Case 4 Patient with long standing , low grade fever of 100F over the past 2 months. She has had a chronic, non productive cough. On physical examination, you find a systolic murmur at the LSB, radiating to the axilla. Echocardiogram demonstrates tricuspid and mitral valve vegetations. The patient has severe dental carries. You strongly suspect some fastidious gram negative bacilli that are commonly found in the oropharynx. You are most likely thinking of? A. Legionella B. Chlamydia C. Anaerobic strep D. HACEK organisms E. Bacillus anthracis

Case 4 You are most likely thinking of? A. Legionella B. Chlamydia C. Anaerobic strep _•D. HACEK organisms_ •E. Bacillus anthracis

HACEK Organisms Haemophilus Actiniobacillus actinomycetomemcomitans Cardiobacterium hominis Eikenella corrodens Kingella kingae

Case 5 6 month old is brought to your office in mid-January. This child’s mother reports that the infant has had a low grade fever, wheezing with coughing, and diminished appetite. The most likely diagnosis is : A. Bronchiolitis secondary to RSV B. Pneumonia secondary to S. pneumoniae C. Aspiration pneumonia D. Asthma E. Bronchitis secondary to H. Influenzae

Case 5 The most likely diagnosis is : A. Bronchiolitis secondary to RSV B. Pneumonia secondary to S. pneumoniae C. Aspiration pneumonia D. Asthma E. Bronchitis secondary to H. Influenzae

Case 6 34 year old emigrant from Sweden, where he worked for 10 years as a sandblaster. He has had BCG vaccine as a child. Upon arrival to the US, 2 years ago, he was prescribed INH for 6 months because his PPD intermediate skin test was 10mm. He stopped after 2 months on his own. He now presents to you for a routine physical examination. The physical examination is normal. His chest x-ray demonstrates some small fibrotic changes at the apex of both lungs. What is your next step? A. Advise that he have PFT tests and an ABG for a restrictive lung disease. B. That he receive an additional 3 months of INH C. That he be placed on Nafcillin D. That he restart his INH prophylaxis from the beginning. E. That he receive a 2 step PPD skin test

Case 6 What is your next step? A. Advise that he have PFT tests and an ABG for a restrictive lung disease. B. That he receive an additional 3 months of INH C. That he be placed on Nafcillin _•D. That he restart his INH prophylaxis from the beginning._ •E. That he receive a 2 step PPD skin test

Case 7 58 year old male with a chronic cough producing, on average 20cc of clear colored sputum daily (4 teaspoons per day). He has a history of smoking 30 pack years. His PFT’s are generally stable with reduced flow rates compatible with obstructive lung disease. He sees you because he has developed an acute exacerbation of his COPD, with a decrease in his PaO2 from a usual 60 mm Hg to 50 mm Hg. His PaCO2 has risen from 50 mm Hg to 60 mm Hg. You suspect he has an exacerbation secondary to a chest infection. You prescribe Azithromycin for him. Which organism listed below is among the most common causing an exacerbation of COPD? A. Myocoplasma pneumoniae B. Moraxella catarrhalis C. Chlamyida pneumoniae D. TWAR E. Pseudomonas aeruginosa

Case 7 Which organism listed below is among the most common causing an exacerbation of COPD? A. Myocoplasma pneumoniae _•B. Moraxella catarrhalis_ C. Chlamyida pneumoniae D. TWAR E. Pseudomonas aeruginosa

Case 8 36 year old migrant farm worker comes to a community outreach health clinic complaining of hemoptysis. For the past 2 months, while she has travelled from Tijuana, Mexico, up through California’s central agricultural valley, she has suffered from intermittent episodes of a hacking cough, as well as intermittent joint pain. Physical exam reveals some faint crackles in her left upper lobe, and three small, tender, violaceous subcutaneous nodules on her right pretibial region. Laboratory studies are unremarkable, but a chest radiograph reveals a 3 cm thin walled cavity in the left upper lobe with no surrounding infiltrate. A PPD skin test shows 4 mm of induration 72 hours after placement. What is the most likely organism? A. Blastomycosis B. Coccidiomycosis C. A unicellular, oval-shaped diploid fungus that reproduces by budding D. Paragonimiasis E. Tuberculosis

Case 8 What is the most likely organism? A. Blastomycosis _•B. Coccidiomycosis_ C. A unicellular, oval-shaped diploid fungus that reproduces by budding D. Paragonimiasis E. Tuberculosis

Case 9 56 year old male that is HIV positive. He has recurrent bouts of candidiasis. Recently he complains of dyspnea, non productive cough and fever, confusion and headache. Chest x-ray demonstrates a diffuse interstitial infiltrate. His PaO2 is 50 mm Hg. Cat scan of his head demonstrates abscesses with ring like contrast enhancement. His CD4 count is 40. He has a pet cat at home. A. An organism that stains positive to methanamine silver. B. Tachyzoites that stain with H and E. C. Acid Fast Bacilli D. A rickettsia like organism often transmitted with exposure to infected placentas and birth fluids of sheep and other mammals. E. A disorder that begins with a flu symptoms stage that resolves and comes back affecting the liver, lungs, and kidneys going to renal failure

Case 9 •A. An organism that stains positive to methanamine silver. _•B. Tachyzoites that stain with H and E._ C. Acid Fast Bacilli D. A rickettsia like organism often transmitted with exposure to infected placentas and birth fluids of sheep and other mammals. E. A disorder that begins with a flu symptoms stage that resolves and comes back affecting the liver, lungs, and kidneys going to renal failure

Case 10 36 year old cigarette smoking female that presents with a sudden onset of chills, fever, rigor, and non-productive cough. Physical examination demonstrates decreased breath sounds in her right lower lobe. She has rusty colored sputum. Chest x-ray demonstrates a consolidation present in her RLL. Her CBC demonstrates an elevated WBC of 15,000 with multiple immature forms. You are unable to obtain a sputum gran stain/culture. Base upon you knowledge of community acquired pneumonia, you correctly surmise that? A. “humoral immunity” will be the primary response to this organism B. “cellular immunity” will be the primary response to this organism C. IgE antibodies will be the primary response to this organism D. A granulomatous response will be the primary response to this organism E. Her initial immune response will be IgG antibodies followed by IgM antibodies 14 days later

Case 10 •Base upon you knowledge of community acquired pneumonia, you correctly surmise that? _•A. “humoral immunity” will be the primary response to this organism_ B. “cellular immunity” will be the primary response to this organism C. IgE antibodies will be the primary response to this organism D. A granulomatous response will be the primary response to this organism E. Her initial immune response will be IgG antibodies followed by IgM antibodies 14 days later

Case 11 33 year old male rural veterinarian who had flu like symptoms one week ago. He now presents with the sudden onset of fever, severe headache, myalgias, chills, cough, chest pain, neck stiffness, and prostration. On physical examination, his temp is 105F, he appears jaundiced, and his liver and spleen are enlarged. Auscultation of his lungs reveals rales at the bases. Chest x-ray demonstrates a bilateral pattern of patchy alveolar infiltrations. His BUN and creatinine are both elevated and he has red cell casts in his urine. Diffuse areas containing alveoli filled with erythrocytes is noted on lung biopsy. You strongly suspect a pathogenic organism associated with animal urine. To that end you find? A. Agglutination antibodies to leptospirosis B. Antibodies to C. burnetti C. Mycobacterium kansasii D. A replicative RNA virus E. Antibodies to Wucheria bancrofti

Case 11 •To that end you find? _•A. Agglutination antibodies to leptospirosis_ B. Antibodies to C. burnetti C. Mycobacterium kansasii D. A replicative RNA virus E. Antibodies to Wucheria bancrofti

Case 12 70 year old female that is seeing you in the office with a chief complaint that for the last 2-3 days she has had a temperature of 100F, minor chills, myalgia, malaise, and headache. She has a dry cough. The cough is non productive. Auscultation of her lungs demonstrate some mild rales, that clear with deep cough. This is the same type of virus that affected her last year at this time. You correctly suspect that the organism changed from last year because of? A. The development of antibiotic resistance B. A major change in the reassortment of segments of the genome RNA C. Minor changes associated with antigenic drift D. Alterations in the gram negative coccobacillus cell wall E. Both the hemagglutinin & neuraminidase are replaced through recombination of RNA segments with those of animal viruses

Case 12 You correctly suspect that the organism changed from last year because of? A. The development of antibiotic resistance B. A major change in the reassortment of segments of the genome RNA _•C. Minor changes associated with antigenic drift_ D. Alterations in the gram negative coccobacillus cell wall E. Both the hemagglutinin & neuraminidase are replaced through recombination of RNA segments with those of animal viruses

Case 13 Your patient has a history of immune thrombocytopenic purpura. After a failure in her response to prednisone, she responded to therapy with a therapeutic splenectomy. Her ITP has been stable now for five years. She now presents to you with sudden onset of chills, rigors, cough, and fever. She has a purulent cough and rib pain with respiration. Auscultation reveals decreased breath sounds on the left. Chest x-ray presents a multilobar pattern with bilateral lower lobe infiltrates. There is some consolidation on the left. You suspect that she acquired this infection because she: A. No longer has the full ability to produce opsonizing IgG antibody to this encapsulated organism B. Now has altered cellular immunity to fungal organisms C. No longer produces adequate amount of IgA D. Has developed in an immotile ciliary syndrome E. Has reactivated a Ghon complex lesion.

Case 13 •You suspect that she acquired this infection because she: _•A. No longer has the full ability to produce opsonizing IgG antibody to this encapsulated organism_ B. Now has altered cellular immunity to fungal organisms C. No longer produces adequate amount of IgA D. Has developed in an immotile ciliary syndrome E. Has reactivated a Ghon complex lesion.

Case 14 Your patient is a 25 year old male with a CD4 count of 200. Physical examination reveals an alert male, in no distress. Lungs are clear. PPD skin test is negative. As his primary doctor, you correctly ? A. Prescribe prophylactic INH therapy B. Prescribe prophylactic Trimethoprim/Sulfamethoxazole C. Perform pulmonary function tests to look for early signs of restrictive lung disease D. Perform sputum cultures for MAC E. Perform antigen tests for toxoplasmosis

Case 14 As his primary doctor, you correctly ? A. Prescribe prophylactic INH therapy _•B. Prescribe prophylactic Trimethoprim/Sulfamethoxazole_ C. Perform pulmonary function tests to look for early signs of restrictive lung disease D. Perform sputum cultures for MAC E. Perform antigen tests for toxoplasmosis

Case 15 35 year old chicken farmer in West Virginia. He has been healthy all his previous life. His family is also very healthy. He presents to you with “flulike” illness, arthralgias and myalgias that have been ongoing for the last 6 weeks. He has a non productive cough and low grade fever. Chest x-ray shows bilateral nodules and hilar lymphadenopathy. There are some bilateral interstitial infiltrates as well. His PPD skin test is 11 mm of induration. In order to make you diagnosis, you correctly find? A. Positive serology for Blastomycosis B. Positive serology for Histoplasmosis C. Positive AFB culture/ stain D. The presence of gram negative bacilli in sputum specimens E. The presence of complement components on the surfaces of circulating RBC’s

Case 15 In order to make you diagnosis, you correctly find? A. Positive serology for Blastomycosis _•B. Positive serology for Histoplasmosis_ C. Positive AFB culture/ stain D. The presence of gram negative bacilli in sputum specimens E. The presence of complement components on the surfaces of circulating RBC’s

Case 16 66 year old male with a history of congestive heart failure, ischemic heart disease, hypertension, and diabetes. His medications include insulin, amiodarone, Lasix, and digoxin. You are seeing him in the office because of a cough for the past month, marked weakness, and low grade fever. Physical exam finds decreased breath sounds and basilar rales bilaterally. He has a grade II/VI systolic murmur that radiates up to his carotids bilaterally. There are petechiae noted on his upper and lower extremities. His liver and spleen are enlarged to palpation. He appears pale. He has marked lymphadenopathy in the cervical, axillary, and inguinal region. He exhibits nuchal rigidity with a positive “Kernig’s” sign. His CBC demonstrates 9 grams of HgB and 50,000 WBC’s. The differential demonstrates 80% lymphocytes, 20% granulocytes. His platelet count is 50,000. Chest x-ray demonstrates a left sided pleural effusion and a left sided consolidation in the lower lobe. Thoracentesis demonstrates a glucose of 50, and a pH of 7.15. There are numerous WBC’s. Gram stain demonstrates the presence of a gram negative coccus that has a prominent polysaccharide capsule and grows on “ chocolate” agar. The infecting organism is? A. H. influenzae B. B. anthracis C. N. Meningitides D. K. pneumonia E. R. prowazekii

Case 16 The infecting organism is? A. H. influenzae B. B. anthracis _•C. N. Meningitides_ D. K. pneumonia E. R. prowazekii

Case 17 47 year old male who has been recently diagnosed with active tuberculosis. He has been treated with a classic four drug regimen. He is now complaining of orange urine. His orange urine is secondary to ? A. Ethambutol B. INH C. Rifampin D. Pyrizinamide E. Streptomycin

Case 17 His orange urine is secondary to ? A. Ethambutol B. INH _•C. Rifampin_ D. Pyrizinamide E. Streptomycin

Pneumonia and TB part 2 , Pulmonary Embolism Flashcards by Drew Armstrong

Case 4

Patient with long standing , low grade fever of 100F over the past 2 months. She has had a chronic, non productive cough. On physical examination, you find a systolic murmur at the LSB, radiating to the axilla.
Echocardiogram demonstrates tricuspid and mitral valve vegetations. The patient has severe dental carries. You strongly suspect some fastidious gram negative bacilli that are commonly found in the oropharynx.
You are most likely thinking of?
A. Legionella
B. Chlamydia
C. Anaerobic strep
D. HACEK organisms
E. Bacillus anthracis

Case 4

You are most likely thinking of?

A. Legionella
B. Chlamydia
C. Anaerobic strep

•D. HACEK organisms

•E. Bacillus anthracis

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HACEK Organisms

Haemophilus
Actiniobacillus actinomycetomemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae

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Case 5

6 month old is brought to your office in mid-January. This child’s mother reports that the infant has had a low grade fever, wheezing with coughing, and diminished appetite.
The most likely diagnosis is :
A. Bronchiolitis secondary to RSV
B. Pneumonia secondary to S. pneumoniae
C. Aspiration pneumonia
D. Asthma
E. Bronchitis secondary to H. Influenzae

Case 5

The most likely diagnosis is :
A. Bronchiolitis secondary to RSV
B. Pneumonia secondary to S. pneumoniae
C. Aspiration pneumonia
D. Asthma
E. Bronchitis secondary to H. Influenzae

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RSV

•Most common cause of bronchiolitis and pneumonia in children under 1 year of age in the United States.

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Case 6

34 year old emigrant from Sweden, where he worked for 10 years as a sandblaster. He has had BCG vaccine as a child. Upon arrival to the US, 2 years ago, he was prescribed INH for 6 months because his PPD intermediate skin test was 10mm. He stopped after 2 months on his own. He now presents to you for a routine physical examination. The physical examination is normal. His chest x-ray demonstrates some small fibrotic changes at the apex of both lungs.
What is your next step?
A. Advise that he have PFT tests and an ABG for a restrictive lung disease.
B. That he receive an additional 3 months of INH
C. That he be placed on Nafcillin
D. That he restart his INH prophylaxis from the beginning.
E. That he receive a 2 step PPD skin test

Case 6

What is your next step?

A. Advise that he have PFT tests and an ABG for a restrictive lung disease.
B. That he receive an additional 3 months of INH
C. That he be placed on Nafcillin

•D. That he restart his INH prophylaxis from the beginning.

•E. That he receive a 2 step PPD skin test

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Case 7

58 year old male with a chronic cough producing, on average 20cc of clear colored sputum daily (4 teaspoons per day). He has a history of smoking 30 pack years. His PFT’s are generally stable with reduced flow rates compatible with obstructive lung disease. He sees you because he has developed an acute exacerbation of his COPD, with a decrease in his PaO2 from a usual 60 mm Hg to 50 mm Hg. His PaCO2 has risen from 50 mm Hg to 60 mm Hg. You suspect he has an exacerbation secondary to a chest infection. You prescribe Azithromycin for him.
Which organism listed below is among the most common causing an exacerbation of COPD?
A. Myocoplasma pneumoniae
B. Moraxella catarrhalis
C. Chlamyida pneumoniae
D. TWAR
E. Pseudomonas aeruginosa

Case 7

Which organism listed below is among the most common causing an exacerbation of COPD?
A. Myocoplasma pneumoniae

•B. Moraxella catarrhalis

C. Chlamyida pneumoniae
D. TWAR
E. Pseudomonas aeruginosa

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Case 8

36 year old migrant farm worker comes to a community outreach health clinic complaining of hemoptysis. For the past 2 months, while she has travelled from Tijuana, Mexico, up through California’s central agricultural valley, she has suffered from intermittent episodes of a hacking cough, as well as intermittent joint pain. Physical exam reveals some faint crackles in her left upper lobe, and three small, tender, violaceous subcutaneous nodules on her right pretibial region. Laboratory studies are unremarkable, but a chest radiograph reveals a 3 cm thin walled cavity in the left upper lobe with no surrounding infiltrate. A PPD skin test shows 4 mm of induration 72 hours after placement.
What is the most likely organism?
A. Blastomycosis
B. Coccidiomycosis
C. A unicellular, oval-shaped diploid fungus that reproduces by budding
D. Paragonimiasis
E. Tuberculosis

Case 8

What is the most likely organism?
A. Blastomycosis

•B. Coccidiomycosis

C. A unicellular, oval-shaped diploid fungus that reproduces by budding
D. Paragonimiasis
E. Tuberculosis

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Case 9

56 year old male that is HIV positive. He has recurrent bouts of candidiasis. Recently he complains of dyspnea, non productive cough and fever, confusion and headache. Chest x-ray demonstrates a diffuse interstitial infiltrate. His PaO2 is 50 mm Hg. Cat scan of his head demonstrates abscesses with ring like contrast enhancement. His CD4 count is 40. He has a pet cat at home.
A. An organism that stains positive to methanamine silver.
B. Tachyzoites that stain with H and E.
C. Acid Fast Bacilli
D. A rickettsia like organism often transmitted with exposure to infected placentas and birth fluids of sheep and other mammals.
E. A disorder that begins with a flu symptoms stage that resolves and comes back affecting the liver, lungs, and kidneys going to renal failure

Case 9

•A. An organism that stains positive to methanamine silver.

•B. Tachyzoites that stain with H and E.

C. Acid Fast Bacilli
D. A rickettsia like organism often transmitted with exposure to infected placentas and birth fluids of sheep and other mammals.
E. A disorder that begins with a flu symptoms stage that resolves and comes back affecting the liver, lungs, and kidneys going to renal failure

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Case 10

36 year old cigarette smoking female that presents with a sudden onset of chills, fever, rigor, and non-productive cough. Physical examination demonstrates decreased breath sounds in her right lower lobe. She has rusty colored sputum. Chest x-ray demonstrates a consolidation present in her RLL. Her CBC demonstrates an elevated WBC of 15,000 with multiple immature forms. You are unable to obtain a sputum gran stain/culture.
Base upon you knowledge of community acquired pneumonia, you correctly surmise that?
A. “humoral immunity” will be the primary response to this organism
B. “cellular immunity” will be the primary response to this organism
C. IgE antibodies will be the primary response to this organism
D. A granulomatous response will be the primary response to this organism
E. Her initial immune response will be IgG antibodies followed by IgM antibodies 14 days later

Case 10

•Base upon you knowledge of community acquired pneumonia, you correctly surmise that?

•A. “humoral immunity” will be the primary response to this organism

B. “cellular immunity” will be the primary response to this organism
C. IgE antibodies will be the primary response to this organism
D. A granulomatous response will be the primary response to this organism
E. Her initial immune response will be IgG antibodies followed by IgM antibodies 14 days later

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Case 11

33 year old male rural veterinarian who had flu like symptoms one week ago. He now presents with the sudden onset of fever, severe headache, myalgias, chills, cough, chest pain, neck stiffness, and prostration. On physical examination, his temp is 105F, he appears jaundiced, and his liver and spleen are enlarged. Auscultation of his lungs reveals rales at the bases. Chest x-ray demonstrates a bilateral pattern of patchy alveolar infiltrations. His BUN and creatinine are both elevated and he has red cell casts in his urine. Diffuse areas containing alveoli filled with erythrocytes is noted on lung biopsy. You strongly suspect a pathogenic organism associated with animal urine.
To that end you find?
A. Agglutination antibodies to leptospirosis
B. Antibodies to C. burnetti
C. Mycobacterium kansasii
D. A replicative RNA virus
E. Antibodies to Wucheria bancrofti

Case 11

•To that end you find?

•A. Agglutination antibodies to leptospirosis

B. Antibodies to C. burnetti
C. Mycobacterium kansasii
D. A replicative RNA virus
E. Antibodies to Wucheria bancrofti

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Case 12

70 year old female that is seeing you in the office with a chief complaint that for the last 2-3 days she has had a temperature of 100F, minor chills, myalgia, malaise, and headache. She has a dry cough. The cough is non productive. Auscultation of her lungs demonstrate some mild rales, that clear with deep cough. This is the same type of virus that affected her last year at this time.
You correctly suspect that the organism changed from last year because of?
A. The development of antibiotic resistance
B. A major change in the reassortment of segments of the genome RNA
C. Minor changes associated with antigenic drift
D. Alterations in the gram negative coccobacillus cell wall
E. Both the hemagglutinin & neuraminidase are replaced through recombination of RNA segments with those of animal viruses

Case 12

You correctly suspect that the organism changed from last year because of?
A. The development of antibiotic resistance
B. A major change in the reassortment of segments of the genome RNA

•C. Minor changes associated with antigenic drift

D. Alterations in the gram negative coccobacillus cell wall
E. Both the hemagglutinin & neuraminidase are replaced through recombination of RNA segments with those of animal viruses

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Case 13

Your patient has a history of immune thrombocytopenic purpura. After a failure in her response to prednisone, she responded to therapy with a therapeutic splenectomy. Her ITP has been stable now for five years. She now presents to you with sudden onset of chills, rigors, cough, and fever. She has a purulent cough and rib pain with respiration. Auscultation reveals decreased breath sounds on the left. Chest x-ray presents a multilobar pattern with bilateral lower lobe infiltrates. There is some consolidation on the left.
You suspect that she acquired this infection because she:
A. No longer has the full ability to produce opsonizing IgG antibody to this encapsulated organism
B. Now has altered cellular immunity to fungal organisms
C. No longer produces adequate amount of IgA
D. Has developed in an immotile ciliary syndrome
E. Has reactivated a Ghon complex lesion.

Case 13

•You suspect that she acquired this infection because she:

•A. No longer has the full ability to produce opsonizing IgG antibody to this encapsulated organism

B. Now has altered cellular immunity to fungal organisms
C. No longer produces adequate amount of IgA
D. Has developed in an immotile ciliary syndrome
E. Has reactivated a Ghon complex lesion.

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Case 14

Your patient is a 25 year old male with a CD4 count of 200. Physical examination reveals an alert male, in no distress. Lungs are clear. PPD skin test is negative.
As his primary doctor, you correctly ?
A. Prescribe prophylactic INH therapy
B. Prescribe prophylactic Trimethoprim/Sulfamethoxazole
C. Perform pulmonary function tests to look for early signs of restrictive lung disease
D. Perform sputum cultures for MAC
E. Perform antigen tests for toxoplasmosis

Case 14

As his primary doctor, you correctly ?
A. Prescribe prophylactic INH therapy

•B. Prescribe prophylactic Trimethoprim/Sulfamethoxazole

C. Perform pulmonary function tests to look for early signs of restrictive lung disease
D. Perform sputum cultures for MAC
E. Perform antigen tests for toxoplasmosis

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Case 15

35 year old chicken farmer in West Virginia. He has been healthy all his previous life. His family is also very healthy. He presents to you with “flulike” illness, arthralgias and myalgias that have been ongoing for the last 6 weeks. He has a non productive cough and low grade fever. Chest x-ray shows bilateral nodules and hilar lymphadenopathy. There are some bilateral interstitial infiltrates as well. His PPD skin test is 11 mm of induration.
In order to make you diagnosis, you correctly find?
A. Positive serology for Blastomycosis
B. Positive serology for Histoplasmosis
C. Positive AFB culture/ stain
D. The presence of gram negative bacilli in sputum specimens
E. The presence of complement components on the surfaces of circulating RBC’s

Case 15

In order to make you diagnosis, you correctly find?
A. Positive serology for Blastomycosis

•B. Positive serology for Histoplasmosis

C. Positive AFB culture/ stain
D. The presence of gram negative bacilli in sputum specimens
E. The presence of complement components on the surfaces of circulating RBC’s

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Case 16

66 year old male with a history of congestive heart failure, ischemic heart disease, hypertension, and diabetes. His medications include insulin, amiodarone, Lasix, and digoxin. You are seeing him in the office because of a cough for the past month, marked weakness, and low grade fever. Physical exam finds decreased breath sounds and basilar rales bilaterally. He has a grade II/VI systolic murmur that radiates up to his carotids bilaterally. There are petechiae noted on his upper and lower extremities. His liver and spleen are enlarged to palpation. He appears pale. He has marked lymphadenopathy in the cervical, axillary, and inguinal region.
He exhibits nuchal rigidity with a positive “Kernig’s” sign. His CBC demonstrates 9 grams of HgB and 50,000 WBC’s. The differential demonstrates 80% lymphocytes, 20% granulocytes. His platelet count is 50,000. Chest x-ray demonstrates a left sided pleural effusion and a left sided consolidation in the lower lobe. Thoracentesis demonstrates a glucose of 50, and a pH of 7.15. There are numerous WBC’s. Gram stain demonstrates the presence of a gram negative coccus that has a prominent polysaccharide capsule and grows on “ chocolate” agar.
The infecting organism is?
A. H. influenzae
B. B. anthracis
C. N. Meningitides
D. K. pneumonia
E. R. prowazekii

Case 16

The infecting organism is?
A. H. influenzae
B. B. anthracis

•C. N. Meningitides

D. K. pneumonia
E. R. prowazekii

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Case 17

47 year old male who has been recently diagnosed with active tuberculosis. He has been treated with a classic four drug regimen. He is now complaining of orange urine.
His orange urine is secondary to ?
A. Ethambutol
B. INH
C. Rifampin
D. Pyrizinamide
E. Streptomycin

Case 17

His orange urine is secondary to ?
A. Ethambutol
B. INH

•C. Rifampin

D. Pyrizinamide
E. Streptomycin

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Case 18

81 year old nursing home resident is brought to the hospital because of altered mental status for the past day. Her husband states that she was in her usual state of health yesterday. He states she had a “coughing fit” after he fed her dinner last night. Her past medical history is significant for noninsulin-dependent diabetes mellitus and cerebral vascular accident that has left her with some residual dysarthria. Her blood pressure is 95/55 mm Hg, pulse is 97/min, and respirations are 19/min. Her temperature is 38.3C (101.0F) and oxygen saturation is 94% on room air (corrects to 99% with 4 liters of oxygen). She is awake, minimally responsive, and in no respiratory distress.
On her lung examination you note localized rales at the right lower lung field. You suspect aspiration pneumonia and place an intravenous line and obtain a chest x-ray. The x-ray shows a right sided consolidation that obscures the right heart border.
Which of the following is the most appropriate course of management?
A. Administer a high dose of corticosteroids and admit to the hospital.
B. Administer intravenous clindamycin and admit to the hospital
C. Administer a high dose of intravenous penicillin and admit to the hospital
D. Arrange for immediate bronchoscopy
E. Prescribe oral clindamycin and oxygen therapy and discharge to the nursing home.

Case 18

Which of the following is the most appropriate course of management?
A. Administer a high dose of corticosteroids and admit to the hospital.

•B. Administer intravenous clindamycin and admit to the hospital

C. Administer a high dose of intravenous penicillin and admit to the hospital
D. Arrange for immediate bronchoscopy
E. Prescribe oral clindamycin and oxygen therapy and discharge to the nursing home.

Case 19

27 year old postal worker at the Parker post office. For the past 4 days he has had flu like symptoms manifested by fever, fatigue, myalgias, malaise, a non-productive cough, and at times some chest discomfort. He seemed to improve for a day or so, the then developed severe dyspnea, cyanosis, hypoxia, hemoptysis, stridor, chest pain, and diaphoresis. Physical examination reveals crepitant rales and the suggestion of pleural effusion. His temp is 101F, HR 110, RR 20. His chest x-ray demonstrates a widened mediastinum without a definite infiltrate.
The causative organism is?
A. A large gram positive, non motile, spore forming bacillus
B. An obligate intracellular bacteria that infect only humans
C. A rickettsial disease that is common in livestock farmers, shepherd, and farm workers worldwide
D. An organism that has no cell wall
E. Classified as a fungus

Case 19

•The causative organism is?

•A. A large gram positive, non motile, spore forming bacillus

B. An obligate intracellular bacteria that infect only humans
C. A rickettsial disease that is common in livestock farmers, shepherd, and farm workers worldwide
D. An organism that has no cell wall
E. Classified as a fungus

Case 20

Mother of a 7 year old boy that was recently adopted from Pakistan 1 year ago. Upon arrival to the USA, the child was diagnosed with active TB and successfully treated with medications (INH, Rifampin, and PZA). The mothers PPD skin test was previously negative. Her physical exam is normal, chest x-ray is normal and she has no symptoms. You now note that she has 3mm of induration.
Which of the following is true?
A. The mother should be treated with 6 months of INH.
B. The mother should be treated with INH and Rifampin
C. The mother should get retested again in 6 months to a year.
D. The mother should receive BCG vaccine
E. The mother should have sputum cultures for AFB

Case 20

Which of the following is true?
A. The mother should be treated with 6 months of INH.
B. The mother should be treated with INH and Rifampin

•C. The mother should get retested again in 6 months to a year.

D. The mother should receive BCG vaccine
E. The mother should have sputum cultures for AFB

Case 1

Your patient is a 47 year old male whose wife reports he snores loudly and stops breathing in his sleep for the last 6 months. He has long been overweight and gained 30 pounds in the last 4 months. He falls asleep while driving his car.
Physical exam: Weight 250 lb, BP 170/100, ENT with small tonsils and a relatively large tongue.
Polysomnographic study reveals 30 obstructive events in an 8 hour episode. There is a mean duration of 12 seconds with the lowest O2 sat of 92%. All sleep stages are entered at normal intervals and in normal proportions.
The most appropriate next step is ?
A) Further testing in the lab with nasal CPAP
B) Tonsillectomy
C) Weight loss, alteration of sleep position, avoidance of evening ETOH
D) Amphetamine therapy
E) Medroxyprogesterone therapy

Case 1

•The most appropriate next step is ?

•A) Further testing in the lab with nasal CPAP

B) Tonsillectomy
C) Weight loss, alteration of sleep position, avoidance of evening ETOH
D) Amphetamine therapy
E) Medroxyprogesterone therapy

Case 5

Your patient is a 60 year old male in the ER with acute onset of chest pain while lifting a heavy object. The pain is sharp and accentuated by deep breathing and upper extremity movement. He is short of breath and has a long history of asthma. Ten years earlier he had a superficial thrombophlebitis in his left leg.
Chest exam demonstrates bilateral wheezing. Homan’s sign is positive. Chest x-ray is normal. ABG shows a PaO2 of 70, PaCO2 of 35, and pH of 7.45 on room air.
His vital signs are stable. His lung scan is on the next slide.
Based on this he should:
A) receive anticoagulant therapy
B) receive albuterol and corticosteroids
C) undergo a pulmonary angiogram prior to initiating therapy
D) receive immediate thrombolytic therapy
E) a Greenfield filter should be inserted

Case 5

•Based on this he should:

•A) receive anticoagulant therapy

B) receive albuterol and corticosteroids
C) undergo a pulmonary angiogram prior to initiating therapy
D) receive immediate thrombolytic therapy
E) a Greenfield filter should be inserted

Case 6

A 22 year old male is hospitalized with a comminuted femur fracture after an automobile accident. At the time of admission 2 days ago surgery was performed to stabilize the fracture.
On hospital day 2 he suddenly develops dyspnea, petechiae, and mental confusion. The petechiae are noted over the head, neck, anterior chest, and axillae. They are raised.
Physical examination reveals tachypnea and impending shock. ABG’s demonstrate marked hypoxia with a decreased PaCO₂.
Based upon the history and physical, you correctly believe that this patient?
A) Has a hypercoagulable state causing pulmonary embolus
B) Will demonstrate pulmonary and cerebral microvasculature mechanical obstruction and biochemical injury
C) Will demonstrate an elevated troponin compatible with an acute MI
D) Suffers from gas bubbles that have entered the circulation and obstruct vascular flow and cause distal ischemic injury
E) Is the result of long term thrombus formation in the pulmonary artery

Case 6

Based upon the history and physical, you correctly believe that this patient?
A) Has a hypercoagulable state causing pulmonary embolus

•B) Will demonstrate pulmonary and cerebral microvasculature mechanical obstruction and biochemical injury

C) Will demonstrate an elevated troponin compatible with an acute MI
D) Suffers from gas bubbles that have entered the circulation and obstruct vascular flow and cause distal ischemic injury
E) Is the result of long term thrombus formation in the pulmonary artery

Case 8

You are seeing a patient 8 hours after the delivery of her first child. She is a 24 year old female with the sudden onset of chest pain and difficulty breathing 1 hour ago. She senses a feeling of impending doom. The delivery was spontaneous and without complications.
Upon examination, the patient is in shock with a BP of 65/40. She has marked tachycardia. The patient’s hemoglobin is 11 grams and her platelets are 25,000. She demonstrates the presence of fibrin degradation products with a prolonged PT, PTT, and decreased fibrinogen.
The most likely pathophysiologic process here is?
A) Amniotic fluid embolus causing DIC and ARDS
B) Antithrombin III deficiency
C) Protein C deficiency
D) Protein S deficiency
E) Mutation in factor V gene (factor V Leiden)

Case 8

•The most likely pathophysiologic process here is?

•A) Amniotic fluid embolus causing DIC and ARDS

B) Antithrombin III deficiency
C) Protein C deficiency
D) Protein S deficiency
E) Mutation in factor V gene (factor V Leiden)

Case 9

35 year old woman in the ER developed shortness of breath this am. She denies cough, chest pain, or fever. She has a significant past medical history of a deep venous thrombosis 2 years ago. She takes oral contraceptives. She has smoked 15 pack years and currently smokes.
On exam her pulse is 110, RR 24, and BP 110/60. Oxygen sat 90%
A ventilation perfusion scan is reported as “high probability of a pulmonary embolism
Which of the following is the most likely electrocardiographic finding?
A) Atrial fibrillation
B) Nonspecific ST-T wave changes and sinus tachycardia
C) Right axis deviation
D) Right bundle branch block
E) S wave in lead I, Q in lead III, inverted T wave in lead III

Case 9

Which of the following is the most likely electrocardiographic finding?
A) Atrial fibrillation

•B) Nonspecific ST-T wave changes and sinus tachycardia

C) Right axis deviation
D) Right bundle branch block
E) S wave in lead I, Q in lead III, inverted T wave in lead III

Case 10 ## Footnote * A 56-year old female present to the emergency room with an 6 hour history of increased dyspnea and chest tightness. Past medical history is remarkable for congestive heart failure with an ejection fraction of 35%, COPD with FEV1 of 45 % of predicted. Medications are lisinopril, metoprolol, furosemide, budesonide/formoterolol inhaler, and an albuterol inhaler as needed. * Physical examination: Anxious appearing female in moderate respiratory distress. Temp 100.5 F, blood pressure 110/60 mm Hg, pulse 115/minute, respiratory rate 24/minute. Oxygen saturation is 90% on 5 liters nasal cannula. Pulmonary examination is remarkable for bilateral expiratory wheezes, and there are no inspiratory crackles. Hear sounds are distant. There is trace bilateral lower extremity edema. * What is on your differential diagnosis? * What testing would you do to further evaluate this patient? * How would you treat this patient? * Electrolytes, Kidney Function Tests, and CBC are normal. * Electrocardiogram shows sinus tachycardia, but no ischemic changes. * Chest x-ray demonstrates hyperinflation and cardiomegaly but no effusion or infiltrate. * Does this change your differential diagnosis? * You administer two doses of nebulized ipratroprium and albuterol to your patient. Her dyspnea and oxygen saturations do not improve. * Which of the following is the most appropriate next step in management of this patient? * A) Administer aminophylline * B) Administer furosemide * C) Obtain a CT angiogram of the chest * D) Obtain an echocardiogram * E) Start levofloxacin

Case 10 ## Footnote * Which of the following is the most appropriate next step in management of this patient? * A) Administer aminophylline * B) Administer furosemide **_•C) Obtain a CT angiogram of the chest_** * D) Obtain an echocardiogram * E) Start levofloxacin

Case 11 ## Footnote * 25 year old female presents to the emergency room with a 2 hour history of sudden onset of dyspnea, right sided sharp chest pains that are exacerbated by taking deep breaths, and a racing heart. She recently returned from visiting family in southeast Missouri. She felt fine while on vacation. * PMH: denies other medical problems * Family History: sister with history of DVT * Soc History: smokes ½ pack of cigarettes per day * Medications: birth control pills, but sometimes has trouble remembering to take them * Allergies: NKDA * Exam: * Mild respiratory distress * Temp 99F, BP 100/60, HR 120, RR 24, Sat 87% on room air * Lungs CTA * Heart RRR, tachycardic * Extremities no edema * What further testing would you do? * Electrolytes and renal function are normal * CBC is normal * 12 lead EKG with sinus tachycardia. * Qualitative hCG testing is positive * What are this patient’s risk factors for pulmonary embolism or DVT? * What is Virchow’s triad?

Case 11 ## Footnote * What are this patient’s risk factors for pulmonary embolism or DVT? * What is Virchow’s triad?

Case 11 ## Footnote •How would you assess this patient’s risk for pulmonary embolism?

Case 11 ## Footnote •How would you assess this patient’s risk for pulmonary embolism? **Well’s Clinical Prediction for Likelihood of Pulmonary Embolism**

Well’s Clinical Prediction for Likelihood of Pulmonary Embolism ## Footnote * Predisposing Factors * Symptoms * Signs

Well’s Clinical Prediction for Likelihood of Pulmonary Embolism ## Footnote * Predisposing Factors * Previous VTE 1.5 * Recent Surgery of Immobilization 1.5 * Cancer 1 * Symptoms * Hemoptysis 1 * Signs * Heart rate \> 100 beats/min 1.5 * Clinical signs of DVT 3

Well’s Clinical Prediction for Likelihood of Pulmonary Embolism ## Footnote * Clinical Judgement * Clinical Probability Total Points

Well’s Clinical Prediction for Likelihood of Pulmonary Embolism ## Footnote * Clinical Judgement * Alternative diagnosis less likely than PE 3 * Clinical Probability Total Points * Low \< 2 * Moderate 2-6 * High \> 6

Case 11 ## Footnote •What testing would you perform now?

Case 11 ## Footnote * Your Ventilation Perfusion Scan returns high probability. How would you treat this patient? * A) Start IV Heparin followed by warfarin after 24 hours of therapeutic heparin * B) Start subcutaneous Low Molecular Weight Heparin followed by warfarin in 24 hours * C) Treat with subcutaneous Low Molecular Weight Heparin through pregnancy followed by warfarin for 3 months after delivery * D) Treat with warfarin alone

Case 11 ## Footnote * Your Ventilation Perfusion Scan returns high probability. How would you treat this patient? * A) Start IV Heparin followed by warfarin after 24 hours of therapeutic heparin * B) Start subcutaneous Low Molecular Weight Heparin followed by warfarin in 24 hours * **_C) Treat with subcutaneous Low Molecular Weight Heparin through pregnancy followed by warfarin for 3 months after delivery_** * D) Treat with warfarin alone

•How does warfarin work? Clotting Factors and Anticoagulant Proteins affected by warfarin

•How does warfarin work? Clotting Factors and Anticoagulant Proteins affected by warfarin * Warfarin decreases hepatic synthesis of: * Factors * II * VII * IX * X * Protein C * Protein S

Warfarin ## Footnote * Why is a therapeutic overlap required with either heparin or low molecular weight heparin when starting warfarin? * In other words, why don’t we just start warfarin alone?

Warfarin ## Footnote * Why is a therapeutic overlap required with either heparin or low molecular weight heparin when starting warfarin? * In other words, why don’t we just start warfarin alone? **Clotting Factors and Anticoagulant Proteins affected by warfarin** **•Factor =** Half Life **•II =** 42-72 hours **•VII =** 4-6 hours **•IX =** 21-30 hours **•X =** 27-48 hours **•Protein C =** 8 hours **•Protein S =** 60 hours

Case 11 ## Footnote •After completion of low molecular weight heparin through the pregnancy followed by 3 months of oral warfarin, you would like to consider discontinuation of anticoagulant therapy. What hypercoagulable studies would you consider in this patient?

Case 11 * Hypercoagulation Workup * Lupus anticoagulant * Factor V Leiden * Prothrombin G20210A Mutation * Antithrombin III deficiency * Protein C Deficiency * Protein S Deficiency

Case 12 ## Footnote * A 34-year old Haitian immigrant presents to her primary care physician with a chief complaint of cough productive of blood tinged sputum, fevers, and 15 pound weight loss over the last 3 months. * Past Medical History: none * Social History : No tobacco or alcohol use. She works as a nurse * Medications: oral contraceptives * Allergies: NKDA * Examination: Thin, young female in no acute distress * VS Temperature 99 F, Blood pressure 110/80 mmHg, Pulse 90, RR 16 * Lungs: rales LUL * Heart: RRR, S1S2, no rubs, gallops, or murmurs * Extremities: No cyanosis, clubbing, or edema * How would you proceed with working this patient up?

Case 12 ## Footnote * How would you proceed with working this patient up? * **Zieh-Neelsen stain is positive for acid fast bacterium** **•Culture with Lowenstein-Jensen Agar.**

Case 12 ## Footnote •How would you treat this patient?

Case 12 ## Footnote * How would you treat this patient? * Isoniazid * Rifampin * Ethambutol * Pyrizinamide * Start with two months with 4 medicines, then INH and Rifampin for 4-7 months. Culture will also determine appropriate antibiotic choice.

Case 12 ## Footnote •What are the medication side effects to be aware of?

Case 12 ## Footnote * What are the medication side effects to be aware of? * INH * Hepatotoxicity * Peripheral neuropathy * Rifampin * Hepatotoxicity * Inducer of cytochrome p450 * Orange urine and secretions * Pyrizinamide * Hepatotoxicity * Ethambutol * Optic neuritis * Red/Green color blindness

Case 13 ## Footnote * A 69-year old male presents to the emergency room with a two-day history of fevers, chills, and cough productive of rust-colored sputum. She lives at home and has never been hospitalized. She was last treated with antibiotics 6 months ago for a cellulitis of her right lower extremity. She has no drug allergies. * Physical examination: Temp 102.4 F, BP 86/54 mm Hg, pulse 110 beat/min, RR 32 breath/min, and pulse oximetry of 88% on room air. * Chest examination: rales in the right lower lobe * Cardiac examination: tachycardic, otherwise normal * Mental status: oriented to name, but not place or date * Labs: White count 13,000 cells/mL with a left shift, BUN 24 mg/dL, Creatinine 1.5 mg/dL * Chest x-ray: right lower lobe consolidation * What is the best course of action for this patient? * A) Admit to hospital for antibiotic treatment * B) Discharge home for antibiotic treatment * C) Admit to hospital, but hold treatment until cultures return * D) Discharge home, but hold treatment until cultures return

Case 13 ## Footnote What is the best course of action for this patient? **_•A) Admit to hospital for antibiotic treatment_** * B) Discharge home for antibiotic treatment * C) Admit to hospital, but hold treatment until cultures return * D) Discharge home, but hold treatment until cultures return

CURB-65

CURB-65 ## Footnote * Prognostic tool to determine if admission to the hospital is appropriate. Score one point for each indicator. * Confusion * BUN ≥ 20 * RR ≥ 30 * SBP \< 90, DBP \< 60 * age \> 65 * If a patient scores ≥ 3, hospitalization is appropriate

Case 13 ## Footnote * What antibiotic would you give this patient? * A) Azithromycin * B) Levofloxacin * C) Amphotericin B * D) Itraconazole * E) Oseltamivir

Case 13 ## Footnote * What antibiotic would you give this patient? * A) Azithromycin **_•B) Levofloxacin_** * C) Amphotericin B * D) Itraconazole * E) Oseltamivir