doc_clotaire
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A 21-year-old man comes to the clinic because he has become increasingly short of breath and has had a cough for the past week.
He appears dyspneic and has a temperature of 38.3EC (101.0EF). On physical examination he has bibasilar rales and generalized
lymphadenopathy (1 to 2 cm). Rectal examination shows multiple perianal contusions and a small amount of blood oozing from the
anal orifice. Chest x-ray film shows bilateral patchy alveolar infiltrates. The most appropriate course of action is to order blood tests and to do which of the following?
(A) Admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
(B) Admit him to the hospital and begin administration of penicillin and gentamicin, intravenously
(C) Begin administration of erythromycin, orally, and see him again the next day
(D) Prescribe isoniazid and rifampin, orally
(E) Recommend aspirin, fluids and rest at home
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| robin082006
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(A) Admit him to the hospital and begin administration of trimethoprim-sulfamethoxazole, intravenously
Homosexual+alveolar infiltrates--> suspected PCP
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| Aashi
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A Direct q on PCP------------>A
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| doc_clotaire
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The correct answer is A
. The history and physical in this 21-year-old man raises the possibility of HIV infection. There is a strong suggestion of homosexuality, given that the
rectal examination demonstrates multiple perianal contusions and blood oozing from the
anal orifice. Furthermore, this man has generalized lymphadenopathy; his chief complaint
is of pulmonary distress with an x-ray consistent with Pneumocystis carinii pneumonia.
Since the patient has become increasingly short of breath and is febrile, he should be
treated with intravenous therapy.
There is nothing here to suggest the possibility of a gram-negative pneumonia, so
gentamicin (choice B) is wrong.
The use of oral erythromycin (choice C) might be appropriate in a patient in whom
Mycoplasma pneumonia is suspected; however, as described above, the strong suspicion
of HIV infection makes this a less likely diagnosis than pneumocystis.
Isoniazid and rifampin (choice D) is not indicated in this case because the findings are
more consistent with Pneumocystis carinii pneumonia than with tuberculosis.
Aspirin, fluids, and rest (choice E) are inappropriate management for this patient with
Pneumocystis carinii pneumonia.
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| doc_clotaire
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6. The correct answer is E
The patient is presenting with signs of septic shock from
pyelonephritis, including nausea, confusion, chills, fever, flank pain, and cloudy urine.
The hemorrhagic extremity lesions are most likely a sign of septicemia and toxemia.
Immediate treatment with intravenous antibiotics is necessary to prevent
cardiopulmonary collapse and death.
Diabetic ketoacidosis (choice A) is a possibility, but the cloudy urine, chills, fever, and
hypotension point to developing pyelonephritis and septic shock in this patient. Diabetic
ketoacidosis alone would be unlikely to give a fever and chills.
Hyperosmolar coma (choice B) typically presents with decreased consciousness in the
absence of signs of sepsis. The cloudy urine, chills, fever, and hypotension point to
developing pyelonephritis and septic shock in this patient.
Meningitis (choice C) is unlikely because the neck is supple. Meningitis cannot be
definitively excluded without a lumbar puncture, however. In this patient, the signs and
symptoms clearly point to pyelonephritis and sepsis, and another source of infection does
not need to be worked up at this time.
Pneumonia (choice D) is unlikely because the lungs are clear. This could be confirmed
by a chest x-ray. However, the patient in this case has signs and symptoms consistent
with pyelonephritis and sepsis.
The correct answer is A.
This patient is young and quite ill. She has multiple medical
issues active at once and therefore, the question requires focus on the physical findings. A
history of insulin dependent diabetes, coupled with the presence of retinopathy on exam,
is an indication that this patient has poorly controlled diabetes. The physical findings of
fever and right CVA pain associated with a history of multiple recurrent urinary
infections makes clear that this patient has an active infection. The danger for her is that
of diabetic ketoacidosis or severe renal damage. In the case of anuria, the most common
cause in poorly controlled diabetics is papillary necrosis. Renal papillary necrosis occurs
in about 2 out of 10,000 people. It is most commonly associated with analgesic
nephropathy and it also occurs in patients with diabetic nephropathy. Diabetics with
retinal lesions have a 20-50% incidence of concomitant renal disease. Anuria is the
setting of severe diabetes is almost always associated with acute tubular necrosis (ATN)
from a cell death such as that with papillary necrosis.
Bladder outlet obstruction (choice B) or renal lithiasis (choice D) are unlikely is this
patient since she has no history of renal calculi.
Neurogenic bladder (choice C) commonly occurs with advanced diabetes as part of the
general autonomic neuropathy. However, it is not an acute occurrence and since the
patient had no history of generalized autonomic dysfunction or bladder dysfunction, this
is unlikely to be the cause of her anuria.
Tumor encroachment on the ureters (choice E) is highly unlikely given that there is no
component of this patient’s history or physical exam that suggests tumor.
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| mjl1717
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Good doc_ clotaire! ... And a pathologist could use a "methenamine silver" stain to highlight this organism.. [Thats what its about!] 
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| doc_clotaire
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Guys , I am SORRY that I put the answers of " kill 2 birds with one stone here "
Please do not pay attention to it , it was a stupid mistake from me ,
SO SORRY PATNERS !
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