: Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect. 2013;14(1):73.

Category: Gastroenterology system

The answer is B. Ginseng is touted to protect the body against stress. Pharmacologically, ginseng lowers blood glucose levels (even in patients without diabetes mellitus) and, therefore, may cause intraoperative complications, especially in patients who fasted before surgery. Ginseng may also have a platelet inhibitory effect, and this effect may be irreversible. It should be discontinued at least 7 days before surgery.

Additional Reading: Asian ginseng. National Center for Complementary and Alternative Medicine (NCCAM). From: http://nccam.nih.gov/health/asianginseng/ataglance.htm.

Category: Nonspecific system

The answer is C. The 2012 ACCP anticoagulation guidelines recommend starting low-molecular-weight heparin either 12 hours or more preoperatively or 12 hours or more postoperatively. Thromboembolic prophylaxis should be continued for at least 10 to 14 days postoperatively and until the patient is full ambulatory. Patient at high risk for DVT may require a longer course of anticoagulation. Patients at increased risk include those who experience prolonged immobility post-repair, patient in whom surgery was delayed, or prior history of thromboembolism.

Additional Reading: Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed. American College of Chest Physician Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(suppl 2): e278S.

Category: Cardiovascular system

The answer is D. Coagulation times are not routinely indicated in patients undergoing surgery. Studies have shown that the yield is very low and that abnormal results are expected or do not significantly affect management. Coagulation studies would be indicated if the patient is receiving anticoagulant therapy, has a family or personal history that suggests a bleeding disorder, or has evidence of liver disease.

Additional Reading: Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologist Task Force of Preanesthesia Evaluation. Anesthesiol. 2012;116(3):522-538.

Category: Hematologic system

The answer is B. Child abuse is a difficult problem that must be identified as quickly as possible. Most children who die of child abuse are younger than 5 years. Most child abuse takes place in the home and is instituted by persons known to and trusted by the child. Although widely publicized, abuse in day care and foster-care settings accounts for only a minority of confirmed cases of child abuse. Child abuse is 15 times more likely to occur in families in which spousal abuse occurs. Children are three times more likely to be abused by their fathers than by their mothers. Once a health care worker has any suspicion of child abuse, he or she is legally required to report the case for investigation. Protection of the child is the most important goal. The child should be hospitalized in a safe environment while further investigation by social workers is performed. Children younger than 3 years are the most commonly abused. Clinical findings include multiple fractures (especially spiral-type fractures), multiple bruises in different stages of healing, intestinal trauma injuries, burns, poor nutrition, poor development, and bizarre accidents reported by parents. More than 50% of fractures in children younger than 1 year are secondary to abuse. Before discharge from the hospital, the child’s home environment must be determined to be safe by the appropriate protection agency. Further counseling for the child and family should be initiated after discharge. Unfortunately, therapy for child-abusing adults fails in approximately 33% of cases. As adults, children who were abused have a higher incidence of depression and drug abuse.

Additional Reading: Abused and neglected children. Nelson Textbook of Pediatrics, 19th ed. Philadelphia, PA: Elsevier/Saunders; 2011.

Category: Patient/population-based care

The answer is B. The diagnosis of intestinal malrotation should be suspected in any infant who presents with bilious emesis, acute duodenal obstruction, or abdominal tenderness associated with hemodynamic deterioration. Intestinal malrotation is a condition that results during development of the fetus. As the bowel develops outside the abdomen, it returns to the body cavity with a counterclockwise rotation. When malrotation occurs, the bowel returns in a clockwise rotation, and intestinal obstruction can result. Presenting symptoms that include vomiting of bile-stained material, abdominal distention, and dehydration soon after birth. Barium enema may be misleading in the diagnosis of malrotation and is used only as an adjunct to the
upper GI series. Barium enema can be helpful in the diagnosis of volvulus if it shows complete obstruction of the transverse colon, particularly if the head of the barium column has a beaked appearance.

Additional Reading: Schaider JJ. Malrotation. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2010.

Category: Gastroenterology system

The answer is A. Lumbar disc disease usually results from posterior herniation of the nucleus pulposus that impinges on the spinal cord. The most common site is the L5-S1 interspace, which affects the first sacral nerve root. Patients typically recall a precipitating event such as lifting a heavy object. Symptoms include severe back pain that radiates to the legs and is aggravated by coughing, sneezing, or forward flexion of the trunk. The condition is the most common cause of sciatica. Examination may show decreased sensation in a dermatome pattern, weakness, decreased reflexes, and a positive straight leg-raising test. In severe cases, patients may experience bowel or bladder incontinence. Radiographs and laboratory tests are generally unnecessary, except in the few patients in whom a serious cause is suspected on the basis of a comprehensive history and physical examination. Surgical evaluation is indicated in patients with worsening neurologic deficits or intractable pain that is resistant to conservative treatment. Bed rest should not be recommended for patients with nonspecific acute low back pain. Moderate quality evidence suggests that bed rest is less effective at reducing pain and improving function at 3 to 12 weeks than advice to stay active. Prolonged bed rest can also cause adverse effects such as joint stiffness, muscle wasting, loss of bone mineral density, pressure ulcers, and venous thromboembolism (VTE). The treatment plan should be reassessed in patients who do not return to normal activity within 4 to 6 weeks. Most mild cases can be treated with the limitation of aggravating activity, anti-inflammatory agents, and muscle relaxants.

Additional Reading: Diagnosis and treatment of acute low back pain. Am Fam Physician. 2012;85(4):343-350.

Category: Musculoskeletal system

The answer is E. Patients with nonmelanoma skin cancer measuring >2 cm, lesions with indistinct margins, recurrent lesions, and those close to important structures, including the eyes, nose, and mouth, or for more invasive histologic subtypes (micronodular, infiltrative, and morpheaform), or for tumors with high risk of recurrence should be considered for referral for complete excision via Mohs’ micrographic surgery. The Mohs’ surgeon can confirm the complete removal of the lesion by immediately reviewing the pathology during a staged excision, which, in these high-risk settings, can require removal of much more tissue than might have been clinically apparent initially. The recurrence rate for tumors treated with Mohs’ micrographic surgery is approximately 1% at 5 years, whereas standard surgical excision has an approximately 5% of recurrence rate at 5 years.

Additional Reading: Diagnosis and treatment of basal cell and squamous cell carcinoma. Am Fam Physician. 2012;86(2):161-168.

Category: Integumentary

The answer is A. Tracheoesophageal fistula is a congenital defect seen in newborns. The incidence is 1 in 3,500 live births. Boys and girls are equally affected. The condition is commonly associated with esophageal atresia. Polyhydramnios occurs in approximately two-thirds of pregnancies. Symptoms include excessive secretions with coughing and aspiration after feedings. Complications include the development of cyanosis and aspiration pneumonia. Diagnosis can be established by the inability to pass a red-rubber catheter or nasogastric tube further than approximately 10 to 15 cm into the stomach. Antero-posterior radiographs confirm catheter curled in the upper esophageal pouch. If gas is noted below the diaphragm, then an associated fistula is present. If not, the patient most likely is affected with esophageal atresia alone. Care must be taken to avoid aspiration of dye during diagnostic tests.

Additional Reading: Schwartz MW. Tracheoesophageal fistula and esophageal atresia, Pediatric. The 5-Minute Pediatric Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2012.

Category: Gastroenterology system

The answer is C. Lithotripsy has been used to fragment and remove renal and ureteral stones. The procedure involves placing the patient on a lithotripsy gantry so the calculus overlies a circular window in the table containing the water bath and is focused on the calculus. The procedure is more effective for stones <2 cm in diameter. Calcium oxalate and cystine stones are usually dense and require increased energy. Alternative modes of stones should be considered for large or hard calculi, stones in a calyceal diverticulum, or in patients with complex renal anatomy. Percutaneous nephrolithotomy and extracorporeal shock-wave lithotripsy may reduce the need for further invasive surgery, but the risks and benefits should be weighed carefully in asymptomatic persons.

Additional Reading: Treatment and prevention of kidney stones: an update. Am Fam Physician. 2011;84(11):1234-1242; and Clinical evidence kidney stones. Am Fam Physician. 2013;87(6):441-443.

Category: Nonspecific system

The answer is A. Topical nifedipine in addition to lidocaine gel is effective and well tolerated in the treatment of chronic anal fissures.

Additional Reading: Hemorrhoids. Am Fam Physician. 2011; 84(2):204-210.

Category: Gastroenterology system

The answer is D. Melena is the passage of black tarry stools, which is secondary to GI bleeding. In most cases, the source is located in the upper GI tract; however, a source in the distal right colon or small intestine can also cause melena. Approximately 100 to 200 mL of blood loss is needed to cause melena. Other causes for black stools that are often confused with melena include iron, bismuth, licorice, blueberries, and lead. Beets and tomatoes can sometimes make stools appear reddish.

Additional Reading: Diagnosis and management of upper gastrointestinal bleeding. Am Fam Physician. 2012;85(5):469-476.

Category: Gastroenterology system

The answer is B. The following local anesthetics without epinephrine have the following durations of action:

The use of epinephrine should be avoided in areas such as the fingers, nose, penis, and toes or other distal appendages. The vasoconstrictive effect can lead to ischemic necrosis. The most common reason for inadequate anesthesia is not allowing enough time for the anesthetic to take effect. In most cases, the surgeon should wait at least 5 minutes after injection before starting a procedure.

The following local anesthetics with epinephrine have the following durations of action:

Additional Reading: Infiltration of local anesthetics. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Integumentary

The answer is B. Most blunt objects (with the exception of button batteries) in the esophagus may be observed for up to 24 hours. If the object fails to pass into the stomach, it should be removed or possibly pushed into the stomach. Objects that have been lodged in the esophagus for >24 hours or for an unknown duration should be removed endoscopically. If the object has been lodged in the esophagus for >2 weeks, there is significant risk of erosion into surrounding structures, and surgical consultation should be obtained before attempting removal. Early intervention is indicated for patients who have swallowed button or disc batteries because of the potential for voltage burns and direct corrosive effects. Burns can occur as early as 4 hours after ingestion.

Additional Reading: Body ingestion in children. Am Fam Physician. 2005;72(2):287-291.

Category: Gastroenterology system

The answer is B. Before elective surgery, a review of the patient’s history is necessary. Routine pre-op labs (complete blood count [CBC], hemoglobin, platelets, electrolytes, glucose, coagulation, and liver test) have not been shown to improve outcomes for otherwise healthy patients. Hemoglobin measurement for patients >65 years old who
are undergoing major surgery and for younger patients undergoing surgery that is expected to result in significant blood loss should be considered. Creatinine is indicated for patient >50 undergoing intermediate or high-risk surgery and younger patients suspected of having renal disease, when hypotension is likely during surgery or when nephrotoxic medications will be used. A urine pregnancy test should be considered for women of childbearing age. Coagulation studies would be indicated if the patient is receiving anticoagulant therapy, has a family or personal history that suggests a bleeding disorder, or has evidence of liver disease. An electrocardiogram (ECG) is indicated for vascular surgical procedures, for patients with preexisting cardiovascular disease who are undergoing intermediate-risk surgery, and in severely obese patient with poor effort tolerance or at least one additional cardiovascular risk. Chest X-rays or pulmonary function test are not ordered for the healthy patient, but is indicated for those with cardiopulmonary disease and those >50 who are undergoing abdominal aortic aneurysm (AAA) surgery or upper abdominal/thoracic surgery. In general, patients in whom cardiac stress testing was normal within the previous 2 years or who have had coronary bypass surgery within the previous 5 years and are without symptoms require no further assessment. Clinically stable patients who have undergone angioplasty between 6 months and 5 years previously require no further assessment. However, patients who have had angioplasty within the previous 6 months may require cardiac reevaluation and/or consultation with a cardiologist before surgery. Patients at high risk for complications usually warrant cardiology consultation and possibly angiography. Cardiac stress testing should be performed in patients at intermediate risk and with poor functional capacity or who are undergoing high-risk procedures such as vascular surgery. For patients with minor clinical predictors, only patients who have poor functional capacity and are undergoing a high-risk procedure requires stress testing. Patients with positive stress test results warrant cardiology consultation before proceeding with surgery. Assessment of left ventricular function is not routinely indicated for preoperative evaluation whether or not the patient has cardiac disease. The preoperative assessment guideline from the American College of Physicians notes that radionuclide or echocardiographic assessment of left ventricular function does not appear to improve the risk prediction provided by the clinical examination alone. In summary, recommendations do not call for preoperative cardiac testing in all patients. The need for further cardiac evaluation before surgery is determined by the clinical risk predictors identified from the patient’s history, physical examination, ECG, and functional status, along with the risk associated with the operation itself. Pulmonary function testing may be helpful in diagnosing and assessing disease severity. Baseline chest radiographs may be helpful in at-risk patients. Preoperative guidelines do not define the degree of pulmonary function impairment that would prohibit surgery other than that for lung resection.

Additional Reading: Preoperative testing before noncardiac surgery: guidelines and recommendations. Am Fam Physician. 2013;87(6):414-418.

Category: Nonspecific system

The answer is A. Hallux valgus (bunions) is more common in women than in men. Symptoms include a painless or painful bump (exostosis) that forms on the medial aspect of the first metatarsal joint. Contributing physical factors include hyperelasticity syndromes, metatarsus varus, short first metatarsal joint, and pes valgus. Other factors include a family history of bunions and the prolonged use of narrow high-heeled shoes. Conservative treatment is usually all that is needed and includes wide shoes, the use of bunion pads, ice, rest, and antiinflammatory agents for acute pain. Most cases referred for surgery have intermetatarsal angles greater than 10 degrees or fail to improve with conservative measures. Absolute contraindications for surgery include peripheral vascular disease and local tissue infections, whereas relative contraindications include narcissistic personality disorders, painless cosmetic bunions, and age 65 years or older. A bunionette is a bony prominence on the lateral aspect of the fifth metatarsal head.

Additional Reading: Hallux valgus deformity. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Musculoskeletal system

The answer is B. Epinephrine administration should be avoided in the following areas: nose, ear lobes, or tip of the penis. It is also avoided near the terminal arterial branches in the digits. Epinephrine is contraindicated in digital anesthesia in patients with peripheral artery disease and in patients with periorbital infiltration with narrow-angle glaucoma and in large wounds in patients with underlying conditions (e.g., hyperthyroidism, pheochromocytoma, severe hypertension, coronary artery disease) that may be exacerbated by epinephrine effect.

Epinephrine infiltration with local anesthetics should be avoided in patients receiving beta blockers, monoamine oxidase inhibitors, phenothiazines, or tricyclic antidepressants and patients with catecholamine sensitivity.

Additional Reading: Myth of not using lidocaine with epinephrine in the digits. Am Fam Physician. 2010;81(10):1188.

Category: Integumentary

The answer is E. Antibiotic prophylaxis (amoxicillin 2 g orally 30 to 60 minutes before the procedure) is recommended
for patients who have high-risk cardiac conditions, which include

The guidelines suggest preventive treatment for high-risk cardiac patients, not for all dental procedures but only for those that involve manipulation of gingival tissue (around bone and teeth) or the periapical region of teeth (tip of the tooth root). The guidelines do not recommend antibiotics for routine anesthetic injections through noninfected tissue, placement or adjustment of orthodontic appliances, shedding of baby teeth, or bleeding from trauma to the lips or inside of the mouth.

Further the American Heart Association (AHA) guideline no longer consider any GI (colonoscopy or esophagogastroduodenoscopy) or genitourinary procedures high risk and therefore do not recommend routine use of endocarditis prophylaxis even in patient with the highest risk cardiac conditions.

Vaginal or cesarean delivery is not an indication for routine antibiotic prophylaxis.

Additional Reading: Prevention of infective endocarditis: guidelines from the American Heart Association. Circulation. 2007;116(15):1736.

Category: Cardiovascular system

The answer is B. Epiglottitis is a severe, life-threatening condition usually seen in children between 3 and 10 years of age. The condition was usually the result of a Haemophilus influenzae type B (Hib) infection. In recent years, the occurrence of epiglottitis has been reduced dramatically by the widespread use of the Hib vaccine. Other causes include bacterial infections by Streptococcus and Staphylococcus species. Manifestations include stridor with inspiration and expiration, high fever, dysphagia, drooling, and toxic appearance. Children may lean forward with their neck outstretched to minimize airway obstruction. Laboratory findings include an elevated white blood cell (WBC) count and positive blood cultures. Arterial blood gases may show hypoxia. Lateral neck radiographs show a swollen epiglottis with obstruction of the airway (positive thumb sign). Treatment involves securing the child’s airway, but this should be accomplished only by trained personnel. Before intubation, the child should not be moved nor placed in a supine position. Oxygen should also be avoided because of the risk of aggravating the child and possible complete obstruction of the airway. Intravenous antibiotics should be started immediately, and the child should be monitored in an intensive care setting.

Additional reading: Acute inflammatory upper airway obstruction: acute epiglottitis. Nelson Textbook of Pediatrics, 19th ed. Philadelphia, PA: Elsevier/Saunders; 2011.

Category: Respiratory system

The answer is A. Lidocaine has the fastest onset of action.

Additional Reading: Infiltration of local anesthetics. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Integumentary

The answer is C. The goal of suturing is to approximate the skin and eliminate unnecessary dead space. Tension at the wound site should be minimized. To achieve maximal cosmetic result, a suture is chosen based on the clinical situation. Monofilament sutures have significantly lowered the incidence of infection compared with multifilament sutures that can harbor bacteria. Nonabsorbable sutures (i.e., nylon, silk, polypropylene [prolene], braided polyester [Mersilene/Surgidac, ethibond/Ti-cron], and polybutester) are usually used to close the superficial layer of skin. Absorbable sutures (i.e., catgut, chromic catgut, Dexon II [polycaprolate], Maxon, and Vicryl [Polyglactin 10], Poliglecaprone [PDSII], and Caprosyn) are used to close deep layers of skin.

Additional Reading: Essentials of skin laceration repair. Am Fam Physician. 2008;78(8):945-951.

Category: Nonspecific system

The answer is C. Almost all patients with ocular problems should have visual acuity testing before anything else is done. If this is difficult, a local anesthetic may be applied. The main exception to this rule is a chemical burn of the eye, which should be irrigated for 30 minutes before further evaluation or treatment is undertaken.

Additional Reading: Ocular emergencies. Am Fam Physician. 2007;76(6):829-836.

Category: Special sensory

The answer is E. Somatization disorder usually begins in the teens or twenties and is characterized by multiple unexplained physical symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical history. Abuse of alcohol, narcotics, or other drugs is also commonly seen.

Hypochondriacs are overly concerned with bodily functions and often provide extensive, detailed medical histories. Malingering is an intentional pretense of illness to obtain personal gain. Patients with panic disorder have episodes of intense, short-lived attacks of cardiovascular, neurologic, or GI symptoms. Generalized anxiety disorder is characterized by unrealistic worry about life circumstances accompanied by symptoms of motor tension, autonomic hyperactivity, or vigilance and scanning.

Additional Reading: Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia, PA: Lippincott Williams & Wilkins; 2009, pp. 1927-1935.

Category: Psychogenic

The answer is D. In cases of severe blunt trauma to the chest, multiple rib fractures may lead to flail chest. By definition, a flail chest occurs in the presence of two or more fractures in three or more consecutive ribs, causing instability of the chest wall; however, the condition can also occur after costochondral separation. The diagnosis is made by noting paradoxical chest wall motion in which the chest wall depresses with inspiration and expands with expiration. There may be coexisting intrathoracic or intra-abdominal injuries. Initial management of flail chest consists of oxygen and close monitoring of early signs of respiratory compromise, ideally using both pulse oxymetry and capnography. Noninvasive positive airway pressure by mask may obviate the need for endotracheal intubation in alert patients. Patients with severe injuries, respiratory distress, or progressively worsening respiratory function require endothracheal intubation in alert patients.

Additional Reading: Schaider JJ. Flail chest. Rosen and Barkin’s 5-Minute Emergency Medicine Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2010.

Category: Respiratory system

The answer is A. Sodium bicarbonate may be added to neutralize the acidic local anesthetic and to reduce the burning sensation associated with anesthetic administration. Addition of a 1 cc of a 1 mEq/mL solution of bicarbonate for every 9 cc of local anesthetic can alleviate this burning and improve patient comfort.

Additional Reading: Infiltration of local anesthetics. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Integumentary

The answer is B. TPN is indicated for those patients who require nutritional support but cannot meet their nutritional needs through oral intake and for whom enteral feedings is contraindicated or not tolerated. Central venous access is usually required. TPN requires water (30 to 40 mL/kg/day), carbohydrate as dextrose (70% 3.4 kcal/g), amino acids 10% (4 kcal/g), and fat 20% (9 kcal/g), depending on the degree of catabolism. Indications include malnourished patients scheduled for surgery, chemotherapy, or radiation. Patients with severe burns, anorexia, coma, Crohn’s disease, ulcerative colitis, or pancreatitis may benefit from TPN. The following should be monitored daily: weight, plasma urea and glucose (several times daily until stable), complete blood cell count, blood gases, accurate fluid balance, 24-hour urine, and electrolytes. When the patient becomes stable, the frequency of these tests can be reduced. Liver function tests should be performed, and plasma proteins, PT, plasma and urine osmolality, and calcium, magnesium, and phosphate should be measured.

Additional Reading: Nutrition support in critically ill patients: parenteral nutrition. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Nonspecific system

The answer is A. Appendicitis during pregnancy may be difficult to diagnose. The WBC count is mildly elevated during a normal pregnancy, making it difficult to distinguish the leukocytosis seen with infection. In addition, as pregnancy progresses, the position of the appendix migrates superiorly (usually above the iliac crest in patients at more than 5 months’ gestation). Therefore, there is a greater risk for perforation in those with appendicitis as pregnancy progresses. In addition, there is a greater risk of perinatal mortality when the appendix is perforated. The complications involved with appendectomy include premature labor and infection. The differential diagnosis of abdominal pain during pregnancy is extensive and includes gastroenteritis, inflammatory bowel disease, cholecystitis, intestinal obstruction, pancreatitis, pyelonephritis, nephrolithiasis, spontaneous abortion, round ligament pain, ectopic pregnancy, uterine contractions, placental abruption, and pelvic infections.

Additional Reading: Evaluation of acute pelvic pain in women. Am Fam Physician. 2010;82(2):141-147.

Category: Gastroenterology system

The answer is C. Acute appendicitis is the most common reason leading to emergent abdominal surgery. The overall diagnostic accuracy achieved by traditional history, physical examination, and laboratory tests has been approximately 80%. The accuracy of diagnosis varies and is more difficult in women of childbearing age, children, and elderly persons. If the diagnosis of acute appendicitis is clear from the history and physical examination, prompt surgical referral is warranted. In atypical presentations, ultrasonography and CT may help lower the rate of false-negative appendicitis diagnoses, reduce morbidity from perforation, and lower medical expenses. Ultrasonography is safe and readily available, with sensitivity of 86% and specificity of 81%; however, CT scan has better specificity (91% to 98%) and sensitivity (95% to 100%). Disadvantages of CT include radiation exposure, cost, and possible complications from contrast media.

Additional Reading: Appendicitis acute. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Gastroenterology system

The answer is C. Scaphoid fractures account for approximately 60% of carpal bone fractures and are often missed on the initial radiograph. They frequently occur following a fall onto an outstretched hand. Symptoms include pain over the anatomic “snuff box” (area between the extensor pollicis brevis and the extensor pollicis longus tendons) and pain with radial deviation of the wrist. Reduction is seldom necessary; however, the arm, wrist, and thumb should be immobilized with a thumb spica cast for at least 6 weeks. If pain persists for longer than 4 months, there is an increased risk of nonunion or avascular necrosis with development of arthritis. Surgery may be indicated for this condition. If clinically suspected, radiographs (including scaphoid views) should be performed initially. Plain wrist films usually do not detect these fractures. In some cases, a bone scan or tomograms may be necessary to confirm the diagnosis. Bony electrical stimulation has also been shown to be effective in the healing of scaphoid fractures. Displaced fractures require open reduction with screw fixation.

Additional Reading: Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004;70(5):879-884.

Category: Musculoskeletal system

The answer is A. Hip arthroplasty is usually reserved for elderly patients with severe degenerative or rheumatoid arthritis. Indications include intractable pain or severe limitation of motion that interferes with the patient’s activity level. Those patients with rheumatoid arthritis have longer and more lasting improvement than those with osteoarthritis. Complications include bleeding, infection, and the major immediate complication of thromboembolism. Bone resorption is a major complication that may affect the life of the prosthesis. Long-term complications include loosening of the prosthesis, which may require further surgery. In most cases, relief is immediate after hip replacement, and 90% of hip replacements are never revised.

Additional Reading: Osteoarthritis of the hip. Am Fam Physician. 2010;81(4):444-445.

Category: Musculoskeletal system

The answer is E. A felon is an infection of the pulp space of a phalanx. A felon usually is caused by inoculation of bacteria into the fingertip
through a penetrating trauma. The most commonly affected digits are the thumb and index finger. Predisposing causes include splinters, bits of glass, abrasions, and minor trauma. A felon also may arise when an untreated paronychia spreads into the pad of the fingertip. The most common site is the distal pulp, which may be involved centrally, laterally, and apically. The septa between pulp spaces ordinarily limit the spread of infection, resulting in an abscess, which creates pressure and necrosis of adjacent tissues. The underlying bone, joint, or flexor tendons may become infected, and intense throbbing pain and a swollen pulp are present. If diagnosed in the early stages of cellulitis, a felon may be treated with elevation, oral antibiotics, and warm-water or saline soaks. Radiographs should be obtained to evaluate for osteomyelitis or a foreign body. Tetanus prophylaxis should be administered when necessary. If fluctuance is present, incision and drainage are appropriate along with administration of appropriate antibiotics (usually a cephalosporin or anti-staphylococcal penicillin).

Additional Reading: Common acute hand infections. Am Fam Physician. 2003;68:2167-2176.

Category: Integumentary