Question of the Week # 472

A 9-year-old boy is brought to the hospital with a wound to his left hand. He was in a fight with peer who bit him. His past medical history is unremarkable and he takes no medications. He has no known allergies. On examination, the child is crying. There is a 2-cm wound over the dorsum of his palm. What is the most appropriate course of action?
A. Clean the wound and prescribe amoxicillin-clavulanate.
B. Clean the wound and prescribe doxycycline.
C. Clean the wound and prescribe ciprofloxacin.
D. Clean the wound, close it with interrupted sutures and prescribe ciprofloxacin.
E. Clean the wound, close it with interrupted sutures and prescribe amoxicillin-clavulanate.

Question of the Week # 465

465) A 6-year-old boy is brought to the emergency department 2 hours after he was bitten by a peer in kindergarten in a fight. The child’s mother is frantic and wants to “sue the center for allowing such behavior!” The child is up-to-date on his vaccinations. The other child is very healthy and his vaccinations are current. On physical examination, there is puncture wound on the right hand. You gently clean the wound and consult with the hand surgeon who says that there does not appear to be any damage to the nerves, muscles, tendons, or joints of the hand. What is the most appropriate next step?

A. close the wound with a suture
B. obtain a wound culture
C. provide ampicillin-sulbactam
D. send him home with a follow-up appointment within 48 hours
E. vigorously irrigate and debride the wound

Question of the Week # 393

393)  A 36 year old homeless man is evaluated in the Emergency Room for intermittent fever, cough, night sweats and weight-losss. He also reports having chronic cough with progressively increasing bloody expectoration for the past 1 month. He has lost about 10lbs weight over the past 3 months. He smokes 1 pack per day and has a history of intravenos drug abuse. On examination, he is cachectic.  He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 120/80 mm Hg, Oxygen saturation 98%.  Reminder of the physical examination is unremarkable. Which of the following is the most appropriate initial step in managing this patient?

A) Sputum samples for Acid Fast Bacilli

B) Start Multi-drug therapy for Tuberculosis

C) Obtain a Chest X-ray

D) Tuberculin Skin test

E) Air-Borne Isolation

F) Test for HIV

Question of the Week # 322

322)  A 45 year man is evaluated in emergency department for severe cough accompanied by bloody expectoration. Cough is of 4 month duration associated with sputum production but he is worried because of the new change in the character of his sputum which is now frankly bloody. He reports a weight-loss of 10 lbs in the past two months.  He has intermittent nigh-sweats and low grade fever on a daily basis. On examination, his temperature is 100F, Pulse 98/min, RR 20/min and Blood Pressure 100/60 mm HG.  He appears cachectic and in moderate distress due to cough. On auscultation, high-pitched bronchial breath sounds are heard in the right upper chest.

A chest-x-ray is shown below:

The patient is admitted and is placed on respiratory, negative-pressure isolation. HIV rapid test is positive. Sputum smears for Acid Fast Bacilli (AFB) are positive. A CD4 count is 155/μl ( Normal = 650 to 1150/µl). Which of the following is the most appropriate next step in management at this time?

A) Bronchoscopy and send bronchial washing for clutures

B) Start Multi-Drug anti-tuberculosis Therapy alone

C) Start Highly Active Antiretroviral Therapy (HAART) plus Multi-drug Anti-TB therapy

D) Start HAART and await sputum for AFB identification and sensitivity testing

E) Start Clarithromycin for Mycobacterium Avium Intracellulare (MAC)

Question of the week # 312

312) A 73 year old man with history of Dementia and well-controlled Parkinson’s disease was admitted to the hospital 3 days ago with fever, hypotension and dysuria. He was diagnosed with sepsis secondary to urinary tract infection and has been on treatment with Ampicillin and Gentamicin. Urine cultures revealed enterococci. Over the past two days, his blood pressure improved and he has been afebrile however, he has become increasingly immobile and excessively tremulous. He is unable to rise from a chair or walk without help.  His home medications include Levodopa, Benserazide and Selegeline. On physical examination, blood pressure is 130/80 mm Hg. He is alert, awake and oriented. He has severe bilateral resting tremor, generalized rigidity and bradykinesia . Results of routine blood tests showed no abnormality and CT of the head is normal.  Which of the following is the most appropriate management at this time?

A) Increase Levodopa

B) Add Carbidopa

C) Discontinue Gentamicin

D) Add Piperacillin-Tazobactam

E) Start Bromocriptine

Question of the week # 262

262) A 17 year old male is admitted with fever and severe pain while swallowing for the past 1 week. He denies any rash or joint pains. His girlfriend had similar symptoms 1 month ago that resolved spontaneously. He was started on azithromycin by his primary doctor as outpatient however, the symptoms have not subsided. On examination, temperature is 102F. Throat examination reveals diffuse pharyngeal erythema and swelling of the tonsils with exudates. There are no mucosal ulcerations. Abdominal examination reveals moderate splenomegaly. Laboratory investigations reveal WBC count 12000/µl with 60% Lymphocytes, Hemoglobin 14gm% and Platelet count 120k/µl. Peripheral smear shows atypical lymphocytes comprising 30% of lymphocyte population. Liver panel reveal mild elevation of transaminases with AST 80U/L and ALT 96U/L. Total bilirubin is 0.6gm%. A heterophile antibody test is negative on two occasions. Ebstein Barr Virus serology including EBV viral capsid antigen (VCA) – IgM and IgG as well as EBV nuclear antigen antibody (EBNA-IgG) has been ordered. Which of the following combinations are most consistent with this patient’s presentation?

A)     VCA IgG  negative, VCA IgM negative, EBNA-IgG positive

B)      VCA IgG  positive, VCA IgM negative, EBNA-IgG positive

C)      VCA IgG  negative, VCA IgM negative, EBNA-IgG negative

D)     VCA IgG  positive, VCA IgM positive, EBNA-IgG positive

E)      VCA IgG  positive, VCA IgM positive, EBNA-IgG negative

Question of the Week # 253

253 )  A 75 year old african-american woman with history of Alzheimer’s dementia and recent cerebro-vascular accident is transferred from the Nursing home for deterioration in mental status and fever. As per the nursing home staff, she has stopped feeding and has been having fever for the past three days. On examination, her temperature is 102F, Heart rate is 130/min, Respiratory rate 28/min and Blood pressure 80/45 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A foley catheter is in place draining very cloudy urine. Dipstick urinalysis revealed 2+ protein, positive leucoesterase and nitrite. Blood cultures are obtained and the intravenous normal saline is started via. two large bore needles. In managing her Septic Shock, which of the following is the most appropriate goal that must be met in the first 6 hours of adequate resuscitation?

A) Mean Arterial Blood pressure > 50mm Hg

B) Serum Creatinine < 1.5 mg%

C) Urine output > 0.25ml/kg/hr

D) Mixed Venous Saturation > 65%

E) Hematocrit > 30%

Note: Surviving Sepsis guidelines

Question of the Week # 252

252 )  A 75 year old african-american woman with history of Alzheimer’s dementia and recent cerebro-vascular accident is transferred from the Nursing home for deterioration in mental status and fever. As per the nursing home staff, she has stopped feeding and has been having fever for the past three days. On examination, her temperature is 102F, Heart rate is 130/min, Respiratory rate 28/min and Blood pressure 80/45 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A foley catheter is in place draining very cloudy urine. Dipstick urinalysis revealed 2+ protein, positive leucoesterase and nitrite. Blood cultures are obtained and the intravenous normal saline is started via. two large bore needles. Which of the following is the most important next step in managing this patient?

A) Put in reverse trendelenberg position

B) Place a central venos catheter

C) Start Dopamie infusion via. peripheral access

D) Intravenous Hydrocortisone

E) Obtain Arterial Blood Gas analysis

note: Surviving Sepsis guidelines

Question of the Week # 251

251 )  A 65 year old woman is evaluated in your office for pain in bilateral feet for the past four weeks. The pain is burning in quality and is associated with intense itching. Her past medical history is significant for difficult to control Type II Diabetes Mellitus. Her recent HgbA1C was 7.9% and Creatinine was 1.8mg%.  On physical examination, she is obese, afebrile and in no apparent distress. She has diminished pinprick and vibration sensation in glove and stocking pattern in bilateral upper and lower extremities. Dorsalis pedis and posterior tibial pulses are mildly diminished. There are multiple erythematous tiny vesicles between the toes and on the plantar aspect of the both feet.  Which of the following is the most appropriate treatment option for this patient’s pain?

A)      Oral Pregabilin

B)      Topical Corticosteroids

C)      Oral Cefazolin

D)     Topical Terbinafine

E)     Topical Acyclovir

Question of the Week # 249

249 )  A 64 year old  man is evaluated in your office for a left sided headache that started 24 hours ago. He describes the headache as a burning sensation over his left temple and the forehead. He also reports fatigue and malaise for the past one day. He has no significant past medical history.   On examination, he has a low grade fever at 100.4F, Blood pressure is 120/70 mm Hg. Physical examination reveals hyperesthesia on his left forehead and skin findings as shown in the picture below:

Which of the following is the most appropriate immediate next step in management ?

A) Mupirocin cream

B) Start Oral Cephalexin

C) Refer to Ophthalmology

D) Refer to Dermatology

E) Topical Acyclovir

Question of the Week # 248

248 )  A 34 year old  african-american man with past medical history of HIV infection is evaluated in the Emergency Room for severe shortness of breath on exertion for the past few hours. He also reports dry cough for the past 3 days. He has been non-compliant with Anti-retroviral therapy and his most recent CD4 count was 160 cells/µl. On examination, he is febrile with a temperature of 101F, respiratory rate is 22, Blood pressure is 120/70 mm Hg. Oxygen saturation is 86% by pulse-oximetry. Chest examination reveals scattered rhonchii bilaterally. He is immediately placed on 4 liters oxygen by nasal cannula and his repeat oxygen saturation is 94%.  Arterial blood gases on 4 liters nasal oxygen show Ph 7.45, Po2 75, Pco2 32, Hco3- 24. A chest x-ray shows bilateral interstitial infiltrates. A Lactic Dehydrogenase level is elevated at 700U/L.   Which of the following is most appropriate management ?

A) Intubation

B) Start Trimethoprim/ Suflamethoxazole

C) Start Trimethoprim/ Sulfamethoxazole, Levofloxacin and Corticosteroids

D) Start Trimethoprim/ Sulfamethoxazole and Corticosteroids

E) Start Levofloxacin

 

Question of the Week # 247

247 )  A 32 year old  hispanic woman with past medical history of HIV infection on Anti-retroviral therapy evaluated in your office because she is concerned about her potential exposure to Tuberculosis. Her father has come to visit her from Mexico and he was diagnosed with cavitary tuberculosis of left lung three week ago. He is currently receiving multi-drug anti-tuberculosis therapy. The patient says she has been taking care of her father at home since the diagnosis was made. A Tuberculin skin test is administered and is negative after 72 hours. Patient denies any fever, cough, chest pain or weight loss. Which of the following is most appropriate management ?

A) Re-assurance

B) Repeat PPD in 3 months

C) Start Isoniazid

D) Chest X-ray

E) Repeat PPD in one year

Question of the Week # 246

246 )  A 32 year old Mexican woman is evaluated in your office because she is concerned about her potential exposure to Tuberculosis. Her father has come to visit her from Mexico and he was diagnosed with cavitary tuberculosis of left lung three week ago. He is currently receiving multi-drug anti-tuberculosis therapy. The patient says she has been taking care of her father at home since the diagnosis was made. A Tuberculin skin test is administered and is negative after 72 hours. Patient denies any fever, cough, chest pain or weight loss. Which of the following is most appropriate management ?

A) Re-assurance

B) Repeat PPD in 3 months

C) Start Isoniazid

D) Chest X-ray

E) Repeat PPD in one year

Question of the Week # 233

233 )  A 36 year old man is evaluated in the emergency room for nausea, vomiting and diarrhea. He also reports fever of one day duration. He denies any rash. He has had 4 to 5 watery bowel movements in the last 24 hours. The diarrhea started 3 days ago and is progressively worse. He feels extremely weak.  His last sexual activity was 6 months ago and he always uses condoms. He denies any fever or  using any recent medications. He works in tourism industry and returned from a business trip to Mexico one week ago.  On examination, temperature is 101F, blood pressure 90/50 mm hg, his oral mucosa are dry. Abdominal examination is benign. The patient has been adequately hydrated and feels better now though, he continues to have diarrhea. Which of the following is the most appropriate next step in management?

A) Observation

B) Rifaximin

C) Amoxicillin

D) Trimethoprim-Sulfamethoxazole

E) Metronidazole

Question of the Week # 231

231) A 62 year old woman was admitted to the hospital two days ago for complicated acute pyelonephritis. She was initially started on piperacillin-tazobactam. On day 2 of hospital stay, urinary cultures are positive for ampicillin resistant enterococci. The patient is started on Vancomycin . While receiving her first dose of vancomycin, she develops flushing, redness and itching over her upper body. On physical examination, her temperature is 101F, HR 120/min and blood pressure is 120/70 mm hg.  There is  erythema on her chest. An intravenous cannula is in place on her left arm. There is no erythema or tenderness at the cannula site. Which of the following is the most appropriate next step in management?

A)     Diphenhydramine

B)     Stop Vancomycin and switch to Linezolid

C)     Change the IV cannula

D)     Methylprednisolone

E)     Stop Vancomycin and restart at slower rate

Question of the Week # 227

227 )  A 32 year old man is evaluated in the clinic for intensely itchy rash . The rash appeared suddenly on his trunk 24 hours ago  and has spread to his extremities. He denies any fever or  using any recent medications. His travel history is significant for a trip to Colarado 3 days ago where he stayed with his friend in a hotel room. He enjoyed camping in the mountains and spent his evenings in the hotel building’s swimming pool. On examination, there  are multiple red papules all over his body and extremities but not on the head and the neck. Some of the papules are tender. Which of the following is the most appropriate next step in management?

A) Doxycycline

B) Lyme Serology

C) Ciprofloxacin

D) Reassurance

E) Amoxicillin-Clavulunate

Question of the Week # 220

220 )  A 32 year old woman presents to the office for evaluation of dysuria, frequency and urgency. She has had two episodes of urinary tract infection in the last 4 months. Her previous episodes were managed with 3 day course of trimethoprim-sulfamethoxazole.  She has been using cranberry juice but has not experienced any improvement in recurrences. At this time, she denies any flank pain or fever.  She is sexually active with one partner and uses diaphragms with spermicide for contraception. Physical examination is normal except for mild supra-pubic tenderness. There is no costo-vertebral angle tenderness. Urinalysis  reveals pyuria and 3+ leukoesterase. There are no WBC casts. Which of the following is the most appropriate recommendation to avoid recurrent urinary tract infections in this patient?

A) Post-coital voiding

B) Post-Coital Trimethoprim-sulfamethoxazole

C) Avoid vaginal spermicides

D) CT scan abdomen

E) Daily Trimethoprim-Sulfamethoxazole

Question of the Week # 219

219 )  A 32 year old woman presents to the office for evaluation of recurrent urinary tract infections. She has had two episodes of cystitis in the last 4 months. In the past she was managed with 3 day course of trimethoprim-sulfamethoxazole. Now, she presents with burning micturition, urgency and frequency. She denies flank pain or fever.  She uses diaphragms with spermicide for contraception. She is sexually active with one partner and her last sexual intercourse was 5 months ago since her partner is away on a business tour. Physical examination is normal except for mild supra-pubic tenderness. Which of the following is the most appropriate recommendation to avoid recurrent urinary tract infections in this patient?

A) Post-coital voiding

B) Post-Coital Trimethoprim-sulfamethoxazole

C) Avoid vaginal spermicides

D) CT urogram and Cystoscopy

E) Daily Trimethoprim-Sulfamethoxazole

Question of the Week # 218

218 )  A 36 year old woman presents to the office for a routine follow up visit. Her past medical history is significant for recurrent urinary tract infections which are unrelated to sexual intercourse. She was initially managed on intermittent self-treatment with Trimethoprim-Sulfamethoxazole. However, in view of frequent episodes of UTI she was started on continuous Trimthoprim prophylaxis one week ago. She denies any fever or abdominal pain. She has not had dysuria or frequency or urgency over the last 5 days. Physical examination is normal. Laboratory investigations reveal a WBC count of 6.3k/µl with normal differential, Sodium 140meq/l, Potassium 4.0meq/l, Blood urea nitrogen 10mg% and Creatinine 1.4mg% . Her labs obtained 1 month ago show Blood urea nitrogen of 12mg% and creatinine of 0.7mg%. The most likely explanation for her increased creatinine?

A) Allergic Interstitial Nephritis

B) Acute Tubular Necrosis

C) Pyelonephritis

D) Decreased tubular secretion

E) Papillary necrosis

Question of the Week # 217

217 )  A 36 year old woman presents to the office complaining of burning urination, urgency and frequency. She denies fever or abdominal pain. She is sexually active with one partner for the past 1 month and her partner always uses condoms.  Her past medical history is significant for peri-partum cardiomyopathy 2 years ago which spontaneously resolved. She recalls that she was treated with furosemide for her peripheral edema at that time however, the drug had to be stopped due to a severe rash. On physical examination, she is afebrile. There is mild supra-pubic tenderness with out any costo-vertebral angle tenderness. Urinalysis reveals bacteriuria and several white blood cells with out any casts. Which of the following is the most appropriate next  step in managing this patient?

A) Admit for Intravenous antibiotics

B) Trimethoprim-Sulfamethoxazole

C) Piperacillin-Tazobactam

D) Moxifloxacin

E) Trimethoprim

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