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Britney is a 20-year-old woman with a gradual onset of lower abdominal pain x 24 hours. She denies nausea, vomiting, diarrhea, or urinary symptoms. Her LMP was 12 days ago with normal timing and flow. She is sexually active with one male partner. She took some Advil last night and it may have helped a little, but she hasn't taken anything today. She reports that she hasn't really eaten much and doesn't feel hungry. Pain has progressively increased and is worse with bumps in the road. She rates it a 6/10 at the worst and says it is constant, but better if she lies still (4/10).
Habits: never smoker, ETOH occasionally at parties, cannabis daily, no illicit or IVDA
Meds: ibuprofen, mirena
Allergies: amoxicillin (hives)
ROS: Abd: (+)pain, denies flank pain, denies melena or BRBPR, denies n/v/d, normal flatus
Vitals: 38.2ºC (100.8ºF), HR 74, BP 122/66, RR 16, 99% RA, BMI 28
Physical: Abd: non-distended, bowel sounds, slightly hypoactive, non-distended, soft, tenderness right lower quadrant as well as +Rovsing, rectal exam normal
Labs: elevated WBC, low bilirubin,
UA: trace leukocyte esterase

The transvaginal pelvic US demonstrated normal adnexa with normal doppler flow with no e/o torsion, cysts. Uterus normal. IUD positioned appropriately. Neg study. Transabdominal US: bowel gas pattern, non-visualized appendix.

Your patient has been resting and has had some IVFs, Tylenol for her fever, and some pain medication. She feels much better and wants to go home. She thinks maybe she had some mid-cycle pain. She's afebrile now and her vitals are all within normal limits. You re-examine and note improvement.

Which of the following is the next best step in the management of this patient?
Mr. H is an 80-year-old man with a history of Dementia, T2DM, PVD, PAD, Peripheral neuropathy, chronic non-healing diabetic foot ulcers, HTN, with A-fib on coumadin anticoagulation presenting for evaluation of wounds on his right foot and swelling of his lower leg. He has had open chronic wounds of the right foot x 3 years. He sees wound care RN, last seen yesterday and there was a concern for acutely worsening infection of the right great toe and lateral wound. The wound has been managed with mediplex dressings and an ortho shoe/diabetic shoe that off-loads his toes. PCP was notified and called in PO antibiotic. Referral to the vascular surgeon was made, with an upcoming appointment in the next week for an arteriogram. The wife notes that the right great toe looks even more swollen and the odor was worse, so she brings him to the ED. The patient denies fever, pain in the limb. He has had increased difficulty with walking on the right foot and manages on the heel because of his special diabetic shoe. Review of his chart shows last wound culture from April: polymicrobial, G-, Pseudomonas and Corynebacterium.
PMH: Dementia, TIA, A-fib, T2DM, HTN, PAD, PVD, PN, BPH, ED, diabetic foot ulcers right foot, chronic, chronic venous insufficiency
PSH: left 5th toe amputation (remote) revascularization left LE(remote), endarterectomy, penile implant
Habits: remote tobacco use, none x 30 years, denies ETOH, denies illicit drugs and cannabis
Current Medications:
metoprolol
amiodarone
glucophage
warfarin
tamsulosin
atorvastatin
Tylenol PRN
losartan
ROS: Skin: + chronic non-healing diabetic foot ulcers; Cardio: neg for palpitations, chest pain, + for right LE edema lower leg, + hx of varicose veins; Neuro: +peripheral neuropathy, diminished sensation bilateral LE
Vitals: 37.4ºC (100ºF), HR 68, BP 146/76, RR 18, 99% RA, BMI 20.4
Physical: Skin: left LE with brown chronic venous stasis dermatitis; right LE/foot: open wound base of the right great toe, 2cm, boggy, macerated, malodorous drainage, and surrounding tissue swelling and erythema. no tenderness, right lateral distal 5th metatarsal with an open wound that extends to the sole of the foot, 2cm. wound probed, cannot clearly appreciate based of wounds, erythema contained to right great toes and dorsum foot; no lymphatic streaking, distal right lower leg with purple/red discoloration/venous stasis, skin blanches.

Which of the following represents the patient's greatest current risk for wound infection?
Hyperglycemia/diabetes
3 MULTIPLE CHOICE OPTIONS
Mr. Monroe is a 55-year-old man with a 2-month history of lower back pain that has become much worse over the past two days. He reports a sharp increase in his pain after lifting some heavy soil into his SUV at Home Depot over the weekend. He initially felt a sharp pain and pop with radiating pain to the right lower extremity. His pain is worsened by walking and sitting and improved with standing and lying down. He denies difficulty with bowel or bladder control/voiding. The pain now radiates constantly to the back of his right leg and feels like stabbing/sharp pain shooting down his leg. He reports some numbness to the right foot. He is having trouble sleeping and has not been able to go to work. He was unable to attend his physical therapy session yesterday due to pain. He rates his pain 8/10 and had a difficult time sitting in the car to get to the hospital and is having difficulty lifting his leg to walk and is needing to hold on to things, rating walking pain 10/10. He had an appointment to see neurosurgery but hasn't seen them yet.
PMH: HTN, hyperlipidemia, obesity, obstructive sleep apnea
Habits: never smoker, rare ETOH, denies illicit drugs and cannabis
Meds: lisinopril and simvastatin
Allergies: NKDA
ROS: MSK: lower back pain, no other hip/UE pain, no swelling
Vitals: 37.0ºC (98.6ºF), HR 100, BP 158/86, RR 20, 99% RA, BMI 33
PE: MSK: UE with full ROM and strength, Exam difficult as patient having pain. left LE grossly normal with ROM and strength (hip flexors, knee flex/ext, dorsi/plantar flexion of the foot) Right LE difficult d/t pain, + SLR on the right, hip strength grossly intact, right knee extension 3/5, right foot dorsiflexion 2+/5 (patient can weakly raise partial ROM against gravity) Great toe 2/5.
Neuro: A&Ox3, sensation diminished left LE especially over the right great toe and anterior lower leg, gait patient able to ambulate with significant difficulty and required assistance, unable to stand upright, right foot drop. Reflexes intact bilateral UE and left Achilles, 1+/decreased right patellar reflex.

Which of the following symptoms is the LEAST concerning in Mr. Monroe's history?
obesity
3 MULTIPLE CHOICE OPTIONS
Mr. Monroe is a 55-year-old man with a 2-month history of lower back pain that has become much worse over the past two days. He reports a sharp increase in his pain after lifting some heavy soil into his SUV at Home Depot over the weekend. He initially felt a sharp pain and pop with radiating pain to the right lower extremity. His pain is worsened by walking and sitting and improved with standing and lying down. He denies difficulty with bowel or bladder control/voiding. The pain now radiates constantly to the back of his right leg and feels like stabbing/sharp pain shooting down his leg. He reports some numbness to the right foot. He is having trouble sleeping and has not been able to go to work. He was unable to attend his physical therapy session yesterday due to pain. He rates his pain 8/10 and had a difficult time sitting in the car to get to the hospital and is having difficulty lifting his leg to walk and is needing to hold on to things, rating walking pain 10/10. He had an appointment to see neurosurgery but hasn't seen them yet.
PMH: HTN, hyperlipidemia, obesity, obstructive sleep apnea
Habits: never smoker, rare ETOH, denies illicit drugs and cannabis
Meds: lisinopril and simvastatin
Allergies: NKDA
ROS: MSK: lower back pain, no other hip/UE pain, no swelling
Vitals: 37.0ºC (98.6ºF), HR 100, BP 158/86, RR 20, 99% RA, BMI 33
PE: MSK: UE with full ROM and strength, Exam difficult as patient having pain. left LE grossly normal with ROM and strength (hip flexors, knee flex/ext, dorsi/plantar flexion of the foot) Right LE difficult d/t pain, + SLR on the right, hip strength grossly intact, right knee extension 3/5, right foot dorsiflexion 2+/5 (patient can weakly raise partial ROM against gravity) Great toe 2/5.
Neuro: A&Ox3, sensation diminished left LE especially over the right great toe and anterior lower leg, gait patient able to ambulate with significant difficulty and required assistance, unable to stand upright, right foot drop. Reflexes intact bilateral UE and left Achilles, 1+/decreased right patellar reflex.

Which of the following imaging studies will confirm the suspected etiology of Mr. Monroe's lower back pain?
MRI non-contrast of the lumbar spine
3 MULTIPLE CHOICE OPTIONS
You are rounding on a 58yo man, Mr. Jones, who is POD #4 s/p bilateral Total Knee Arthroplasty (TKA). He has been out of bed with physical therapy and walking about 50-100 feet with a rolling walker twice daily. No stair trials yet; has 2-step entry without a railing at home. He has been using the Continuous Passive Motion (CPM) machine, alternating LEs regularly to improve his ROM and declines SCDs on the contralateral leg. The Foley was pulled POD #1 and OT cleared him for his basic ADLs seated at the edge of the bed. He requires assistance for LE dress and donning socks/shoes, however, his wife agrees to assist with this at home. He and transfers to the bedside commode and chair with the FWW. He has not yet completed a tub/shower transfer. His antibiotic was discontinued on POD#2 and PCA was discontinued two days ago. He has been well controlled on oral opioids until this morning when he started to report increasing left calf pain. He required a parenteral dose of pain meds at 0600. The nurse was concerned about the wound as the lower leg seemed a little red and more swollen. Intake has been appropriate for food/fluids, normal diet. The patient denies chest pain or shortness of breath. He is also having abdominal pain/bloating and has not had a BM yet. He denies urinary complaints and is happy to have the catheter out and is using the urinal. He is very anxious to go home today and asks when he can be released.
Review of Chart H&P:
PMH: HTN, obesity, OSA, and osteoarthritis
PSH: tonsils and adenoids (child), appendectomy (child), sinus surgery 10 years ago, BTKA
Habits: former smoker, rare ETOH, no illicit drug use, no cannabis use
Vaccinations: tetanus up to date, annual influenza up to date
Meds:
lisinopril 20mg daily, enoxaparin 30mg SC Q12hrs, oxycodone 10mg Q4 hours for pain. He has PRN orders for Tylenol for pain or fever, fentanyl IV 50mcg PRN breakthrough pain, Senna, and Colace
Vitals: 38ºC (100.4ºF), HR 112, BP 148/78, RR 18, 98% RA, height 5'11", weight 244 pounds, BMI 34
PE: Extremities: bilateral surgical evaluated: Right incision Clean/dry/intact; dressing with scant serous drainage, staples in place, right calf 13cm circumference, no edema, negative Homan's; Left incision: some strike-through bleeding visible on dressing, no purulence but serosanguinous drainage present distally, with some erythema, noted laterally, and an associated blister of the skin outside of the boundary of the adhesive from dressing without crepitus (see Haiku image below), left calf 16cm circumference, slight pitting edema 2+ up to the knee, positive Homan's sign on the left.
Labs: elevated WBCs, low Hgb, low Hct, elevated glucose

What is the most likely cause of his fever based on time/number of days post-op and the physical exam/history?
superficial surgical site infection
3 MULTIPLE CHOICE OPTIONS
You are rounding on a 58yo man, Mr. Jones, who is POD #4 s/p bilateral Total Knee Arthroplasty (TKA). He has been out of bed with physical therapy and walking about 50-100 feet with a rolling walker twice daily. No stair trials yet; has 2-step entry without a railing at home. He has been using the Continuous Passive Motion (CPM) machine, alternating LEs regularly to improve his ROM and declines SCDs on the contralateral leg. The Foley was pulled POD #1 and OT cleared him for his basic ADLs seated at the edge of the bed. He requires assistance for LE dress and donning socks/shoes, however, his wife agrees to assist with this at home. He and transfers to the bedside commode and chair with the FWW. He has not yet completed a tub/shower transfer. His antibiotic was discontinued on POD#2 and PCA was discontinued two days ago. He has been well controlled on oral opioids until this morning when he started to report increasing left calf pain. He required a parenteral dose of pain meds at 0600. The nurse was concerned about the wound as the lower leg seemed a little red and more swollen. Intake has been appropriate for food/fluids, normal diet. The patient denies chest pain or shortness of breath. He is also having abdominal pain/bloating and has not had a BM yet. He denies urinary complaints and is happy to have the catheter out and is using the urinal. He is very anxious to go home today and asks when he can be released.
Review of Chart H&P:
PMH: HTN, obesity, OSA, and osteoarthritis
PSH: tonsils and adenoids (child), appendectomy (child), sinus surgery 10 years ago, BTKA
Habits: former smoker, rare ETOH, no illicit drug use, no cannabis use
Vaccinations: tetanus up to date, annual influenza up to date
Meds:
lisinopril 20mg daily, enoxaparin 30mg SC Q12hrs, oxycodone 10mg Q4 hours for pain. He has PRN orders for Tylenol for pain or fever, fentanyl IV 50mcg PRN breakthrough pain, Senna, and Colace
Vitals: 38ºC (100.4ºF), HR 112, BP 148/78, RR 18, 98% RA, height 5'11", weight 244 pounds, BMI 34
PE: Extremities: bilateral surgical evaluated: Right incision Clean/dry/intact; dressing with scant serous drainage, staples in place, right calf 13cm circumference, no edema, negative Homan's; Left incision: some strike-through bleeding visible on dressing, no purulence but serosanguinous drainage present distally, with some erythema, noted laterally, and an associated blister of the skin outside of the boundary of the adhesive from dressing without crepitus (see Haiku image below), left calf 16cm circumference, slight pitting edema 2+ up to the knee, positive Homan's sign on the left.
Labs: elevated WBCs, low Hgb, low Hct, elevated glucose

After considering the information gathered on rounds (physical exam and functional update), and review of the labs, what is the next best step in the management of this patient?