Download Vraag 59

Vraag 59:
A 32-year-old man with AIDS and a recent CD4 cell count of 6/µL is admitted to the hospital
with a 2-week history of fever and chills, a nonproductive cough, and gradually worsening
dyspnea at rest and on exertion. He has been unable to tolerate highly active antiretroviral
therapy and has taken no medications for the past 3 years.
On physical examination, temperature is 38.3 °C (101.0 °F), blood pressure is 100/68 mm
Hg, pulse rate is 110/min, and respiration rate is 18/min. Cardiopulmonary examination
discloses tachycardia with no murmur and diffuse crackles throughout all lung fields. The
alveolar-arterial oxygen gradient is 50 mm Hg.
A chest radiograph shows bilateral interstitial pulmonary infiltrates. An induced sputum
sample shows few leukocytes and no predominant organism. Bronchoscopy is scheduled.
Which of the following is the most appropriate empiric treatment for this patient?
A- Ceftriaxone and azithromycin
B- Isoniazid, rifampin, pyrazinamide, and ethambutol
C- Trimethoprim-sulfamethoxazole
D- Trimethoprim-sulfamethoxazole and prednisone
Vraag 97:
A 60-year-old woman is evaluated for the acute onset of fever, chills, nonproductive cough,
diarrhea, and altered mental status after returning from a cruise. She is the third person on
the cruise who has presented with these symptoms within the past several days. Medical
history is significant for a 10-year history of diabetes mellitus controlled with diet and
metformin therapy.
On physical examination, temperature is 39.4 C, blood pressure is 100/56 mm Hg, pulse rate
is 100/min, and respiration rate is 32/min. Crackles are heard at the left lung base. On
neurologic examination, the patient is oriented only to person.
Laboratory studies indicate a hematocrit of 34%, a leukocyte count of 18,000/µL (18 ×
109/L), a platelet count of 149,000/µL (149 × 109/L), and a serum sodium concentration of
125 meq/L (125 mmol/L). Chest radiograph reveals an alveolar infiltrate in the left lower lobe
and a small left pleural effusion.
Which of the following studies is most likely to be helpful in determining the cause of
pneumonia in this patient?
A- Acid-fast bacilli sputum smear
B- Blood culture
C- Legionella urinary antigen test
D- Nasal swab for influenza virus
E- Thoracentesis
Vraag 114:
A 26-year-old man is evaluated in the emergency department for the acute onset of a
nonproductive cough and right-sided pleuritic chest pain of 2 days’ duration. The patient is an
injection drug user, with his last use approximately 4 days ago. Results of his most recent
HIV test 2 months ago were negative. The remainder of the medical history is
noncontributory, and he takes no medications.
On physical examination, temperature is 39.4 °C (103.0 oF), blood pressure is 120/80 mm
Hg, pulse rate is 100/min, and respiration rate is 20/min. Cardiopulmonary examination
reveals clear lungs and a grade 3/6 holosystolic murmur heard best at the right sternal
border that increases on inspiration.
Laboratory studies indicate a hematocrit of 39%, a leukocyte count of 17,000/µL (17 × 109/L)
with 15% band forms, and a platelet count of 160,000/µL (160 × 109/L). Chest radiograph
reveals small infiltrates in the left upper lobe, right upper lobe, and right lower lobe. Blood
cultures are obtained.
Which of the following empiric antimicrobial regimens should be initiated?
A- Azithromycin plus ceftriaxone
B- Levofloxacin plus clindamycin
C- Amoxicilin-clavulanic acid + erythromycin
D- flucloxacillin+ gentamicin
E- Vancomycin plus cefepime
Vraag 4:
A 57-year-old woman is evaluated for the acute onset of dyspnea and dry cough that have
rapidly worsened over the past 3 days. The patient underwent liver transplantation 15
months ago. The patient’s current therapy consists of sirolimus, azathioprine, prednisone,
and inhaled pentamidine. She is allergic to sulfonamides.
On physical examination, temperature is 38.4 °C (101.1 °F), blood pressure is 140/80 mm
Hg, pulse rate is 110/min, and respiration rate is 23/min. Arterial oxygen saturation is 83% on
ambient air. Pulmonary examination reveals scattered fine crackles bilaterally. Complete
blood count, blood urea nitrogen level, serum creatinine level, and urinalysis are all normal.
A chest radiograph shows slight, diffuse, increased opacities bilaterally. A CT scan of the
chest reveals bilateral diffuse, fine alveolar and interstitial infiltrates. A sputum sample cannot
be obtained.
Which of the following is the most likely cause of this patient’s findings?
A- Aspergillus fumigatus
B- Candida glabrata
C- Pneumocystis jirovecii
D- Staphylococcus aureus
E - Streptococcus pneumoniae
Vraag 86:
A 45-year-old woman is evaluated for fever, diminished appetite, weight loss, and cough
productive of foul-smelling sputum of 2 weeks’ duration. She has a history of chronic
alcoholism and frequent hospital admissions for alcohol-withdrawal seizures, with the most
recent episode occurring 3 weeks ago.
On physical examination, temperature is 38.3 oC (101.0 oF), blood pressure is 130/84 mm
Hg, pulse rate is 80/min, and respiration rate is 18/min. Her breath is foul smelling and
dentition is poor. Pulmonary examination reveals some crackles and rhonchi in the right
anterior chest.Laboratory studies indicate a leukocyte count of 12,500/µL (12.5×109/L) with
8% band forms. The chest radiograph is shown .
Sputum Gram stain results indicate gram-positive cocci in chains, gram-negative bacilli, and
gram-positive bacilli.
Which of the following empiric antimicrobial regimens should be initiated?
A- Ampicillin-sulbactam
B- Aztreonam
C- Ceftriaxone
D- Levofloxacin
E- Metronidazol
Vraag 43:
A 70-year-old man is evaluated in the emergency department for the acute onset of fever,
cough productive of yellow sputum, right-sided pleuritic chest pain, and dizziness. He has a
history of diabetes mellitus and hypertension treated with hydrochlorothiazide, lisinopril,
glyburide, and metformin.
On physical examination, temperature is 35.0 C, blood pressure is 110/70 mm Hg, pulse rate
is 120/min, and respiration rate is 36/min. He appears to be in acute respiratory distress.
Pulmonary examination reveals dullness to percussion, increased fremitus, and crackles at
the right lung base. He is oriented only to person.
Laboratory studies:
Hematocrit 42%
Leukocyte count 23,000/µL (23 × 109/L) with 40% band forms
Platelet count 150,000/µL (150 × 109/L)
Blood urea nitrogen 46 mg/dL (16.4 mmol/L)
Creatinine 1.4 mg/dL (123.8 µmol/L)
Arterial blood gas studies (ambient air): PO2 50 mm Hg
PCO2 30 mm Hg
pH 7.48
Chest radiograph shows a right lower lobe infiltrate.
Which of the following is the most appropriate management of this patient?
A- Admit to general medical floor
B- Admit to the intensive care unit
C- Observe in the emergency department for 12 hours
D- Treat as an outpatient
Vraag 39:
A 54-year-old woman is hospitalized for recurrent pneumonia, the present episode of which
began 3 days ago. She has been hospitalized twice over the past 2 months for pneumonia
that was treated with 2-week regimens of amoxicillin plus clavulanic acid and clarithromycin
plus ceftriaxone, respectively, with improvement within 1 to 3 days of therapy. Each episode
was characterized by the sudden onset of fever, chest tightness, dyspnea, nonproductive
cough, and diffuse interstitial pulmonary infiltrates on chest radiograph.
Medical history is otherwise unremarkable. For the past 2 months, she has been housesitting for a friend who has a hot tub that she uses occasionally. On physical examination,
she is mildly dyspneic. Temperature is 37.7 °C (99.9 °F), blood pressure is 135/80 mm Hg,
pulse rate is 90/min, and respiration rate is 22/min. Arterial oxygen saturation is 90% on
ambient air. Diffuse fine crackles are heard throughout both lung fields. The leukocyte count
is 7600/µL (7.6 × 109/L), and the serum lactate dehydrogenase level is 450 U/L.
A chest radiograph shows an interstitial micronodular pattern most prominent in the lower
and mid-lung zones. HIV serology and bronchoscopic lavage results of routine cultures and
rapid testing for influenza; parainfluenza 1, 2, and 3; adenovirus; respiratory syncytial virus;
Chlamydophila pneumoniae; and Mycoplasma pneumoniae are negative. The results of a
mycobacterial smear are negative, and cultures are pending.
Which of the following is the most appropriate treatment?
ABCDE-
Ceftriaxone and azithromycin
Corticosteroids
Doxycycline
Ethambutol and clarithromycin
Piperacillin-tazobactam
Vraag 106:
A 36-year-old woman is evaluated for repeated episodes of sinusitis. Five years ago, she
had a prolonged episode of maxillary sinusitis requiring treatment with amoxicillin. Since
then, she has had three episodes of sinusitis and two episodes of bacterial pneumonia that
have responded well to antibiotic therapy. The patient is otherwise well. Her parents are alive
and well, but a maternal aunt died in her 20s of pneumonia.
On physical examination, vital signs are normal. BMI is 26. Pulmonary examination reveals a
few crackles at the right posterolateral lung base. Complete blood count, serum electrolytes,
renal function tests, and HIV serologies are normal.
Radiographs of the chest reveal diffuse, right lower lobe densities. A CT scan of the head
shows mucosal thickening in the maxillary, sphenoid, and ethmoid sinuses, and a CT scan of
the chest reveals bronchiectasis and bullous changes in the right lower lobe.
Which of the following is the most appropriate next diagnostic step?
A- Bone marrow aspirate
B- Bronchoscopy with bronchoalveolar lavage
C- HIV RNA viral load testing
D- Quantitative immunoglobulin assay
E- T-cell subset panel
Vraag 30
A 39-year-old man with pancreatic cancer is evaluated for profound neutropenia occurring
with each of several rounds of chemotherapy. His absolute neutrophil count has been less
than 100/µL (0.10 × 109/L) for the past 15 days. He also has a cough productive of bloodtinged brown sputum and has had temperatures to 40.1 °C (104.1 °F) for 3 days. Empiric
treatment with piperacillin/tazobactam is started. Chest radiographs reveal several cavitary
lesions in both lungs.
CT:
On physical examination, temperature is 39.1 °C (102.3 °F), blood pressure is 98/62 mm Hg,
pulse rate is 118/min, and respiration rate is 24/min. Pulmonary examination discloses
bilateral crackles and occasional wheezes.
Laboratory studies:
Hemoglobin 8.3 g/dL (83 g/L)
Leukocyte count <100/µL (0.1 × 109/L)
Platelet count <10,000/µL (10 × 109/L)
Creatinine 1.2 mg/dL (106 µmol/L)
Nasopharyngeal swab and expectorated sputum cultures both grow Aspergillus fumigatus.
Which of the following is the most appropriate addition to his treatment?
A- Amphotericin B deoxycholate
B- Fluconazole
C- Ketoconazole
D- Liposomal amphotericin B
E- Voriconazole