Fungus-Amongus
A professional landscaper comes in complaining of new skin lesions on his R arm. They appear nodular with overlying erythema, and appear to be spreading along a lymphatic chain up the arm.
What is the most likely causative agent?
What is Sporothrix schenckii
51-year-old man is evaluated in the emergency department for an abrupt loss of consciousness while sitting in a restaurant. The event was witnessed, and the patient was noted to shake for several seconds before he regained consciousness. No prodromal symptoms occurred before the episode. After the event, he had no confusion or altered sensorium. Medical history is significant for nonischemic cardiomyopathy. He is slightly limited by shortness of breath during exercise. He has been taking metoprolol succinate and lisinopril for 9 months.
On physical examination, temperature is normal, blood pressure is 134/78 mm Hg, pulse rate is 72/min, and respiration rate is 15/min. Cardiac examination reveals a regular rhythm with intermittent ectopy. The chest is clear to auscultation. The estimated central venous pressure is normal. No edema is present. Carotid massage produces no bradycardia.
Laboratory findings are notable for a negative result on a serum troponin test.
Telemetry in the emergency department demonstrates short runs of nonsustained ventricular tachycardia. A 12-lead electrocardiogram shows premature ventricular contractions. An echocardiogram demonstrates a left ventricular ejection fraction of 25%.
Which of the following is the most appropriate management?
A. Electroencephalography
B. Exercise treadmill stress testing
C. Implantable cardioverter-defibrillator placement
D. PET of the mediastinum
E. Tilt-table testing
C. Implantable cardioverter-defibrillator placement
Implantable cardioverter-defibrillator (ICD) therapy is indicated in patients with nonischemic cardiomyopathy who have a left ventricular ejection fraction less than or equal to 35% and who have New York Heart Association functional class II or III symptoms; ICD implantation is also reasonable for patients with nonischemic cardiomyopathy and unexplained syncope and significant left ventricular dysfunction.
The probability that a patient who has a normal test is actually free of disease.
What is Negative predictive value (NPV)?
Contact dermatitis, such as with a latex allergy, produces this type of immune reaction.
What is Type IV?
Name the causative agent (s) of one of the most common causes of chronic skin infections.
What are dermatophytes.
A 48-year-old woman is evaluated during a new-patient visit. She reports no symptoms. She is fairly sedentary but is trying to become more active by joining the local health club. She has noticed that she is “out of shape” but can cycle on a stationary bike with moderate intensity to the end of her 30-minute workout. Medical history is otherwise unremarkable. She takes no medications.
On physical examination, vital signs are normal. The estimated central venous pressure is 6 cm H2O. The apical impulse is not palpable. Cardiac examination reveals a grade 2/6 midsystolic murmur localized to the left sternal border without radiation. The murmur does not change with respiration or handgrip but does diminish in intensity with standing. The S2 is physiologically split. There are no clicks. The lungs are clear to auscultation. Peripheral pulses are normal in volume and contour. No edema is present.
Which of the following is the most appropriate management?
A. Cardiac magnetic resonance imaging
B. Transesophageal echocardiography
C. Transthoracic echocardiography
D. Routine clinical follow-up without imaging
D. Routine clinical follow-up without imaging
Short, soft systolic murmurs (grade <3) that are well localized to the left sternal border and are not associated with symptoms often do not require further investigation.
This measures the probability that the test result is due to chance alone.
What is P-Value?
This is how to establish a diagnosis for a patient with the classic triad of purpura, abdominal pain, and arthalgia for IgA vasculitis.
What is biopsy of affected organ?
Name this fungus:
- Grows in the soil, particularly in the southwestern part of the US (Arizona, CA)
- Can cause pneumonia (Valley fever)
- Extrapulomary manifestaiton of infections can be cutaneous or rhuematologic
What is Coccidioides
An 81-year-old woman is evaluated following drug-eluting stent placement for stable but disabling angina 1 month ago. After stent placement, she was started on aspirin and clopidogrel. She is currently asymptomatic, and she is interested in minimizing the duration of dual antiplatelet therapy because of her age and comorbid illnesses. Medical history is significant for hyperlipidemia, hypertension, stage 3 chronic kidney disease, and previous peptic ulcer disease. Other medications are lisinopril, metoprolol, atorvastatin, and pantoprazole.
On physical examination, vital signs are normal. Oxygen saturation is 98% breathing ambient air. The remainder of the examination is unremarkable.
Which of the following is the most appropriate management of this patient's antiplatelet therapy?
A. Discontinue clopidogrel now
B. Discontinue clopidogrel in 5 months
C. Discontinue clopidogrel in 11 months
D. Discontinue clopidogrel and aspirin in 11 months
E. Discontinue clopidogrel in 29 months
B. Discontinue clopidogrel in 5 months
Dual antiplatelet therapy is recommended for at least 6 months after drug-eluting stent placement for treatment of stable angina.
In patients who undergo PCI with bare metal stent placement, DAPT may be discontinued after 1 month; however, this patient with a drug-eluting stent requires longer therapy.
The equation (TP+FN)/(TP+FP+TN+FN) measures this.
What is Prevalence?
90% of cases of mixed cryoglobulinemia are associated with this infection.
What is Hepatitis C infection?
Name the 3rd most frequent cause of invasive fungal infections in immunocompromised patients.
What is Mucormycosis
A 19-year-old man is evaluated for a heart murmur noted on physical examination. He reports no symptoms. Medical history is noncontributory. He takes no medications.
On physical examination, vital signs are normal. The patient is of short stature with hypertelorism, neck webbing, and a low hairline. The central venous pressure is elevated with a prominent a wave. Apical impulse is normal, and a prominent impulse is noted at the left upper sternal border. The S1 is normal; the S2 is soft. A grade 4/6 late-peaking systolic murmur is heard best at the left sternal border and second left intercostal space. An ejection click is not audible. The remainder of the examination is unremarkable.
Echocardiogram demonstrates a dysplastic pulmonary valve with a peak instantaneous systolic gradient of 65 mm Hg. Pulmonary regurgitation is moderate. The right ventricular size and function are normal, but right ventricular hypertrophy is present. The left heart size and function are normal.
Which of the following is the most likely genetic disorder responsible for this patient's findings?
A. Down syndrome
B. Marfan syndrome
C. Noonan syndrome
D. Turner syndrome
C. Noonan syndrome
Noonan syndrome is commonly associated with congenital cardiac lesions, including pulmonary stenosis.
This patient has features of Noonan syndrome, which is an autosomal dominant disorder commonly associated with congenital cardiac lesions, including pulmonary stenosis; the valve is usually dysplastic.
Noonan syndrome should be considered in all patients with pulmonary stenosis, particularly those with short stature, variable intellectual impairment, unique facial features, neck webbing, hypertelorism, and other cardiac abnormalities.
300 subjects were randomized for a trial for the efficacy of a drug. Placebo group has 90% mortality at 1 year. Treatment group has 75% mortality at one year. How many patients need to be treated to save one life?
15/100
A 26-year-old woman is evaluated for a 4-week history of progressive dyspnea on exertion. She has experienced malaise and myalgia for the past 6 months, noting that her arms ache when she does physical activity with them. She was previously healthy. She reports no rashes, headache or jaw claudication, gastrointestinal symptoms, or neurologic symptoms.
On physical examination, blood pressure is 120/60 mm Hg in the right arm and 95/50 in the left arm, pulse rate is 80/min, and respiration rate is 18/min. There is no rash. A reduced radial pulse in the left upper extremity is noted. A grade 2/6 decrescendo diastolic murmur at the left sternal border is heard. The lungs are clear. There is no synovitis. Strength is normal.
Laboratory studies:
Complete blood count
Normal, except for anemia
Erythrocyte sedimentation rate 90 mm/h
Hemoglobin 10 g/dL (100 g/L)
Creatinine: Normal
Antinuclear antibodies: Negative
Urinalysis: Negative
Transthoracic echocardiogram shows mild to moderate aortic valve regurgitation, dilated aortic root, normal valve leaflets, left ventricle dilation, and normal left ventricular ejection fraction.
Which of the following is the most likely diagnosis?
A Giant Cell Arteritis
B IgA Vasculitis
C Kawasaki disease
D Polyarteritis nodosa
E Takayasu Arteritis
E. Takayasu arteritis
Name the 5 major clinical forms of Mucormycosis.
What are:
1. Rhinocerebral
2. Pulmonary
3. Abdominopelvic
4. Primary cutaneous
5. Disseminated
A 45-year-old woman is evaluated for a 12-month history of exertional dyspnea. She experiences shortness of breath during mild exertion, such as house chores and walking on flat surfaces. She describes her symptoms as debilitating, as they have interfered with her activities of daily living. She has not had symptoms at rest, and she has had no palpitations. She takes hydrochlorothiazide for hypertension.
On physical examination, temperature is normal, blood pressure is 112/72 mm Hg, pulse rate is 76/min, and respiration rate is normal. The apical impulse is slightly sustained but not displaced. S1 is increased. There is an early diastolic sound followed by a soft rumble heard best at the apex. S2 is normal.
An echocardiogram shows findings consistent with moderate rheumatic mitral stenosis and minimal mitral regurgitation. The mean gradient across the mitral valve is 8 mm Hg, and the mitral valve area is calculated to be 1.8 cm2. The mitral valve is pliable. Moderate pulmonary hypertension is present, with an estimated pulmonary artery systolic pressure of 45 mm Hg.
Which of the following is the most appropriate next step in management?
A. Exercise echocardiography
B. Medical therapy
C. Percutaneous balloon mitral valvuloplasty
D. Surgical mitral valve replacement
A. Exercise echocardiography
In patients with mitral stenosis who have a discrepancy between the clinical findings and the echocardiographic findings, exercise echocardiography should be pursued to assess the response of the mitral gradient and pulmonary pressures.
This means a positive likelihood ratio of 10%.
What does it mean is 10% of those tested are likely to have the disease?
This vasculitis may occur in the setting of Hepatitis B infection, HIV infection, or hairy cell leukemia.