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26 Cards in this Set
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1. A 30-year-old male patient complains of fever and sore throat for several days. The patient presents to you today with additional complaints of hoarseness, difficulty breathing, and drooling. On examination, the patient is febrile and has inspiratory stridor. Which of the following is the best course of action?
a. Begin outpatient treatment with ampicillin b. Culture throat for ß-hemolytic streptococci c. Admit to intensive care unit and obtain otolaryngology consultation d. Schedule for chest x-ray |
1. c. Admit to intensive care unit and obtain otolaryngology consultation
This patient, with the development of hoarseness, breathing difficulty, and stridor, is likely to have acute epiglottitis. Because of the possibility of impending airway obstruction, the patient should be admitted to an intensive care unit for close monitoring. The diagnosis can be confirmed by indirect laryngoscopy or soft tissue x-rays of the neck, which may show an enlarged epiglottis. Otolaryngology consult should be obtained. The most likely organism causing this infection is Haemophilus influenzae. Many of these organisms are ß-lactamase-producing and would be resistant to ampicillin. The clinical findings are not consistent with the presentation of streptococcal pharyngitis. Lateral neck films would be more useful than a chest x-ray. |
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2. A 70-year-old patient with long-standing type 2 diabetes mellitus presents with complaints of pain in the left ear with purulent drainage. On physical exam, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The peripheral white blood cell count is normal. The organism most likely to grow from the purulent drainage is
a. Pseudomonas aeruginosa b. Staphylococcus aureus c. Candida albicans d. Haemophilus influenzae e. Moraxella catarrhalis |
2. a. Pseudomonas aeruginosa
--Ear pain and drainage in an elderly diabetic patient must raise concern about malignant external otitis. The swelling and inflammation of the external auditory meatus strongly suggest this diagnosis. This infection usually occurs in older diabetics and is almost always caused by P. aeruginosa. --H. influenzae and M. catarrhalis frequently cause otitis media, but not external otitis. |
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A 25-year-old male student presents with the chief complaint of rash. There is no headache, fever, or myalgia. A slightly pruritic maculopapular rash is noted over the abdomen, trunk, palms of the hands, and soles of the feet. Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic, flat, wartlike lesions are noted around the anal area. Laboratory studies show the following:
Hct: 40% Hgb: 14 g/dL WBC: 13,000/μL Diff: Segmented neutrophils: 50% Lymphocytes: 50% 3. The most useful laboratory test in this patient is a. Weil-Felix titer b. Venereal Disease Research Laboratory (VDRL) test c. Chlamydia titer d. Blood cultures |
b. Venereal Disease Research Laboratory (VDRL) test
The diffuse rash involving palms and soles would in itself suggest the possibility of secondary syphilis. The hypertrophic, wartlike lesions around the anal area, called condyloma lata, are specific for secondary syphilis. The VDRL slide test will be positive in all patients with secondary syphilis. The Weil-Felix titer has been used as a screening test for rickettsial infection. In this patient, who has condyloma lata and no systemic symptoms, Rocky Mountain spotted fever would be unlikely. No chlamydial infection would present in this way. Blood cultures might be drawn to rule out bacterial infection such as chronic meningococcemia; however, the clinical picture is not consistent with a systemic bacterial infection. Penicillin is the drug of choice for secondary syphilis. Ceftriaxone and tetracycline are usually considered to be alternative therapies. Interferon alpha has been used in the treatment of condyloma acuminata, a lesion that can be mistaken for syphilitic condyloma. |
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A 25-year-old male student presents with the chief complaint of rash. There is no headache, fever, or myalgia. A slightly pruritic maculopapular rash is noted over the abdomen, trunk, palms of the hands, and soles of the feet. Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic, flat, wartlike lesions are noted around the anal area. Laboratory studies show the following:
Hct: 40% Hgb: 14 g/dL WBC: 13,000/μL Diff: Segmented neutrophils: 50% Lymphocytes: 50% 4. The treatment of choice for this patient is a. Penicillin b. Ceftriaxone c. Tetracycline d. Interferon α e. Erythromycin |
a. Penicillin
The diffuse rash involving palms and soles would in itself suggest the possibility of secondary syphilis. The hypertrophic, wartlike lesions around the anal area, called condyloma lata, are specific for secondary syphilis. The VDRL slide test will be positive in all patients with secondary syphilis. The Weil-Felix titer has been used as a screening test for rickettsial infection. In this patient, who has condyloma lata and no systemic symptoms, Rocky Mountain spotted fever would be unlikely. No chlamydial infection would present in this way. Blood cultures might be drawn to rule out bacterial infection such as chronic meningococcemia; however, the clinical picture is not consistent with a systemic bacterial infection. Penicillin is the drug of choice for secondary syphilis. Ceftriaxone and tetracycline are usually considered to be alternative therapies. Interferon alpha has been used in the treatment of condyloma acuminata, a lesion that can be mistaken for syphilitic condyloma. |
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A 20-year-old female college student presents with a 5-day history of cough, low-grade fever (temperature 100°F), sore throat, and coryza. On exam, there is mild conjunctivitis and pharyngitis. Tympanic membranes are inflamed, and one bullous lesion is seen. Chest exam shows few basilar rales. Laboratory findings are as follows:
Hct: 38 WBC: 12,000/μL Lymphocytes: 50% Mean corpuscular volume (MCV): 83 nL Reticulocytes: 3% of red cells CXR: bilateral patchy lower lobe infiltrates 5. The sputum Gram stain is likely to show a. Gram-positive diplococci b. Tiny gram-negative coccobacilli c. White blood cells without organisms d. Acid-fast bacilli |
c. White blood cells without organisms
This young woman presents with symptoms of both upper and lower respiratory infection. The combination of sore throat, bullous myringitis, and infiltrates on chest x-ray is consistent with infection due to M. pneumoniae. This minute organism is not seen on Gram stain. Neither S. pneumoniae nor H. influenzae would produce this combination of upper and lower respiratory tract symptoms. The patient is likely to have high titers of IgM cold agglutinins. The low hematocrit and elevated reticulocyte count reflect a hemolytic anemia that can occur from mycoplasma infection. These IgM class antibodies are directed to the I antigen on the erythrocyte membrane. The treatment of choice for mycoplasma infection is erythromycin. |
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A 20-year-old female college student presents with a 5-day history of cough, low-grade fever (temperature 100°F), sore throat, and coryza. On exam, there is mild conjunctivitis and pharyngitis. Tympanic membranes are inflamed, and one bullous lesion is seen. Chest exam shows few basilar rales. Laboratory findings are as follows:
Hct: 38 WBC: 12,000/μL Lymphocytes: 50% Mean corpuscular volume (MCV): 83 nL Reticulocytes: 3% of red cells CXR: bilateral patchy lower lobe infiltrates 6. This patient is likely to have a. High titers of adenovirus b. High titers of IgM cold agglutinins c. A positive silver methenamine stain d. A positive blood culture for Streptococcus pneumoniae |
b. High titers of IgM cold agglutinins
This young woman presents with symptoms of both upper and lower respiratory infection. The combination of sore throat, bullous myringitis, and infiltrates on chest x-ray is consistent with infection due to M. pneumoniae. This minute organism is not seen on Gram stain. Neither S. pneumoniae nor H. influenzae would produce this combination of upper and lower respiratory tract symptoms. The patient is likely to have high titers of IgM cold agglutinins. The low hematocrit and elevated reticulocyte count reflect a hemolytic anemia that can occur from mycoplasma infection. These IgM class antibodies are directed to the I antigen on the erythrocyte membrane. The treatment of choice for mycoplasma infection is erythromycin. |
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A 20-year-old female college student presents with a 5-day history of cough, low-grade fever (temperature 100°F), sore throat, and coryza. On exam, there is mild conjunctivitis and pharyngitis. Tympanic membranes are inflamed, and one bullous lesion is seen. Chest exam shows few basilar rales. Laboratory findings are as follows:
Hct: 38 WBC: 12,000/μL Lymphocytes: 50% Mean corpuscular volume (MCV): 83 nL Reticulocytes: 3% of red cells CXR: bilateral patchy lower lobe infiltrates 7. Treatment of choice is a. Erythromycin b. Supportive therapy c. Trimethoprim-sulfamethoxazole d. Cefuroxime |
a. Erythromycin
This young woman presents with symptoms of both upper and lower respiratory infection. The combination of sore throat, bullous myringitis, and infiltrates on chest x-ray is consistent with infection due to M. pneumoniae. This minute organism is not seen on Gram stain. Neither S. pneumoniae nor H. influenzae would produce this combination of upper and lower respiratory tract symptoms. The patient is likely to have high titers of IgM cold agglutinins. The low hematocrit and elevated reticulocyte count reflect a hemolytic anemia that can occur from mycoplasma infection. These IgM class antibodies are directed to the I antigen on the erythrocyte membrane. The treatment of choice for mycoplasma infection is erythromycin. |
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A 19-year-old male presents with a 1-week history of malaise and anorexia followed by fever and sore throat. On physical examination, the throat is inflamed without exudate. There are a few palatal petechiae. Cervical adenopathy is present. The liver is percussed at 12 cm and the spleen is palpable.
Throat culture: negative for group A streptococci Hct: 38% Hgb: 12 g/dL Reticulocytes: 4% WBC: 14,000/μL Segmented: 30% Lymphocytes: 60% Monocytes: 10% Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2) Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220) Aspartate (AST): 40 U/L (normal 8 to 20 U/L) Alanine (ALT): 35 U/L (normal 8 to 20 U/L) Alkaline phosphatase: 40 IU/L (normal 35 to 125) 8. The most important initial test is a. Liver biopsy b. Strep screen c. Peripheral blood smear d. Toxoplasmosis IgG e. Lymph node biopsy |
c. Peripheral blood smear
This young man presents with classic signs and symptoms of infectious mononucleosis. In a young patient with fever, pharyngitis, lymphadenopathy, and lymphocytosis, the peripheral blood smear should be evaluated for atypical lymphocytes. A heterophile antibody test should be performed. The symptoms described in association with atypical lymphocytes and a positive heterophile test are virtually always due to Epstein-Barr virus. Neither liver biopsy nor lymph node biopsy is necessary. Workup for toxoplasmosis or cytomegalovirus infection or hepatitis B and C would be considered in heterophile-negative patients, Hepatitis does not occur in the setting of rheumatic fever, and an antistreptolysin O titer is not indicated. Corticosteroids are indicated in the treatment of infectious mononucleosis when severe hemolytic anemia is demonstrated or when airway obstruction occurs. Neither fatigue nor the complication of hepatitis is an indication for corticosteroid therapy. |
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A 19-year-old male presents with a 1-week history of malaise and anorexia followed by fever and sore throat. On physical examination, the throat is inflamed without exudate. There are a few palatal petechiae. Cervical adenopathy is present. The liver is percussed at 12 cm and the spleen is palpable.
Throat culture: negative for group A streptococci Hct: 38% Hgb: 12 g/dL Reticulocytes: 4% WBC: 14,000/μL Segmented: 30% Lymphocytes: 60% Monocytes: 10% Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2) Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220) Aspartate (AST): 40 U/L (normal 8 to 20 U/L) Alanine (ALT): 35 U/L (normal 8 to 20 U/L) Alkaline phosphatase: 40 IU/L (normal 35 to 125) 9. The most important serum test is a. Heterophile antibody b. Hepatitis B IgM c. Cytomegalovirus IgG d. ASLO titer e. Hepatitis C antibody |
a. Heterophile antibody
This young man presents with classic signs and symptoms of infectious mononucleosis. In a young patient with fever, pharyngitis, lymphadenopathy, and lymphocytosis, the peripheral blood smear should be evaluated for atypical lymphocytes. A heterophile antibody test should be performed. The symptoms described in association with atypical lymphocytes and a positive heterophile test are virtually always due to Epstein-Barr virus. Neither liver biopsy nor lymph node biopsy is necessary. Workup for toxoplasmosis or cytomegalovirus infection or hepatitis B and C would be considered in heterophile-negative patients, Hepatitis does not occur in the setting of rheumatic fever, and an antistreptolysin O titer is not indicated. Corticosteroids are indicated in the treatment of infectious mononucleosis when severe hemolytic anemia is demonstrated or when airway obstruction occurs. Neither fatigue nor the complication of hepatitis is an indication for corticosteroid therapy. |
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A 19-year-old male presents with a 1-week history of malaise and anorexia followed by fever and sore throat. On physical examination, the throat is inflamed without exudate. There are a few palatal petechiae. Cervical adenopathy is present. The liver is percussed at 12 cm and the spleen is palpable.
Throat culture: negative for group A streptococci Hct: 38% Hgb: 12 g/dL Reticulocytes: 4% WBC: 14,000/μL Segmented: 30% Lymphocytes: 60% Monocytes: 10% Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2) Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220) Aspartate (AST): 40 U/L (normal 8 to 20 U/L) Alanine (ALT): 35 U/L (normal 8 to 20 U/L) Alkaline phosphatase: 40 IU/L (normal 35 to 125) 10. Corticosteroids would be indicated if a. Liver function tests worsen b. Fatigue lasts more than 1 week c. Severe hemolytic anemia is demonstrated d. Hepatitis B is confirmed |
c. Severe hemolytic anemia is demonstrated
This young man presents with classic signs and symptoms of infectious mononucleosis. In a young patient with fever, pharyngitis, lymphadenopathy, and lymphocytosis, the peripheral blood smear should be evaluated for atypical lymphocytes. A heterophile antibody test should be performed. The symptoms described in association with atypical lymphocytes and a positive heterophile test are virtually always due to Epstein-Barr virus. Neither liver biopsy nor lymph node biopsy is necessary. Workup for toxoplasmosis or cytomegalovirus infection or hepatitis B and C would be considered in heterophile-negative patients, Hepatitis does not occur in the setting of rheumatic fever, and an antistreptolysin O titer is not indicated. Corticosteroids are indicated in the treatment of infectious mononucleosis when severe hemolytic anemia is demonstrated or when airway obstruction occurs. Neither fatigue nor the complication of hepatitis is an indication for corticosteroid therapy. |
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Match the clinical description with the most likely organism.
a. Streptococcus pneumoniae b. Staphylococcus aureus c. Viridans streptococci d. Providencia stuartii e. Actinomyces israelii f. Haemophilus ducreyi g. Neisseria meningitidis h. Listeria monocytogenes 11. A 30-year-old female with mitral valve prolapse and mitral regurgitant murmur develops fever, weight loss, and anorexia after undergoing a dental procedure. (CHOOSE 1 ORGANISM) |
c. Viridans streptococci
The 30-year-old-female with mitral valve prolapse has developed subacute bacterial endocarditis. The likely etiologic agent is a viridans streptococci. Viridans streptococci cause most cases of subacute bacterial endocarditis. No other agent listed is likely to cause this infection. The 80-year-old-male with a Foley catheter in place has developed a nosocomial infection likely secondary to urosepsis. Providencia species frequently cause urinary tract infection in the hospitalized patient. The young man with a fluctuant lesion and fistula over the mandible presents a classic picture of cervicofacial actinomycosis. The sickle cell anemia patient who presents with concomitant pneumonia and meningitis has overwhelming infection with S. pneumoniae due to functional asplenia. S. pneumoniae causes a particularly severe infection associated with sickle cell disease. |
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Match the clinical description with the most likely organism.
a. Streptococcus pneumoniae b. Staphylococcus aureus c. Viridans streptococci d. Providencia stuartii e. Actinomyces israelii f. Haemophilus ducreyi g. Neisseria meningitidis h. Listeria monocytogenes 12. An 80-year-old-male, hospitalized for hip fracture, has a Foley catheter in place when he develops shaking chills, fever, and hypotension. (CHOOSE 1 ORGANISM) |
d. Providencia stuartii
The 30-year-old-female with mitral valve prolapse has developed subacute bacterial endocarditis. The likely etiologic agent is a viridans streptococci. Viridans streptococci cause most cases of subacute bacterial endocarditis. No other agent listed is likely to cause this infection. The 80-year-old-male with a Foley catheter in place has developed a nosocomial infection likely secondary to urosepsis. Providencia species frequently cause urinary tract infection in the hospitalized patient. The young man with a fluctuant lesion and fistula over the mandible presents a classic picture of cervicofacial actinomycosis. The sickle cell anemia patient who presents with concomitant pneumonia and meningitis has overwhelming infection with S. pneumoniae due to functional asplenia. S. pneumoniae causes a particularly severe infection associated with sickle cell disease. |
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Match the clinical description with the most likely organism.
a. Streptococcus pneumoniae b. Staphylococcus aureus c. Viridans streptococci d. Providencia stuartii e. Actinomyces israelii f. Haemophilus ducreyi g. Neisseria meningitidis h. Listeria monocytogenes 13. A young man develops a painless, fluctuant purplish lesion over the mandible. Cutaneous fistula is noted after several weeks. (CHOOSE 1 ORGANISM) |
e. Actinomyces israelii
The 30-year-old-female with mitral valve prolapse has developed subacute bacterial endocarditis. The likely etiologic agent is a viridans streptococci. Viridans streptococci cause most cases of subacute bacterial endocarditis. No other agent listed is likely to cause this infection. The 80-year-old-male with a Foley catheter in place has developed a nosocomial infection likely secondary to urosepsis. Providencia species frequently cause urinary tract infection in the hospitalized patient. The young man with a fluctuant lesion and fistula over the mandible presents a classic picture of cervicofacial actinomycosis. The sickle cell anemia patient who presents with concomitant pneumonia and meningitis has overwhelming infection with S. pneumoniae due to functional asplenia. S. pneumoniae causes a particularly severe infection associated with sickle cell disease. |
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Match the clinical description with the most likely organism.
a. Streptococcus pneumoniae b. Staphylococcus aureus c. Viridans streptococci d. Providencia stuartii e. Actinomyces israelii f. Haemophilus ducreyi g. Neisseria meningitidis h. Listeria monocytogenes 14. A sickle cell anemia patient presents with high fever, toxicity, signs of pneumonia, and stiff neck. (CHOOSE 1 ORGANISM) |
a. Streptococcus pneumoniae
The 30-year-old-female with mitral valve prolapse has developed subacute bacterial endocarditis. The likely etiologic agent is a viridans streptococci. Viridans streptococci cause most cases of subacute bacterial endocarditis. No other agent listed is likely to cause this infection. The 80-year-old-male with a Foley catheter in place has developed a nosocomial infection likely secondary to urosepsis. Providencia species frequently cause urinary tract infection in the hospitalized patient. The young man with a fluctuant lesion and fistula over the mandible presents a classic picture of cervicofacial actinomycosis. The sickle cell anemia patient who presents with concomitant pneumonia and meningitis has overwhelming infection with S. pneumoniae due to functional asplenia. S. pneumoniae causes a particularly severe infection associated with sickle cell disease. |
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Select an antiviral agent for each patient.
a. Ganciclovir b. Acyclovir c. Interferon α d. Didanosine e. Ribavirin f. Amantadine g. Vidarabine h. Zalcitabine 15. A military recruit develops pneumonia secondary to influenza A. Symptoms began 24 h prior to physician visit. |
f. Amantadine
Amantadine has been shown to alter the course of influenza A favorably, particularly when begun within 48 h of the start of symptoms. The HIV-positive patient with a low CD4 count and visual blurring has developed cytomegalovirus retinitis. Gancyclovir is the drug of choice (foscarnet has also been used effectively). Interferon α has been approved for intralesional therapy of condyloma acuminatum (venereal warts caused by papillomavirus). Ribavirin improves mortality in mechanically ventilated infants with RSV infection. |
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Select an antiviral agent for each patient.
a. Ganciclovir b. Acyclovir c. Interferon α d. Didanosine e. Ribavirin f. Amantadine g. Vidarabine h. Zalcitabine 16. An HIV-positive patient with a CD4 count of 50 complains of the onset of visual blurring; opacity is seen on funduscopic exam. |
a. Ganciclovir
Amantadine has been shown to alter the course of influenza A favorably, particularly when begun within 48 h of the start of symptoms. The HIV-positive patient with a low CD4 count and visual blurring has developed cytomegalovirus retinitis. Gancyclovir is the drug of choice (foscarnet has also been used effectively). Interferon α has been approved for intralesional therapy of condyloma acuminatum (venereal warts caused by papillomavirus). Ribavirin improves mortality in mechanically ventilated infants with RSV infection. |
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Select an antiviral agent for each patient.
a. Ganciclovir b. Acyclovir c. Interferon α d. Didanosine e. Ribavirin f. Amantadine g. Vidarabine h. Zalcitabine 17. A sexually active young woman has anogenital warts and requests intralesional therapy. |
c. Interferon α
Amantadine has been shown to alter the course of influenza A favorably, particularly when begun within 48 h of the start of symptoms. The HIV-positive patient with a low CD4 count and visual blurring has developed cytomegalovirus retinitis. Gancyclovir is the drug of choice (foscarnet has also been used effectively). Interferon α has been approved for intralesional therapy of condyloma acuminatum (venereal warts caused by papillomavirus). Ribavirin improves mortality in mechanically ventilated infants with RSV infection. |
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Select an antiviral agent for each patient.
a. Ganciclovir b. Acyclovir c. Interferon α d. Didanosine e. Ribavirin f. Amantadine g. Vidarabine h. Zalcitabine 18. An infant with respiratory syncytial virus infection requires mechanical ventilation. |
e. Ribavirin
Amantadine has been shown to alter the course of influenza A favorably, particularly when begun within 48 h of the start of symptoms. The HIV-positive patient with a low CD4 count and visual blurring has developed cytomegalovirus retinitis. Gancyclovir is the drug of choice (foscarnet has also been used effectively). Interferon α has been approved for intralesional therapy of condyloma acuminatum (venereal warts caused by papillomavirus). Ribavirin improves mortality in mechanically ventilated infants with RSV infection. |
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Select the fungal agent most likely responsible for the disease process described.
a. Histoplasma capsulatum b. Blastomycosis dermatitidis c. Coccidioides immitis d. Cryptococcus neoformans e. Candida albicans f. Aspergillus fumigatus g. Zygomycosis 19. A young, previously healthy male presents with verrucous skin lesions, bone pain, fever, cough, and weight loss. Chest x-ray shows nodular infiltrates. |
b. Blastomyces dermatitidis
Blastomycosis presents with signs and symptoms of chronic respiratory infection. The organism has a tendency to produce skin lesions in exposed areas that become crusted, ulcerated, or verrucous. Bone pain is caused by osteolytic lesions. Mucormycosis is a zygomycosis that originates in the nose and paranasal sinuses. Sinus tenderness, bloody nasal discharge, and obtundation occur usually in the setting of diabetic ketoacidosis. Aspergillus can result in several different infectious processes, including aspergilloma, disseminated Aspergillus in the immunocompromised patient, or allergic bronchopulmonary aspergillosis. Bronchopulmonary aspergillosis is the most likely diagnosis in the young woman with asthma and eosinophilia. Bronchial plugs, often filled with hyphal forms, result in repeated infiltrates and exacerbation of wheezing. |
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Select the fungal agent most likely responsible for the disease process described.
a. Histoplasma capsulatum b. Blastomycosis dermatitidis c. Coccidioides immitis d. Cryptococcus neoformans e. Candida albicans f. Aspergillus fumigatus g. Zygomycosis 20. A diabetic patient is admitted with elevated blood sugar and acidosis. The patient complains of headache and sinus tenderness and has black, necrotic material draining from the nares. |
g. Zygomycosis
Blastomycosis presents with signs and symptoms of chronic respiratory infection. The organism has a tendency to produce skin lesions in exposed areas that become crusted, ulcerated, or verrucous. Bone pain is caused by osteolytic lesions. Mucormycosis is a zygomycosis that originates in the nose and paranasal sinuses. Sinus tenderness, bloody nasal discharge, and obtundation occur usually in the setting of diabetic ketoacidosis. Aspergillus can result in several different infectious processes, including aspergilloma, disseminated Aspergillus in the immunocompromised patient, or allergic bronchopulmonary aspergillosis. Bronchopulmonary aspergillosis is the most likely diagnosis in the young woman with asthma and eosinophilia. Bronchial plugs, often filled with hyphal forms, result in repeated infiltrates and exacerbation of wheezing. |
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Select the fungal agent most likely responsible for the disease process described.
a. Histoplasma capsulatum b. Blastomycosis dermatitidis c. Coccidioides immitis d. Cryptococcus neoformans e. Candida albicans f. Aspergillus fumigatus g. Zygomycosis 21. A young woman presents with asthma and eosinophilia. Fleeting pulmonary infiltrates occur with bronchial plugging. |
f. Aspergillus fumigatus
Blastomycosis presents with signs and symptoms of chronic respiratory infection. The organism has a tendency to produce skin lesions in exposed areas that become crusted, ulcerated, or verrucous. Bone pain is caused by osteolytic lesions. Mucormycosis is a zygomycosis that originates in the nose and paranasal sinuses. Sinus tenderness, bloody nasal discharge, and obtundation occur usually in the setting of diabetic ketoacidosis. Aspergillus can result in several different infectious processes, including aspergilloma, disseminated Aspergillus in the immunocompromised patient, or allergic bronchopulmonary aspergillosis. Bronchopulmonary aspergillosis is the most likely diagnosis in the young woman with asthma and eosinophilia. Bronchial plugs, often filled with hyphal forms, result in repeated infiltrates and exacerbation of wheezing. |
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A 40-year-old male develops bilateral facial weakness after returning from a camping trip in Wisconsin that lasted 6 weeks. The patient gives a history of arthralgias. On exam, he cannot close either eye well or raise either eyebrow. The first heart sound is diminished. There is no evidence of arthritis.
Hgb: 14 g/dL WBC: 10,000/μL VDRL: negative FTA-Abs: positive ECG: first-degree AV block 22. Which of the following would be most useful? a. CT scan of head b. MRI of head c. More detailed history d. Kveim test |
c. More detailed history
This patient presents with a symptom complex that includes facial nerve palsies, arthralgia, and first-degree AV block. Facial nerve palsy has been increasingly recognized as a first manifestation of Lyme disease. Within several weeks of the onset of illness, about 8% of patients develop cardiac involvement, with heart block being the most common manifestation. During this stage of early disseminated infection, musculoskeletal pain is common. The diagnosis of Lyme disease is based on careful history and physical exam with serologic confirmation by detection of antibody to Borrelia burgdorferi. Neither CT or MRI of head would be indicated as the lesion is a peripheral facial palsy. Sarcoidosis can also cause both facial nerve palsy and AV block, but it is much less likely, and the Kveim test is rarely used to pursue this diagnosis. The treatment of choice for Lyme disease at this stage would be penicillin or ceftriaxone. |
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A 40-year-old male develops bilateral facial weakness after returning from a camping trip in Wisconsin that lasted 6 weeks. The patient gives a history of arthralgias. On exam, he cannot close either eye well or raise either eyebrow. The first heart sound is diminished. There is no evidence of arthritis.
Hgb: 14 g/dL WBC: 10,000/μL VDRL: negative FTA-Abs: positive ECG: first-degree AV block 23. The likely cause of these symptoms is a. Intracranial infection b. Lyme disease c. Endocarditis d. Herpes simplex |
b. Lyme disease
This patient presents with a symptom complex that includes facial nerve palsies, arthralgia, and first-degree AV block. Facial nerve palsy has been increasingly recognized as a first manifestation of Lyme disease. Within several weeks of the onset of illness, about 8% of patients develop cardiac involvement, with heart block being the most common manifestation. During this stage of early disseminated infection, musculoskeletal pain is common. The diagnosis of Lyme disease is based on careful history and physical exam with serologic confirmation by detection of antibody to Borrelia burgdorferi. Neither CT or MRI of head would be indicated as the lesion is a peripheral facial palsy. Sarcoidosis can also cause both facial nerve palsy and AV block, but it is much less likely, and the Kveim test is rarely used to pursue this diagnosis. The treatment of choice for Lyme disease at this stage would be penicillin or ceftriaxone. |
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A 40-year-old male develops bilateral facial weakness after returning from a camping trip in Wisconsin that lasted 6 weeks. The patient gives a history of arthralgias. On exam, he cannot close either eye well or raise either eyebrow. The first heart sound is diminished. There is no evidence of arthritis.
Hgb: 14 g/dL WBC: 10,000/μL VDRL: negative FTA-Abs: positive ECG: first-degree AV block 24. Treatment of choice is a. Penicillin or ceftriaxone b. Acyclovir c. Corticosteroids d. Aminoglycoside |
a. Penicillin or ceftriaxone
This patient presents with a symptom complex that includes facial nerve palsies, arthralgia, and first-degree AV block. Facial nerve palsy has been increasingly recognized as a first manifestation of Lyme disease. Within several weeks of the onset of illness, about 8% of patients develop cardiac involvement, with heart block being the most common manifestation. During this stage of early disseminated infection, musculoskeletal pain is common. The diagnosis of Lyme disease is based on careful history and physical exam with serologic confirmation by detection of antibody to Borrelia burgdorferi. Neither CT or MRI of head would be indicated as the lesion is a peripheral facial palsy. Sarcoidosis can also cause both facial nerve palsy and AV block, but it is much less likely, and the Kveim test is rarely used to pursue this diagnosis. The treatment of choice for Lyme disease at this stage would be penicillin or ceftriaxone. |
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25. You are a physician in charge of the patients who reside in a nursing home. Several of the patients have developed influenza-like symptoms, and the community is in the midst of an influenza A outbreak. None of the nursing home residents have received the influenza vaccine. What course of action is most appropriate?
a. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine (i.e., allergy to eggs) b. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine; also give amantadine for 2 weeks c. Give amantadine alone to all residents d. Do not give any prophylactic regimen |
25. b. Give the influenza vaccine to all residents who do not have a contraindication
Influenza A is a potentially lethal disease in the elderly and chronically debilitated patient. In institutional settings such as nursing homes, outbreaks are likely to be particularly severe. Thus prophylaxis is extremely important in this setting. All residents should receive the vaccine unless they have known egg allergy (patients can choose to decline the vaccine). Since protective antibodies to the vaccine will not develop for 2 weeks, amantadine can be used for protection against influenza A during the interim 2-week period. A reduced dose is given to elderly patients. |
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26. An elderly male develops fever 3 days after cholecystectomy. He
becomes short of breath, and chest x-ray shows a new right lower lobe infiltrate. Sputum Gram stain shows gram-positive cocci in clumps, and preliminary culture results suggest staphylococci. The initial antibiotic of choice is a. Penicillinase-resistant penicillin such as nafcillin b. Vancomycin c. Antibiotic therapy should be based on the incidence of methicillin-resistant staphylococci in that hospital d. Quinolones have become the drug of choice for pneumonia |
26. The answer is c.
In the treatment of hospital-acquired staphylococcal pneumonia, the incidence of methicillin-resistant staph in the local facility will be very important. In most hospitals, methicillin-resistant staph is common enough to require initial therapy with vancomycin. Oxacillin would be the drug of choice only if the incidence of methicillin-resistant staph is very low. Quinolones are often useful in the treatment of community-acquired pneumonia, but they would not be effective against methicillin-resistant staph. |
