186.A 51-year-old diabetic man complains of intense right-ear pain and
discharge. On physical examination, his BP is 145/65 mm Hg, HR 91 beats
per minute, and temperature 101°F. He withdraws when you retract the
pinna of his ear. The external auditory canal is erythematous, edematous,
and contains what looks like friable granulation tissue in the external audi-
tory canal. The tympanic membrane is partially obstructed but appears to
be erythematous, as well. Which of the following statements regarding this
patient’s condition is true?
a. It is a common complication of otitis externa that afflicts otherwise healthy
patients.
b. The mainstay of treatment is outpatient with oral antibiotics.
c. Patients are usually afebrile and have minimal ear pain.
d. It is caused by P aeruginosa.
e. Hearing loss is the most common complication.
187.A 26-year-old woman presents to the ED with fever, malaise, and an
evolving rash in the right axilla that she initially thought was from an insect
bite that she received while hiking 1 week earlier. She complains of gener-
alized fatigue, nausea, headache, and joint pain over the past several days.
Her vitals are BP of 120/75 mm Hg, HR of 75 beats per minute, RR of
16 breaths per minute, and temperature of 101°F. On physical examination,
she is awake and alert, with a nonfocal neurological examination. Her neck
is supple, but she is diffusely tender over the shoulder, knee, and hip joints
bilaterally without any distinct effusions. Her abdomen is soft and non-
tender. She has a 9-cm erythematous annular plaque with a central clear-
ing under her right axilla. Which of the following is the next best step?
a. Consult dermatology for a biopsy of the rash.
b. Perform a LP and begin treatment with IV ceftriaxone.
c. Prescribe doxycycline 21 days and arrange follow-up with her primary-care
doctor.
d. Prescribe hydrocortisone cream for the rash and acetaminophen for the
headache and joint pain.
e. Perform serologic testing for Borrelia burgdorferiand begin treatment only if
positive.
Fever 187