QUESTION: 65

A 76-year-old alcoholic male with hypertension, type II diabetes, and a history of congestive heart presented with cough, fever, malaise, and chills. His initial vitals were: HR 110, T: 102°F, RR: 25, B P 90/60, O2 saturation 93% on 4L/NC. The patient decompensated in the ER and was intubated. Intubation was achieved after three attempts secondary to patient vomiting during the initial attempts. Patient was admitted to the ICU with a diagnosis of sepsis and respiratory failure secondary to suspected pneumonia. After obtaining blood and sputum cultures, the initial empiric antibiotic coverage should be which of the following?

gatifloxacin alone
vancomycin and metronidazole
ceftriaxone and azithromycin
ceftriaxone, gatifloxacin, and azithromycin
ampicillin/sulbactam and gatifloxacin

Answer(s): E

Explanation:

Patients with pneumonia who are admitted to the ICU should be given empiric antibiotic coverage once the cultures are sent. According to the guidelines set forth by the Infectious Disease Society of America, empiric antibiotic coverage could be initiated with any of the following:

This patient is at high risk for aspiration because of his vomiting and history of alcoholism. Thus, choice E would be the most appropriate initial regimen in order to cover gram-positive, gram- negative, atypical, and anaerobic pathogens. The ampicillin-sulbactam covers gram positive, negative, and anaerobes. The flouroquinolone adds the atypical coverage in addition to providing gram-positive/ -negative coverage.

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QUESTION: 66

A 31-year-old female health care worker presents to your clinic after a needlestick injury from a patient who subsequently left against medical advice prior to laboratory analysis for HIV or hepatitis. You advise your colleague that:

If the patient had HIV, her risk of seroconversion is 20%.
If the patient had Hepatitis B, her risk of seroconversion is 2%.
If the patient had Hepatitis C, her risk of seroconversion is 5%.
If the patient had HIV, her risk of seroconversion is 0.3%.
If the patient had Hepatitis C, her risk of seroconversion is 50%.

Answer(s): D

Explanation:

The rate of HBV transmission to susceptible health care workers ranges from 6 to 30% after a single needlestick exposure to an HBV-positive patient. The average incidence of anti-HCV seroconversion after unintentional needle sticks or sharps exposure from an HCV-positive source is 1.8% (range, 07%). Average risk of HIV transmission after a percutaneous exposure to HIV-infected blood is approximately 0.3%. Postexposure prophylaxis may reduce the risk of transmission of HIV following a needlestick.

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QUESTION: 67

A 35-year-old woman schedules an appointment in an outpatient clinic for evaluation and treatment of a "mouth problem." She says that she has white spots in her mouth that have been present for a few weeks. In response to your questioning, she states that she has been experiencing fatigue and a 20-lb weight loss over the past several months, although she attributes these symptoms to a dramatic increase in work hours at her job over the same period of time. She denies having any other chronic medical issues and does not use any prescription or OTC medications. As you examine her, you note the presence of white plaques on her buccal mucosa, palate, and tongue. Scraping of the plaques with a tongue depressor elicits pain as well as a small amount of bleeding. Nontender generalized cervical and submandibular lymphadenopathy is present.

Which of the following questions would potentially yield the most useful information in this patient's diagnosis and treatment?

"Do you have a family history of cancer?"
"Have you traveled outside of the country within the past 12 months?"
"Have you engaged in unprotected sexual intercourse?"
"Do you have any sick contacts?"
"How much do you smoke?"

Answer(s): C

Explanation:

This patient's presenting symptoms are consistent with oropharyngeal candidiasis, or thrush. While risk factors for the development of thrush include recent antibiotic use, use of inhaled corticosteroids, and head or neck radiation, thrush is also commonly encountered in immunocompromised patients, such as those positive for HIV. Due to the patient's apparently benign prior medical history and the new onset of multiple complaints in addition to her oral candidal infection, an HIV infection should be considered. In order to assess a patient's risk for HIV exposure, a thorough history should be taken. Risk factors for HIV infection include unprotected sexual intercourse, multiple sexual partners, IV drug use, occupational exposure to blood or bodily fluids, blood transfusion prior to 1985, and use of nonsterile equipment in tattooing or body piercing.
Generally, individuals positive for HIV should not receive live vaccines. Administration of inactivated influenza vaccine is recommended annually in all individuals positive for HIV. Live attenuated influenza vaccine was FDA approved in 2003 in an intranasal formulation but is contraindicated in individuals with immunocompromise. The varicella and MMR vaccines should not be administered to patients with severely symptomatic HIV infection. The
OPV is no longer recommended for use in the United States despite its continued use in many other parts of the world. Instead, inactivated polio vaccine (IPV) is recommended and is safe for use in HIV- positive individuals.

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QUESTION: 68

A 35-year-old woman schedules an appointment in an outpatient clinic for evaluation and treatment of a "mouth problem." She says that she has white spots in her mouth that have been present for a few weeks. In response to your questioning, she states that she has been experiencing fatigue and a 20-lb weight loss over the past several months, although she attributes these symptoms to a dramatic increase in work hours at her job over the same period of time. She denies having any other chronic medical issues and does not use any prescription or OTC medications. As you examine her, you note the presence of white plaques on her buccal mucosa, palate, and tongue. Scraping of the plaques with a tongue depressor elicits pain as well as a small amount of bleeding. Nontender generalized cervical and submandibular lymphadenopathy is present.

Which of the following immunizations is safe to administer to this patient?

inactivated influenza vaccine
live attenuated influenza vaccine (FluMist)
varicella vaccine
oral polio vaccine (OPV)
measles mumps rubella (MMR) vaccine

Answer(s): A

Explanation:

This patient's presenting symptoms are consistent with oropharyngeal candidiasis, or thrush. While risk factors for the development of thrush include recent antibiotic use, use of inhaled corticosteroids, and head or neck radiation, thrush is also commonly encountered in immunocompromised patients, such as those positive for HIV. Due to the patient's apparently benign prior medical history and the new onset of multiple complaints in addition to her oral candidal infection, an HIV infection should be considered. In order to assess a patient's risk for HIV exposure, a thorough history should be taken. Risk factors for HIV infection include unprotected sexual intercourse, multiple sexual partners, IV drug use, occupational exposure to blood or bodily fluids, blood transfusion prior to 1985, and use of nonsterile equipment in tattooing or body piercing.
Generally, individuals positive for HIV should not receive live vaccines. Administration of inactivated influenza vaccine is recommended annually in all individuals positive for HIV. Live attenuated influenza vaccine was FDA approved in 2003 in an intranasal formulation but is contraindicated in individuals with immunocompromise. The varicella and MMR vaccines should not be administered to patients with severely symptomatic HIV infection. The
OPV is no longer recommended for use in the United States despite its continued use in many other parts of the world. Instead, inactivated polio vaccine (IPV) is recommended and is safe for use in HIV- positive individuals.

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QUESTION: 65

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QUESTION: 66

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QUESTION: 67

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