System Based Practice 2013

Question 1

18. A 60-year-old Middle Eastern woman with a dark complexion is seen in the emergency department for a nondisplaced humeral fracture. She has osteoporosis based on a previous bone mineral density test and a history of fracture. Laboratory studies should include measuring levels of
19. vitamin D2.
20. vitamin D3.
21. 25 hydroxycholecalciferol.
22. 1,25 dihydrocholecalciferol.
23. 24,25-dihydroxycholecalciferol.

Answer 1

3. 25 hydroxycholecalciferol.

RECOMMENDED READINGS

Patton CM, Powell AP, Patel AA. Vitamin D in orthopaedics. J Am Acad Orthop Surg. 2012 Mar;20(3):123-9. Review. PubMed PMID: 22382284.

Bogunovic L, Kim AD, Beamer BS, Nguyen J, Lane JM. Hypovitaminosis D in patients scheduled to undergo orthopaedic surgery: a single-center analysis. J Bone Joint Surg Am. 2010 Oct 6;92(13):2300-4. PubMed PMID: 20926724.

Question 2

40. A 63-year-old African-American man is scheduled for right shoulder arthroplasty for degenerative joint disease. He has no history of infection, connective tissue disease, or tobacco and alcohol abuse. Laboratory studies drawn on the day of surgery show a leukocyte count of 2.2 X 109 cells/L (reference range, 4.5 X 10⁹ cells/L). All other laboratory and presurgical evaluations are within defined limits. What is the best appropriate course of action?
41. Perform the surgery after consultation with a hematologist.
42. Perform the surgery because this value is not abnormally low for this patient.
43. Delay surgery and immediately repeat the white blood cell count.
44. Cancel the surgery because of the abnormally low white blood cell count.
45. Cancel the surgery; a delay is needed to consider this value.

Answer 2

2. Perform the surgery because this value is not abnormally low for this patient.

RECOMMENDED READINGS

Haddy TB, Rana SR, Castro O. Benign ethnic neutropenia: what is a normal absolute neutrophil count? J Lab Clin Med. 1999 Jan;133(1):15-22. Review. PubMed PMID: 10385477.

Eichner ER. Sports medicine pearls and pitfalls: benign neutropenia in athletes. Curr Sports Med Rep. 2009 Jul-Aug;8(4):162-3. Review. PubMed PMID: 19584599.

Hsieh MM, Everhart JE, Byrd-Holt DD, Tisdale JF, Rodgers GP. Prevalence of neutropenia in the U.S. population: age, sex, smoking status, and ethnic differences. Ann Intern Med. 2007 Apr 3;146(7):486-92. PubMed PMID: 17404350.

Question 3

77. What is the leading cause of medication errors, delays in diagnosis and treatment, and wrong-site

surgeries?

1. Not enough sleep
2. Too heavy a caseload
3. Inadequate preparation
4. Communication failures
5. Lack of patient participation

Answer 3

4. Communication failures

Question 4

85. Figures 85a through 85c are the injury and reconstruction images of a 48-year-old man who had his right arm amputated 5 cm below his elbow by a machine. His postsurgical course is uneventful. He is pleasant in all interactions with those treating him. He is fitted with an dhas learned to use a myoelectric prosthesis. He is discharged from physical therapy with the evaluation that he is capable of returning to his job activities. The best next step should be to
86. return him to work as soon as possible.
87. evaluate independently his ability to use his myoelectric prosthesis.
88. obtain a functional capacity evaluation and compare it to his job description.
89. offer the opportunity to be evaluated by psychology before returning to work.
90. recommend vocational rehabilitation because his prosthesis is too slow to use for work.

Answer 4

4. offer the opportunity to be evaluated by psychology before returning to work.

RECOMMENDED READINGS

Richards T, Garvert DW, McDade E, Carlson E, Curtin C. Chronic psychological and functional sequelae after emergent hand surgery. J Hand Surg Am. 2011 Oct;36(10):1663-8. Epub 2011 Sep 8. PubMed PMID:21862240.

Question 5

96. Which finding is most associated with intimate partner violence
97. Multiple extremity fractures
98. Isolated abdominal injury
99. Isolated lower-extremity fracture
100. Evidence of drug or alcohol use by the partner
101. Repeated visits to the emergency department

Answer 5

5. Repeated visits to the emergency department

Question 6

150. A 25-year-old red-haired healthy woman with no history of substance abuse underwent fixation of a fractured distal radius under supraclavicular block but required an unusual amount of intravenous sedation and analgesia. Afterwards, she came to the emergency department in extreme pain. Compartment syndrome was ruled out; on maximum dose oral opiates, she improved over time. At her postoperative visit, she comes in with her red-haired mother, who related similar need for high dose pain medications. Examination is otherwise uneventful. What is the most appropriate course?
151. Perform a drug test
152. Question her drug and alcohol history
153. Refer her to the pain service within a week
154. Give her more high-dose pain medication
155. Discuss a possible inherited lower pain tolerance

Answer 6

5. Discuss a possible inherited lower pain tolerance

Question 7

159. A 38-year-old Hindu man underwent serial debridement for necrotizing fasciitis of the hand and forearm. Although the infection has cleared, he has extensive areas of exposed tendon both volarly and dorsally. An option for coverage is an acellular collagen matrix derived from fetal bovine dermis. In addition to obtaining routine informed consent for this procedure, the physician should explain the material’s
160. origin.
161. durability.
162. permeability.
163. resorption rate.
164. tensile strength.

Answer 7

1. origin.

Question 8

178. Ganglion excision is scheduled for a 55-year-old male laborer born in Mexico. You communicate between his limited English, your modest Spanish, and his daughter’s command of both languages. He agrees to the procedure, and wishes no further information by a translator, despite your offering patient brochures and use of a patient-oriented computer kiosk. What is the next most appropriate step?
179. Postpone the surgery
180. Obtain translator services anyway
181. Ask whether he and his daughter understand the procedure
182. Request further family members be present for the decision
183. Ask him and his daughter to, in their own words, explain the proposed plan

Answer 8

5. Ask him and his daughter to, in their own words, explain the proposed plan

Question 9

209. An otherwise healthy 25-year-old Hispanic man is seen in the emergency department; he is accompanied by his supervisor. He has a cut to his right hand from a table saw and requires emergency surgery. All of his responses are single-word answers, and when asked if he has any questions before proceeding with surgery, he says “No.” The physician should now
210. proceed with surgery, considering he has signed the informed consent sheet.
211. ask the supervisor to explain the procedure to him.
212. ask him to explain in his own words his injury and the proposed procedure.
213. have a second surgeon examine him and sign the informed consent.
214. discuss his surgery and planned after-surgery care through a translator before proceeding with the surgery.

Answer 9

3. ask him to explain in his own words his injury and the proposed procedure.

Question 10

237. A 21-year-old man has leg weakness after a motor vehicle collision. Examination reveals normal strength in his upper extremities, with 2/5 strength in the quadriceps, 2/52 ankle platarflexion, and 0/5 ankle and great toe extension. Examination shows no rectal tone but intact perirectal sensation. A CT scan reveals a T9-T10 dislocation. What best describes his spinal cord injury?
238. Complete, American Spinal Injury Association (ASIA) A
239. Complete, ASIA B
240. Incomplete, ASIA B
241. Incomplete, ASIA C
242. Incomplete, ASIA D

Answer 10

4. Incomplete, ASIA C

Question 11

250. When using a presurgical safety checklist and timeout, which surgical team member has been shown to be the most effective in reducing surgical complications?
251. Scrub nurse
252. Circulating nurse
253. Anesthesiologist
254. Surgeon
255. Surgeon delegating different aspects of the presurgical checklist/timeout to various members of the team

Answer 11

4. Surgeon

Question 12

263. After treating a supracondylar humeral fracture in a 4-year old child, nerve palsy is identified. The treating physician should acknowledge the nerve damage and should offer
264. an apology and accept blame.
265. an apology and not accept blame.
266. an apology and accept partial blame.
267. no apology and accept blame.
268. no apology and not accept blame.

Answer 12

2. an apology and not accept blame.