177.A 67-year-old woman presents to the ED with a painful facial rash
that has been worsening over the past 2 days. On physical examination,
she has a deeply erythematous, shiny area of warm and tender skin on her
left face with a sharply-demarcated and indurated border. There is minimal
edema. Vitals are HR 88 beats per minute, BP 125/70 mm Hg, RR 16 breaths
per minute, and temperature 101°F. Which of the following is the most
appropriate next step in management?
a. IV antibiotics and hospital admission
b. Oral cephalosporin and outpatient follow-up
c. IV acyclovir and Tzanck smear
d. Systemic steroids and laboratory testing for rheumatoid factor
e. Dermatology consult and biopsy of the rash
178.A 47-year-old man presents to urgent care complaining of a 2-day
history of sore throat and subjective fever at home. He denies cough or
vomiting. His BP is 130/75 mm Hg, HR is 85 beats per minute, tempera-
ture is 101°F, and his RR is 14 breaths per minute. He has tonsillar swelling
without exudates and bilaterally enlarged and tender lymph nodes of the
neck. The rapid streptococcal antigen test is negative. Which of the follow-
ing is the next best step in management?
a. Administer penicillin and discharge the patient.
b. Schedule a lymph node biopsy to rule out lymphoma.
c. Observe for 6 hours.
d. Perform a throat culture, symptomatic care, and treat if results are positive.
e. Administer amantadine to patient and all contacts.
179.A 28-year-old man who just finished a 7-day course of antibiotics for
pharyngitis presents to the ED with progressive difficulty swallowing. His BP
is 130/65 mm Hg, HR is 95 beats per minute, temperature is 100.1°F, RR is
16 breaths per minute, and oxygen saturation is 99%. On examination, the
patient is in no acute distress but has a fluctuant mass on the right side of the
soft palate with deviation of the uvula. Which of the following is the most
appropriate next step in management?
a. Needle aspiration, antibiotics, and follow-up in 24 hours
b. Pain control, observation for 6 hours
c. Admission for incision and drainage in the OR
d. Antibiotics and follow-up in 24 hours
e. CT scan, antibiotics, and follow-up in 24 hours
Fever 183