Multiple Choice Questions (MCQ)

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Category: Critical Care Medicine-Surgery, Trauma, and Transplantation--->Skin, Soft Tissue, and Extremities
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Question 1# Print Question

A 25-year-old male with no significant past medical history presents to the emergency department complaining of pain and “redness” of his left lower extremity. He denies any history of trauma or injury to the area. His vital signs are notable for:

  • Temp: 102.2F
  • HR 110
  • BP 95/65
  • RR 25
  • Sat 100% on room air

On examinaton, he is clearly agitated and in pain. His left lower extremity is erythematous and tender to palpation without any noticeable skin breakdown, crepitus, or evidence of external trauma. All of the following statements about the evaluation and diagnosis of a necrotizing soft tissue infection (NSTI) are true EXCEPT:

A. Clinical manifestations of a NSTI can include erythema, edema, pain out of proportion to examination, overlying skin changes, and systemic signs of infection including fever and hypotension
B. Symptoms are typically acute in onset and rapidly progressive over a short period of time
C. The LRINEC score, developed specifically to aid in differentiation of NSTI from other soft tissue infections, has high sensitivity and specificity and thus a negative score rules out NSTI
D. If clinical suspicion for a NSTI is high, surgical intervention should not be delayed for further diagnostic evaluation
E. Computed Tomography (CT) is the best radiographic imaging modality in the evaluation of a NSTI

Question 2# Print Question

A 55-year-old male with a history of methicillin-resistant Staphylococcus aureus (MRSA) colonization presents to the emergency department with complaints of purulent drainage from his surgical incision. He is now 7 days postop from his sigmoid colectomy. On examination, his temperature is 102°F and hemodynamically within normal limits. His incision has skin staples in place and moderate surrounding erythema extending >5 cm from the wound edge and associated induration. Purulent drainage is easily expressed from the most inferior aspect of the incision.

Which of the following is the most appropriate management of this patient?

A. Open the incision, obtain a fluid culture, and start on an empiric course of IV Vancomycin and Piperacillin-Tazobactam
B. Open the incision, obtain a fluid culture and start on an empiric course of IV Vancomycin alone
C. Discharge home on a 7-day course of oral Cephalexin
D. Open the incision, obtain a fluid culture, and start on an empiric course of IV Piperacillin-Tazobactam alone
E. Open the incision, obtain a fluid culture, and hold off on starting antimicrobial therapy until culture data returns

Question 3# Print Question

A 30-year-old male presents with significant erythema overlying his right arm and a fever to 101.0°F. He explains that he sustained an abrasion over the affected area while at work, and when the redness started 2 days ago he was prescribed a course of antibiotics by the Urgent Care Clinic, which he has been taking without improvement of his symptoms. An ultrasound shows edema and a phlegmon without an obvious abscess collection. He is admitted to the hospital and started on IV cefoxitin. Over the next 48 hours it is noted that even though there is some regression of the erythema, a firm, fluctuant area can be palpated in the subcutaneous tissue measuring >2 cm.

What is the most appropriate next step in management?

A. Broaden antibiotics to IV Piperacillin-Tazobactam
B. Broaden antibiotics to IV Vancomycin
C. Repeat ultrasound
D. CT scan of the arm
E. No change in current management

Question 4# Print Question

A patient is admitted to the surgical critical care unit after being found down for an unknown period of time following presumed assault. The patient was intubated at the scene. In addition to a multitude of other injures, the patient is noted to have an acute kidney injury (AKI) with an elevated creatine kinase (CK) to 10,000. On examination, all extremity compartments are soft.

With regards to the management of AKI from traumatic rhabdomyolysis, which of the following statements is true?

A. In the absence of other indications for renal replacement therapy, prophylactic hemodialysis is recommended in the setting of elevated CK above 5,000 U/L
B. Commonly seen laboratory abnormalities include elevated CK, hypocalcemia, hypokalemia, and hypophosphatemia
C. Resuscitation with sodium bicarbonate solution, titrated to urine pH, can prevent acute renal failure
D. If the patient is oligo-anuric, the addition of mannitol is recommended
E. Early, aggressive resuscitation with normal saline solution fundamental to treatment

Question 5# Print Question

A 60-year-old male with a past medical history notable for obesity, hypertension, hyperlipidemia, and type 2 diabetes presents to the emergency department with complaints of significant scrotal and perineal pain with associated drainage. He explains that the symptoms started about 24 hours before presentation and have been rapidly progressive since. His vital signs are as follows: Temp 102.5°F, HR 102 bpm, BP 90/65 mm Hg, RR 18, Sat 100% on room air. On examination, he is diaphoretic and noticeably uncomfortable. His scrotum and perineum are diffusely erythematous and tender to palpation, with a pinpoint area draining dishwasher color fluid that is malodorous. All of the following are appropriate next steps in the management of a patient presenting with Fournier’s gangrene EXCEPT:

A. Aggressive fluid resuscitation to markers of end organ perfusion as dictated by early goal-directed therapy
B. After acquiring appropriate culture data, initiation of broad spectrum antimicrobial therapy with empiric coverage for NSTI causing organisms
C. Obtaining radiographic imaging to delineate the extent of infection and to aid in operative planning D. Early surgical consultation for urgent evaluation and operative debridement
D. Postoperative admission to a surgical intensive care unit for ongoing monitoring and hemodynamic support

Category: Critical Care Medicine-Surgery, Trauma, and Transplantation--->Skin, Soft Tissue, and Extremities
Page: 1 of 2