An 18-year-old boy with cystic fibrosis presents to the Emergency Department with a 4-day history of progressively worsening productive cough, fever, and malaise. His temperature is 38.8°C, blood pressure is 110/75 mmHg, heart rate is 104 beats per minute, and respiratory rate is 24 breaths per minute. Chest x-ray demonstrates a right lower lobe infiltrate.
Which antibiotic would be most beneficial for empiric treatment of this patient?
Piperacillin–tazobactam. Cystic fibrosis patients are particularly susceptible to Pseudomonas infections, and the only answer choice that has good coverage of Pseudomonas is D. (A) Vancomycin is used for resistant S. pneumoniae and MRSA. (B) Clindamycin is useful for anaerobic infections (e.g., aspiration pneumonia). (C) Azithromycin is the antibiotic of choice for outpatient treatment of community-acquired pneumonia (CAP). (E) Ceftriaxone is used for inpatient treatment of pneumonia. Trimethoprim– sulfamethoxazole is used for PCP pneumonia. Rifampin is used for the treatment of TB.
A 62-year-old man presents with acute swelling of his left knee. He describes excruciating pain and swelling for the past 2 days. The patient presented with a similar episode 2 years ago, but is unable to recall what condition he was diagnosed with and what medication he was administered. He has a past medical history of diabetes, hyperlipidemia, hypertension, and chronic alcoholism. He drinks 5 to 6 beers per day. He has a temperature of 38.4°C, blood pressure of 120/80 mmHg, and heart rate of 75 beats per minute. Physical examination reveals a tender and erythematous left knee with significantly limited range of motion and marked swelling.
Which of the following is the best next step in management for this patient?
Joint aspiration with synovial fluid analysis. This patient is presenting with signs and symptoms consistent with an acute gout attack. Although unable to recall the exact name of his previous diagnosis, the previous acute episode and patient’s alcohol use lend credence to the history of gouty arthritis. Furthermore, the patient is presenting with acute left knee pain, swelling, and low-grade fever, all confirming the likely diagnosis of gout. Given that septic arthritis and pseudogout can show clinical similarities to gout, it is imperative to first perform joint aspiration and synovial fluid analysis. Synovial fluid analysis of gout will demonstrate a leukocyte count of 2,000 to 50,000/mm3 and negatively birefringent needle-shaped crystals with a negative gram stain and negative culture. (A) Indomethacin (an NSAID) is very helpful in treating acute gout. Nonetheless, the diagnosis of gout must first be confirmed prior to administering indomethacin especially with its side effect profile. (C) Uric acid levels will certainly be elevated in gout (elevated uric acid is the underlying cause of the clinical manifestations); however, uric acid levels do not have a high degree of sensitivity or specificity for diagnosing gout. (D) An x-ray of the knee is not as specific as synovial fluid analysis for diagnosing gout.
A 55-year-old woman presents to the office with a 1-week history of dry cough, sore throat, and nasal congestion. She has a 5 pack-year smoking history but successfully quit over 15 years ago. She was diagnosed with asthma as a child and used an albuterol inhaler intermittently, but has not seen a physician or received an inhaler in the last 10 years. The patient’s temperature is 36.7°C, blood pressure is 120/80 mmHg, and heart rate is 72 beats per minute. Mild rhinorrhea is present but there are no other significant examination findings. A chest radiograph is obtained and shown below.
What is the best next step in management of this patient?
Reassurance. This patient has findings of an upper respiratory infection (URI) including nasal congestion, sore throat, cough, and rhinorrhea. Other common features are sneezing and malaise. The most common pathogens associated with URI include rhinovirus, coronavirus, parainfluenza virus, adenovirus, enterovirus, and RSV. No medications have been demonstrated to shorten the duration of illness, thus reassurance is the correct answer. (A) An albuterol inhaler or nebulizer would be the appropriate treatment if the patient had an asthma exacerbation. However, the patient’s only distant history of asthma and absence of wheezing on lung examination make this diagnosis unlikely. (B) Further evaluation with CT imaging is inappropriate given her normal examination and normal chest radiograph. (C) Azithromycin would be an appropriate answer for a COPD exacerbation; however, her smoking history is minimal and her presenting symptoms lack sputum production or dyspnea. (D) A rapid strep test would be appropriate if the patient met two to three Centor criteria; however, she has a cough without fever, tonsillar exudates, or lymphadenopathy, which gives her a score of zero and makes her risk of streptococcal infection less than 10%.
A 45-year-old woman presents to her physician complaining of 3 weeks of fevers and pain in her knees and ankles. She also states that she often wakes up during the night drenched in sweat. On examination, her temperature is 38.1°C, blood pressure is 123/56 mmHg, heart rate is 78 beats per minute, and oxygen saturation is 98% on room air. She has 1+ radial pulses, 2+ dorsalis pedis pulses, and mild decreased range of motion in her bilateral knees secondary to pain.
Which of the following is the most appropriate next step in management?
Prednisone. The patient’s age and symptoms are consistent with Takayasu arteritis, a large vessel vasculitis defined by granulomatous thickening of the aortic arch and proximal great vessels. Corticosteroids are the preferred treatment. (A) Methotrexate is a treatment for rheumatoid arthritis, which may present with arthritis and low-grade fevers; however, this would not explain the discrepancy between her upper and lower extremity pulses. (C) Endovascular stent placement would be considered if there was concern for coarctation of the aorta. However, coarctation of the aorta (associated with Turner syndrome) has the opposite findings from our patient, showing a decreased blood pressure in the lower extremities with hypertension in the upper extremities. There is also delayed femoral pulses (brachial–femoral delay). (D) Ceftriaxone would be an appropriate treatment for gonococcal arthritis; however, this diagnosis would not produce the difference in upper and lower extremity pulses.
A 47-year-old woman presents to the clinic complaining of headache and nasal discharge. She says that this has happened to her many times before, and it goes away with antibiotics. She also mentions that her urine has been unusually dark for the past few days. On examination, a saddle nose deformity is noted. A urinalysis is performed and shows significant blood with red blood cell casts.
What is the most likely diagnosis?
Granulomatosis with polyangiitis. Formerly known as Wegener granulomatosis, this necrotizing small vasculitis often presents with recurrent sinusitis, pulmonary involvement (infiltrates/nodules on chest x-ray, hemoptysis), and renal involvement (rapidly progressive glomerulonephritis). Testing for c-ANCA should be performed, and the patient should receive immunosuppressive agents (steroids + rituximab or cyclosporine). This patient has sinusitis with a nephritic syndrome, making this a concerning diagnosis. (A) Goodpasture syndrome often presents with pulmonary and renal involvement; however, the recurrent sinusitis and saddle nose deformity seen in this patient suggests granulomatosis with polyangiitis. (B) Poststreptococcal glomerulonephritis is a common cause of the nephritic syndrome; however, it occurs a couple of weeks after a group A strep infection (throat or skin) and would not occur concurrently with sinusitis. (D) Congenital syphilis can also produce a saddle nose deformity, but it would not cause recurrent sinusitis and glomerulonephritis.
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