Diabetic wounds US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Diabetic wounds. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Diabetic wounds US Medical PG Question 1: A 30-year-old man presents to his primary care physician for pain in his left ankle. The patient states that he was at karate practice when he suddenly felt severe pain in his ankle forcing him to stop. The patient has a past medical history notable for type I diabetes and is currently being treated for an episode of acute bacterial sinusitis with moxifloxacin. The patient recently had to have his insulin dose increased secondary to poorly controlled blood glucose levels. Otherwise, the patient takes ibuprofen for headaches and loratadine for seasonal allergies. Physical exam reveals a young healthy man in no acute distress. Pain is elicited over the Achilles tendon with dorsiflexion of the left foot. Pain is also elicited with plantar flexion of the left foot against resistance. Which of the following is the best next step in management?
- A. Refrain from athletic activities for 1 to 2 weeks
- B. Rehabilitation exercises and activity as tolerated
- C. Ibuprofen and rest
- D. Change antibiotics and refrain from athletic activities (Correct Answer)
Diabetic wounds Explanation: The patient is experiencing **Achilles tendonitis**, likely a side effect of **moxifloxacin**, which is known to cause **tendinopathy** and **tendon rupture**, especially in patients with **diabetes** or those initiating **corticosteroids** [1]. **Discontinuation of moxifloxacin** and avoidance of strenuous activities are crucial to prevent further tendon damage, with alternative antibiotics for sinusitis [1].
*Refrain from athletic activities for 1 to 2 weeks*
- While **refraining from activity** is important, it is insufficient on its own because the underlying cause (moxifloxacin) would persist, potentially worsening the tendon injury.
- This option does not address the need to **change the causative medication**, which is the primary intervention for fluoroquinolone-induced tendinopathy [1].
*Rehabilitation exercises and activity as tolerated*
- **Rehabilitation exercises** are typically introduced in later stages of recovery, after the acute inflammation has subsided and the causative agent is removed.
- **Activity as tolerated** is inappropriate when there is a high risk of **tendon rupture** due to drug-induced tendinopathy; initial management requires strict rest.
*Ibuprofen and rest*
- **Ibuprofen** can help with pain and inflammation, but it does not address the underlying **fluoroquinolone-induced tendinopathy**.
- While **rest** is important, the continued use of moxifloxacin would still predispose the patient to further tendon injury or rupture, making simply resting an incomplete solution.
Diabetic wounds US Medical PG Question 2: A 45-year-old male presents to his primary care physician complaining of drainage from his left great toe. He has had an ulcer on his left great toe for over eight months. He noticed increasing drainage from the ulcer over the past week. His past medical history is notable for diabetes mellitus on insulin complicated by peripheral neuropathy and retinopathy. His most recent hemoglobin A1c was 9.4%. He has a 25 pack-year smoking history. He has multiple sexual partners and does not use condoms. His temperature is 100.8°F (38.2°C), blood pressure is 150/70 mmHg, pulse is 100/min, and respirations are 18/min. Physical examination reveals a 1 cm ulcer on the plantar aspect of the left great toe surrounded by an edematous and erythematous ring. Exposed bone can be palpated with a probe. There are multiple small cuts and bruises on both feet. A bone biopsy reveals abundant gram-negative rods that do not ferment lactose. The pathogen most likely responsible for this patient’s current condition is also strongly associated with which of the following conditions?
- A. Otitis externa (Correct Answer)
- B. Waterhouse-Friedrichsen syndrome
- C. Gastroenteritis
- D. Toxic shock syndrome
- E. Rheumatic fever
Diabetic wounds Explanation: ***Otitis externa***
- The patient's presentation with a chronic **diabetic foot ulcer** with exposed bone and **gram-negative, non-lactose fermenting rods** on bone biopsy indicates **osteomyelitis** caused by ***Pseudomonas aeruginosa***.
- ***Pseudomonas aeruginosa*** is strongly associated with **otitis externa** (swimmer's ear), particularly **malignant otitis externa** in diabetic and immunocompromised patients.
- This is a classic association tested on USMLE: *Pseudomonas* causes both diabetic foot osteomyelitis and otitis externa.
*Waterhouse-Friedrichsen syndrome*
- This syndrome involves adrenal hemorrhage and fulminant sepsis, classically caused by ***Neisseria meningitidis***.
- Not associated with *Pseudomonas aeruginosa*.
*Gastroenteritis*
- Primarily caused by enteric pathogens such as *Salmonella*, *Shigella*, *Campylobacter*, *E. coli*, or viral agents.
- *Pseudomonas aeruginosa* is not a typical cause of gastroenteritis.
*Toxic shock syndrome*
- Caused by exotoxins from ***Staphylococcus aureus*** (TSST-1) or **Group A Streptococcus** (pyrogenic exotoxins).
- Not associated with *Pseudomonas aeruginosa*.
*Rheumatic fever*
- A delayed autoimmune complication of **Group A Streptococcal pharyngitis**.
- Not related to *Pseudomonas* infections or diabetic foot ulcers.
Diabetic wounds US Medical PG Question 3: A 57-year-old man presents to his primary care provider with progressive right foot swelling, redness, and malaise. He reports seeing a blister on his forefoot several months ago after he started using new work boots. He has dressed the affected area daily with bandages; however, healing has not occurred. He has a history of type 2 diabetes mellitus and stage 2 chronic kidney disease. He has smoked 20 to 30 cigarettes daily for the past 25 years. Vital signs are a temperature of 38.1°C (100.58°F), blood pressure of 110/70 mm Hg, and pulse of 102/minute. On physical examination, there is a malodorous right foot ulcer overlying the first metatarsophalangeal joint. Fluctuance and erythema extend 3 cm beyond the ulcer border. Moderate pitting edema is notable over the remaining areas of the foot and ankle. Which of the following is the best initial step for this patient?
- A. Minor amputation
- B. Graded compression stockings
- C. Antibiotics and supportive care (Correct Answer)
- D. Superficial swabs
- E. Endovascular intervention
Diabetic wounds Explanation: ***Antibiotics and supportive care***
- The patient presents with clear signs of **infection**, including fever, tachycardia, local erythema extending beyond the ulcer, fluctuance, and a malodorous ulcer, warranting immediate initiation of **empiric broad-spectrum antibiotics**.
- His history of **diabetes mellitus** and long-standing ulcer makes him highly susceptible to serious foot infections, including potential osteomyelitis, which requires prompt medical management to prevent progression and sepsis.
- **Supportive care** including wound care, glycemic control, and hemodynamic monitoring is essential alongside antibiotics.
*Minor amputation*
- While amputation might be considered in severe, limb-threatening infections or cases with extensive non-viable tissue, it is an **invasive procedure** and premature as an initial step when less invasive medical management has not yet been attempted.
- **Initial medical management** with antibiotics is crucial to control the infection before considering surgical interventions like amputation.
*Graded compression stockings*
- **Compression therapy** is typically used to manage chronic venous insufficiency or lymphedema, where the primary issue is venous hypertension or lymphatic fluid accumulation.
- In this patient, the prominent issue is an **active infection** with systemic signs, making compression stockings inappropriate as an initial intervention, as they do not address the infection and could potentially worsen tissue perfusion in the setting of arterial disease.
*Superficial swabs*
- Superficial swabs of ulcers are **unreliable** for identifying causative pathogens in deep-seated diabetic foot infections, as they typically only detect colonizing organisms rather than true pathogens.
- While appropriate **deep tissue cultures or bone biopsy** may be obtained to guide targeted therapy, empiric broad-spectrum antibiotics should be initiated immediately in a patient with systemic signs of infection rather than delaying treatment pending culture results.
- The best initial step is to start antibiotics first, with cultures obtained concurrently or shortly thereafter.
*Endovascular intervention*
- **Endovascular intervention** (e.g., angioplasty, stenting) addresses peripheral arterial disease (PAD) by improving blood flow to the limb, which is important for long-term wound healing in ischemic ulcers.
- However, the immediate priority in this patient is to **control the active infection**, which is manifesting with systemic inflammatory response. Revascularization may be considered later to aid healing once the infection is stabilized, as performing vascular procedures during acute infection carries increased risks of complications.
Diabetic wounds US Medical PG Question 4: A 43-year-old woman comes to the physician because of a 3-month history of a painless ulcer on the sole of her right foot. There is no history of trauma. She has been dressing the ulcer once daily at home with gauze. She has a 15-year history of poorly-controlled type 1 diabetes mellitus and hypertension. Current medications include insulin and lisinopril. Vital signs are within normal limits. Examination shows a 2 x 2-cm ulcer on the plantar aspect of the base of the great toe with whitish, loose tissue on the floor of the ulcer and a calloused margin. A blunt metal probe reaches the deep plantar space. Sensation to vibration and light touch is decreased over both feet. Pedal pulses are intact. An x-ray of the right foot shows no abnormalities. Which of the following is the most appropriate initial step in management?
- A. Surgical revascularization of the right foot
- B. Amputation of the right forefoot
- C. Total contact casting of right foot
- D. Intravenous antibiotic therapy
- E. Sharp surgical debridement of the ulcer (Correct Answer)
Diabetic wounds Explanation: ***Sharp surgical debridement of the ulcer***
- The presence of a **painless ulcer**, decreased sensation (neuropathy), and a calloused margin with loose tissue indicates a **neuropathic ulcer** common in diabetic patients. **Sharp surgical debridement** is crucial to remove non-viable tissue and promote healing.
- The probe reaching the deep plantar space suggests a potential deep infection or osteomyelitis, which needs aggressive debridement to remove all infected and necrotic tissue. However, since the X-ray is normal, it is less likely to have osteomyelitis, but it needs to be ruled out by further investigations.
*Surgical revascularization of the right foot*
- This is primarily indicated for **ischemic ulcers** where blood supply is compromised.
- The patient has **intact pedal pulses**, meaning good distal blood flow, making revascularization unnecessary at this stage.
*Amputation of the right forefoot*
- Amputation is a measure of last resort for **severe, non-healing ulcers** with extensive infection or gangrene that fail to respond to conservative and surgical debridement.
- The current presentation does not warrant such an extreme intervention as a first step.
*Total contact casting of right foot*
- **Total contact casting** is used for **off-loading pressure** from a neuropathic ulcer to facilitate healing.
- While it's an important step in management, it should generally follow **debridement** to ensure a clean wound bed.
*Intravenous antibiotic therapy*
- This is indicated if there are definitive signs of **spreading infection** (e.g., cellulitis, fever, purulence).
- While debridement helps prevent infection by removing necrotic tissue, there is no mention of systemic signs of infection or severe local infection requiring immediate IV antibiotics.
Diabetic wounds US Medical PG Question 5: A 56-year-old woman undergoes open reduction and internal fixation of the distal tibia 1 day after a fall. She has had rheumatoid arthritis for 12 years and diabetes mellitus for 2 years. Her medications over the past year have included metformin, prednisone, calcium supplements, and methotrexate. Prior to surgery, insulin was added to her medications, and the dose of prednisone was increased. She has had appropriate nutrition over the years with regular follow-ups with her healthcare professional. Which of the following is the most appropriate supplement to prevent wound failure in this patient?
- A. Glutamine
- B. Zinc
- C. Vitamin A
- D. Arginine
- E. Vitamin C (Correct Answer)
Diabetic wounds Explanation: ***Vitamin C***
- This patient is at high risk for **wound healing complications** due to her comorbidities (diabetes, rheumatoid arthritis) and medications (prednisone, methotrexate). **Vitamin C** (ascorbic acid) is essential for **collagen synthesis** and cross-linking, which is crucial for wound strength and tissue repair.
- While other options play a role in wound healing, Vitamin C is particularly important in patients with **impaired healing** due to chronic inflammation, corticosteroid use, and metabolic disorders, as it counteracts their negative effects on collagen formation.
*Glutamine*
- **Glutamine** is an important fuel for rapidly dividing cells, including immune cells and fibroblasts, and can be beneficial in catabolic states.
- However, its role in directly counteracting the specific challenges of this patient's wound healing (corticosteroid use, diabetes, rheumatoid arthritis) is **less direct** compared to Vitamin C's role in collagen synthesis.
*Zinc*
- **Zinc** is a cofactor for numerous enzymes involved in cell proliferation, immune function, and collagen synthesis.
- While important, zinc deficiency is not explicitly indicated, and its role as a primary intervention to prevent wound failure in a patient with **prednisone-induced healing impairment** is secondary to vitamin C.
*Vitamin A*
- **Vitamin A** can help reverse the negative effects of **corticosteroids** on wound healing by promoting epithelialization and collagen synthesis.
- While relevant due to prednisone use, its overall importance in **collagen formation** and direct wound strength is not as profound or broad as Vitamin C.
*Arginine*
- **Arginine** is a precursor for nitric oxide, which improves blood flow to wounds, and is involved in collagen formation and immune function.
- Although beneficial for wound healing, particularly in critically ill patients, it is **not the most appropriate single supplement** for addressing the specific collagen synthesis impairment seen in this patient's context of corticosteroid use and chronic disease.
Diabetic wounds US Medical PG Question 6: A 40-year-old woman presents with a ‘tingling’ feeling in the toes of both feet that started 5 days ago. She says that the feeling varies in intensity but has been there ever since she recovered from a stomach flu last week. Over the last 2 days, the tingling sensation has started to spread up her legs. She also reports feeling weak in the legs for the past 2 days. Her past medical history is unremarkable, and she currently takes no medications. Which of the following diagnostic tests would most likely be abnormal in this patient?
- A. Noncontrast CT of the head
- B. Serum hemoglobin concentration
- C. Nerve conduction studies (Correct Answer)
- D. Serum calcium concentration
- E. Transthoracic echocardiography
Diabetic wounds Explanation: ***Nerve conduction studies***
- The patient's ascending **motor weakness** and **sensory paresthesias** following a gastrointestinal infection are classic symptoms of **Guillain-Barré Syndrome (GBS)**, which is characterized by **demyelination** of peripheral nerves.
- **Nerve conduction studies** would reveal **markedly slowed conduction velocities**, **conduction block**, and **prolonged distal latencies**, indicating the demyelinating neuropathy characteristic of GBS.
*Noncontrast CT of the head*
- This test is primarily used to evaluate **acute neurological deficits** suggestive of stroke, hemorrhage, or mass lesions within the brain.
- The patient's symptoms are consistent with a **peripheral neuropathy** and do not suggest a central nervous system pathology.
*Serum hemoglobin concentration*
- This measures the concentration of **hemoglobin in the blood** and is used to diagnose **anemia**.
- While anemia can cause fatigue, it does not typically cause the **ascending paralysis** and **paresthesias** described, nor is it directly related to a recent stomach flu in this manner.
*Serum calcium concentration*
- This measures the level of **calcium in the blood**, which is important for muscle and nerve function.
- While extreme imbalances can cause neurological symptoms, there is no direct indication or typical association between the patient's symptoms and a primary calcium disorder.
*Transthoracic echocardiography*
- This imaging test evaluates the **structure and function of the heart**.
- The patient's symptoms are neurological and do not suggest a primary cardiac etiology or complication that would warrant an echocardiogram.
Diabetic wounds US Medical PG Question 7: A 39-year-old man comes to the physician for a follow-up examination. He was treated for a urinary tract infection with trimethoprim-sulfamethoxazole 2 months ago. He is paraplegic as a result of a burst lumbar fracture that occurred after a fall 5 years ago. He has hypertension and type 2 diabetes mellitus. Current medications include enalapril and metformin. He performs clean intermittent catheterization daily. He has smoked one pack of cigarettes daily for 19 years. His temperature is 37.1°C (98.8°F), pulse is 95/min, respirations are 14/min, and blood pressure is 120/80 mm Hg. He appears malnourished. Examination shows palpable pedal pulse. Multiple dilated tortuous veins are present over both lower extremities. There is a 2-cm wound surrounded by partial-thickness loss of skin and a pink wound bed over the right calcaneum. Neurologic examination shows paraparesis. His hemoglobin A1c is 6.5%, and fingerstick blood glucose concentration is 134 mg/dL. Which of the following is most likely to have prevented this patient's wound?
- A. Broad-spectrum antibiotic therapy
- B. Cessation of smoking
- C. Heparin therapy
- D. Topical antibiotic therapy
- E. Frequent position changes (Correct Answer)
Diabetic wounds Explanation: ***Frequent position changes***
- This patient is paraplegic, which increases his risk for **pressure ulcers** due to prolonged immobility and sustained pressure on bony prominences like the calcaneum.
- **Frequent repositioning** redistributes pressure, preventing skin breakdown and promoting circulation, thereby avoiding pressure injuries.
*Broad-spectrum antibiotic therapy*
- The wound is described as a **partial-thickness loss** with a pink wound bed, suggesting it's not primarily an infected wound requiring broad-spectrum antibiotics to prevent its formation.
- Antibiotics are used to **treat existing infections**, not prevent pressure ulcers in a non-infected state.
*Cessation of smoking*
- While **smoking impairs wound healing** and overall vascular health, it is not the most direct or primary preventative measure for a pressure ulcer caused by immobility.
- Smoking cessation would improve **long-term vascular health** and *ulcer healing*, but frequent position changes addresses the immediate cause of pressure.
*Heparin therapy*
- **Heparin** is an anticoagulant used to prevent **thrombosis** (blood clots), which is not the primary mechanism behind pressure ulcer formation.
- While immobility can contribute to deep vein thrombosis, heparin would not prevent the **mechanical pressure-induced skin damage** that causes a calcaneal wound.
*Topical antibiotic therapy*
- Similar to systemic antibiotics, topical antibiotics are used for **treating localized infections** or preventing them in *open wounds*.
- This wound is a result of pressure, and preventing its formation requires addressing the pressure itself, not merely applying antibiotics to the skin surface.
Diabetic wounds US Medical PG Question 8: A 15-year-old boy is brought to the emergency department by ambulance after his mother found him having muscle spasms and stiffness in his room. His mother stated he scraped his foot on a rusty razor on the bathroom floor 2 days prior. On presentation, his temperature is 102.0°F (38.9°C), blood pressure is 108/73 mmHg, pulse is 122/min, and respirations are 18/min. On physical exam, he is found to have severe muscle spasms and rigid abdominal muscles. In addition, he has a dirty appearing wound on his right foot. The patient's mother does not recall any further vaccinations since age 12. Finally, he is found to have difficulty opening his mouth so he is intubated. Which of the following treatment(s) should be provided to this patient?
- A. Wound debridement and antitoxin
- B. Antitoxin
- C. Wound debridement
- D. Wound debridement and booster vaccine
- E. Wound debridement, antitoxin, and booster vaccine (Correct Answer)
Diabetic wounds Explanation: ***Wound debridement, antitoxin, and booster vaccine***
- The patient presents with classic symptoms of **tetanus** (muscle spasms, stiffness, trismus, fever) following a contaminated wound, and an uncertain vaccination history.
- **Wound debridement** removes the source of toxin production, **antitoxin** (tetanus immune globulin) neutralizes circulating toxin, and a **booster vaccine** provides active immunity against future infections.
*Wound debridement and antitoxin*
- While **wound debridement** and **antitoxin** are critical for acute management, omitting the booster vaccine leaves the patient vulnerable to future tetanus infections.
- A booster dose is essential to stimulate the patient's own immune system and provide **long-term immunity**, especially with a history of unknown vaccination status.
*Antitoxin*
- Administering only **antitoxin** would neutralize circulating toxins but would not address the ongoing production of toxins from the contaminated wound.
- It also wouldn't provide **active immunization** to protect against future exposures.
*Wound debridement*
- **Wound debridement** alone removes the bacterial source but does not neutralize the already circulating **tetanus toxin**, which is responsible for the severe neurological symptoms.
- It also fails to provide immediate passive immunity with antitoxin or active immunization with a booster.
*Wound debridement and booster vaccine*
- This option correctly addresses removing the source and providing active immunity but critically misses the immediate need for **antitoxin** to neutralize existing toxins and alleviate the life-threatening symptoms.
- The **tetanus toxin** acts rapidly, and prompt neutralization is crucial to prevent further neurological damage and improve prognosis.
Diabetic wounds US Medical PG Question 9: A 45-year-old woman comes to the physician because of right foot pain for 3 months. She has a burning sensation in the plantar area between the third and fourth metatarsals that radiates to the third and fourth digits. She had a right distal radius fracture that was treated with a splint and physical therapy three months ago. She is an account executive and wears high heels to work every day. Vital signs are within normal limits. Examination of the right lower extremity shows intact skin. The posterior tibial and dorsalis pedis pulses are palpable. When pressure is applied to the sole of the foot between the metatarsal heads the patient feels pain and there is an audible click. Tapping on the affected area causes pain that shoots into the third and fourth digits. Which of the following is the most likely diagnosis?
- A. Ganglion cyst
- B. Metatarsal osteochondrosis
- C. Intermetatarsal neuroma (Correct Answer)
- D. Osteomyelitis
- E. Third metatarsal stress fracture
Diabetic wounds Explanation: ***Intermetatarsal neuroma***
- The patient's presentation of a **burning sensation** between the third and fourth metatarsals, radiating to the digits, along with the reproduction of pain and an **audible click** (Mulder's sign) on palpation, are classic signs of an intermetatarsal neuroma, commonly known as **Morton's neuroma**.
- **Tinel's sign** (pain with tapping) in the affected area confirms nerve involvement, and wearing high heels is a common predisposing factor.
*Ganglion cyst*
- While ganglion cysts can cause pain, they typically present as a **palpable, mobile mass** and do not characteristically cause a burning sensation that radiates to the digits, or an audible click.
- The symptoms described are more consistent with **nerve compression** rather than a space-occupying lesion alone.
*Metatarsal osteochondrosis*
- This condition, such as **Freiberg's disease**, typically affects the **metatarsal head**, most commonly the second metatarsal, and presents with pain and swelling exacerbated by activity.
- It does not usually involve a radiating **burning sensation** or the characteristic click observed in this patient.
*Osteomyelitis*
- Osteomyelitis is a bone infection characterized by **severe, constant pain**, fever, redness, and swelling, often with elevated **inflammatory markers** (ESR, CRP).
- The patient's skin is intact, vital signs are normal, and there are no signs of infection, making this diagnosis unlikely.
*Third metatarsal stress fracture*
- A stress fracture typically causes ** localized pain** in the bone, which worsens with weight-bearing or activity and improves with rest.
- It would not typically involve a **burning sensation** radiating into the toes or an audible click, which are indicative of nerve pathology.
Diabetic wounds US Medical PG Question 10: A 42-year-old man sustains a deep laceration requiring surgical debridement. The wound care team debates between primary closure versus healing by secondary intention. The wound is 6 cm long, 2 cm wide, located on the lower leg with mild contamination from soil exposure, and the patient is a heavy smoker with peripheral vascular disease. Evaluate which approach best synthesizes the risk-benefit analysis for optimal outcome?
- A. Skin grafting after granulation tissue formation
- B. Immediate primary closure with prophylactic antibiotics
- C. Delayed primary closure after 3-5 days of wound observation (Correct Answer)
- D. Healing by secondary intention with negative pressure therapy
- E. Primary closure with tension-relieving retention sutures
Diabetic wounds Explanation: ***Delayed primary closure after 3-5 days of wound observation***
- This approach, also known as **tertiary intention**, is ideal for **contaminated wounds** as it allows time for the inflammatory phase to reduce bacterial load before final closure.
- It balances the risk of infection from **soil exposure** and **peripheral vascular disease** with the benefit of better functional and cosmetic outcomes compared to secondary intention.
*Skin grafting after granulation tissue formation*
- This technique is typically reserved for **extensive skin loss** or large defects where edges cannot be approximated, which is not indicated for a 6 cm linear laceration.
- It involves a more complex surgical procedure and carries a high risk of failure in patients with **peripheral vascular disease** and **smoking-related** poor microcirculation.
*Immediate primary closure with prophylactic antibiotics*
- Primary closure of a **contaminated wound** significantly increases the risk of **wound dehiscence** and abscess formation, especially in a low-perfusion area like the lower leg.
- The patient’s history of **smoking** and **vascular disease** further impairs oxygen delivery and immune response, making immediate closure premature.
*Healing by secondary intention with negative pressure therapy*
- While this reduces infection risk, it leads to a prolonged healing period and significant **scar contracture**, which can impair movement on the lower leg.
- It is less efficient than delayed primary closure for a cleanable laceration and is usually reserved for **chronically infected** or non-approximable wounds.
*Primary closure with tension-relieving retention sutures*
- Placing sutures under tension in a patient with **peripheral vascular disease** further compromises **capillary perfusion**, leading to skin flap necrosis.
- Retention sutures do not address the primary concern of **bacterial contamination** from the soil, which remains trapped within the closed wound space.
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