Transcript 2008 Test Questions

EVALUATION QUESTIONS
Clinical Presentation and Diagnosis of TB
1. A 32 year-old man complains of cough and
malaise for the past three weeks. His wife is
currently being treated for active tuberculosis. Of
the following choices, your first step would be:
A. Begin an empiric trial of treatment with a
fluoroquinolone antibiotic for a possible communityacquired pneumonia
B. Obtain a chest film to confirm your suspicion for TB
which will make sputum testing unnecessary
C. Obtain three sputum specimens for AFB microscopy
(including at least one early morning specimen)
D. Both answers A and C
Clinical Presentation and Diagnosis of TB
2. In high prevalence areas, the AFB sputum
microscopy smear:
A. Is highly specific for TB
B. Identifies those at greatest risk of dying from TB
C. Identifies those most likely to transmit disease
D. All of the above
Clinical Presentation and Diagnosis of TB
3. A 54 year-old woman complains of cough,
fever, and unexpected weight loss over the past
month. She admits smoking 10 cigarettes per
day for over 20 years. Three sputum smears
were negative for AFB. You would consider
each of the following except:
A. An empiric trial of antibiotics (non-fluoroquinolone)
B. Obtaining a chest film for further evaluation
C. A trial of bronchodilator medication alone and
follow-up in 3 months
D. Sending sputum specimens for AFB culture
Microbiologic Diagnosis of TB
1. All of the following can increase sensitivity of
sputum smear microscopy except:
A. Fluorescence microscopy
B. Sputum collection after the start of
anti-tuberculosis treatment
C. Concentration by centrifugation and/or
sedimentation
D. Chemical pretreatment
Microbiologic Diagnosis of TB
2. A 37 year-old man with diabetes presents with clinical
symptoms highly suspicious for TB. Three sputum smears
are negative. The patient collected the specimens ten days
before he brought them back and kept them in a cool area of
the house (no refrigeration). Which of the following
statements is most correct?
A. Three negative smears predict that a culture would be
negative, and therefore a culture offers no further diagnostic
advantage and need not be obtained
B. A lack of response to broad-spectrum antimicrobial agents and
a chest film suggestive of TB, would together suggest a
diagnosis of smear-negative TB
C. The delay in transport and lack of refrigeration for the sputum
specimens are unlikely to have a negative effect on results
D. Six sputum specimens for smear microscopy would have
doubled the sensitivity for diagnosing TB compared to three
specimens
Microbiologic Diagnosis of TB
3. Advantages of culture for TB compared to
sputum microscopy alone include all of the
following except:
A. Obtaining a positive culture can allow for
drug-susceptibility testing
B. Culture can allow for identification of
non-tuberculous mycobacterium species
C. Culture has a higher sensitivity than smear
microscopy for diagnosing TB.
D. Culture, particularly by liquid media, can be faster
than smear microscopy
Initial Treatment of Tuberculosis
1. A 28 year-old woman taking standard four-drug
treatment for TB for five weeks now complains
of nausea, vomiting, and right upper-quadrant
discomfort. When seen in clinic she is noted to
have scleral icterus and right upper-quadrant
tenderness. Her urine is dark colored. What is
the appropriate action to take at this time?
A. Stop all drugs
B. Stop isoniazid
C. Give pyridoxine (vitamin B6)
D. Replace pyrazinamide with streptomycin
Initial Treatment of Tuberculosis
2. A 68 year-old woman with smear-positive TB needs to
start treatment. She lives too far to be given directlyobserved treatment (DOT) by your office. Which
treatment regimen is preferred for this patient?
A. Isoniazid and ethambutol for twelve months
B. Isoniazid/rifampicin/ethambutol for the first two months,
followed by isoniazid/rifampicin for an additional four
months
C. Fixed-dose combination of
isoniazid/rifampicin/pyrazinamide for nine months
D. Fixed-dose combinations of
isoniazid/rifampicin/ethambutol/pyrazinamide for the first
two months, followed by isoniazid/rifampicin for an
additional four months
Initial Treatment of Tuberculosis
3. In considering treatment for extrapulmonary
disease, all of the following statements are correct
except:
A. Extrapulmonary disease is a sign of disseminated
disease, and therefore always requires a longer
duration of treatment
B. Most presentations of extrapulmonary TB can be
treated with the same standard six month regimens
used for pulmonary TB
C. Extending the duration of therapy is recommended by
many experts for central nervous system (CNS) and
bone/joint extrapulmonary TB
D. Corticosteroids are sometimes recommended for
pericardial and central nervous system (CNS)
extrapulmonary TB
Fostering Adherence to Treatment
1. A 62 year-old patient has been taking TB treatment for three
months. She has hypertension and has been your patient for ten
years. Although she has always been good at listening to all of your
advice in the past, she has missed her last two appointments, and
her husband now informs you that he is worried because she is not
taking her TB medications at home as directed. He states that she
rarely goes out of the house now, and she avoids her friends. In
addition to asking about possible side effects from the medications,
what else would be good to address during her next appointment?
A. Ask how she is coping with the diagnosis, understanding that
emotional factors such as fear, stigma, and depression may
play a role in non-adherence
B. Talk to her about directly-observed therapy as a way to help her
succeed with treatment and support her closely
C. Assess her understanding of TB disease and treatment, and
ask her what she thinks might be interfering with her ability to
take her medications as directed
D. All of the above
Fostering Adherence to Treatment
2. As a clinic caregiver and administrator, you note that the clinic has
a high rate of TB treatment failure and default. Healthcare team and
system interventions that could improve patient adherence and
completion rates include all of the following except:
A. Develop a joint case conference to discuss problem TB cases with
doctors, nurses, and other clinic healthcare workers involved with the
TB patients, to put together all aspects of patient care and problemsolve jointly
B. Define a list of strict rules for adherence that patients must follow in
order to receive care for tuberculosis at the clinic. Post the rules and
enforce. All patients will see the same information, staff will not have to
spend time reviewing issues with patients, and the clinic will run more
efficiently
C. Provide written educational material for patients in appropriate
languages, and consider a peer-assistance program.
D. Develop a reminder system to contact defaulters through letters and/or
telephone, and consider a system of incentives or enablers that could
help improve adherence
Fostering Adherence to Treatment
3. To develop a patient-centered system of care for TB, all
of the following would be good to consider except:
A. The patient may be involved in deciding which TB medications
they prefer to take in order to individualize treatment regimens
B. The patient’s needs and expectations regarding TB care
should be explored, looking for ways to improve adherence,
and thus, treatment outcomes
C. Foster relationships between patients and providers that rely
on mutual respect and mutual responsibility toward a shared
goal, rather than just offering expert advice and assuming
passive compliance
D. Promote patient self-management through appropriate
education and support. Support should be gender-sensitive
and age-specific, and should be tailored to the cultural context
Tuberculosis and HIV Infection
1. In the evaluation of a patient with a clinical presentation
suspicious for both TB and HIV infections, all of the
following statements are correct except:
A. In a seriously ill patient, consider initiation of empiric
antibiotic treatment early in addition to obtaining
sputum for AFB microscopy (and culture if available),
chest radiograph and HIV tests.
B. AFB smear-negative cases become more difficult to
evaluate due to the need to distinguish TB from other
HIV-related pulmonary diseases
C. Infection control issues need to be considered
throughout the evaluation process to safeguard other
potentially vulnerable patients and healthcare workers.
D. The incidence of smear-negative TB decreases as the
CD4 drops (<200).
Tuberculosis and HIV Infection
2. A 25 year-old woman presents with 6 weeks of
fever, weight loss, and a large swollen left
supraclavicular lymph node. On examination she
has patches of white exudate on her oral mucosa.
A chest radiograph reveals a left lower lobe
infiltrate and left hilar adenopathy. Your
evaluation should include all of the following
except:
A. A needle aspiration of the lymph node with
specimens sent for AFB microscopy (and culture
and histopathology if available)
B. Sputum specimens for AFB microscopy
C. An empiric trial of ciprofloxacin
D. HIV testing
Tuberculosis and HIV Infection
3. All of the following statements regarding
tuberculosis and HIV co-infection are correct
except:
A. The risk of TB is increased only in the later stages
of HIV infection (CD4 cell count <100)
B. Advanced HIV disease (lower CD4 cell count) is
more often associated with atypical clinical and
radiographic presentations of TB
C. The incidence of extrapulmonary TB increases
with advanced immunosuppression
D. Isoniazid preventative therapy is effective in HIVinfected individuals
TB/HIV: Treatment
1.
A 45 year-old man with AIDS had documented
clinical improvement after two months of standard
TB treatment and subsequently began ART. After
one month of combined TB treatment and ART,
symptoms of cough with new infiltrates on chest
radiograph are discovered. Which of the following
need to be considered in the differential diagnosis
at this time:
A. TB treatment failure
B. New opportunistic respiratory infection
C. Immune reconstitution inflammatory syndrome
D. All of the above
TB/HIV: Treatment
2. The antiretroviral therapy regimen of choice for
a patient on first-line TB treatment with
isoniazid, rifampicin, ethambutol, and
pyrazinamide would be:
A. A triple nucleoside (NRTI) regimen
B. Ritonavir “super-boosted” protease inhibitor (PI)
regimen
C. A dual protease inhibitor (PI) regimen
D. Efavirenz plus two nucleosides (NRTIs) if not
pregnant
TB/HIV: Treatment
3.
A 50 year-old woman with sputum smear-positive TB
and new HIV infection is started on both a standard
four-drug TB regimen and a three-drug ART regimen at
the same time. The patient’s adherence is spotty and
one week later she complains of severe nausea and
vomiting. All of the following statements are correct
except:
A.
B.
C.
D.
Nausea and vomiting can be side effects seen with either TB
or ART drugs
The initial high pill burden may be contributing to the patient’s
poor adherence
Starting both TB and HIV treatments together has made the
job of finding the cause of the symptoms more complicated
Prioritizing the start of ART first, with a delay in TB treatment
would have been the recommended sequence
Drug-resistant Tuberculosis
1. A 68 year-old man presents with cough and weight loss
for 2 months. He recalls treatment for TB eight years
ago, but believes it only lasted a few months. A chest
film reveals a cavitary infiltrate in the right apex of the
lung. Factors that predict or are associated with a risk
for the development of drug-resistance in this case
would include all of the following except:
A. Poor adherence to prior TB treatment
B. Development of chronic diarrhea with possible
malabsorption of drugs
C. New diagnosis of diabetes
D. Persistent cough and weight loss after two months of
standard therapy
Drug-resistant Tuberculosis
2. Extensively-drug resistant (XDR) TB is defined
as TB that is resistant to:
A. At least six anti-tuberculosis drugs
B. At least isoniazid and rifampicin
C. Isoniazid, rifampicin, ethambutol, pyrazinamide,
streptomycin, and a fluoroquinolone
D. Isoniazid, rifampicin, a fluoroquinolone, and at least
one of these three injectable agents (amikacin,
kanamycin, capreomycin)
Drug-resistant Tuberculosis
3. Which of the following statements regarding the
microbiologic pathogenesis of drug-resistant
tuberculosis is most correct?
A. Patients with cavitary tuberculosis have a low bacillary load and
therefore are unlikely to harbor any naturally occurring drugresistant organisms
B. Mono-therapy with a single anti-tuberculosis drug can lead to
selective proliferation of naturally occurring drug-resistant
organisms
C. Acquired resistance to anti-tuberculosis drugs only occurs for
isoniazid and rifampicin
D. In a patient on a standard initial four-drug treatment regimen
with evidence for clinical failure in whom there is a high
suspicion for drug resistance, the addition of a fluoroquinolone
alone will reduce the risk for further development of drug
resistance
Management of Drug-resistant TB
1. The 5 year-old son of a woman you are currently
treating for known isoniazid and rifampicin resistant
tuberculosis presents with cough and malaise for
three weeks and an abnormal chest film. Of the
following available regimens, choose the one best
option:
A. Begin empiric treatment with at least four drugs that the
mother’s organism is known to be susceptible to
B. Begin empiric treatment with the standard initial regimen of
isoniazid, rifampicin, ethambutol, and pyrazinamide with the
addition of a fluoroquinolone
C. Begin empiric treatment with the standard initial regimen of
isoniazid, rifampicin, ethambutol, and pyrazinamide
D. Treat first for a potential community-acquired pneumonia with
a fluoroquinolone
Management of Drug-resistant TB
2. Reasonable steps for building a regimen for
multidrug-resistant tuberculosis after drugsensitivities results are known include all of the
following except:
A. Always start by choosing any available first-line drug that the
isolate remains susceptible to
B. Aim for a total of four to six drugs that the isolate is known to
be sensitive to (preferably not drugs used previously by the
patient)
C. Second-line agents (like cycloserine, ethionimide, and PAS)
would be preferred over injectable agents to minimize
healthcare resources used in association with injections and
improve patient comfort
D. If there are not four to six drugs available among the first- and
second-line agents, third-line agents could be considered,
preferably in consultation with an expert
Management of Drug-resistant TB
3. Clinical management and monitoring plans for
the care of MDR/XDR-TB should include (as
resources permit) all of the following except:
A. Daily patient-centered directly observed treatment
(DOT) throughout the entire treatment course
B. Diligent recording of drugs given, bacteriological
results, chest film findings and any occurrence of
medication toxicity
C. Periodic sputum specimens for smear and culture,
both to document culture conversion and monitor
for signs of treatment failure
D. Monthly sputum for drug-sensitivity testing
throughout the entire course of treatment
Contact Evaluation
1. A 23 year-old school teacher has recently been
diagnosed with active pulmonary TB. She is
concerned about the risk of transmitting disease
to the children she teaches in a small, poorlyventilated classroom. Aspects of her clinical
presentation that would suggest a higher
degree of infectious risk include all of the
following except:
A. Sputum smear positive for M. tuberculosis
B. Significant cough symptoms
C. Cavitary-disease on chest film
D. Extrapulmonary cervical lymphadenitis
Contact Evaluation
2. A 42 year-old man has been diagnosed with smear-positive pulmonary TB.
He works five days per week as an accountant in a small office with two
other co-workers and lives in an apartment building with his wife and son.
Other activities include a 2-hour weekly football game with his teammates
outdoors. In regards to planning a contact evaluation for this case, all of the
following statements are correct except:
A. It would be important to assess the clinical factors that influence
infectious risk in this case, such as the presence and duration of cough
symptoms
B. It would be important to gather information regarding the age, health
status (especially if risk for HIV or immunodeficiency), and whether
symptoms of TB are present in any of the close contacts
C. Evaluation of his football teammates as contacts would be a high
priority, even if his cough symptoms are minimal
D. It would be important to consider the size of the office, the level of
ventilation, and the amount of contact time between co-workers and
the patient when deciding whether further testing and evaluation for the
co-workers is needed
Contact Evaluation
3. Contacts to an infectious pulmonary case of TB
found to have latent TB infection (LTBI) who
have the highest risks for progression to active
TB disease once infected include:
A. Children <5 years of age
B. Spouses due to the extended duration of exposure
C. Persons with HIV infection
D. Both A and C