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A 62-year-old man is brought to the emergency department because of a 12-hour history of fever, fatigue, and severe pain in the toes of his left foot. He rates the pain as a 9 on a 10point scale. He has not had abdominal pain. Six weeks ago, he was discharged from the hospital following antibiotic treatment for diverticulitis; at that time, he was prescribed a 14-day course of intravenous piperacillin and tazobactam to be administered at home via percutaneous intravenous catheter. He has hypertension treated with atenolol. His temperature is 38.9°C (102°F), pulse is 120/min and regular, respirations are 22/min, and blood pressure is 100/60 mm Hg. There is an intravenous catheter in his medial right arm. A grade 2/6, decrescendo, diastolic murmur is heard best at the upper right sternal border. The abdomen is flat and nontender. There is no pedal edema. The second and third toes of the left foot are pale blue and tender. His leukocyte count is 17,000/mm3 (70% segmented neutrophils, 10% bands, and 20% lymphocytes). A blood culture is positive for Staphylococcus aureus. Echocardiography shows vegetations on the aortic valve. Which of the following is most likely to have prevented this complication?
A) Implantation of a port instead of a catheter for administration of piperacillin and tazobactam (WRONG)
B) Initiation of ampicillin and gentamicin therapy instead of piperacillin and tazobactam
C) Addition of fluconazole to the medication regimen for his diverticulitis
D) Removal of the percutaneous intravenous catheter after completion of piperacillin and tazobactam therapy
E) Administration of the pneumococcal polysaccharide vaccine, 23-valent, at discharge
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2. Three weeks after undergoing arteriography through the right groin for evaluation of progressive left calf claudication, a 64-year-old man is noted to have a palpable thrill and a continuous machinery murmur at the arteriography site. Examination shows decreased pedal pulses on the right; pulses had been normal prior to the procedure. The arteriogram is shown ( http://imgur.com/a/WekUl). Which of the following factors is most predictive of the development of heart failure in this patient?
A) Degree of edema in the lower extremity
B) Groin compression causing bradycardia
C) Presence of pallor with elevation and dependent rubor
D) Presence of a pseudoaneurysm
E) Size of the abnormality
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E, AV fistula causing high output heart failure.
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3. A 25-year-old construction worker has had fever and a painful, swollen right hand for 2 days. His temperature is 39°C (102.2°F). The dorsum of the hand is swollen, erythematous, and tender; there is a small traumatic laceration on the dorsum of the hand with a beefyred expanding margin and red streaks extending up the arm. The axillary lymph nodes are palpable and tender. Which of the following is the most likely pathogen?
A) Bacteroides fragilis
B) Clostridium difficile
C) Clostridium perfringens
D) Clostridium tetani
E) Enterobacter cloacae
F) Enterococcus faecalis
G) Escherichia coli
H) Staphylococcus epidermidis
I) Streptococcus pneumoniae
J) Streptococcus pyogenes (Group A)
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4. A 42-year-old man who is HIV positive comes to the emergency department because of a 6week history of moderate pain and intermittent bleeding from his rectum. He also has an enlarging mass in his rectum that he first noticed 6 months ago; he has not sought treatment for the pain until today. He has a 10year history of perianal warts that were last treated 2 years ago with topical podophyllin. His medications are tripledrug antiretroviral therapy; he also takes ibuprofen for pain. Vital signs are within normal limits. There is no inguinal lymphadenopathy. Examination shows a 10-cm, cauliflower-like mass involving the entire perineum. A photograph of the mass is shown ( http://imgur.com/a/iPF8F). Laboratory studies show:
Hemoglobin 14 g/dL
Leukocyte count 16,000/mm3
Segmented neutrophils 72%
Bands 8%
Eosinophils 4%
Basophils 4%
Lymphocytes 10%
Monocytes 2%
Platelet count 215,000/mm3
CD4+ Tlymphocyte count 300/mm3 (Normal≥500)
Serum
Na+ 142 mEq/L
K+ 4.3 mEq/L
Cl− 98 mEq/L
HCO3− 28 mEq/L
Urea nitrogen 26 mg/dL
Creatinine 0.9 mg/dL
Which of the following is the most appropriate next step in management?
A) Topical podophyllin therapy
B) Administration of the human papillomavirus vaccine
C) Biopsy of the mass
D) Chemotherapy
E) Radiation therapy
F) Local excision of the mass
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3) J) Most common bug causing Lymphangitis ----- Streptococcus pyogenes(Group A )
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5. A 37-year-old woman comes to the physician because of a 3 month history of neck swelling and tightness in her throat. She has not had weakness, weight change, or heat or cold intolerance. Examination shows a diffusely enlarged and firm thyroid gland; there is no nodularity. Serum thyroid-stimulating hormone, thyroxine (T4), and triiodothyronine (T3) concentrations are within normal limits. Serum studies show circulating antibodies against thyroid peroxidase and thyroglobulin. Which of the following is the most likely diagnosis?
A) Anaplastic thyroid carcinoma
B) Chronic lymphocytic thyroiditis (Hashimoto disease)
C) Graves disease
D) Papillary carcinoma of the thyroid gland (wrong)
E) Subacute thyroiditis
IF the answer is actually B, then how come the thyroid hormones are normal??
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6. A 65-year-old woman is brought to the emergency department 1 hour after she fell. She has right wrist pain. Her last visit to a physician was 10 years ago. Examination shows swelling and tenderness of the right wrist. An xray of the wrist shows no fracture, but subperiosteal bone resorption is noted in the distal phalanges. Her serum calcium concentration is 12.4 mg/dL, and serum creatinine concentration is 1.2 mg/dL. Which of the following serum concentrations is most likely to be decreased in this patient?
A) 1,25-Dihydroxycholecalciferol
B) Magnesium (wrong)
C) Parathyroid hormone
D) Phosphorus
E) Vitamin C
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7. An 87-year-old woman is brought to the emergency department from a skilled nursing care facility because of a change in mental status during the past 12 hours. She has severe dementia, Alzheimer type, and is unable to give a history. She is currently taking donepezil, atenolol, digoxin, lisinopril, sertraline, docusate, psyllium, and aspirin. On arrival, she is agitated and does not respond to verbal stimuli. Her temperature is 38°C (100.4°F), pulse is 92/min, respirations are 24/min, and blood pressure is 148/86 mm Hg. The lungs are clear to auscultation. The abdomen is distended. There is diffuse guarding with no rebound. Test of the stool for occult blood is negative. Her hematocrit is 34%, leukocyte count is 9500/mm3, and platelet count is 267,000/mm3. An x-ray of the abdomen is shown ( http://imgur.com/a/jb7aK). Which of the following is the most appropriate next step in management?
A) Serial measurement of cardiac enzyme activities
B) CT scan of the abdomen
C) Discontinuation of sertraline
D) Sigmoidoscopy-guided placement of a rectal tube
E) Exploratory laparatomy (Wrong)
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