Unit 2 Part 3 Flashcards
A patient reports daily, recurrent fever associated with sweating, chills, and recent weight loss. What may this type of fever indicate?
a. An underlying disease caused by animal bites
b. Fever related to an immunocompromised state
c. Possible exposure to tropical diseases
d. Tuberculosis (TB) or lymphoma
D
Hectic fever, or recurring fever associated with weight loss, sweating, and chills is concerning for tuberculosis or lymphoma.
Fever from animal bites or travel to tropical areas is diagnosed after a history of exposure.
A patient has a fever of unknown etiology and blood tests reveal elevated eosinophils. The patient has no history of asthma or allergies. What may be the cause of this fever?
a. Animal bite
b. Endocarditis
c. Lymphoma
d. Parasites
D
Eosinophils classically suggest a parasitic infection, asthma, or allergy. They are not present with other conditions unless there is concern for infection or underlying asthma or allergies.
Which patients with fever should generally be treated with antipyretics? (Select all that apply.)
a. Children between the ages of 3 months to 5 years
b. Patients taking antibiotics to treat infection
c. Patients with temperature greater than 41C
d. Patients with urinary tract infection
e. Those with underlying cardiovascular disease
A, C, E
Children under 5 years are more prone to febrile seizures. Patients with very high temperatures should be treated to prevent CNS damage. Patients with underlying cardiovascular disease should be treated to avoid excessive metabolic demands. It is not especially necessary to treat fever in patients with UTI or for those taking antibiotics.
A 65-year-old patient who has not had an influenza vaccine is exposed to influenza and comes to the clinic the following day with fever and watery, red eyes. What will the provider do initially?
a. Administer LAIV influenza vaccine
b. Begin treatment with an antiviral medication
c. Observe for improvement or worsening for 24 hours
d. Perform a nasal swab for RT-PCR assay
D
Samples to isolate the virus should be collected within 12 to 36 hours of onset of illness and this should be performed to confirm the disease. Administration of the LAIV influenza vaccine will not prevent symptoms in this patient, is not recommended in persons over 59 years of age, and is contraindicated when also giving antiviral medications. Antiviral drugs should be started within 48 hours of onset of illness and may be started empirically while waiting on cultures because this patient is higher risk than younger patients. Because identification of the virus and effectiveness of treatment are time-limited, it is not correct to watch and wait for symptoms to worsen.
A previously healthy patient develops influenza which is confirmed by RT-PCR testing and begins taking an antiviral medication. The next day, the patient reports increased fever and
cough without respiratory distress. The patient’s lungs are clear and oxygen saturations are 97% on room air. What will the provider recommend?
a. Admission to the hospital for treatment of complications
b. Empirical antibiotics to treat a possible secondary infection
c. Referral to a specialist for evaluation and treatment
d. Symptomatic treatment with close follow-up in clinic
D
This patient does not have risk factors for serious complications and may be managed as an outpatient. Symptoms should begin to gradually improve a few days after the onset of symptoms. Because this patient is stable, watchful waiting with symptomatic care and close follow up is acceptable. It is not necessary to admit to the hospital, refer to a specialist, or begin antibiotic therapy currently.
The parent of a 4-month-old infant who has had an episode of bronchiolitis asks the provider if the infant may have an influenza vaccine. What will the provider tell this parent?
a. The infant should be given prophylactic antiviral medications.
b. The infant should have an influenza vaccine now with a booster in 1 month.
c. The infant should have the live attenuated influenza vaccine (LAIV).
d. The infant should not but family and all close contacts should be vaccinated.
D
Infants are not given influenza vaccine until age 6 months. To protect infants younger than 6 months, it is important for other family members and close contacts to be vaccinated. LAIV is approved for use in children over age 2 years. Antiviral prophylaxis is not recommended.
A provider is concerned that a young child may have latent tuberculosis infection (LTBI). Which test will be performed initially to screen for this infection?
a. Chest radiograph
b. Interferon gamma release assay
c. Mantoux test
d. Two-step TST
C
The Mantoux test is the most cost-effective test to administer as an initial screen. Chest radiograph is not used to detect LTBI because there is no radiographic evidence with latent infection. The IGRA may be used but is more costly and the sensitivity in young children has not been established. The two-step TST is not indicated.
A patient who diagnosed with human immunodeficiency virus (HIV) infection has a negative tuberculosis skin test with induration less than 10 mm. The provider learns that the patient lives with a person who has active tuberculosis. What is the next step in managing this patient?
a. Begin empirical antibiotic therapy.
b. Order a chest radiograph.
c. Perform an interferon gamma release assay.
d. Refer to an infectious disease specialist.
B
Patients who are immunocompromised who have had contact with a person with infectious TB should have a chest radiograph. Until infection is established, empirical antibiotic therapy is not indicated to reduce the risk of antibiotic resistance. IGRA is not indicated. If radiograph results are positive, or if the diagnosis remains unclear, referral is indicated
A 25-year-old patient has a tuberculosis (TB) skin test which reveals an area of induration of 12 mm. The patient is a recent immigrant from Mexico and lives in a homeless shelter. What is the recommended treatment for this patient?
a. Administer the bacillus Calmette-Guérin (BCG) vaccine
b. Begin isoniazid (INH) preventive therapy
c. Order isoniazid (INH) and Rifampin
d. Perform regular TB skin testing every few months
B
Patients younger than 35 who have any risk factors for TB and with an area of induration
10 mm should be considered for INH preventive therapy. This patient is an immigrant from Mexico and lives in a homeless shelter, so TB preventive therapy is acceptable. BCG vaccine is not helpful. INH and Rifampin are used if patients develop symptoms or if there is antibiotic resistance.
An adolescent patient has fever, pharyngitis, and cervical lymphadenopathy and has a negative group A beta-hemolytic throat culture. A complete blood count shows absolute lymphocytosis, but a heterophil antibody test is negative for Epstein-Barr virus (EBV). What will the provider tell the patient about the likelihood of infectious mononucleosis (IM)?
a. It will be necessary to repeat the heterophil antibody test in a few weeks.
b. Liver function tests will help to confirm a diagnosis of EBV-IM.
c. The likelihood of EBV infectious mononucleosis is still high.
d. This IM is most likely caused by a virus other than Epstein-Barr virus.
C
Because heterophil antibodies may not reach detectable levels early in the disease, it is possible to have a negative result. This patient has symptoms and the suspicion for disease remains high. Repeat testing in 7 to 10 days will help confirm the diagnosis. A positive heterophil antibody test with absolute lymphocytosis is diagnostic of acute IM. Epstein-Barr nuclear antigen is measured 6 to 8 weeks after onset of symptoms to distinguish between acute and previous infection. LFTs may be elevated in patients with IM, but this is not diagnostic
An adolescent patient who plays football in high school is diagnosed with Epstein-Barr virus (EBV) infectious mononucleosis and is noted to have splenomegaly. What will the provider
recommend to this patient about returning to sports?
a. Abdominal ultrasounds are recommended to determine safety.
b. Corticosteroid therapy may help shorten the course of the disease.
c. He may return to minimal contact practice in 2 to 3 weeks.
d. It will be safe to play football in 3 to 4 weeks.
A
Patients with splenomegaly should be encouraged to refrain from strenuous activity for 3 to 4 weeks to avoid the risk of splenic rupture. Serial US studies beginning at week 2 to 3 may be helpful in determining the risk of rupture. Corticosteroids have not been shown to reduce the severity or duration of symptoms. Strenuous activity is not recommended until 3 to 4 weeks; without an US, it is not possible to ensure absolute safety for sports.
A patient diagnosed with Epstein-Barr virus–associated infectious mononucleosis (EBV-IM) also has group A beta-hemolytic streptococcal pharyngitis and is being treated with amoxicillin. On the third day of treatment, the patient develops a rash. A urinalysis is normal. What does this indicate?
a. A reaction to the amoxicillin
b. A streptococcal rash
c. Hematologic complications
d. Hemolytic-uremic syndrome
A
80% to 100% of patients with IM who are taking amoxicillin will develop a rash. A streptococcal rash appears at the onset of symptoms, not 3 days after initiation of antibiotics. This rash does not indicate hematologic complications or hemolytic-uremic syndrome.
A 50-year-old patient with diabetes mellitus has a low-grade fever and pain on one foot. The provider notes erythema and swelling at the site along with several superficial skin ulcers without necrosis and suspects osteomyelitis. Which type of diagnostic study will the provider order?
a. Biopsy of bone or debridement cultures
b. Blood cultures and serologic markers of inflammation
c. Magnetic resonance imaging of the foot
d. Plain radiograph of the foot
D
A patient with diabetic foot infection suspected of having osteomyelitis should have a plain radiograph to identify bony abnormality or soft tissue changes. MRI may be performed if more specific evaluation is needed or if abscess is suspected. Blood cultures are not diagnostic of osteomyelitis. Biopsy and debridement cultures increase the risk of further infection if poor healing at the site occurs.
A 3-year-old child has marked pain in one leg localized to the upper tibia with refusal to bear weight. The child has a high fever and a toxic appearance. Which type of osteomyelitis is most likely?
a. Chronic osteomyelitis
b. Hematogenous osteomyelitis
c. Osteomyelitis from a contiguous focus
d. Peripheral vascular disease osteomyelitis
B
Young children are more likely to have hematogenous osteomyelitis, especially with acute symptoms. Chronic osteomyelitis is more common with underlying diseases such as diabetes. Contiguous focus osteomyelitis occurs when organisms are introduced from a puncture wound, foreign body, or adjoining soft tissue infection. Peripheral vascular causes are more common in chronically ill patients.
A patient has osteomyelitis related to vascular insufficiency. Which initial consultation is necessary?
a. Infectious disease consultation
b. Neurosurgical consultation
c. Surgical consultation
d. Wound care specialist consultation
C
Because patients with vascular insufficiency who develop osteomyelitis may need debridement or draining of lesions, a surgical consult is necessary. Infectious disease consults are obtained for patients with resistant organisms or complex wounds. Neurosurgical consults are needed for patients with epidural abscess. Wound care consults are needed for patients with progressive or chronic wounds.
