Transcript MCQs-1

A 30-year-old woman presents with the acute onset of fever, pleuritic
chest pain, and a productive cough. The patient's history is
unremarkable except for recurrent cystitis for which she takes
trimethoprim-sulfamethoxazole. She smokes cigarettes. On physical
examination her temperature is 40 °C, pulse rate is 120/min, respiration
rate is 36/min, and blood pressure is 130/80 mm Hg. Abnormalities are
localized to the right lung where crackles, rhonchi, and egophony are
heard. Oxygen saturation is 85% by pulse oximetry. Chest radiograph
shows a right lower lobe pneumonia. Sputum Gram stain is purulent
with few epithelial cells and a predominance of gram-positive diplococci.
Which of the following antimicrobial agents would be the best
initial therapy for this patient?
1.
2.
3.
4.
5.
Ciprofloxacin
Vancomycin
Trimethoprim-sulfamethoxazole
Ceftriaxone
Ceftazidime
1
Infectious Disease review
Questions
Hail M. Al-Abdely, MD
2
A 68-year-old man is brought to the emergency department by his
wife because of increased cough and confusion. The patient's usual
cough had increased over the past 3 days and is associated with
increased sputum production and dyspnea. He has an 80-pack-year
smoking history. His wife noted confusion for the first time this
morning.
On physical examination, the patient is somnolent. His neck does not
move easily to passive flexion. Neurologic examination is nonfocal. A
sputum sample cannot be obtained. Chest radiograph shows a lobar
infiltrate. Lumbar puncture with cerebrospinal fluid examination
reveals polymorphonuclear pleocytosis with a low glucose, elevated
protein, and negative Gram stain. Blood cultures have been drawn.
Which of the following antibiotic regimens should be started
promptly?
1.
Ceftriaxone
2.
Ceftriaxone and vancomycin
3. Vancomycin
4.
Trimethoprim-sulfamethoxazole
5.
Levofloxacin
3
A 60-year-old woman comes to the emergency department because of a very painful
right thigh. She has arthritis and is taking nonsteroidal anti-inflammatory agents for
control of joint pain. She also has type 2 diabetes mellitus treated with a sulfonylurea.
On Friday morning, she noted pain in her right upper thigh and thought that it might
be an exacerbation of her arthritis, so she took an extra dose of ibuprofen. Late that
night, the thigh became swollen and exquisitely tender. She went to the emergency
department where she is seen by a resident.
On physical examination, she is obese and in slight distress. Her temperature is 38.9
°C. Mild tachycardia is noted. The joint examination shows a pattern consistent with
osteoarthritis. Her right thigh is swollen and extremely tender to deep touch. There is
a small (4 x 5 cm) red patch in the middle of the tender area. A radiograph of the thigh
shows no gas in the soft tissues and no bony changes aside from features of
osteoarthritis in the hip and knee. She is given cefazolin, 1 g every 8 hours, and is
admitted to the hospital with a diagnosis of cellulitis. The next day, her pain is worse,
and the red area on her thigh is slightly larger (5 x 5.5 cm). Fever is still present, and
she looks more ill. A CT scan of the thigh is performed without intravenous contrast
and shows no gas in the soft tissues and diffuse swelling of the muscle groups.
Cefazolin is continued at the same dose. On the third day, she is somewhat delirious
and requires intravenous morphine for pain control.
Which of the following is the most appropriate next step?
1.
2.
3.
4.
5.
Epidural placement of a catheter for better pain control
Change the cefazolin to vancomycin
Add levofloxacin to the cefazolin
Elevate the leg and apply warm packs
Refer for surgical evaluation
4
A 65-year-old woman is seen in a clinic because of cough, shortness of
breath, and fever. She has mild Alzheimer's disease and type 2 diabetes
mellitus controlled with oral hypoglycemic agents. On physical examination,
her temperature is 37.8 °C, pulse rate is 85/min, respiration rate is 24/min,
and blood pressure is 145/75 mm Hg. She denies headache. Her neck is
supple. Bibasilar crackles and decreased breath sounds are auscultated at
the right lung base. Cardiac examination shows an S4 gallop rhythm but no
murmur. The abdominal examination is unremarkable. There is mild edema
of both ankles. Chest radiograph shows an infiltrate in the right lower lobe
without a pleural effusion. The patient is unable to produce sputum for
examination. Leukocyte count is 16,000/µL with 93% polymorphonuclear
neutrophils, 5% band forms, and 2% lymphocytes. Results of blood cultures
are pending.
Which of the following is the most appropriate therapy for this
patient?
1.
2.
3.
4.
5.
Oral trimethoprim-sulfamethoxazole
Oral azithromycin
Oral levofloxacin
Oral cefuroxime axetil
Intravenous vancomycin
5
A 67-year-old man develops a fever while in the intensive care unit
following partial colectomy for removal and drainage of a peridiverticular
abscess. CT scan of the abdomen shows an intraabdominal abscess,
which is drained by placing a percutaneous catheter. Catheter drainage
and blood cultures are positive for Enterobacter cloacae. Intravenous
catheters are changed, and ceftriaxone and metronidazole are begun.
The patient becomes afebrile, and a follow-up blood culture is negative.
Four days later, fever recurs, and a blood culture is again positive for E.
cloacae. A repeat abdominal CT scan is unchanged.
Which of the following is the most likely explanation for the
recurrent findings?
1.
2.
3.
4.
Recurrent central venous catheter sepsis
Resistance of the initial strain of E. cloacae to ceftriaxone
Emergence of a mutant, ceftriaxone-resistant strain of E. cloacae
Development of endocarditis
6
A 78-year-old woman presents to the emergency department with sudden onset of
increasing abdominal pain and fever. On physical examination, her temperature is
39.4 °C, respiration rate is 24/min, and blood pressure is 110/55. Her abdomen is
distended and tender, and bowel sounds are decreased.
Laboratory studies: Leukocyte count 21,000/µL Polymorphonuclear
neutrophils74% Band forms10% Lymphocytes10% Monocytes 6% Serum total
bilirubin 40 mol/dL Serum Alk phos 250 U/L AST35 U/L After intravenous fluids and
imipenem-cilastatin are begun, fever resolves and blood pressure normalizes. On the
eighth hospital day, diarrhea and abdominal pain develop. An assay for Clostridium
difficile toxin is positive, and oral vancomycin is added to imipenem-cilastatin. On the
14th hospital day, fever recurs and blood cultures are obtained. The microbiology
laboratory reports the next day that the blood cultures are growing gram-positive
cocci in short chains that are resistant to vancomycin. The central venous catheter is
changed.
What is the most likely causative organism?
1.
2.
3.
4.
5.
Streptococcus bovis
Streptococcus meliri
Staphylococcus aureus
Coagulase-negative staph.
Enterococcus faecium
7
Which of the following is the most appropriate antimicrobial
regimen for this patient?
1.
2.
3.
4.
5.
Ampicillin and gentamicin
Chloramphenicol
Linezolid
Levofloxacin
Ceftriaxone
8
A 78-year-old man presents with a 4-day history of fever and cough
productive of thick sputum. He has never smoked. Clarithromycin, given
for the past 2 days, has been ineffective. A blood culture drawn in the
office is reported to be growing gram-positive cocci in pairs. Chest
radiograph shows an infiltrate in the right lower lobe. The patient is
unable to produce sputum for examination.
Which of the following antibiotics, administered intravenously, is
the most appropriate initial therapy?
1.
Azithromycin
2.
Vancomycin
3.
Ceftazidime
4.
Trimethoprim-sulfamethoxazole
5.
Ciprofloxacin
9
A 45-year-old man presents with fever, cough productive of thick sputum,
diarrhea, and abdominal cramps of 4 days' duration after returning from
Spain. On physical examination, his temperature is 38.9 °C . Lung
examination shows occasional scattered wheezes but no crackles. No
cardiac murmur is audible. His abdomen is slightly tender with
hyperactive bowel sounds but no guarding or rebound. Leukocyte count
is 13,000/µL with 90% polymorphonuclear neutrophils and 10%
lymphocytes. A test for fecal leukocytes is positive. After cultures of blood
and stool are obtained, the patient is started on ciprofloxacin.
For which of the following potential diarrheal pathogens in this
patient is resistance to ciprofloxacin most likely?
1.
Campylobacter jejuni
2.
Salmonella typhi
3.
Shigella dysenteriae
4.
Salmonella typhimurium
5.
Plesiomonas shigelloides
10
A 29-year-old man who currently uses injection drugs presents with fever
and rigors. On physical examination, his temperature is 40 °C. There are
hemorrhagic papular lesions on his distal left index finger and right great
toe and petechiae in the palpebral conjunctivae. The lungs are clear.
Cardiac examination shows a grade 2/6 systolic ejection murmur and a
grade 2/4 diastolic murmur at the upper right and lower left sternal border.
Abdominal examination is unremarkable, and there are no joint effusions
or tenderness. Leukocyte count is 19,000/µL, and serum creatinine is 1.2
mg/dL. Four sets of blood cultures grow gram-positive cocci in clusters,
and vancomycin and gentamicin are begun. The next day, the blood
isolates are identified as methicillin-susceptible Staphylococcus aureus.
You choose to continue gentamicin.
Which of the following changes should also be made in the antibiotic
regimen?
1.
2.
3.
4.
5.
Continue vancomycin
Change vancomycin to nafcillin
Change vancomycin to ceftriaxone
Change vancomycin to ciprofloxacin
Add rifampin
11
A 42-year-old woman presents after having symptoms of upper respiratory tract
infection for 4 days that were followed by 2 days of coughing productive of yellowish
phlegm, mild pleuritic chest pain, and fevers to 38.9 °C. The medical history includes
type 2 diabetes mellitus but no previous pneumonia. The only medication is an oral
contraceptive. The patient reports smoking 5 cigarettes a day for 15 years and denies
any risk factors for HIV infection. The review of systems shows mild anorexia, but the
patient is able to take oral liquids and food and to go about her daily activities.
Patient appears mildly ill but in no distress. Her dentition is good. The temperature is
38.5 °C. The pulse rate is 100/min, respiration rate is 24/min with mild splinting, and
blood pressure is 110/60 mm Hg. The chest examination shows dullness to
percussion, bronchial breath sounds, and coarse crackles at the left base. The
findings of the cardiac, abdominal, and extremity examinations are unremarkable.
The leukocyte count is 11,300/µL with 20% band forms. Oxygen saturation is 96%
while the patient is breathing room air. A chest radiograph shows left lower lobe
consolidation with a blunted left costophrenic angle that suggests a small effusion.
What pathogens must be kept in mind in designing an antibiotic regimen for
this patient?
1. Pseudomonas aeruginosa
2. Methicillin-resistant Staphylococcus aureus
3. Penicillin-resistant Streptococcus pneumoniae
4. Aspergillus fumigatus
5. Anaerobic bacteria
12
A 66-year-old man with a history of significant renal failure due to poorly controlled
hypertension is admitted to the intensive care unit following a large subarachnoid
hemorrhage. He required intubation on arrival and has remained ventilated for 3
weeks. Seven days after admission, he developed a catheter-associated urinary tract
infection due to Escherichia coli, which was treated with ceftriaxone for 7 days. Two
days ago (4 weeks after admission), he developed a fever to 39.2 °C, and thick,
purulent sputum was suctioned from his endotracheal tube. A chest radiograph
showed evidence of a new right lower lobe infiltrate. A Gram's stain of an
endotracheal tube aspirate showed abundant polymorphonuclear cells and gramnegative rods. Blood samples were obtained for culture, and the patient was started
on empiric therapy with ceftriaxone.
This morning, the patient is still febrile and requires vasopressors to maintain his
blood pressure. You receive a call from the microbiology laboratory to tell you that the
patient's blood cultures are positive for gram-negative rods. The microbiologist also
informs you that the endotracheal aspirate is growing E. coli with the following
sensitivity pattern:
Ampicillin:Resistant
Cefazolin:Resistant
Cefuroxime:Resistant
Ceftriaxone:Sensitive
Ceftazidime:Resistant
Gentamicin:Sensitive
Trim-sulfa:Resistant
Ciprofloxacin:Resistant
Imipenem:Sensitive
What should you do next to manage this patient's infection?
1. Continue the ceftriaxone
2. Discontinue the ceftriaxone and start gentamicin
3. Continue the ceftriaxone and add gentamicin
4. Discontinue the ceftriaxone and start imipenem
5. Continue the ceftriaxone and add imipenem
13
A 63-year-old woman is hospitalized for symptomatic hyperglycemia and acidosis as
complications of diabetes. She has no history of loss of consciousness, confusion, or
other neurologic process. She has had two similar hospitalizations over the previous 4
years. After admission, she has a good response to insulin and fluid therapy, but on the
third day of hospitalization, she develops a fever, and a chest radiograph reveals an
infiltrate in the left upper lobe. Her admission chest radiograph, which had been read as
normal, was, in retrospect, found to show a small patch of infiltrate in that same area.
Culture of an expectorated sputum specimen shows many leukocytes and some grampositive diplococci among mixed flora interpreted as normal respiratory flora. The patient's
physician prescribes levofloxacin for "community-acquired pneumonia." The patient's fever
persists, and a sputum culture done before antibiotics were started is found to show a
predominance of pneumococci and normal respiratory flora. Another sputum specimen is
sent for culture, and this time, there is essentially a pure growth of pneumococci. Both
isolates of pneumococcus are tested for susceptibility according to laboratory protocol,
and the results show a penicillin minimal inhibitory concentration (MIC) of 0.05 µg/mL,
which is interpreted as "highly susceptible." Levofloxacin was continued for communityacquired pneumonia, but the patient did not improve and continued to produce sputum
containing leukocytes and pneumococci. Chest radiographs continued to show an infiltrate
in the left upper lobe, without evidence of cavitation or pleural disease. Blood and urine
cultures were repeatedly negative.
The best explanation for this outcome is:
1.
Resistance to levofloxacin
2.
Superinfection with hospital flora
3.
Recurrent pulmonary emboli or infarcts
4.
Anaerobic bacterial pneumonia due to aspiration
5.
Laboratory error in determining penicillin MIC
14
An 80-year-old woman is admitted to the coronary care unit following a large inferior
myocardial infarction. She required immediate intubation and ventilatory assistance. One
week after her admission, she developed pneumonia, for which she was treated with a 2week course of imipenem. During this time, she also developed moderate renal failure,
which was believed to be due to poor renal perfusion, and an indwelling urinary catheter
was inserted to monitor her urine output.
Her clinical status gradually improved, and she was extubated 4 weeks after admission.
She was transferred to a medical ward 3 days later. Five weeks after admission, the
patient developed a fever and rigors, and blood cultures grew methicillin-resistant
Staphylococcus aureus, which was believed to have originated from an infected peripheral
intravenous catheter site. The catheter was removed, and she was treated with a 2-week
course of vancomycin.
She continued to improve slowly with daily physical and occupational therapy. Six weeks
after admission, a urine specimen was taken from the indwelling catheter as it was being
changed and was sent for culture. Forty-eight hours later, the following identification and
sensitivity report was issued from the microbiology laboratory:
Identification:Enterococcus faecium
Ampicillin:Resistant
Gentamicin:Resistant
Streptomycin:Resistant
Teicoplanin:Sensitive
Vancomycin:Resistant
The patient denies fevers, chills, and dysuria. Her neutrophil count is within normal limits.
Your next action should be to:
1. Start ciprofloxacin and doxycycline
2. Remove the catheter and observe the patient
3. Obtain and start teicoplanin
4. Start linezolid
5. Start quinupristin/dalfopristin
15
An 84-year-old woman with a 10-year history of dementia is transferred from a nursing
home to the hospital for evaluation of a new fever. She is being fed through a gastrostomy
tube, and she requires both an indwelling bladder catheter and a diaper. She has no
known allergies. She has had three prior episodes of fever in the last 6 months. When she
had a fever in the nursing home, she was given ciprofloxacin through the gastrostomy
tube. On physical examination in the emergency room, the patient has a temperature of
38.8 °C, pulse rate of 84/min, respiration rate of 24/min, and blood pressure of 94/48 mm
Hg. She is unresponsive. Her neck is supple, and her lungs are clear. There is an S4
gallop but no significant murmurs. The abdomen is soft and nontender, with no masses or
organomegaly. The extremities are warm but not swollen or red. Rectal examination is
normal, and the stool is brown and negative for occult blood. The Foley catheter is filled
with cloudy urine. In urinalysis and urine culture reports available from 2 days earlier,
urinalysis showed trace protein, many leukocytes, rare erythrocytes, and copious bacteria,
and urine culture showed Klebsiella pneumoniae. The susceptibility report was limited and
indicated that the organism was susceptible to ceftriaxone and resistant to ceftazidime,
ciprofloxacin, tobramycin, and tetracycline.
Which of the following antimicrobial agents would be most likely to be effective for
this woman?
1.
Cefotaxime
2.
Aztreonam
3.
Imipenem
4.
Gentamicin
5.
Levofloxacin
16
A 31-year-old married man comes to a local health clinic because of a 2-day
history of dysuria and urethral discharge. Otherwise, his health has been good. He
takes no medications except ranitidine for occasional heartburn. He is allergic to
cephalexin, with which he developed a rash 2 years earlier. He is just back from a
trip to sout-east Asia where he had several sexual contacts. Physical examination
shows a healthy-looking man in no distress. His vital signs are normal, and the
only finding is a copious, yellow urethral discharge. Gram's stain of the discharge
shows many polymorphonuclear leukocytes and intracellular and extracellular
gram-negative diplococci. The patient is given a single dose of ciprofloxacin and a
single dose of azithromycin and told to abstain from sexual activity until all
symptoms have been gone for at least 48 hours. He returns to the clinic 3 days
later with persistent dysuria and discharge. Gram's stain of the urethral discharge
again shows numerous leukocytes and gram-negative intracellular and
extracellular diplococci.
The most likely reason for his persistent symptoms is:
1.
Poor ciprofloxacin absorption secondary to H2-receptor antagonist therapy
2.
Insufficient dose of azithromycin
3.
Neisserial resistance to ciprofloxacin
4.
Mixed initial infection
5.
Neisserial infection of his wife
17
A 68-year-old diabetic man was recently discharged from the hospital after treatment
for congestive heart failure. While in the hospital, he was found to be colonized with
methicillin-resistant Staphylococcus aureus (MRSA) and received chlorhexidine baths
and intranasal mupirocin. He was also found to have peripheral neuropathy and a
chronic, inactive, small ulcer over the head of the right metatarsal.
The patient's son calls this morning to tell you that his hather is very confused,
feverish, and sweaty and that his right foot is swollen and red. You ask him to bring
him to the hospital, and you meet him in the emergency room. On physical
examination, the patient's right foot is inflamed and foul-smelling.
Laboratory studies:
Leukocyte count 13,000/µL Hemoglobin 11.8 g/dL Blood glucose16 mol/dL Gram's
stain of a specimen from the foot ulcer Gram-negative bacilli, gram-positive cocci in
chains, and gram-positive cocci in clusters
Which of the following is the best therapy for this patient?
1.
2.
3.
4.
5.
Imipenem
Cefazolin and metronidazole
Nafcillin, ceftriaxone, and metronidazole
Vancomycin, ceftriaxone, and metronidazole
Quinupristin/dalfopristin
18
The infection control committee of KFSH&RC is reviewing strategies to
reduce the incidence of antibiotic-resistant nosocomial pneumonia and
sepsis.
In addition to a multidisciplinary effort, which of the following
strategies is most likely to accomplish this goal?
1.
Combination antibiotic therapy for serious infections
2.
Restricted hospital formulary
3.
Routine use of broad-spectrum antibiotics
4.
Routine consultation with an infectious disease specialist
19
A 29-year-old man is admitted to the hospital with communityacquired pneumonia. Blood cultures yield Streptococcus
pneumoniae resistant to penicillin (MIC = 4.0 µg/mL).
To which of the following antimicrobial agents is the
organism most likely to be susceptible?
1.
2.
3.
4.
5.
Azithromycin
Ceftriaxone
Amoxicillin
Levofloxacin
Trimethoprim-sulfamethoxazole
20
A 68-year-old paraplegic man is transferred to the hospital from the nursing home
because he has fever and mild confusion. His general physical examination is
unchanged since his last office visit, except that over the sacrum he has a deep
decubitus ulcer that has developed and progressed rapidly. The admitting
physician performs local débridement and wound care and prescribes imipenem
for possible sepsis. On the third hospital day, the patient is clinically better, and a
blood culture from admission and deep-tissue cultures from the débridement both
show Klebsiella pneumoniae with the following resistance phenotype:
Ampicillin-Resistant
Cefazolin-Resistant
Ceftriaxone-Susceptible
Ceftazidime-Resistant
Imipenem-Susceptible
Ciprofloxacin-Resistant
Tobramycin-Susceptible
Which of the following treatment choices is most reasonable at this point?
1.
Continue imipenem
2.
Change to ceftriaxone; add anaerobic coverage
3.
Change to tobramycin; add anaerobic coverage
4.
Change to moxifloxacin alone for broader-spectrum fluoroquinolone coverage
5.
Stop antibiotics, as dèbridement has removed the source of the infection
21
A previously healthy 40-year-old mother of two is evaluated because of a
9-day history of malaise, runny nose, scratchy throat, and cough. She
has no fever, chest pain, or shortness of breath. Nasal secretions were
clear but now are yellowish; cough is usually nonproductive, except in the
morning when it produces green sputum.
What is the most appropriate management strategy for this patient?
1.
A 7-day course of amoxicillin
2.
A 7-day course of amoxicillin-clavulanate
3.
Symptomatic treatment and reassurance
4.
A 10-day course of levofloxicin
22
A previously healthy 26-year-old medical student is evaluated
because of a 7-day history of abundant, thick, yellow nasal
secretions and post-nasal drip. He has no fever and only mild
sinus tenderness. He mentions that he has had "sinusitis" before
and has always needed an antibiotic. He even suggests which
antibiotics could be prescribed.
What is the most appropriate management strategy for this
patient?
1.
Decongestants or nasal sprays and reassurance
2.
Antibiotics for 10 days
3.
Antibiotics for 1 month
4.
Antibiotics for 14 days
23
A community hospital implements a locally derived set of infection
management practice guidelines.
Adherence to the guidelines by the medical staff will most
likely result in which of the following outcomes?
1. Stable antibiotic susceptibility patterns for bacteria
2. No change in overall use of antibiotics
3. Increase in the use of inadequate antimicrobial treatment
regimens
4. Increase in adverse drug effects
24
A 42-year-old woman is evaluated because of a 2-day history of dysuria.
She had one prior urinary tract infection 7 years earlier and responded to
a short course of trimethoprim-sulfamethoxazole. After the urine dipstick
shows a strongly positive reaction for nitrites, she asks whether she could
again take trimethoprim-sulfamethoxazole.
Which of the following would be the best answer?
1.
No, trimethoprim-sulfamethoxazole is no longer considered a first-line
treatment for urinary tract infection
2.
Yes, trimethoprim-sulfamethoxazole is still an effective treatment for urinary
tract infection even when resistance is measured in vitro
3.
Yes, if local resistance patterns to trimethoprim-sulfamethoxazole show only a
small probability of resistance
4.
No, prior treatment with trimethoprim-sulfamethoxazole makes it unlikely that
the organisms causing the infection are susceptible to trimethoprimsulfamethoxazole
25
A 30-year-old otherwise healthy man is evaluated because of a
10-day history of cough. The cough was initially productive of
small amounts of clear sputum, which has now turned yellowish.
He has no fever, chills, or shortness of breath but has difficulty
sleeping because of the persistent cough. On physical
examination, his vital signs are normal and examination of the
lungs reveals no wheezing, crackles, or rhonchi.
In addition to symptomatic relief with antitussives, what is
the most appropriate treatment strategy for this patient?
1.
2.
3.
4.
5.
Salmeterol metered-dose inhaler as needed at bedtime
A 2-week course of clarithromycin
A 7-day course of amoxicillin
A 7-day course of amoxicillin-clavulanate
Observation only
26
A 56-year-old businessman is planning a trip to east Asia for a period of 3
weeks. He is in generally good health except for chronic bronchitis. His
medicines control his illness fairly well, but he asks if he should carry
antibiotics with him in case he should develop an exacerbation. He
agrees not to take anything with him, but on his return from the trip he
calls from the airport sounding very short of breath and coughing. On
examination that day, he has a fever of 38.3 °C and loud rhonchi and
some wheezes. A chest radiograph shows some patchy lesions that look
worse than on his baseline radiograph. His capillary oxygen saturation is
the same as his baseline level.
In addition to treatment for his airway disease, which of the
following is the next step in this patient's management?
1.
2.
3.
4.
5.
Anticoagulation for pulmonary embolus
Oral amoxicillin-clavulanate
Oral azithromycin
Oral gatifloxacin
Intravenous ceftazidime
27
A 34-year-old man is evaluated because of a 4-day history of sore
throat. He is able to swallow but indicates that the pain is
significant. He has taken analgesics inconsistently. He has no
febrile sensation or cough. On examination, he is afebrile. His
pharynx is erythematous, but no plaques are visible, and he has
no tender enlarged cervical lymph nodes. He is concerned
because he has small children, and they currently have symptoms
of upper respiratory infection, including sore throat and fever.
What would be the next appropriate step in managing this
patient?
1.
2.
3.
4.
Get a rapid strep test and if positive start antibiotics
Treat symptoms only
Send off a throat culture and treat with antibiotics until result
comes back
Treat him and his children with antibiotics
28
A 19 year-old Saudi female with sickle-cell disease presented to the
ER with 2 day history of fever, cough and SOB. O/E was febrile
39C, RR 30 and BP 80/50. Has crackles bilaterally and CXR
revealed bilateral lower lobe consolidation. WBC 24000 with 35%
band forms, HgB 39 gm/l.
The appropriate antibiotic regimen for this patient is:
1. Penicilin G 3 MU every 4 hours
2. Ceftriaxone 2gm every 24 hours
3. Ceftazidime 2gm every 8 hours and gentamicin 2mg/kg every 12
hours
4. Vancomycin 1gm every 12 hours and Ceftriaxone 2gm every 24
hours
5. Nafcillin 2gm every 4 hours and ciprofloxacin 400mg i.v every 12
hours
29
A 60 year-old Saudi male, heavy smoker for 40 years. Presented to ER
with 4 months history of fever and yellowish sputum. He lost 10 kgs
over 2 months. He was treated with antibiotics twice in another
hospital over the past month. He had temporary improvement but got
worse after stopping the antibiotics. He is otherwise well with no other
illnesses. CXR shown.
30
The most likely explanation for his illness is:
1. Recurrent aspiration
2. Resistant pneumococcal pneumonia
3. Atypical pneumonia
4. Post obstruction bacterial pneumonia
5. Pulmonary tuberculosis
31
The following is true about necrotizing fasciitis:
1.
2.
3.
4.
5.
Streptococcus pyogenes is the most common cause in diabetic
ulcers progressing to fasciitis
Bactroides fragilis is the most common cause of post-operative
necrotizing fasciitis of the abdominal wall.
Staphylococcus aureus is not a common cause of necrotizing
fasciitis in non-diabetics.
Antibiotic therapy is the mainstay treatment for necrotizing fasciitis
Nafcillin is the drug of choice for necrotizing fascitis.
32
A 24 year-old Saudi female with sickle-cell disease presents to
ER with a 10-day history of fever and dry cough and 2 days
history of severe bone pain and rigors. Temp 39 C and chest
examination was unremarkable. CXR revealed a left upper lobe
infiltrates with cavitations. CXR 10 days earlier was normal. The
patient is on methotrexate weekly and prednisone daily for
rheumatoid arthritis.
All the followings are possible causes of the chest infiltrates
except.
1.
2.
3.
4.
5.
Mycobacterium tuberculosis
Staphylococcus aureus
Pseudomonas aeruginosa
Klebsiella pneumoniae
Mixed alpha streptococci and anaerobes
33