2007-04-22

Front 1

positive PPD result for apatient with numerous risk factors for tuberculosis

Back 1

>5 mm induration at 48 hours

Front 2

positive PPD for low-risk patients

Back 2

>15 mm induration at 48 hours

Front 3

used for treatment of latent tuberculosis (TB) in patients who have a compliance issue.

Back 3

Isoniazid and rifampin

Front 4

used to treat latent tuberculosis, where there are no acid-fast bacillus (AFB) present in sputum.

Back 4

Isoniazid

Front 5

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

Back 5

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.

Front 6

secondary bacterial pneumonia following influenza, Radiographic findings for include cavitation and thin-walled cysts. dx?

Back 6

Staphylococcus aureus

Front 7

pneumoniae that is more common in alcoholics and diabetics. It is classically associated with current-red jelly sputum production. dx?

Back 7

Klebsiella pneumoniae

Front 8

Lung infection. Radiographic appearance would be apical fibronodular infiltrates. dx?

Back 8

Mycobacterium tuberculosis

Front 9

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

Back 9

Option D (Mycoplasma pneumoniae)

Front 10

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.

Back 10

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.

Front 11

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.

Back 11

Hashimoto thyroiditis

Front 12

the most valuable test to confirm CLL or a different diagnosis, such a prolymphocytic, large granular lymphocytic, or mantle cell leukemia/lymphoma.

Back 12

Peripheral blood flow cytometry

The presence of circulating clonal B lymphocytes expressing CD5, CD19, CD20, and CD 23 confirms the diagnosis of CLL.

Front 13

an infection of the submandibular space. Infection usually spreads from a diseased second or third mandibular molar.

Back 13

Ludwig angina

Front 14

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

Back 14

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.

Front 15

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

Back 15

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.

Front 16

Cryptococcus does not typically affect patients until the CD4+ count is below

Back 16

until the CD4+ count is below 100.

Front 17

Chancroid is treated with

Back 17

azithromycin

Front 18

community-acquired pneumonia tx

Back 18

(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.

Front 19

chronic recurrent lesion that affects the apocrine glands and gradually worsens.

Back 19

Hidradenitis suppurativa

Front 20

may prolong the QT interval
A. Amoxicillin (Azithromycin)
B. Augmentin
C. Ceftriaxone
D. Moxifloxacin
E. Sulfamethoxazole (Bactrim)

Back 20

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.

Front 21

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

Back 21

Option A (C6 deficiency) is incorrect. C6 deficiency is associated with recurrent meningococcal meningitis and gonococcemia.

Front 22

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

Back 22

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.

Front 23

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

Back 23

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.

Front 24

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

Back 24

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.

Front 25

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

Back 25

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.

Front 26

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

Back 26

an early prosthetic valve infection and makes the most likely organism Staphylococcus epidermidis, a skin contaminant.

Front 27

the second most common cause of IE in patients with early prosthetic valve endocarditis.

Back 27

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.

Front 28

endocarditis (IE) a year after undergoing aortic valve replacement. the most likely organism

Back 28

(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.

Front 29

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.

Back 29

Enterococcus faecalis

Front 30

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

Back 30

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.

Front 31

following administration of penicillin presents with low-grade fever, chills, rigors myalgia, bone pain, and anorexia. dx?

Back 31

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.

Front 32

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.

Back 32

secondary syphilis, usually appears 6 to 12 weeks after appearance of the chancre.

Front 33

glucose level in exudative effusion

Back 33

much lower pleural-to-plasma glucose ratio.

Front 34

noninfectious transudates, glucose levels

Back 34

glucose levels should be close to the plasma glucose levels.

Front 35

light's criteria determine whether...

Back 35

whether an effusion is exudative or transudative

Front 36

exudative effusions should have pleural fluid protein/serum protein greater than

Back 36

0.5
Light’s criteria

Front 37

exudative effusions should have pleural fluid LDH/serum LDH greater than X

or, pleural fluid LDH more than ...

Back 37

Light’s criteria
Light’s criteria>0.6

or pleural fluid LDH more than two thirds the upper limit for serum LDH.

Front 38

M. tuberculosis organism can/cannot be detected in pleural fluid.

Back 38

M. tuberculosis organism cannot be detected in pleural fluid. The organism is usually inside macrophages and is extremely fastidious and notoriously difficult to culture.

Front 39

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.

Back 39

measles pneumonia or “black measles,”Vaccination as scheduled with measles-mumps-rubella at 12 to 15 months of age could have prevented this illness.

Front 40

The antimicrobial treatment for rheumatic fever

Back 40

penicillin V PO for at least 10 days or one single intramuscular dose of benzathine penicillin G.

Front 41

he antimicrobial treatment for rheumatic fever in case of a previous history of allergy to penicillin.

Back 41

Oral erythromycin is used in case of a previous history of allergy to penicillin.

Front 42

Hypoxia after ambulation is a hallmark of

Back 42

(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.

Front 43

Lyme disease. The causative organism is a spirochete that is best treated with

Back 43

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.

Front 44

Lyme disease is caused by a rickettsia/spirochete

Back 44

spirochete

Front 45

Ehrlichiosis is caused by a rickettsia/spirochete

Back 45

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.