NBDE Quiz # 29
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NBDE Quiz # 29
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1. Question
A 24-year-old male presents to the emergency department very toxic and ill appearing. He is having difficulty breathing, is febrile, and is notably swollen below the jaw line. He complains of pain and difficulty swallowing and is also noted to be drooling. His mother mentions that he has had a toothache for the past 2 weeks.
Initial management would include:
Correct- The correct answer is C. Initial management should be the establishment and maintenance of an adequate airway is the sine qua non o therapy. Death is most likely from the acute phase of cellulitis by airway obstruction. Ludwig’s angina results from the involvement of infection/cellulitis of the bilateral submandibular, sublingual, and submental spaces. In light of signs and symptoms of an impending loss of the patient’s airway (difficulty breathing, pain on swallow, uncontrolled secretions, edema noted in the submandibular region), the acute problems need to be addressed first; in turn, establishment of a secure airway is required as the initial management. Following the establishment of a secure airway, intravenous antibiotics, and incision and drainage with the removal of the offending tooth/teeth is generally curative. Without an airway, the patient cannot ventilate. Antibiotics should be started upon establishment of an airway to treat the underlying infection. Generally, an empiric broad spectrum antibiotic is used to cover for Grampositive and anaerobic bacteria. Administration of intravenous fluids and pain medications are indicated since the patient is likely dehydrated from his difficulty in swallowing and general malaise and discomfort. Caution is used with regard to pain control prior to a secure airway since it could further depress the patient’s respiratory drive. Incision and drainage is an effective treatment if the patient did not show signs of respiratory distress (difficulty breathing, pain on swallow, uncontrolled secretions). This procedure will likely follow the establishment of an airway to irrigate and debride the areas of infection. Drains are usually left in the drainage site to prevent reaccumulation of purulence. The extraction of the source of infection is generally curative; however, with the extension of the infection into multiple fascial spaces, further treatment with incision and drainage is required
Incorrect- The correct answer is C. Initial management should be the establishment and maintenance of an adequate airway is the sine qua non o therapy. Death is most likely from the acute phase of cellulitis by airway obstruction. Ludwig’s angina results from the involvement of infection/cellulitis of the bilateral submandibular, sublingual, and submental spaces. In light of signs and symptoms of an impending loss of the patient’s airway (difficulty breathing, pain on swallow, uncontrolled secretions, edema noted in the submandibular region), the acute problems need to be addressed first; in turn, establishment of a secure airway is required as the initial management. Following the establishment of a secure airway, intravenous antibiotics, and incision and drainage with the removal of the offending tooth/teeth is generally curative. Without an airway, the patient cannot ventilate. Antibiotics should be started upon establishment of an airway to treat the underlying infection. Generally, an empiric broad spectrum antibiotic is used to cover for Grampositive and anaerobic bacteria. Administration of intravenous fluids and pain medications are indicated since the patient is likely dehydrated from his difficulty in swallowing and general malaise and discomfort. Caution is used with regard to pain control prior to a secure airway since it could further depress the patient’s respiratory drive. Incision and drainage is an effective treatment if the patient did not show signs of respiratory distress (difficulty breathing, pain on swallow, uncontrolled secretions). This procedure will likely follow the establishment of an airway to irrigate and debride the areas of infection. Drains are usually left in the drainage site to prevent reaccumulation of purulence. The extraction of the source of infection is generally curative; however, with the extension of the infection into multiple fascial spaces, further treatment with incision and drainage is required