A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications and denies changes in the color of the stool. Physical examination is significant for pale skin and conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7.8 g/dL, reticulocytopenia, microcytosis, and hypochromia. Which of the following is the most appropriate next step in the management of the anemia in this woman?
A. Start iron therapy as soon as possible.
B. Transfuse RBCs and start iron therapy.
C. Start B12 and folate replacement.
D. Identify the cause of the anemia with a thorough history and physical examination.
E. Start iron therapy and B12 replacement.
Correct Answer: D Section: (none)
Explanation:
Iron-deficiency anemia (IDA) is characterized by a low MCV, low ferritin, and a high erythrocyte protoporphyrin in serum. Microcytosis and hypochromia are the hallmark in the peripheral smear. Elevated erythrocyte protoporphyrin in serum can also be seen in anemia of chronic disease and chronic lead poisoning. The USPSTF recommends screening pregnant women for IDA, but found insufficient evidence to recommend for or against routine screening in other asymptomatic persons. However, the guidelines did recommend routine iron supplementation in asymptomatic infants 612 months of age who are at high risk of IDA. Infants are considered to be at high risk if they are living in poverty; are Black, Native American, or Alaskan Native; are immigrants from a developing country; are preterm or low birth weight; or if their primary dietary intake is unfortified cow's milk. The most common cause of cobalamin deficiency is pernicious anemia. Rarely, hypersecretion of gastric acid (i.e., Zollinger-Ellison syndrome) results in cobalamin deficiency. The peripheral smears in folate and cobalamin deficiency are indistinguishable, showing macrocytosis and hypersegmented neutrophils. Both methylmalonic acid and homocysteine levels become elevated with cobalamin deficiency. Folate deficiency is caused by decreased intake, increased utilization, or impaired absorption. Because body stores of folate are low, persons who have an inadequate consumption will become anemic in several months. The recommended amount of dietary folate is 400 g/day. Anemia is not a diagnosis in itself; it is an objective sign of the presence of a disease. It is always secondary to an underlying condition. In most cases, a thorough history and physical examination can help elicit the pathogenesis of the anemia and direct appropriate treatment.
Question 722:
A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications
and denies changes in the color of the stool. Physical examination is significant for pale skin and
conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7.8 g/dL,
reticulocytopenia, microcytosis, and hypochromia.
In vitamin B12 or folate deficiency, which of the following statements is correct?
A. High serum levels of homocysteine and decreased levels of methylmalonic acid are reliable indicators of cobalamin deficiency.
B. The recommended amount of dietary folate is 800 g/day.
C. The peripheral smear in patients with cobalamin deficiency is identical to that found in folate deficiency.
D. The most common cause of cobalamin deficiency is hypersecretion of gastric acid (i.e., Zollinger-Ellison syndrome).
E. Because body folate stores are high, individuals with low consumption of folate will take several years to become anemic.
Correct Answer: C Section: (none)
Explanation:
Iron-deficiency anemia (IDA) is characterized by a low MCV, low ferritin, and a high erythrocyte protoporphyrin in serum. Microcytosis and hypochromia are the hallmark in the peripheral smear. Elevated erythrocyte protoporphyrin in serum can also be seen in anemia of chronic disease and chronic lead poisoning. The USPSTF recommends screening pregnant women for IDA, but found insufficient evidence to recommend for or against routine screening in other asymptomatic persons. However, the guidelines did recommend routine iron supplementation in asymptomatic infants 612 months of age who are at high risk of IDA. Infants are considered to be at high risk if they are living in poverty; are Black, Native American, or Alaskan Native; are immigrants from a developing country; are preterm or low birth weight; or if their primary dietary intake is unfortified cow's milk. The most common cause of cobalamin deficiency is pernicious anemia. Rarely, hypersecretion of gastric acid (i.e., Zollinger-Ellison syndrome) results in cobalamin deficiency. The peripheral smears in folate and cobalamin deficiency are indistinguishable, showing macrocytosis and hypersegmented neutrophils. Both methylmalonic acid and homocysteine levels become elevated with cobalamin deficiency. Folate deficiency is caused by decreased intake, increased utilization, or impaired absorption. Because body stores of folate are low, persons who have an inadequate consumption will become anemic in several months. The recommended amount of dietary folate is 400 g/day. Anemia is not a diagnosis in itself; it is an objective sign of the presence of a disease. It is always secondary to an underlying condition. In most cases, a thorough history and physical examination can help elicit the pathogenesis of the anemia and direct appropriate treatment.
Question 723:
A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications
and denies changes in the color of the stool. Physical examination is significant for pale skin and
conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7.8 g/dL,
reticulocytopenia, microcytosis, and hypochromia.
The U.S. Preventive Services Task Force (USPSTF) recommends screening for iron deficiency in which of
the following?
A. asymptomatic persons over the age of 65 at risk for gastric cancer
B. immigrants from developing countries
C. asymptomatic infants at high risk
D. pregnant women
E. blood donors
Correct Answer: D Section: (none)
Explanation:
Iron-deficiency anemia (IDA) is characterized by a low MCV, low ferritin, and a high erythrocyte protoporphyrin in serum. Microcytosis and hypochromia are the hallmark in the peripheral smear. Elevated erythrocyte protoporphyrin in serum can also be seen in anemia of chronic disease and chronic lead poisoning. The USPSTF recommends screening pregnant women for IDA, but found insufficient evidence to recommend for or against routine screening in other asymptomatic persons. However, the guidelines did recommend routine iron supplementation in asymptomatic infants 612 months of age who are at high risk of IDA. Infants are considered to be at high risk if they are living in poverty; are Black, Native American, or Alaskan Native; are immigrants from a developing country; are preterm or low birth weight; or if their primary dietary intake is unfortified cow's milk. The most common cause of cobalamin deficiency is pernicious anemia. Rarely, hypersecretion of gastric acid (i.e., Zollinger-Ellison syndrome) results in cobalamin deficiency. The peripheral smears in folate and cobalamin deficiency are indistinguishable, showing macrocytosis and hypersegmented neutrophils. Both methylmalonic acid and homocysteine levels become elevated with cobalamin deficiency. Folate deficiency is caused by decreased intake, increased utilization, or impaired absorption. Because body stores of folate are low, persons who have an inadequate consumption will become anemic in several months. The recommended amount of dietary folate is 400 g/day. Anemia is not a diagnosis in itself; it is an objective sign of the presence of a disease. It is always secondary to an underlying condition. In most cases, a thorough history and physical examination can help elicit the pathogenesis of the anemia and direct appropriate treatment.
Question 724:
While visiting a neighbor, a 14-year-old girl is bitten on the left hand by the neighbor's pet cat. The cat is an indoor pet and has had all of the required routine vaccinations. You see the girl in the office approximately 1 hour after the injury. On the dorsum of the left hand you see two shallow puncture wounds that are not actively bleeding. She has full range of motion of her hand, normal capillary refill, and sensation. You see in the chart that the patient had a diphtheria/tetanus (dT) booster vaccine last year. What is the most appropriate management at this time?
A. Recommend local care at home with hydrogen peroxide and topical antibiotics.
B. Give a booster dT and start oral cephalexin.
C. Give an intramuscular (IM) dose of penicillin and emergently refer to a hand surgeon for debridement.
D. Irrigate the wounds and prescribe oral amoxicillin/clavulanic acid (Augmentin).
E. Start oral ciprofloxacin and refer to the health department for rabies prophylaxis.
Correct Answer: D Section: (none)
Explanation:
Animal bites, most commonly from pet dogs and cats, result in over 1 million wounds in the United States each year. Bites and scratches from cats are prone to infection with organisms that are normally found in the animal's oropharynx. These infections tend to be polymicrobic and include alpha-hemolytic streptococci, staphylococci, and Pasteurella species, among others. Pasteurella infections tend to spread rapidly, often within hours. Cat bites may also result in the transmission of rabies and tetanus. In the setting of a well cared for indoor house pet, rabies would be unlikely and rabies vaccine unnecessary, although reporting the injury to the health department may be required (depending on local statute). A dT booster would not be necessary, as she had one within a year. Surgical debridement would not be necessary for a shallow wound with normal hand function. If there were signs of tendon, nerve, or vascular injury, then surgical evaluation would be mandatory. Local care alone would not be appropriate because of the propensity for cat bite wounds to become infected. Antibiotic prophylaxis is recommended for most cat bite wounds, particularly those involving the hands. The recommended first-line agent is a combination of betalactam and beta-lactamase inhibitor, such as amoxicillin/ clavulanic acid. An alternative regimen includes clindamycin with either TMP-SMZ (Bactrim DS) or a fluoroquinolone.
Question 725:
A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. One month later, a repeat measurement of the patient's CD4 count is 225/L. Which of the following interventions would be the most appropriate at this time?
A. Continue the current regimen without change.
B. Modify the patient's antiretroviral therapy to prevent development of resistance.
C. Discontinue any prophylactic medications that the patient is taking.
D. Begin azithromycin for M. avium complex prophylaxis.
E. Recheck CD4 count due to suspected laboratory error.
Correct Answer: A Section: (none)
Explanation:
Guidelines for the prevention of opportunistic infections in persons with HIV recommend institution of TMPSMZ for P. carinii pneumonia prophylaxis when the CD4 count falls below 200 cells/L. Azithromycin or clarithromycin are recommended for M. avium complex when the CD4 count falls below 50 cells/L. All HIV-infected individuals should be tested for IgG antibody against T. gondii as soon as possible after being diagnosed with HIV infection. Counselling should also be provided regarding avoidance of exposure to sources of Toxoplasma. Ganciclovir would be recommended for CMV prophylaxis if there were a history of prior end-organ disease. In a patient with HIV, a PPD is considered positive if there is 5 mm of induration. In a patient with a normal CXR, no symptoms of active disease and no history of treatment for a prior positive PPD, the recommended treatment would be isoniazid for 9 months. In the absence of a suspicious appearing CXR or symptoms, AFB testing would be unnecessary. A booster test would also be unnecessary, as the initial test is already positive. Multidrug therapy would be indicated only for confirmed or suspected active tuberculosis.
Question 726:
A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy.
A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. He has a PPD
placed and follows up in 48 hours. At the site of the injection you find 6 mm of induration. A CXR is normal.
He has never been treated for tuberculosis or a positive PPD before.
Which management option is most appropriate?
A. Collect sputum samples for 3 days to send for AFB (acid fast bacilli) staining.
B. Empirically start four-drug therapy for active tuberculosis.
C. Empirically start isoniazid daily for 9 months.
D. Have the patient return in 1 week for a second PPD to assess for the presence of a "booster" phenomenon; treat with isoniazid if 10 mm induration.
E. No intervention at this time but repeat the test in 6 months.
Correct Answer: C Section: (none)
Explanation:
Guidelines for the prevention of opportunistic infections in persons with HIV recommend institution of TMPSMZ for P. carinii pneumonia prophylaxis when the CD4 count falls below 200 cells/L. Azithromycin or clarithromycin are recommended for M. avium complex when the CD4 count falls below 50 cells/L. All HIV-infected individuals should be tested for IgG antibody against T. gondii as soon as possible after being diagnosed with HIV infection. Counselling should also be provided regarding avoidance of exposure to sources of Toxoplasma. Ganciclovir would be recommended for CMV prophylaxis if there were a history of prior end-organ disease. In a patient with HIV, a PPD is considered positive if there is 5 mm of induration. In a patient with a normal CXR, no symptoms of active disease and no history of treatment for a prior positive PPD, the recommended treatment would be isoniazid for 9 months. In the absence of a suspicious appearing CXR or symptoms, AFB testing would be unnecessary. A booster test would also be unnecessary, as the initial test is already positive. Multidrug therapy would be indicated only for confirmed or suspected active tuberculosis.
Question 727:
A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. Which of the following management options is most appropriate at this time?
A. Continue with current regiment without change.
B. Add azithromycin for Mycobacterium avium complex prophylaxis.
C. Add TMP-SMZ (Bactrim DS) for Pneumocystis carinii prophylaxis.
D. Test the patient for IgG antibody to Toxoplasma gondii if such a test has not yet been done.
E. Start ganciclovir for CMV prophylaxis.
Correct Answer: D Section: (none)
Explanation:
Guidelines for the prevention of opportunistic infections in persons with HIV recommend institution of TMPSMZ for P. carinii pneumonia prophylaxis when the CD4 count falls below 200 cells/L. Azithromycin or clarithromycin are recommended for M. avium complex when the CD4 count falls below 50 cells/L. All HIV-infected individuals should be tested for IgG antibody against T. gondii as soon as possible after being diagnosed with HIV infection. Counselling should also be provided regarding avoidance of exposure to sources of Toxoplasma. Ganciclovir would be recommended for CMV prophylaxis if there were a history of prior end-organ disease. In a patient with HIV, a PPD is considered positive if there is 5 mm of induration. In a patient with a normal CXR, no symptoms of active disease and no history of treatment for a prior positive PPD, the recommended treatment would be isoniazid for 9 months. In the absence of a suspicious appearing CXR or symptoms, AFB testing would be unnecessary. A booster test would also be unnecessary, as the initial test is already positive. Multidrug therapy would be indicated only for confirmed or suspected active tuberculosis.
Question 728:
A30-year-old female presents to your office for the evaluation of a rash on her back. It has been present and growing for about a week. Along with this rash, she has had a fever, headache, myalgias, and fatigue. Her symptoms started about a week after returning from a camping trip to New England. She denies having any bites from ticks or other insects and exposure to poison ivy and has had no wounds to her skin. On examination, her temperature is 99.5°F and her v ital signs are otherwise normal. Her rash is shown in Figure. Her examination is otherwise unremarkable.
You order IgM and IgG ELISA testing for Borrelia burgdorferi and the results return as negative. Which of the following management options would be most appropriate?
A. Treat the patient with a topical steroid for presumed contact dermatitis.
B. Treat the patient with oral steroids for a presumed systemic allergic reaction.
C. Treat the patient with oral cephalexin for streptococcal cellulitis.
D. Treat the patient with doxycycline for Lyme disease.
E. No medication at present, but have the patient return in 68 weeks for repeat serologic testing and treat for Lyme disease if positive at that time.
Correct Answer: D Section: (none)
Explanation:
Lyme disease is the most common vector-borne disease in the United States. It is caused by infection with
B. burgdorferi, a spirochete that is transmitted to humans through the bite of ticks of the Ixodes family. These ticks are very small, so frequently the victim is unaware of having been bitten. After an incubation of 330 days, a red macule or papule develops at the site of the bite, which expands to form a large annular lesion with partial central clearing or several red rings within an outside ring. The lesion, erythema migrans, is often said to resemble a "bull's-eye" target. Within a few days or weeks of this, the patient often complains of flu-like symptoms fever, chills, myalgias, headache, fatigue caused by the hematogenous spread of the spirochete. Lyme disease has been found in most of the United States, but is most common in the New England states, where over 20% of Ixodes ticks are infected with the spirochete. Left untreated, patients may progress to develop multiple complications, including neurologic, musculoskeletal, or cardiac involvement. Lyme disease is usually diagnosed by recognition of the symptoms and signs, along with serologic testing. However, serologic tests may be negative for several weeks after infection. IgG and IgM should be tested in acute and convalescent samples. Only 2030% of exposures will have positive acute antibody responses, whereas 7080% will have positive convalescent titers. Samples that are positive by ELISA assay should be confirmed by Western blot testing. Empirical antibiotic therapy, preferably with doxycycline, is recommended for patients with a high probability of Lyme disease--such as those with erythema migrans. Doxycycline is the preferred antibiotic for treatment of early stage Lyme disease in adults because of its effectiveness against Lyme disease and other infections, such as human granulocytic ehrlichiosis, which is also transmitted by Ixodes ticks. Waiting to treat until convalescent titers become positive would not be recommended in this patient, who has a high likelihood of having Lyme disease, as it may result in more complications developing and the need for longer and more intensive treatment. For more advanced stages of disease, such as the presence of nervous system involvement or third-degree heart block, parenteral antibiotic treatment is necessary. Ceftriaxone is the treatment of choice in this setting.
Question 729:
A30-year-old female presents to your office for the evaluation of a rash on her back. It has been present and growing for about a week. Along with this rash, she has had a fever, headache, myalgias, and fatigue. Her symptoms started about a week after returning from a camping trip to New England. She denies having any bites from ticks or other insects and exposure to poison ivy and has had no wounds to her skin. On examination, her temperature is 99.5°F and her v ital signs are otherwise normal. Her rash is shown in Figure. Her examination is otherwise unremarkable.
What is the most likely cause of her rash?
A. contact dermatitis secondary to plant exposure
B. infection transmitted by tick bite
C. infection transmitted by mosquito bite
D. group A Streptococcus suprainfection of small puncture wound
E. allergic reaction to ingested (i.e., food) allergen
Correct Answer: B Section: (none)
Explanation: Lyme disease is the most common vector-borne disease in the United States. It is caused by infection with
B. burgdorferi, a spirochete that is transmitted to humans through the bite of ticks of the Ixodes family. These ticks are very small, so frequently the victim is unaware of having been bitten. After an incubation of 330 days, a red macule or papule develops at the site of the bite, which expands to form a large annular lesion with partial central clearing or several red rings within an outside ring. The lesion, erythema migrans, is often said to resemble a "bull's-eye" target. Within a few days or weeks of this, the patient often complains of flu-like symptoms fever, chills, myalgias, headache, fatigue caused by the hematogenous spread of the spirochete. Lyme disease has been found in most of the United States, but is most common in the New England states, where over 20% of Ixodes ticks are infected with the spirochete. Left untreated, patients may progress to develop multiple complications, including neurologic, musculoskeletal, or cardiac involvement. Lyme disease is usually diagnosed by recognition of the symptoms and signs, along with serologic testing. However, serologic tests may be negative for several weeks after infection. IgG and IgM should be tested in acute and convalescent samples. Only 2030% of exposures will have positive acute antibody responses, whereas 7080% will have positive convalescent titers. Samples that are positive by ELISA assay should be confirmed by Western blot testing. Empirical antibiotic therapy, preferably with doxycycline, is recommended for patients with a high probability of Lyme disease--such as those with erythema migrans. Doxycycline is the preferred antibiotic for treatment of early stage Lyme disease in adults because of its effectiveness against Lyme disease and other infections, such as human granulocytic ehrlichiosis, which is also transmitted by Ixodes ticks. Waiting to treat until convalescent titers become positive would not be recommended in this patient, who has a high likelihood of having Lyme disease, as it may result in more complications developing and the need for longer and more intensive treatment. For more advanced stages of disease, such as the presence of nervous system involvement or third-degree heart block, parenteral antibiotic treatment is necessary. Ceftriaxone is the treatment of choice in this setting.
Question 730:
You receive a call from the nurse at a nursing home for a 70-year-old patient of yours who was febrile overnight and had blood cultures, CXR, and urinalysis ordered by the housestaff. The patient was started empirically on a fluoroquinolone orally. The nurse informs you that the CXR and urinalysis were normal but the blood culture grew out Enterococcus faecalis. The patient has been on oral fluoroquinolone for 36 hours and patient is still febrile but appears stable. Which of the following is most appropriate?
A. Continue the oral quinolone and add an intravenous first-generation cephalosporin. B. Discontinue the oral quinolone and start treatment with an intravenous secondgeneration cephalosporin.
B. Discontinue the quinolone and start treatment with an intravenous thirdgeneration cephalosporin.
C. Discontinue the quinolone and start treatment with intravenous ampicillin and an aminoglycoside.
D. Continue the quinolone, but change from oral to IV route of administration.
Correct Answer: D Section: (none)
Explanation:
No cephalosporin is appropriate for the treatment of E. faecalis. This organism is occasionally sensitive to fluoroquinolones, but this choice is unreliable. The combination of ampicillin and an aminoglycoside is synergistic for susceptible E
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