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45 Cards in this Set

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positive PPD result for apatient with numerous risk factors for tuberculosis
>5 mm induration at 48 hours
positive PPD for low-risk patients
>15 mm induration at 48 hours
used for treatment of latent tuberculosis (TB) in patients who have a compliance issue.
Isoniazid and rifampin
used to treat latent tuberculosis, where there are no acid-fast bacillus (AFB) present in sputum.
Isoniazid
A 28-year-old final-year medical student presents to the clinic for her annual purified protein derivative (PPD) test. Forty-eight hours after placement, there is 16 mm of induration. Her body temperature is taken and is 38.8°C (101.8°F). Sputum induction reveals acid-fast bacilli. What is the most appropriate next step in the management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Isoniazid
B. Isoniazid and rifampin
C. Isoniazid, rifampin, and ethambutol
D. Isoniazid, rifampin, ethambutol, and pyrazinamide
E. Rifampin and rifapentine
Option D (Isoniazid, rifampin, ethambutol, and pyrazinamide) is correct. This patient has primary TB. Primary TB presents differently from reactivation TB. The most common symptoms are fever, whereas cough, weight loss, hemoptysis, and night sweats are less common. Demonstration of acid fast bacilli on sputum induction is reasonable for presumptive diagnosis of active TB and should institute multidrug therapy.

Option A (Isoniazid) is incorrect. Isoniazid is used to treat latent tuberculosis, where there are no acid-fast bacillus (AFB) present in sputum. This patient has active tuberculosis.

Option B (Isoniazid and rifampin) is incorrect. Isoniazid and rifampin are used for treatment of latent tuberculosis (TB) in patients who have a compliance issue.

Option C (Isoniazid, rifampin, and ethambutol) is incorrect. This regime lacks pyrazinamide, which has been shown to increase the effectiveness of isoniazid and rifampin.

Option E (Rifampin and rifapentine) is incorrect. Rifapentine is a derivative of rifampin and would not be combined with it.
secondary bacterial pneumonia following influenza, Radiographic findings for include cavitation and thin-walled cysts. dx?
Staphylococcus aureus
pneumoniae that is more common in alcoholics and diabetics. It is classically associated with current-red jelly sputum production. dx?
Klebsiella pneumoniae
Lung infection. Radiographic appearance would be apical fibronodular infiltrates. dx?
Mycobacterium tuberculosis
This is an atypical cause of pneumonia and causes low-grade fever and rarely results in rigors. The CXR is often diffusely infiltrated.
A. Haemophilus influenzae
B. Klebsiella pneumoniae
C. Mycobacterium tuberculosis
D. Mycoplasma pneumoniae
E. Staphylococcus aureus
Option D (Mycoplasma pneumoniae)
Classic signs and symptoms include a very painful thyroid gland that worsens on swallowing, systemic signs of infection, and symptoms preceded by an upper respiratory tract infection.
Granulomatous thyroiditis

also known as de Quervain thyroiditis, subacute painful thyroiditis, or giant cell thyroiditis.

On histologic analysis, there is disruption of the thyroid follicles, which initially results in hyperthyroidism.
the most common cause of hypothyroidism in the Western world. It results in painless enlargement of the thyroid and is not associated with systemic signs of infection.
Hashimoto thyroiditis
the most valuable test to confirm CLL or a different diagnosis, such a prolymphocytic, large granular lymphocytic, or mantle cell leukemia/lymphoma.
Peripheral blood flow cytometry

The presence of circulating clonal B lymphocytes expressing CD5, CD19, CD20, and CD 23 confirms the diagnosis of CLL.
an infection of the submandibular space. Infection usually spreads from a diseased second or third mandibular molar.
Ludwig angina
A 28-year-old male presents to the emergency room with a sore throat that has lasted 3 days. His voice is very hoarse and muffled and he appears uncomfortable. He says his throat pain has progressively gotten worse and now the front of his neck hurts. His vitals signs are temperature 38.9°C (102°F), heart rate 120 beats/min, respiratory rate of 28 breaths/min, blood pressure 144/88 mm Hg, and oxygen saturation 92% on room air. On exam he is drooling, his tonsils are enlarged in size, and he has a woody/brawny edema of his sublingual area. What is the next step in his treatment?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Computed tomography (CT) scan of neck and head
B. Intravenous antibiotics
C. Intravenous steroids
D. Intubation
E. Upper endoscopy
Option D (Intubation) is correct. Given the respiratory rate, drooling, and voice changes, intubation to control and protect the airway is the first step in this patient's care. This patient has Ludwig angina, an infection of the submandibular space. Infection usually spreads from a diseased second or third mandibular molar. Treatment is with airway stabilization and intravenous antibiotics.

Option A (Computed tomography (CT) scan of neck and head) is incorrect. A CT scan of the neck may be helpful to determine if there are any abscesses; but with this patient's respiratory issues, laying him flat for a CT scan without intubation would not be proper.

Option B (Intravenous antibiotics) is incorrect. Although this patient will get antibiotics, given the respiratory distress described, airway protection is the first step.

Option C (Intravenous steroids) is incorrect. Intravenous steroids do not play a role in this condition.

Option E (Upper endoscopy) is incorrect. Upper endoscopy is not necessary.
nocardia infection
A. Acid-fast bacilli
B. Cysts and trophozoites
C. Gram positive rods that are partially acid-fast
D. Gram-positive diplococci
E. Pleomorphic yeast-like cells and formation of narrow-based buds
Option C (Gram positive rods that are partially acid-fast) is incorrect. This is the feature of nocardia infection which usually presents with cavitations on chest X-ray.
Cryptococcus does not typically affect patients until the CD4+ count is below
until the CD4+ count is below 100.
Chancroid is treated with
azithromycin
community-acquired pneumonia tx
(Azithromycin) is correct. This patient has a community-acquired pneumonia. The most likely etiologic agent is Streptococcus pneumoniae, but atypical agents, such as Mycobacterium pneumoniae cannot be completely excluded. Consequently, a macrolide antibiotic is the preferred first-line agent.
chronic recurrent lesion that affects the apocrine glands and gradually worsens.
Hidradenitis suppurativa
may prolong the QT interval
A. Amoxicillin (Azithromycin)
B. Augmentin
C. Ceftriaxone
D. Moxifloxacin
E. Sulfamethoxazole (Bactrim)
Option D (Moxifloxacin) is correct. Moxifloxacin (Avelox) is a new generation quinolone that may prolong the QT interval in patients. In a patient on sotalol, another antibiotic regimen should be chosen or close monitoring of the patient should occur.
associated with recurrent meningococcal meningitis and gonococcemia.
A. C6 deficiency
B. Chronic granulomatous disease
C. Common variable immunodeficiency
D. Hyperimmunoglobulinemia E syndrome
E. Lazy leukocyte syndrome
Option A (C6 deficiency) is incorrect. C6 deficiency is associated with recurrent meningococcal meningitis and gonococcemia.
Quantitation of serum immunoglobulins reveals diminished IgG, IgM, and IgA levels.
A. C6 deficiency
B. Chronic granulomatous disease
C. Common variable immunodeficiency
D. Hyperimmunoglobulinemia E syndrome
E. Lazy leukocyte syndrome
Option C (Common variable immunodeficiency) is incorrect. The patient’s history of previous good health does not point toward a primary immunodeficiency but does not entirely rule it out. Quantitation of serum immunoglobulins reveals diminished IgG, IgM, and IgA levels. This is a good case of common variable immunodeficiency with the reminder that primary immunodeficiencies may be undetected until later in life.
increased susceptibility to fungal infections but not in increased sinopulmonary bacterial infections.
A. C6 deficiency
B. Chronic granulomatous disease
C. Common variable immunodeficiency
D. Hyperimmunoglobulinemia E syndrome
E. Lazy leukocyte syndrome
Option E (Lazy leukocyte syndrome) is incorrect. Myeloperoxidase deficiency in leukocyte results in some increased susceptibility to fungal infections but not in increased sinopulmonary bacterial infections. Immunoglobin levels are not depressed.
unmistakable for the severity of associated bacterial skin infections, which gives the syndrome its alternative designation of “Job’s disease.”
A. C6 deficiency
B. Chronic granulomatous disease
C. Common variable immunodeficiency
D. Hyperimmunoglobulinemia E syndrome
E. Lazy leukocyte syndrome
Option D (Hyperimmunoglobulinemia E syndrome) is correct. Although immunoglobulin (Ig) E levels are not shown, this syndrome manifests at a much earlier age and is unmistakable for the severity of associated bacterial skin infections, which gives the syndrome its alternative designation of “Job’s disease.” Also, other Ig levels are not typically depressed.
Reye syndrome, Testing of what would most likely lead to the correct diagnosis?
A. Serum ammonia
B. Serum blood urea nitrogen (BUN)
C. Serum calcium
D. Serum glucose
E. Serum sodium
Option A (Serum ammonia) is correct. This patient is developing Reye syndrome, which is an acute encephalopathy associated with a fatty change in the liver. The pathogenesis is thought to involve injury to specific hepatic intramitochondrial enzymes. Decreased activity of ornithine transcarbamylase and carbamoyl phosphatase synthetase are thought to lead to hyperammonemia. The cause of mitochondrial dysfunction is unknown, but there is an association between aspirin (and/or anti-emetics) and viral infections. In this case, the child had an upper respiratory tract infection that was treated with aspirin (along with over-the-counter [OTC] antitussive, decongestant, and expectorant) making the diagnosis of Reye syndrome most likely.
patient has infective endocarditis (IE) within 6 weeks after undergoing aortic valve replacement. This classifies the infection as an early prosthetic valve infection and makes the most likely organism
an early prosthetic valve infection and makes the most likely organism Staphylococcus epidermidis, a skin contaminant.
the second most common cause of IE in patients with early prosthetic valve endocarditis.
Staphylococcus aureus is the most common cause of IE in intravenous drug users. It is the second most common cause of IE in patients with early prosthetic valve endocarditis.
endocarditis (IE) a year after undergoing aortic valve replacement. the most likely organism
(Streptococcus viridans) If this patient were to present a year after surgery, Streptococcus viridans would be the most likely cause of these findings, because the valve has had an opportunity to heal into place and act more like a natural valve from a pathological perspective. Endothelialization would have occurred, which alters the sites of adherence for microorganisms. The period of 2 months—12 months is a transitory period between Staphylococcus epidermidis and S. viridans.
endocarditis cause that must be suspected when there has been previous genitourinary tract manipulation. Otherwise, this is a less common organism compared to the others.
Enterococcus faecalis
therapy is started within 48 hours of symptom onset, there is a reduction in duration of symptoms. However, studies have failed to conclusively show a reduction in the risk of complications from
influenza.

A. Amantadine
B. Azithromycin
C. Isoniazid
D. Oseltamivir
E. Trimethoprim-sulfamethoxazole
Option D (Oseltamivir) is correct. This patient most likely has developed influenza. Studies have demonstrated that if antiviral therapy is started within 48 hours of symptom onset, there is a reduction in duration of symptoms. However, studies have failed to conclusively show a reduction in the risk of complications from influenza. Neuraminidase inhibitors, such as oseltamivir and zanamivir, are now considered the first-line agents for therapy.

Option A (Amantadine) is incorrect. Amantadine is a M2 protein inhibitor, which inhibits a proton channel on the influenza A virus necessary for viral replication. Significant resistance, as well as a lack of efficacy against influenza B, has resulted in amantadine falling out of favor as a first-line agent.

Option B (Azithromycin) is incorrect. Azithromycin is used as first-line therapy for community-acquired pneumonia. Typically, there are abnormal findings on examination, such as dullness to percussion, bronchial breath sounds and crackles. There are also CXR findings, such as lobar consolidation or streaky infiltrates.

Option C (Isoniazid) is incorrect. Isoniazid monotherapy is used in the treatment of latent tuberculosis, which is diagnosed after a positive purified protein derivative test.

Option E (Trimethoprim-sulfamethoxazole) is incorrect. Trimethoprim-sulfamethoxazole is a first-line agent for the treatment of Pneumocystis carinii infection. This patient is not immunosuppressed.
following administration of penicillin presents with low-grade fever, chills, rigors myalgia, bone pain, and anorexia. dx?
Option A (Jarisch-Herxheimer reaction) is correct. The genital lesion is the chancre of primary syphilis, a condition treated with penicillin. In as many as 50% of cases (of all forms of syphilis), there may be a transient febrile response following administration of penicillin. This response is termed the Jarisch-Herxheimer reaction and presents with low-grade fever, chills, rigors myalgia, bone pain, and anorexia. It is not an indication to stop therapy, because the reaction is transient and continued therapy will not worsen the symptoms. The pathogenesis of the Jarisch-Herxheimer reaction is still debated.
cutaneous maculopapular rash that is generalized, but particularly affects the palms and soles. There are also condylomata lata, which are gray-white lesions over moist areas and on mucous membranes. There are typically associated fevers, anorexia and malaise.
secondary syphilis, usually appears 6 to 12 weeks after appearance of the chancre.
glucose level in exudative effusion
much lower pleural-to-plasma glucose ratio.
noninfectious transudates, glucose levels
glucose levels should be close to the plasma glucose levels.
light's criteria determine whether...
whether an effusion is exudative or transudative
exudative effusions should have pleural fluid protein/serum protein greater than
0.5
Light’s criteria
exudative effusions should have pleural fluid LDH/serum LDH greater than X

or, pleural fluid LDH more than ...
Light’s criteria
Light’s criteria>0.6

or pleural fluid LDH more than two thirds the upper limit for serum LDH.
M. tuberculosis organism can/cannot be detected in pleural fluid.
M. tuberculosis organism cannot be detected in pleural fluid. The organism is usually inside macrophages and is extremely fastidious and notoriously difficult to culture.
associated with a rapid onset, high fever, pneumonia, and a hemorrhagic exanthem with bleeding from the nose and mouth (and internally). It is most common in infants in developing nations and is usually fatal.
measles pneumonia or “black measles,”Vaccination as scheduled with measles-mumps-rubella at 12 to 15 months of age could have prevented this illness.
The antimicrobial treatment for rheumatic fever
penicillin V PO for at least 10 days or one single intramuscular dose of benzathine penicillin G.
he antimicrobial treatment for rheumatic fever in case of a previous history of allergy to penicillin.
Oral erythromycin is used in case of a previous history of allergy to penicillin.
Hypoxia after ambulation is a hallmark of
(Pneumocystis carinii) is correct. Hypoxia after ambulation is a hallmark of P. carinii pneumonia (PCP). The patient has AIDS and is therefore at risk for PCP. Chest x-ray may show diffuse bilateral infiltrates. Treatment is with sulfamethoxazole (Bactrim). If an arterial blood gas shows a pO2 of less than 70 mm Hg, prednisone should also be used.
Lyme disease. The causative organism is a spirochete that is best treated with
amoxicillin
Option A (Amoxicillin) is correct. The patient’s rash, termed erythema migrans, is pathognomonic evidence of Lyme disease. The causative organism is a spirochete that is best treated with amoxicillin.
Lyme disease is caused by a rickettsia/spirochete
spirochete
Ehrlichiosis is caused by a rickettsia/spirochete
Ehrlichiosis is a tick-borne disease caused by a rickettsial organism. Treatment is with doxycycline. The patient’s rash, termed erythema migrans, is pathognomonic evidence of Lyme disease.