- A 30 year old man presents to the emergency room with 3 days of increasing headache, fevers, and a stiff neck. He has no significant past medical history except for occasional "cold sores" and he takes no medications. An HIV test 4 weeks ago as part of a routine health visit was negative. His friends have witness some bizarre behavior from him on the previous day. Examination is notable for a temperature of 101.2°F (tympanic), mild lymphadenopathy, marked meningismus with positive Kernig's and Brudzinski's signs, and no rash. The white cell count is 12.2K/µl with 87% neutrophils, 5% immature forms (bands), 7% lymphocytes, 1% monocytes. The electrolytes and renal function tests are normal, glucose was 95mg/dL. The cerebrospinal fluid was obtained: the opening pressure was 200mm of water and 5 cc of mildly yellow clear fluid was removed. The protein was 60mg/dL, glucose 60mg/dL. There were 45 white cells (70% neutrophils, 30% lymphocytes), 60 red blood cells with mild xanthochromia, and no atypical cells. The most appropriate therapy pending culture results is [1]:
A. Ceftriaxone, 1gm iv
B. Ceftriaxone, 1gm iv and Acyclovir 10-15mg/kg iv
C. Ceftriaxone, 1gm iv, and Ampicillin, 2gm iv
D. Ampicillin, 2gm iv
E. Ampicillin, 2gm iv and Acyclovir 10-15mg/kg iv - A 26 year old woman presents with 2 weeks of nonproductive cough and lethargy. She started amoxicillin 5 days ago but feels her condition has deteriorated. There is mild left sided chest pain which is worse on inspiration. She takes oral contraceptive pills, does not smoke, and does not use illegal drugs. She has had no sick contacts, has not travelled, and does not have pets. On examination she is a tired, ill appearing young woman with intermittant dry coughing. Her temperature is 99.5° orally, pulse 105bpm, blood pressure 110/70, respiratory rate is 16. Her right ear shows mild erythema on the tympanic membrane without pain. The throat is normal and there is no lymphadenopathy. Her inspiratory effort is stunted by pain, and therecrackles (rales) in the mid left lung zone, without egophany. The cardiac examination is normal. Her abdomen is nontender with no organomegaly and the extremities are pale and cool without rashes. The electrolytes are normal except for a sodium of 132mM (normal 135-145mM). Her white blood count is 9.4K/µl with 60% neutrophils, 6% immature band forms, 30% lymphocytes and 4% monocytes. The hematocrit is 26% (mean corpuscular volume 102fl), and the platelet count is 405K/µl. A chest radiograph shows an ill-defined interstitial infiltrate in the left lower lobe, with possible extension to the left upper lobe. The most likely diagnosis is:
A. Mycoplasma pneumonia
B. Chlamydia pneumonia
C. Legionella pneumonia
D. Pneumococcal pneumonia
E. Heamophilis pneumonia - The anemia is further evaluated and the lactate dehydrogenase is found to be 1200 IU/ml (normal <200IU/ml), total bilirubin 2.1mg/dL, direct 0.4mg/dL. The reticulocyte count is 2.8%. Which test is most likely to confirm the diagnosis [3] ?
A. Anti-streptolysin O titer
B. Anti-DNAse B titer
C. Anti-nuclear antibody titer
D. Cold Agglutinin titer
E. Vitamin B12 and folate levels - A 45 year old patient presents with the fourth episode of sinusitis in 5 months. They were previously treated with two ten day courses of antibiotics: first with erythromycin, then with amoxicillin. The most appropriate action is [4]:
A. CT scan of the sinuses followed by 14 day course of TMP/SFX (Bactrim®)
B. CT scan of the sinuses followed by 14 day course of amoxicillin
C. Empiric 28 day course of amoxicillin with nasal corticosteroids
D. Empiric 28 day course of Augmentin® (amoxicillin-clavulonate)
E. CT scan of the sinuses, 28 day course of Augmentin with nasal corticosteroids - A 72 year old man is recovering from a large anterior myocardial infarction. His ejection fraction is ~25% 1 week after the infarct, and he has symptoms of moderate congestive heart failure. One day before he is to be discharged to a rehabilitation center, he develops a cough productive of green sputum and a fever to 102.4° tympanic. A gram stain of the sputum shows large numbers of neutrophils, large numbers of gram negative rods, and a few gram positive cocci in clusters. The white blood cell count is 15.6K/µl with 75% mature neutrophils, 15% immature band forms, 8% lymphocytes, 2% monocytes. A chest radiograph shows a new right lower lobe infiltrate. The most appropriate therapy pending culture results is (the doses have been adjusted for the patient's renal function) [5]:
A. Ceftriaxone 1gm iv every 24 hours
B. Ceftazidime 2gm iv every 12 hours
C. Ceftazidime 2gm iv every 12 hours with tobramycin, 2mg/kg iv every 12 hours
D. Mezlocillin 3gm iv every 6 hours
E. Imipenam-Cilistatin, 500mg iv every 8 hours - A 65 year old woman with 15 years of type 2 diabetes mellitus presents with a 4 cm painful ulcer on dorsal aspect of her right foot. Her temperature is 98.9°F (tympanic); pulse 92, blood pressure 155/82mm in both arms, respirations 18 per minute. The ulcer is ~1cm deep and is surrounded with painful, erythematous tissue. No bone is directly visualized. There is 2+ bilateral woody induration with skin hyperpigmentation consistent with venous stasis. There is no lymphangitic tracking. The remainder of the exam is unremarkable. Which condition most likely accompanies this ulcer [6] ?
A. Pyomyositis
B. Necrotizing Fasciitis
C. Soft Tissue Abscess
D. Osteomyelitis
E. Spinal Meningitis - What is the most appropriate antibiotic therapy in this patient who has no drug allergies (wound care is carried out twice daily and antibiotics are given for 2-4 weeks) [7] ?
A. Ticarcillin-clavulanate (Timentin®)
B. Clindamycin and Gentamicin
C. Cefazolin (Ancef®, Kefzol®)
D. Ceftriaxone
E. Cefuroxime - A 28 year old intravenous drug abuser presents with fever, night sweats, weight loss, and hematuria. The patient has a history of staphylococcus aureus and group G streptococcal endocarditis. A new murmer is appreciated in the tricuspid region, and transthoracic echocardiography confirms the presence of a vegetation on the tricuspid valve. The most appropriate antibiotic therapy pending culture results is [8]:
A. Oxacillin or Nafcillin only
B. Vancomycin
C. Clindamycin
D. Oxacillin (Nafcillin) and Gentamicin
E. Vancomycin and Gentamicin - Six blood cultures are positive in 48 hours with gram positive cocci in clusters. Antibiotic sensitivities are pending. The patient's fever improves, but his heart rate drops to 50 per minute; the blood pressure is 110/70. An electrocardiogram (ECG) shows type I second degree atrioventricular block (Wenkebach). The most appropriate action is [9]:
A. Add ceftriaxone to the antibiotic regimen
B. Transfer the patient to the intensive care unit and insert a temporary pacemaker wire
C. Perform an urgent transesophageal echocardiogram and insert a temporary pacemaker wire
D. Continue current antibiotic therapy
E. Consult cardiothoracic surgery for open procedure - A 22 year old woman presents with 3 months of diffuse myalgias, fatigue, and occasional headaches. She was hiking about 4 months ago on the south shore of Massachusetts and her symptoms began shortly after that. She recently broke up with her boyfriend and is concerned about being laid off at work. She was seen at a community health center and was told she might have Lyme Disease. An Enzyme-Linked Immunosorbant Assay (ELISA) for Lyme showed a positive IgG at moderate titer with a negative IgM. She would like to begin antibiotic therapy. On examination she is an anxious but well appearing young woman with normal vital signs. Her exam is negative except for mild muscle tenderness in both trapezius areas, in the lower back, and behind the elbows. Her sleep has been disturbed in the last month or so. She is concerned that she will develop neurological symptoms from the Lyme disease. The most appropriate action is [10]: A. Prescribe 1 month of doxycycline, 100mg po twice daily
B. Repeat the Lyme ELISA and prescribe doxycycline, 100mg po twice daily
C. Repeat the Lyme ELISA and a Lyme-Antigen specific Western Blot; no antibiotics for now
D. Repeat the Lyme ELISA and a Lyme-Antigen specific Western Blot; doxycycline as above
E. Administer 1gm of ceftriaxone iv every day for 28 days and repeat the Lyme ELISA
| TOPIC CARD REFERENCES |
- B (Herpes infection must be covered given the patient's behavior and bloody CSF)
- A
- D
- E
- C (Hospital acquired gram negative pneumonia, possible staphylococcus, use two antibiotics.)
- D (Osteomyelitis is frequently present underlying diabetic foot ulcers.)
- A (It is essential to cover mixed infections, including anaerobes; avoid aminoglycosides.)
- E (Vancomycin must be used given the history of enterococcus; gentamicin is synergistic)
- B (Conduction system disease should prompt evaluation of abscess with echocardiography.)
- C