NP Case Studies & Practical Application 2 — Questions and Answers
Question 1: A 58-year-old male with type 2 diabetes presents with a painless, non-healing ulcer on the plantar aspect of his right foot for 3 weeks. ABI is 0.95, HbA1c is 10.2%, and the wound base is pink with no purulence. Which is the most appropriate next step?
- Initiate IV antibiotics and admit for debridement
- Optimize glycemic control and begin offloading with a total contact cast (Correct answer)
- Refer for immediate vascular surgery consultation
- Apply a moisture-retentive dressing and recheck in 4 weeks
Correct answer: Optimize glycemic control and begin offloading with a total contact cast
Neuropathic diabetic foot ulcers without infection require offloading (total contact cast is gold standard) and glycemic optimization as first-line management.
Question 2: A 34-year-old woman at 28 weeks gestation presents with sudden-onset right upper quadrant pain, nausea, and vomiting. BP is 158/102 mmHg, platelets 88,000/μL, AST 210 U/L. What is the most likely diagnosis?
- Acute cholecystitis
- HELLP syndrome (Correct answer)
- Viral hepatitis
- Peptic ulcer disease
Correct answer: HELLP syndrome
HELLP syndrome presents with hemolysis, elevated liver enzymes, and low platelets in the setting of preeclampsia, often with RUQ pain.
Question 3: A 72-year-old woman is started on lisinopril for heart failure with reduced ejection fraction. Two weeks later she returns with a persistent dry cough. What is the best management?
- Add benzonatate for symptomatic relief and continue lisinopril
- Switch to an ARB such as losartan (Correct answer)
- Discontinue RAAS therapy entirely
- Reduce the lisinopril dose by half
Correct answer: Switch to an ARB such as losartan
ACE inhibitor-induced cough is a class effect due to bradykinin accumulation; switching to an ARB provides equivalent HFrEF benefit without this side effect.
Question 4: A 45-year-old man presents with sudden severe headache described as 'the worst of my life,' neck stiffness, and photophobia. CT head is negative. What must be done next?
- Discharge with ibuprofen and neurology follow-up in 1 week
- Perform lumbar puncture to evaluate for xanthochromia (Correct answer)
- Start empiric sumatriptan for migraine
- Obtain an MRI brain with contrast
Correct answer: Perform lumbar puncture to evaluate for xanthochromia
A thunderclap headache with negative CT requires lumbar puncture to rule out subarachnoid hemorrhage, as CT misses up to 5% of cases.
Question 5: A 62-year-old woman with COPD GOLD stage 3 is on dual bronchodilator therapy. She has had 2 exacerbations requiring oral steroids in the past year and her eosinophil count is 320 cells/μL. What is the best next step in therapy?
- Add a long-acting muscarinic antagonist (LAMA)
- Add an inhaled corticosteroid (ICS) to her regimen (Correct answer)
- Start prophylactic azithromycin three times weekly
- Switch to a short-acting bronchodilator only
Correct answer: Add an inhaled corticosteroid (ICS) to her regimen
GOLD guidelines recommend adding ICS to LABA/LAMA in COPD patients with frequent exacerbations and elevated eosinophils (≥300 cells/μL).
Question 6: An 8-year-old boy is brought in for recurrent ear infections — his fourth episode in 12 months. Each time he improves with amoxicillin. Today he is afebrile with mild erythema of the right tympanic membrane. What is the most appropriate recommendation?
- Prescribe high-dose amoxicillin-clavulanate for 14 days
- Refer to otolaryngology for tympanostomy tube evaluation (Correct answer)
- No antibiotics; watchful waiting for 48–72 hours
- Begin prophylactic daily amoxicillin
Correct answer: Refer to otolaryngology for tympanostomy tube evaluation
Four or more acute otitis media episodes in 12 months (or 3 in 6 months) meets criteria for ENT referral for tympanostomy tube consideration.
Question 7: A 28-year-old woman with no significant history presents with a 3-week course of fatigue, pharyngitis, posterior cervical lymphadenopathy, and splenomegaly. Monospot test is negative. What is the next best diagnostic step?
- Treat empirically for streptococcal pharyngitis with penicillin
- Order EBV-specific antibodies (VCA IgM, EA, EBNA) (Correct answer)
- Perform CT chest/abdomen to evaluate lymphadenopathy
- Obtain a bone marrow biopsy to rule out lymphoma
Correct answer: Order EBV-specific antibodies (VCA IgM, EA, EBNA)
Monospot has up to 25% false-negative rate, especially early in illness; EBV-specific serology (VCA IgM) is more sensitive for confirming infectious mononucleosis.
NP Case Studies & Practical Application 2
A 58-year-old male with type 2 diabetes presents with a painless, non-healing ulcer on the plantar aspect of his right foot for 3 weeks.
ABI is 0.95, HbA1c is 10.2%, and the wound base is pink with no purulence.
Which is the most appropriate next step?