Day 22 Flashcards
Q1-A man is admitted for endocarditis. His blood cultures grow S. aureus, and vancomycin is started while waiting sensitivity testing. He develops red skin, particularly on the neck. What should you do?
A-Slow rate of infusion
B-Stop infusion
C-Continue same rate of infusion
Ans: A. Slow the rate of the infusion. Vancomycin is associated with “red man syndrome,” which is red, flushed skin from histamine release. This happens from rapid infusion of vancomycin. There is no specific therapy, and you do not need to switch the medication. If the rate of infusion is slowed, the reaction will not occur. Telavancin does not cause red man syndrome.
Q2-Which of the following is the earliest finding of osteomyelitis on an x-ray?
A-Periosteal elevation
B-Involucrum
C-Sequestrum
D-Punched-out lesions
Ans: A. The earliest finding of osteomyelitis on an x-ray is elevation of the periosteum. Involucrum and sequestrum are terms applied to the formation of abnormal new bone in the periosteum and chunks of bone chipped off from the infection. Punched-out lesions are seen in myeloma, not osteomyelitis. Osteomyelitis does not have an association with fracture.
Q3-A 65-year-old man with diabetes and peripheral arterial disease comes in having had pain in his leg for 2 weeks. There is an ulcer with a draining sinus tract. The x-ray is normal. What is the next best step in determining a diagnosis?
A-Bone scan
B-CT scan
C-MRI
D-Biopsy
Ans: C. The MRI (C) is the next best test to do to determine the diagnosis of osteomyelitis if the x-ray is normal. A bone scan does not have the specificity of an MRI.
Q4-A patient develops recurrent episodes of gonorrhea. What should he be tested for?
A-Presence of a spleen B-HIV C-Terminal complement deficiency D-Steroid use E-Malabsorption
Ans: C. Terminal complement deficiency predisposes a patient to recurrent episodesof Neisseria infection. This includes any form, including genital and CNS infection.
Q5-A 32year woman comes to the emergency department with lower abdominal pain and tenderness, fever, leukocytosis, and cervical motion tenderness. What is the next best step in the management of this patient?
A-Cervical culture B-Pelvic sonogram C-Urine pregnancy test D-Laparoscopy E-Ceftriaxone and doxycycline
Ans: C. The most important thing to do in a woman with lower abdominal pain or tenderness is to exclude an ectopic pregnancy. Perform a urine pregnancy test first and then get a cervical culture and start therapy.
Q6-A 32-year man comes to the clinic with multiple vesicles on his penis. There is enlarged adenopathy in the inguinal area. What is the next step in management?
A-Tzanck prep
B-Viral culture
C-Valacyclovir
D-Valganciclovir
Ans: C. When there are clear vesicular lesions present, there is no need to do a specific diagnostic test for herpes. If the question describes multiple vesicles, then treatment with acyclovir, valacyclovir, or famciclovir for 7–10 days is the next best step in management. Daily suppressive therapy can be prescribed for recurrent genital herpes. If the roofs come off the vesicles and the lesion becomes an ulcer of unclear etiology, then the best initial diagnostic test is a Tzanck prep. The most accurate test for herpes is a viral culture. If there are clear vesicles, this is not necessary; go straight to treatment. Valganciclovir is therapy for cytomegalovirus (CMV). Patients with frequent recurrence should be placed on chronic suppressive therapy. Acyclovir resistant herpes is treated with foscarnet.
Q7-A man comes to the clinic having had a painless, firm genital lesion for the last several days. The inguinal adenopathy is painless.
What is the most accurate diagnostic test?
A-VDRL
B-RPR
C-FTA
D-Darkfield microscopic exam
Ans: D. The VDRL and RPR are only 75 percent sensitive in primary syphilis. There is a false negative rate of 25 percent. The most accurate test in primary syphilis is darkfield microscopy. Darkfield microscopy is far more sensitive than a VDRL or RPR in primary syphilis.
Q8-A man comes in with a painless ulcer and adenopathy. The edges of the ulcer are firm. The VDRL is negative. What is the next best step in management?
A-Repeat the VDRL B-RPR C-FTA D-Darkfield microscopic exam E-Order antiphospholipid antibody
Ans: D. Perform a darkfield examination. The VDRL and RPR can be negative in 25 percent of cases of primary syphilis.
Q9-A 27year, generally healthy woman comes to the office with burning on urination. There are 50 white cells on the urinalysis. What is the next best step in management?
A-Wait for results of urine culture B-Obtain urine culture C-Treat with TMP/SMX for 3 days D-Treat with ciprofloxacin for 7 days E-Perform a renal ultrasound
Ans: C. When there are clear symptoms of cystitis and white cells in the urine, it is not necessary to obtain a urine culture or to wait for results of either the culture or a sonogram. For uncomplicated cystitis, go straight to treatment for 3 days. Ultrasound is important in male patients, as it is unusual for a male patient to have a urinary tract infection in the absence of an anatomic abnormality.
Q10-A 42-year man presents with a target shaped rash that has developed over the last several days. He was on a camping trip in the woods last week in Maine. What is the next best step in management?
A-Serology for IgM B-ELISA C-Western blot D-Doxycycline E-Ceftriaxone
Ans: D. A rash suggestive of Lyme is enough to indicate treatment. A 5-cm-wide target-shaped rash, particularly with a history of camping/hiking, is enough to indicate the need for antibiotic treatment with doxycycline. A characteristic rash is more specific than serology. Ceftriaxone is used for CNS or cardiac Lyme.
Q11-A patient comes to the emergency department with shortness of breath, facial swelling, and lip swelling 30 minutes after a bee sting. There was no response to epi-pen injection in the field. Six hours after a bolus of steroid and diphenhydramine, the patient is still short of breath and still has lip swelling.
Where the patient should be placed?
A-ICU
B-Ward
C-Emergency room
Ans: A. This patient should be placed in the intensive care unit. If the patient comes with anaphylaxis from any cause, the placement of the patient for CCS is based entirely on the response to therapy that occurs after treatment. In this case, the source of the allergic reaction, an insect sting, is irrelevant. What matters is that after moving the clock forward, the symptoms do not resolve. Any persistent lip, facial, or hemodynamic involvement after initial therapy should place the patient in the ICU.
Q12-A man comes in with neurosyphilis. He has a history of life-threatening anaphylaxis to penicillin. He has a history of essential tremor and is on propranolol. He has asthma and is on an inhaled beta agonist and inhaled steroids.
Which of the following is most appropriate?
A-Use ceftriaxone instead of penicillin
B-Stop propranolol prior to desensitizing him
C-Bolus with oral steroids prior to penicillin use
D-Add long acting beta agonists to treatment
Ans: B. Neurosyphilis is only effectively treated with penicillin. The patient must be desensitized. Prior for desensitization it is important to stop propranolol and all beta blockers. This is because epinephrine may have to be used in the event of anaphylaxis when you desensitize the patient. Bolusing with steroids in inappropriate, because anaphylaxis is treated first with epinephrine.
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Q13-A 4-yearboy comes in with recurrent sinopulmonary infections. There are no nodes palpated in the cervical area and no tonsils seen on oral exam. The child has been treated for an infection nearly every 1–2 months since birth. There are no skin infections.
What is the most likely diagnosis?
A-Hyper IgE syndrome
B-IgA deficiency
C-X-linked agammaglobulinemia
D-Common variable immunodeficiency
Ans: C. X-linked agammaglobulinemia is exclusively in male children, whereas common variable immunodeficiency presents in adults. The absence of skin infection in this case goes strongly against hyper IgE syndrome. These patients are best managed with intravenous immunoglobulin infusions on a regular basis and with antibiotics for infections as episodes arise.
Q14-A 40 y/o female complains of 3 months of gradual fatigue, headache, upper abdominal pain, general muscle-bone pain, decreased vision, galactorrhea, amenorrhea, swelling, intermittent anxiety, dizziness, and sweating. Blood test results: Ca = 12.5 mg/dL, increased prolactin, PTH, gastrin and insulin levels; decreased PO4, glucose, LH, and FSH; levels of T4, TSH, calcitonin, creatinine, and K are all normal. What’s the most likely diagnosis?
A-Pituitary adenoma B-MEN-1 C-MEN-2A D-MEN-2B E-Parathyroid adenoma F-Insulinoma
Ans: B. Remember it well. MEN-1 (Wermer syndrome): Pituitary, parathyroid, pancreatic tumors, and facial angiofibromas and collagenomas —“PPP”. MEN-2A (Sipple syndrome): Adrenal pheochromocytoma, thyroid medullary carcinoma, and parathyroid adenoma—“ATP”. MEN-2B: Adrenal pheochromocytoma, thyroid medullary carcinoma, and mucosal neuromas —“ATM”.
Q15-A 58-year man comes to the office a few days after an episode of chest pain. This was his first episode of pain, and he has no risk factors. In the emergency department, he had a normal EKG and normal CK-MB and was released the next day. Which of the following is most appropriate in his further management?
A-Repeat CK-MB B-Statin C-LDL level D-Stress (exercise tolerance) testing E-Angiography
Ans: D. Stress test when the case is equivocal or uncertain for the presence of CAD. Do not do an angiography unless the stress test is abnormal. Exercise tolerance, or “stress,” testing detects coronary artery disease when the heart rate is raised and ST segment depression is detected. This case is asking you to know that a stress test is a way of increasing the sensitivity of detection of CAD beyond an EKG and enzymes.
