QUESTION: 113

An 18-year-old female presents for evaluation of facial acne. On examination, she has multiple comedones, papules, and pustules on her forehead, nose, cheeks, and chin. She also has several distinct nodules, each greater than 5 mm in diameter.
After 6 months of appropriate treatment, the severity of your patient's acne remains essentially unchanged. You rule out several potential causes for the patient's recalcitrant acne and decide that more aggressive therapy is warranted. As you discuss this option with your patient, which of the following side effects of the proposed treatment necessitates extensive counseling prior to initiation of therapy?

pseudotumor cerebri
teratogenicity
hepatotoxicity
nephrotoxicity
cardiotoxicity

Answer(s): B

Explanation:

This patient has nodulocystic acne which is characterized by the presence of multiple comedones, inflammatory papules, pustules, and large nodules. Characteristically, the nodules measure greater than 5 mm in diameter. Initial therapy should include a systemic antibiotic such as tetracycline or erythromycin. Use of local therapy alone may be adequate in individuals with comedonal acne. In cases of acne which feature more of an inflammatory component (with papules and pustules), topical and oral antibiotics are useful. Oral isotretinoin is indicated for severe nodulocystic acne that is unresponsive to other therapies.

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QUESTION: 114

A23-year-old presents with the history of a suspected spider bite to the left groin. On questioning, no one saw a spider. The patient has been healthy except occasional boils under his arms and in the groin.
The patient is afebrile. No family members are sick.

Appropriate treatment would include which of the following?

Benadryl and topical steroids
surgical debridement
incision and drainage
treatment with TMP-SMZ
observation and instructions to the patient to pop any pustules to help it drain

Answer(s): D

Explanation:

Above shows a pustule or furuncle with a necrotic center. With the patient having a history of boils under his arms and groin, a S. aureus infection should be suspected. Communityacquired methicillin- resistant S. aureus (MRSA) infection has been described to present as an appearance similar to a spider bite. Brown recluse spider bites have necrotic centers, but do not usually form pustules. TMP-SMZ is the best oral agent available for MRSA. Benadryl and topical steroids would not be indicated. Surgical debridement is not indicated. If there is a large pustule, incision and drainage of the wound may be useful. Alternatively, a needle aspirant of drainage could be sent for culture. Patients should be instructed not to press on these lesions to express puss. This causes bacterimia and can later lead to serious systemic infections due to S. aureus. If a patient with S. aureus infection becomes febrile, he should be admitted to the hospital for systemic antibiotics. Blood cultures should be taken. S. aureus easily forms abscesses in the skin and in other tissues. Blood-borne infection causes endocarditis, renal furuncles, and osteomyelitis.

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QUESTION: 115

A23-year-old presents with the history of a suspected spider bite to the left groin. On questioning, no one saw a spider. The patient has been healthy except occasional boils under his arms and in the groin.
The patient is afebrile. No family members are sick.

The patient is sent home and a day later develops chills, fever, and the lesion is spreading. Appropriate treatment would include which of the following?

hospital admission, blood cultures, and vancomycin
systemic corticosteroids
surgical excision of any necrotic tissue
observation and monitoring at home with oral clindamycin
hospital admission, blood cultures, and ceftriaxone

Answer(s): A

Explanation:

Above shows a pustule or furuncle with a necrotic center. With the patient having a history of boils under his arms and groin, a S. aureus infection should be suspected. Communityacquired methicillin- resistant S. aureus (MRSA) infection has been described to present as an appearance similar to a spider bite. Brown recluse spider bites have necrotic centers, but do not usually form pustules. TMP-SMZ is the best oral agent available for MRSA. Benadryl and topical steroids would not be indicated. Surgical debridement is not indicated. If there is a large pustule, incision and drainage of the wound may be useful. Alternatively, a needle aspirant of drainage could be sent for culture. Patients should be instructed not to press on these lesions to express puss. This causes bacterimia and can later lead to serious systemic infections due to S. aureus. If a patient with S. aureus infection becomes febrile, he should be admitted to the hospital for systemic antibiotics. Blood cultures should be taken. S. aureus easily forms abscesses in the skin and in other tissues. Blood-borne infection causes endocarditis, renal furuncles, and osteomyelitis

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QUESTION: 116

A 45-year-old male has received intravenous contrast dye prior to CT scan of the abdomen. Twenty minutes later the patient reports severe pruritus. He denies respiratory distress, syncope, or palpitations. His blood pressure is 98/54, pulse is 90, and respiratory rate is 22. On physical examination, he has widespread urticaria. His lungs are clear to auscultation. The next appropriate step would be which of the following?

administration of 0.5 mL of 1:1000 epinephrine subcutaneously
administration of 0.5 mL of 1:100,000 epinephrine subcutaneously
administration of 25 mg of diphenhydramine subcutaneously
administration of intravenous glucocorticoids
careful observation but no medications

Answer(s): A

Explanation:

Anaphylaxis is an acute multisystem allergic reaction to a particular antigen in a sensitized patient. The reaction may be mild or severe. Clinical manifestations may include urticaria and angioedema; laryngeal edema with dyspnea; bronchospasm; tachycardia and hypotension; and vomiting and diarrhea. The correct initial step in the treatment of mild anaphylaxis is the administration of 0.30.5 mL of 1:1000 epinephrine subcutaneously. (Kaspar et al., 2005, pp. 19491950) Epinephrine is the drug of choice for treating severe anaphylactic shock because it is active at both alpha- and beta- adrenergic receptors. The alpha- adrenergic effects constrict the smaller arterioles and precapillary sphincters, thereby markedly reducing cutaneous blood flow. Veins and large arteries also respond to epinephrine. The beta-adrenergic effects of epinephrine cause relaxation of the bronchial smooth muscle and induce a powerful bronchodilation, which is most evident when the bronchial muscle is contracted, as in anaphylactic shock

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