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ABPOPPM In-Training Exam

Module: Wound Care

An 83 year-old non-ambulatory woman presents with a non-healing ulcer on the posterior heel.
Examination reveals a non-draining, malodorous, 4 cm ulcer with a dry eschar and surrounding
erythema. Pedal pulses are palpable and her ABI is .9.

Laboratory findings include a serum albumin level of 3.7 mg/dl (normal 3.5 to 5 mg/dl).

Which of the following is the most appropriate initial treatment?

A. Unna boot, enzymatic debridement


B. Enzymatic debridement, protein supplementation
C. Total contact cast, antibiotics, anti-coagulant therapy
D. Heel protector, antibiotics, debridement

Correct Answer: D

Suggested Reading:

Sheffield PJ, Smith PS, Fife CE. Wound Care Practice, Best Publishing Comp 2004; 335-348

DeKeyser G, Dejaeger E, DeMeyst H, Eders GC. Pressure-reducing Effects of Heel Protectors.


Adv Wound Care, 1994, Jul: 7(4): 30-2, 34

1
ABPOPPM In-Training Exam

Module: Wound Care

Set 1 of 3
Questions 2, 3, and 4 relate to the following clinical scenario:

A 48 year-old female with DM2 is seen in with an ulceration of the left fifth toe. This began six
weeks ago the wound has worsened with time. Redness and swelling was noted three days ago.
Vascular examination demonstrates ankle pressure of 202mm Hg. and brachial pressure of
130mm Hg.

Which of the following is the most appropriate course of action?

A. Plain radiographs, CBC, C-reactive protein, BMP, surgical I&D


B. Bedside debridement, culture, empiric oral antibiotics, MRI
C. Enzymatic debridement, non-invasive arterial testing, IV antibiotics
D. Biopsy, Alginate dressing, compression therapy, Venous Duplex

Correct Answer: A

Suggested Reading:

Sheffield PJ, Smith PS, Fife CE. Wound Care Practice, Best Publishing Comp, 2004; 305-318

Wu SC, Driver VR, Wrobel JS, Armstrong DG. Foot ulcers in the diabetic patient, prevention
and treatment. Vasc Health Risk Manag. 2007 February; 3(1): 65–76

2
ABPOPPM In-Training Exam

Module: Wound Care

Set 2 of 3

Which of the following studies is the most appropriate at this time?

A. Venous Duplex
B. Arteriogram
C. MRI
D. Bone scan

Correct Answer: A

Suggested Reading:

Sheffield PJ, Smith PS, Fife CE. Wound Care Practice, Best Publishing Comp, 2004; 305-318

Wu SC, Driver VR, Wrobel JS, Armstrong DG. Foot ulcers in the diabetic patient, prevention
and treatment. Vasc Health Risk Manag. 2007 February; 3(1): 65–76

3
ABPOPPM In-Training Exam

Module: Wound Care

Set 3 of 3

Which of the following is the most likely infecting organism?

A. Methicillin-resistant staphylococcus aureus


B. Pseudomonas aeruginosa
C. Streptococcus pyogenes
D. Proteus mirabilis

Correct Answer: C

Suggested Reading:

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

4
ABPOPPM In-Training Exam

Module: Wound Care

A 48 year-old male with Factor V Leiden is seen for a wound on his posterior medial calf.

Which of the following studies is most appropriate to confirm the diagnosis?

A. Comprehensive metabolic panel


B. Magnetic resonance angiography
C. Venous Duplex
D. Chest X-ray

Correct Answer: C

Suggested Reading:

Agrawal N, et al. Activated protein C resistance in deep vein thrombosis. Ann Vasc Surg. 2009
May-Jun;23(3):364-6

Giannini M, et al. Advances in ultrasound techniques improve early detection of deep vein
thrombosis. Int Angiol. 2008 Dec;27(6):466-74

5
ABPOPPM In-Training Exam

Module: Wound Care

Set 1 of 2
Question 6 and 7 relate to the following clinical scenario

A 42 year-old male with DM2 is seen in the ED with the foot as shown. Radiograph reveals gas
in the soft tissues over the dorsum of the foot, but no osseous changes.

Following hospital admission, which of the following is the next most appropriate course of
action?

A. Intravenous antibiotics and hyperbaric oxygen


B. Below knee amputation
C. Emergency I&D
D. Bedside debridement and vascular consult

Correct Answer: C

Suggested Reading:

Sheffield PJ, Smith PS, Fife CE. Wound Care Practice, Best Publishing Comp, 2004; 305-318

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

6
ABPOPPM In-Training Exam

Module: Wound Care

Set 2 of 2

Which of the following is the most likely infecting organism?

A. Staphylococcus aureus
B. Streptococcus pyogenes
C. Escherichia coli
D. Clostridium perfringens

Correct Answer: D

Suggested Reading:

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

7
ABPOPPM In-Training Exam

Module: Wound Care

A patient with a history of recurrent DVT states that her "blood thinner" is monitored monthly.

Which of the following is most reliable for evaluating her coagulation status?

A. Activated PTT
B. Prothrombin time
C. Bleeding time
D. International Normalized Ratio (INR)

Correct Answer: D

Suggested Reading:

Witt DM, Delate T, Clark NP, Matrell C, Tran T, Crowther MA, Garcia DA, Ageno W, Hylek
EM. Outcomes and predictors of very stable INR control during chornic anticoagulation therapy.
Bllod. 2009 May 13. [epub ahead of print]

Barnes GD, Froehlich JB. Anticoagulation: where are we and where we need to go. J Thromb
Thrombolysis. 2008 Jul 18. [epub ahead of print

8
ABPOPPM In-Training Exam

Module: Wound Care

A hospitalized patient has an infected laceration and cellulitis of the foot. Initial gram stain
showed heavy growth of gram positive cocci resistant to penicillin, ampicillin, methicillin, and
oxacillin.

Which of the following is the most appropriate antibiotic choice?

A. Nafcillin (Unipen)
B. Ciprofloxacin (Cipro)
C. Trimethoprim-sulfamethoxazole (Bactrim)
D. Cephazolin (Ancef)
E. Vancomycin (Vancocin)

Correct Answer: E

Suggested Reading:

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

9
ABPOPPM In-Training Exam

Module: Wound Care

A 76 year-old female with dementia presents with a painful ingrown toenail. Examination reveals
absent pedal pulses and decreased sensation.

Which of the following is the most appropriate course of action?

A. Femoral angiogram
B. Partial nail avulsion
C. Phenol matrixectomy
D. Vascular consultation

Correct Answer: B

Suggested Reading:

Banks AS, Downey MS, Martin DE, Miller, SJ. McGlamry’s Comprehensive Textbook of Foot
and Ankle Surgery, 3rd Ed. Lippincott William and Wilkins. Jun 15, 2001:203-230

10
ABPOPPM In-Training Exam

Module: Wound Care

This 62 year-old male with right hemiparesis s/p CVA is seen in the ED for treatment of the
ulceration shown. The wound has been present for 2 months, but discoloration and swelling
developed 2 weeks ago. Three days ago he developed purulence, fever, chills, sweats, and
malaise. Medications include Coumadin, Lasix, and Norvasc. He has no known drug allergies.

Which of the following are the most appropriate tests to order prior to proceeding with
emergency I&D?

A. TCpO2, CBC with differential, MRI


B. Radiograph, Basic metabolic panel, INR
C. Swab culture, Venous Duplex, Serum K+
D. Bone scan, EKG, Hgb A1C

Correct Answer: B

Suggested Reading:

Ryan F, Byrne S, O'Shea S. Managing oral anticoagulation therapy: improving clinical


outcomes. A review. J Clin Pharm Ther. 2008 Dec;33(6):581-90

Sella EJ, Grosser DM. Imaging modalities of the diabetic foot. Clin Podiatr Med Surg. 2003
Oct;20(4):729-40

11
ABPOPPM In-Training Exam

Module: Wound Care

Three weeks following surgical debridement of calcaneal osteomyelitis a patient presents with
malaise, anorexia, and diarrhea. He has been on an intravenous second generation cephalosporin.

Which of the following is the most appropriate course of action?

A. Discontinue antibiotic, obtain stool cultures


B. C&S of the surgical site, empiric triple antibiotic regimen
C. Blood cultures, vancomycin (Vancocin)
D. Technetium 99 bone scan, compete blood count (CBC)
E. Amantadine (Symmetrel), atropine/diphenoxylate (Lomotil)

Correct Answer: A

Suggested Reading:

Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J. Clostridium Difficile-Associated
Diarrhea and Colitis. Infection Control and Hospital Epidemiology 1995;16:459-477

Parkes GC, Sanderson JD, Whelan K. The mechanisms and efficacy of probiotics in the
prevention of Clostridium difficile-associated diarrhoea. Lancet Infect Dis. 2009 Apr;9(4):237-
44

12
ABPOPPM In-Training Exam

Module: Wound Care

A 72 year-old female with peripheral neuropathy is referred for evaluation and treatment. The
midfoot bruising began one week ago. There is no history of acute trauma. She believes the foot
has changed shape over the past three months.

After treatment of the acute problem, which of the following is the most appropriate form of off-
loading?

A. Diabetic walker (e.g. DH Walker, Aircast)


B. Depth inlay shoe with custom accommodative insole
C. Total contact cast
D. Felt and foam padding

Correct Answer: C

Suggested Reading:

Ulbrecht JS, Wukich DK. The Charcot foot: medical and surgical therapy. Curr Diab Rep. 2008
Dec;8(6):444-51

Leibner ED, Brodsky JW, Pollo FE, Baum BS, Edmonds BW. Unloading mechanism in the total
contact cast. Foot Ankle Int. 2006 Apr;27(4):281-5

13
ABPOPPM In-Training Exam

Module: Wound Care

A 65 year-old male with DM2 presents with a 0.5cm deep wound on his left fifth toe which began
two months ago after wearing a new pair of shoes. He has been cleansing the area daily with
hydrogen peroxide and dressing with Neosporin and a Band-aid. Radiographs are negative for
osseous changes.

Which of the following is most useful to rule out osteomyelitis?

A. Bone scan
B. Skin temperature measurement
C. Deep tissue culture
D. CRP

Correct Answer: D

Suggested Reading:

Fleischer AE, Didyk AA, Woods JB, Burns SE, Wrobel JS, Armstrong DG. Combined clinical
and laboratory testing improves diagnostic accuracy for osteomyelitis in the diabetic foot. J Foot
Ankle Surg. 2009 Jan-Feb;48(1):39-46. Epub 2008 Nov 13

Palestro CJ, Love C. Nuclear medicine and diabetic foot infections. Semin Nucl Med. 2009
Jan;39(1):52-65

14
ABPOPPM In-Training Exam

Module: Wound Care

A 20 year-old female presents with acute right heel pain, left ankle pain, and left knee pain. She
denies trauma. Her past medical history is remarkable for conjunctivitis one week ago, and
gonorrhea one month ago. She tested negative for HIV. Examination reveals pustules on the
soles of her feet which, when opened, contain keratotic material. The involved joints are swollen,
red, warm, and painful on palpation. Radiologic examination of these joints is within normal
limits.

Which of the following studies is most appropriate?

A. Synovial fluid analysis, C&S of synovial fluid, CBC


B. C&S of synovial fluid, C-reactive protein, chemistry panel (CMP)
C. Anti-nuclear antibodies titer (ANA), CBC, synovial fluid analysis
D. Synovial fluid analysis, C-reactive protein, rheumatoid factor

Correct Answer: A

Suggested Reading:

Klippel, JH. Primer on the Rheumatic Diseases, 13th Edition. Springer Science + Business
Media LLC 2008:21-27

15
ABPOPPM In-Training Exam

Module: Wound Care

A 56 year-old male is seen for treatment of non-healing ulcerations that present with pain on
palpation. His legs have been swollen for the past 20 years, following radiation therapy for
prostate cancer. The current wound has been present five years and has resolved with the use of
Unna boots. The wound demonstrates copious amounts of clear watery drainage.

Which of the following is the most likely diagnosis?

A. Mycetoma
B. Vasculitis
C. Lymphedema
D. Venous stasis ulceration

Correct Answer: C

Suggested Reading:

Tada H, Teramukai S, Fukushima M, Sasaki H. Rick factors for lower limb lypmhdema after
lymph node dissection in patients with ovarian and uterine carcinoma. BMC Cancer. 2009 Feb 5;
9:47

Langbecker D, Hayes SC, Newman B, Janda M. Treatment for upper-limb and lower-limb
lymphedema by professional specializing in lymphedema care. Eur J Cancer Care (engl). 2008
Nov; 17(6):557-64

16
ABPOPPM In-Training Exam

Module: Wound Care

A ten year-old has a skin rash on the dorsum of his foot. The rash is crusted, oozing, inflamed
and tender. There is lymphangitis continuing a short distance proximal to the rash.

Which of the following is the most likely infective agent?

A. Staphylococcus aureus
B. Escherichia coli
C. Pseudomonas aeruginosa
D. Haemophilus influenza
E. Corynebacterium minutisimum

Correct Answer: A

Suggested Reading:

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

17
ABPOPPM In-Training Exam

Module: Wound Care

A 59 year-old male with DM2 presents for treatment of a plantar ulceration beneath the first
metatarsal. The lesion has healed on two separate occasions but recurs despite the use of healing
sandals and depth inlay shoes with total contact insoles.

Which of the following is the next most appropriate treatment?

A. Diabetic walker (e.g. DH Walker, Aircast)


B. Total contact cast
C. Custom molded accommodative orthoses
D. Sesamoidectomy

Correct Answer: B

Suggested Reading:

Leibner ED, Brodsky JW, Pollo FE, Baum BS, Edmonds BW. Unloading mechanism in the total
contact cast. Foot Ankle Int. 2006 Apr;27(4):281-5

Cavanagh PR, Lipsky BA, Bradbury AW, Botek G. Treatment for diabetic foot ulcers. Lancet.
2005 Nov 12;366(9498):1725-35

18
ABPOPPM In-Training Exam

Module: Wound Care

A 67 year-old male with DM2 and coronary artery disease, who is post quadruple coronary artery
bypass graft, is referred for evaluation of discoloration of his left great toe. The problem began
two months ago as a small scab that progressively enlarged.

In addition to standard radiographs which of the following should be ordered?

A. MRI and CBC with differential


B. Basic metabolic panel and CTA
C. ABI, EKG, Chest x-ray
D. CRP, tissue and blood cultures

Correct Answer: B

Suggested Reading:

Hodor L, NG D. Arterial embolus of the lower extremity. An atypical presentation. JAPMA.


1999 Ju;;89(7):373-6

Liapis CD, Avqerinos ED, Kadoglou NP, Kakisis. What a vascular surgeon should know and do
about atherosclerotic risk factors. J VAsc Surg. 2009 May;49(5):1348-54

19
ABPOPPM In-Training Exam

Module: Wound Care

A 40 year-old male presents for the treatment of acute paronychia of five days duration. Green
purulent drainage with erythema at the base of the nail is noted. The patient is allergic to
penicillin and sulfa drugs. The remainder of the medical history is unremarkable and non-
contributory.

Which of the following would be the most appropriate antibiotic?

A. Levofloxacin (Levaquin)
B. Clindamycin (Cleocin)
C. Ampicillin (Principen)
D. Ampicillin/sulbactam (Unasyn)
E. Vancomycin (Vancocin)

Correct Answer: A

Suggested Reading:

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

20
ABPOPPM In-Training Exam

Module: Wound Care

A 49 year-old male with DM2 presents for treatment of a plantar hallux ulceration. The wound
has been present for three months. A similar ulceration had occurred in the same area one year
previously.

Which of the following is the most likely diagnosis?

A. Charcot arthropathy
B. Acute fracture of the phalanx
C. Osteomyelitis
D. Medial calcific sclerosis

Correct Answer: C

Suggested Reading:

Fleischer AE, Didyk AA, Woods JB, Burns SE, Wrobel JS, Armstrong DG. Combined clinical
and laboratory testing improves diagnostic accuracy for osteomyelitis in the diabetic foot. J Foot
Ankle Surg. 2009 Jan-Feb;48(1):39-46. Epub 2008 Nov 13

Lavery LA, Peters EJ, Armstrong DG, Wendel CS, Murdoch DP, Lipsky BA. Risk factors for
developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract. 2009
Mar;83(3):347-52. Epub 2008 Dec 30

21
ABPOPPM In-Training Exam

Module: Wound Care

Set 1 of 2
Questions 22 and 23 relate to the following clinical scenario:

The patient pictured is scheduled for pinch graft coverage of this wound which was the result of
an I&D performed 21 days prior. The patient has DM2 without peripheral neuropathy and has
been treated on Vancomycin for MRSA x 14 days total.

Which of the following antibiotics should be used to provide surgical wound prophylaxis?

A. Ciprofloxacin
B. Vancomycin
C. Ancef
D. Bacitracin irrigation

Correct Answer: C

Suggested Reading:

Zygonis T, Jolly GP, Garbalosa JC. The efficacy of prophylactic antibiotics in elective foot and
ankle surgery. JFAS. 2004 Mar-Apr; 43(2):97-103

Okun S, et al. The use of prophylactic antibiotics in clean podiatric surgery. J Foot Surg. 1984
Sep-Oct;23(5):402-6

22
ABPOPPM In-Training Exam

Module: Wound Care

Set 2 of 2

If pinch graft is not elected, which of the following modalities would result in the LEAST
amount of contraction for the wound shown?

A. Graftjacket (human dermal allograft)


B. Oasis (porcine intestinal submucosa)
C. Apligraf (living bilayered cell therapy)
D. Full thickness autograft

Correct Answer: D

Suggested Reading:

Walden JL, Garcia H, Hawkins H, Crouchet JR, Traber L, Gore DM. Both dermal matrix and
epidermis contribute to an inhibition of wound contraction. Ann Plas Surg. 2000 Aug;45(2):162-
6

Banis JC. Glabrous skin grafts for plantar defects. Foot Ankle Clin. 2001 Dec;6(4):827-37, viii

23
ABPOPPM In-Training Exam

Module: Wound Care

A 63 year-old male presents with chronic pain in the left arch. Examination reveals absent
dorsalis pedis and posterior tibial pulses, hair loss and generalized elevation pallor bilateral.

Which of the following is the most likely cause of his symptoms?

A. Atheromatous emboli
B. Thromboangiitis obliterans
C. Microangiopathy
D. Arteriosclerosis obliterans
E. Raynaud’s disease

Correct Answer: D

Suggested Reading:

Kasper DL. Harrison’s Principles of Internal Medicine 16th Edition. McGraw Hill 2005: 1486-
1495

Sheffield PJ, Smith PS, Fife CE. Wound Care Practice, Best Publishing Comp 2004; 225-249.

24
ABPOPPM In-Training Exam

Module: Wound Care

A 54 year-old male with alcoholic neuropathy presents with a red, hot, swollen, painful right foot
which began 1 week ago. There is no history of acute trauma, change in shoes, or activities. He
reports a prior ulceration at the plantar fifth metatarsal head which healed 1 month ago under the
care of his primary care physician. A current radiograph is obtained.

Which of the following studies would best confirm the diagnosis?

A. Three phase bone scan


B. Rheumatoid factor and ANA
C. CBC with diff and CRP
D. Joint fluid analysis

Correct Answer: C

Suggested Reading:

Fleischer AE, Didyk AA, Woods JB, Burns SE, Wrobel JS, Armstrong DG. Combined clinical
and laboratory testing improves diagnostic accuracy for osteomyelitis in the diabetic foot. J Foot
Ankle Surg. 2009 Jan-Feb;48(1):39-46. Epub 2008 Nov 13

Lavery LA, Peters EJ, Armstrong DG, Wendel CS, Murdoch DP, Lipsky BA. Risk factors for
developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract. 2009
Mar;83(3):347-52. Epub 2008 Dec 30

25
ABPOPPM In-Training Exam

Module: Wound Care

A 45 year-old female smoker presents with acutely painful right toes. Her past medical history
reveals that exposure to cold produces digital changes and a mottled appearance of the skin.

Which of the following is the most likely etiology of her complaints?

A. Atheromatous embolism
B. Thromboangiitis obliterans
C. Raynaud's disease
D. Arteriosclerosis obliterans
E. Diabetic micro angiopathy

Correct Answer: E

Suggested Reading:

Pederson WK. Medical and Surgical Considerations in Patients with Vasculitis and Raynaud’s
Syndrome. Foot Ankle Clin 2001, Dec; (6(4): 699-713

Girish K Patel, Joseph E Grey, and Keith G Harding. ABC of Wound Healing: Uncommon
Causes of Ulceration. BMJ. 2006 March 11; 332(7541): 594–596

26
ABPOPPM In-Training Exam

Module: Wound Care

Set 1 of 2
Questions 27 and 28 relate to two similar clinical scenarios. Choose the best answer for
each:

A 57 year-old female is seen with discoloration of the right great toe after dropping a large can of
vegetables on her toe 24 hours ago. Her neurovascular status is intact. On radiograph the distal
phalanx has a non-displaced transverse fracture. Following nail plate avulsion laceration of the
nail bed is noted.

Which of the following is appropriate antibiotic treatment for this fracture?

A. First generation Cephalosporin


B. PCN and aminoglycocide
C. Piperacillin/Tazobactam
D. Vancomycin

Correct Answer: C

Suggested Reading:

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

Gumann G. Fractures of the foot and ankle. Elsevier, 2004:p12

27
ABPOPPM In-Training Exam

Module: Wound Care

Set 2 of 2

A 57 year-old healthy female presents to the ED with discoloration of the right great toe after
having dropped a large can of vegetables on the toe four hours prior. Neurovascular status is
intact. Following nail plate avulsion laceration of the nail bed is noted. Radiograph reveals a
non-displaced, transverse fracture of the distal phalanx.

Which of the following is the most appropriate antibiotic regimen for this patient?

A. First generation Cephalosporin


B. PCN and aminoglycocide
C. Piperacillin/Tazobactam
D. Vancomycin

Correct Answer: A

Suggested Reading:

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

Gumann G. Fractures of the foot and ankle. Elsevier, 2004:p12

28
ABPOPPM In-Training Exam

Module: Wound Care

A 47 year-old female with rheumatoid arthritis is referred for evaluation and treatment of painful
wounds on the lateral right foot. The wounds began as small discolored spots that opened and
drained clear watery fluid and have progressively enlarged over the past month. Treatment has
consisted of oral antibiotics and Silvadene cream.

Which of the following is the most appropriate treatment plan at this time?

A. Swab culture, bone scan, arterial Doppler


B. Radiograph, tissue culture, biopsy
C. Debridement, MRI, venous Duplex
D. Hospital admission, culture, IV antibiotics

Correct Answer: B

Suggested Reading:

Shanmugam VK, Steen VD, Cupps TR. Lower extremity ulcers in connective tissue disease. Isr
Med Assoc J. 2008 Jul;10(7):534-6

Sheffield PJ, Smith PS, Fife CE. Wound Care Practice, Best Publishing Comp, 2004; 405-424

29
ABPOPPM In-Training Exam

Module: Wound Care

A 51 year-old male complains of right buttock and thigh pain with ambulation. The onset of pain
is dependant upon the distance traveled. It is relieved by standing still for a few minutes. The
patient is also under the care of a urologist for evaluation of impotence.

Which of the following is the most likely diagnosis?

A. Aortoiliac disease
B. Arthritis induced pseudo claudication
C. Femoral neck fracture
D. Pelvic neoplasm

Correct Answer: A

Suggested Reading:

Julsrud ME, Leriche’s Syndrome. JAPMA 1992 April; 82(4): 196-201

Kasper DL. Harrison’s Principles of Internal Medicine 16th Edition. McGraw Hill 2005: 1486-
1495

30
ABPOPPM In-Training Exam

Module: Wound Care

You plan to hospitalize a 49 year-old male with DM1 for the condition shown. The fourth toe
was amputated one month ago for dry gangrene. There was no infection at that time and he was
not placed on antibiotics.

Which of the following antibiotics should be ordered on admission?

A. Levofloxacin
B. Vancomycin
C. Amoxicillin/Clavulanate
D. Piperacillin/Tazobactam

Correct Answer: D

Suggested Reading:

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

31
ABPOPPM In-Training Exam

Module: Wound Care

A 50 year-old male with DM1 presents as shown. He relates walking barefoot on concrete in 105
degree weather. The wound has been draining copious amounts of clear watery fluid. The
surrounding skin is sloughing and is white.

Which of the following is the most appropriate dressing for this wound?

A. Alginate (e.g. Aquacel, Maxsorb, Sorbsan)


B. Silver barrier dressing (e.g. Acticoat-7, Tegaderm-Ag)
C. Antibacterial cream (e.g. Silvadene, Bactroban)
D. Hydrocolloid (e.g. Duoderm, Allevyn, Tegasorb)

Correct Answer: A

Suggested Reading:

Putz Z, Nadas J, Jermendy G. Severe but preventable foot burn injury in diabetic patients with
peripheral neuropathy. Med Sci Monit. 2008 Sep;14(9):CS89-91.

Schwacha MG, Thobe BM, Daniel T, Hubbard WJ. Impact of Thermal Injury on Wound
Infiltration and the Dermal Inflammatory Response. J Surg Res. 2008 Aug 27

32
ABPOPPM In-Training Exam

Module: Wound Care

A 54 year-old patient with DM2 presents for evaluation of calcaneal osteomyelitis. Gram stain
demonstrates many gram positive cocci in chains and clusters and gram negative rods.

Which of the following is the most appropriate empiric antibiotic treatment to begin before open
biopsy can be obtained?

A. Penicillin G (Bicillin)
B. Cephalexin (Keftab) + metronidazole (Flagyl)
C. Ciprofloxacin (Cipro) + clindamycin (Cleocin)
D. Vancomycin (Vancocin)

Correct Answer: C

Suggested Reading:

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

33
ABPOPPM In-Training Exam

Module: Wound Care

Set 1 of 2
Questions 34 and 35 relate to the following clinical scenario:

A 71 year-old male is seen for evaluation of the ulceration seen in the accompanying figure.
Pedal pulses are non-palpable and there is no hair growth noted on the feet or legs. Which of the
following reasons would be an indication to perform transcutaneous oximetry (TCpO2) as
opposed to an ankle brachial index for evaluation of his blood flow?

A. Poor arterial collateralization


B. Presence of pedal ulcerations
C. Arterial vasospasm
D. Medial calcific sclerosis

Correct Answer: D

Suggested Reading:

Fife CE, et al. Transcutaneous oximetry in clinical practice: consensus statements from an expert
panel based on evidence. Undersea Hyperb Med. 2009 Jan-Feb;36(1):43-53

Aboyans V, et al. The association between elevated ankle systolic pressures and peripheral
occlusive arterial disease in diabetic and nondiabetic subjects. J Vasc Surg. 2008 Nov;
48(5):1197-203

34
ABPOPPM In-Training Exam

Module: Wound Care

Set 2 of 2

Which of the following modalities is the first line of treatment for this wound?

A. Platelet derived growth factors


B. Sharp debridement
C. Topical enzymatic agents
D. Antibiotic foot soaks

Correct Answer: B

Suggested Reading:

Sheffield, PJ; Smith, PS; Fife, CE. “Wound Care Practice”, Best Publishing Comp 2004; 159-187

Steed DL, Donohoe D, Webster M, Lindsley L. Effect of Extensive Debridement and Treatment
on the Healing of Diabetic Foot Ulcers. J. Am. Coll. Surg., 1996, 183: 61-64

35
ABPOPPM In-Training Exam

Module: Wound Care

A patient is seen with the pictured VAC dressing, applied incorrectly by the home visiting nurse.

Which of the following describes the error?

A. Sponge is contacting periwound skin


B. Granufoam was used instead of white foam
C. Sponge is too small
D. Negative pressure was set too high

Correct Answer: C

Suggested Reading:

Lee HJ, Kim JW, Oh CW, Min WK, Shon OJ, Oh JK, Park BC, Ihn JC. Negative pressure
wound therapy for soft tissue injuries around the foot and ankle. J Orthop Surg Res. 2009 May
9;4:14

Horch RE, Dragu A, Lang W, Banwell P, Leffler M, Grimm A, Bach AD, Uder M, Kneser U.
Coverage of exposed bones and joints in critically ill patients: lower extremity salvage with
topical negative pressure therapy. J Cutan Med Surg. 2008 Sep-Oct;12(5):223-9

36
ABPOPPM In-Training Exam

Module: Wound Care

A 40 year-old man complains of fever, chills, nausea, vomiting, and severe myalgia five days
after undergoing an uneventful subtalar arthrodesis. The patient has a temperature of 39.6
degrees C (103.3 degrees F), a systolic blood pressure of 90mm Hg, a heart rate of 110 beats/min,
and respirations of 20/min. Examination reveals a diffuse, erythematous, blanching rash over the
entire body, an enlarged, tender liver, and inflamed oral pharynx. The surgical wound is pictured
below. A scant amount of clear exudate covered the incision.

Which of the following is the most likely diagnosis?

A. Anaerobic cellulitis
B. Necrotizing fascitis
C. Clostridial myonecrosis
D. Toxic shock syndrome

Correct Answer: D

Suggested Reading:

Strenge KB, Mangan DB, Idusuyi OB. Postoperative toxic shock syndrome after excision of a
ganglion cyst from the ankle. JFAS 2006- Jul-Aug;45(4):275-7

Zier BG, Byrn C. Septic shock syndrome in the surgical wound care patient. JFAS. 1992 Sep-
Oct;31(5):459-62

37
ABPOPPM In-Training Exam

Module: Wound Care

A 54 year-old female presents with a non-healing foot ulcer. Examination reveals an ankle
brachial index of 1.2 (>1) and a TCpO2 of 45 mmHg (>55 mm Hg).

Which of the following is the most likely explanation?

A. Poor arterial collateralization


B. Medial calcific sclerosis affected the study results
C. Vasospastic disease
D. Venous congestion

Correct Answer: B

Suggested Reading:
Wikstrom J, et al. Lower extremity artery stenosis distribution in an unslected elderly population
and its relation to a reduced ankle-brachial index. J Vasc Surg. 2009 May 14. [epub ahead of
print]

Aboyans V, et al. The association between elevated ankle systolic pressures and peripheral
occlusive arterial disease in diabetic and nondiabetic subjects. J Vasc Surg. 2008 Nov;
48(5):1197-203

38
ABPOPPM In-Training Exam

Module: Wound Care

Which of the following is considered the "cornerstone of therapy" for recalcitrant foot
ulcerations?

A. Platelet derived growth factors


B. Sharp debridement
C. Topical enzymatic agents
D. Antibiotic foot soaks

Correct Answer: B

Suggested Reading:

Sheffield, PJ; Smith, PS; Fife, CE. “Wound Care Practice”, Best Publishing Comp 2004; 159-187

Steed DL, Donohoe D, Webster M, Lindsley L. Effect of Extensive Debridement and Treatment
on the Healing of Diabetic Foot Ulcers. J. Am. Coll. Surg., 1996, 183: 61-64

39
ABPOPPM In-Training Exam

Module: Wound Care

A patient presents with an infected wound on the dorsum of the foot which began three months
ago. He has been treated by his PCP using Ciprofloxacin 500mg BID for the past 21 days. He
has been dressing the wound with Silver sulfadiazine cream (Silvadene) and gauze daily.

Which of the following is the most appropriate treatment?

A. Cefadroxil (Duricef) and gentamicin (Garamycin) cream


B. Erythromycin (E-mycin) and polymyxin B/bacitracin (Polysporin) ointment
C. Dicloxacillin and povidone-iodine (Betadine) ointment
D. Trimethoprim/sulfamethoxazole (Bactrim) and mupirocin (Bactroban) ointment

Correct Answer: D

Suggested Reading:

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

40
ABPOPPM In-Training Exam

Module: Wound Care

The left anterior ankle of a 75 year-old female with a history of CRPS and lymphedema is
shown.

After resolution of infection, which of the following is most appropriate?

A. Split thickness skin graft


B. Graft Jacket (irradiated tissue)
C. Wet to dry sterile dressings
D. Full thickness skin graft

Correct Answer: D

Suggested Reading:

Sheffield, PJ; Smith, PS; Fife, CE. “Wound Care Practice”, Best Publishing Comp 2004; 189-216

Haslik W, et al. Management of Full Thickness Skin Defects in the Hand and Wrist Region.
Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria; Nov 28,
2008

41
ABPOPPM In-Training Exam

Module: Wound Care

A 46 year-old female presents with acute, intense pain in her left calf and foot with no history of
trauma. Examination reveals absent pedal pulses, cyanosis and a cool limb.

Which of the following is the most likely diagnosis?

A. Deep vein thrombosis


B. Thromboangiitis obliterans (Buerger's disease)
C. Vasculitis
D. Raynaud's phenomena
E. Arterial thrombosis

Correct Answer: E

Suggested Reading:

Sheffield, PJ; Smith, PS; Fife, CE. “Wound Care Practice”, Best Publishing Comp 2004; 189-216

Haslik W, et al. Management of Full Thickness Skin Defects in the Hand and Wrist Region.
Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Austria; Nov 28,
2008

42
ABPOPPM In-Training Exam

Module: Wound Care

A 26 year-old male presents with a fever of 38.5 degrees C (101.5 degrees F), malaise, diarrhea,
and cramps in his abdomen. Six week ago, he was treated with surgical resection of the third
metatarsal for osteomyelitis. He was placed on a six week course of cephalexin (Keflex).
Laboratory testing reveals leukocytosis of 12,000 and an electrolyte imbalance.

Which of the following is the most likely diagnosis?

A. Septicemia
B. Recurrence of osteomyelitis
C. Ulcerative colitis
D. Pseudomembranous colitis

Correct Answer: D

Suggested Reading:

Parkes GC, Sanderson JD, Whelan K. The mechanisms and efficacy of probiotics in the
prevention of Clostridium difficile-associated diarrhoea. Lancet Infect Dis. 2009 Apr;9(4):237-
44

Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J. Clostridium Difficile-Associated
Diarrhea and Colitis. Infection Control and Hospital Epidemiology 1995;16:459-477

43
ABPOPPM In-Training Exam

Module: Wound Care

Which Wagner classification level best defines the wounds seen on this diabetic foot?

A. Grade 2
B. Grade 3
C. Grade 4
D. Grade 5

Correct Answer: C

Suggested Reading:

Reference/Additional reading:
Sheffield, PJ; Smith, PS; Fife, CE. “Wound Care Practice”, Best Publishing Comp 2004; 305-318

Wagner FW. The Dysvascular Foot: a system for diagnosis and treatment. Foot and Ankle.
2:64-121, 1981

44
ABPOPPM In-Training Exam

Module: Wound Care

A 68 year-old male is seen for evaluation of an ischemic left great toe. The patient has undergone
endovascular procedure of his superficial femoral artery, but the necrosis continues to spread.

Based on the photo shown, blood flow to which angiosome is compromised?

A. Anterior tibial
B. Posterior tibial
C. Medial plantar
D. Peroneal

Correct Answer: C

Suggested Reading:

Attinger CE, Evans KK, Bulan E, Blume P, Copper P. Angiosomes of the Foot and Ankle and
clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plas
Reconstr Surg. 2006 Jun; 117(7 Suppl):261S-293S.

Attinger CE, Cooper P, Blume P. Vascular Anatomy of the Foot and Ankle. Operative
Techniques in Plastic and Reconstructive Surgery, Vol 4(November), 1997:183-198

45
ABPOPPM In-Training Exam

Module: Wound Care

A 45 year-old diabetic presents with a red, hot, swollen left foot. Examination reveals a purulent
draining sinus.

Which of the following organisms are most likely to be present in the superficial wound culture?

A. Staphylococcus, Streptococcus
B. Pseudomonas, Escherichia
C. Peptostreptococcus, Proteus
D. Pseudomonas, Staphylococcus

Correct Answer: A

Suggested Reading:

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

46
ABPOPPM In-Training Exam

Module: Wound Care

A 49 year-old male is referred for ulceration at the medial left ankle as shown. The patient
describes acute swelling and redness in the left leg of one month’s duration, after driving non-
stop from Tennessee to Arizona. The area of ulceration began as a vesicle that opened and left
the wound pictured.

Which of the following studies are most appropriate at this time?

A. VQ scan, ankle-brachial index, and CRP


B. MRI, arterial Doppler, and blood culture
C. CTA and comprehensive metabolic panel
D. Radiograph, venous Duplex, D-dimer

Correct Answer: D

Suggested Reading:

Seidel AC, Cavakheri G Jr, Miranda F Jr. The role of duplex ultrasonography in the diagnosis of
lower-extremity deep vein thrombosis in non-hospitalized patients. Int Angiol. 2008
Oct;27(5):377-84

Tan M, van Rooden CJ, Westerbeek RE, Huisman MV. Diagnostic management of clinically
suspected acute deep vein thrombosis. Br J Haematol. 2009 May 15 [epub ahead of print]

47
ABPOPPM In-Training Exam

Module: Wound Care

A 52 year-old male presents with a severely painful ulcer on the lateral aspect of the left ankle
thet began as a painful small lump that "broke down". He denies any trauma to the area. Past
medical history is remarkable for well controlled hypertension, and ulcerative colitis. Medications
include verapamil (Covera HS) and sulfasalazine (Azulfidine). Arterial and venous studies are
normal.

Which of the following is the most likely underlying diagnosis?

A. Venous stasis
B. Arterial ischemia
C. Pyoderma gangrenosum
D. Squamous cell carcinoma

Correct Answer: C

Suggested Reading:

Pyoderma gangrenosum at dermi.net: http://www.dermis.net/dermisroot/en/25555/image.htm

Friedman Sonia, Blumberg Richard S, "Chapter 289. Inflammatory Bowel Disease" (Chapter).
Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison's
Principles of Internal Medicine, 17th Edition:
http://www.accessmedicine.com/content.aspx?aID=2883197

48
ABPOPPM In-Training Exam

Module: Wound Care

A hospitalized patient has an infected laceration and cellulitis of the foot. The initial gram stain
and sensitivity is shown below.

Gram Stain: 4+ gram positive cocci

Antibiotic Sensitivity (R/I/S)


Penicillin R
Ampicillin R
Methicillin R
Oxacillin R

Which of the following is the antibiotic of choice?

A. Nafcillin (Unipen)
B. Ciprofloxacin (Cipro)
C. Trimethoprim-sulfamethoxazole (Bactrim)
D. Cephazolin (Ancef)
E. Vancomycin (Vancocin)

Correct Answer: E

Suggested Reading:

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew
DP, Mader JT, Norden C, Tan, JS. IDSA Guidelines: Diagnosis and Treatment of Diabetic Foot
Infections. CID 2004:39

Dennis SL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, Gorbach SL,
Hirschmann JV, Kaplan EL, Montoya JG, Wade JC. IDSA Guidelines: Practice Guidelines for
the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41, 1373-1406

49
ABPOPPM In-Training Exam

Module: Wound Care

A 64 year-old female is seen 36 hours after repair of an abdominal aortic aneurysm and
iliofemoral bypass of the right lower extremity. She was started on sub Q heparin immediately
post-op and received heparin for another 12 hours. She was then started on oral Coumadin.
Examination reveals multiple, painful, black, eschars on several lesser toes of both feet, as shown.
No edema is present. Pedal pulses are palpable bilaterally. Laboratory findings are within the
expected ranges given the patient's medications.

Which of the following is the most likely cause of the


patient's condition?

A. Coumadin usage
B. Heparin usage
C. Microemboli
D. Re-perfusion injury

Correct Answer: C

Suggested Reading:

Carrocio A, et al. The role of aortic stent grafting in the treatment of atheromatous embolization
syndrome: results after a mean of 15 month follow-up. J Vasc Surg. 2004 Sep;40(3):424-9

Kuhan G, Raptis S. ‘Trash foot’ following operations involving the abdominal aorta. Aust NZ J
Surg. 1997 Jan;67(1):21-4

50