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

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