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:
Answer(s): D
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.
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?
Answer(s): C
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. TheOPV 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.
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?
Answer(s): A
A 45-year-old male with type II diabetes, hypertension, and hyperlipidemia presents to your clinic as a new patient. He has been out of his cholesterol medications and came to your office requesting a refill. The patient brought his most recent lipid profile (done after he was off his cholesterol medication for 3 months) which revealed:Cholesterol (total): 242 mg/dLHDL cholesterol: 38 mg/dLTriglycerides (TGs): 660 mg/dLLDL cholesterol = unable to calculate due to high TGsHe also had recent liver function tests that were normal. Based on Adult Treatment Panel (ATP) III guidelines, which of the following medications should be the initial pharmacologic treatment for this patient?
Answer(s): B
According to the Third Report of the National Cholesterol Education Program (NCEP) on the ATP III once the TG levels are in very high range (>500 mg/dL) the focus changes from LDL to reducing TGs, as such high levels can trigger acute pancreatitis. Once the LDL is lower than 500 mg/dL, the attention can be turned toward lowering LDL for CHD reduction. The results of various recent meta-analyses revealed that elevated TGs are also an independent risk factor for CHD. Some factors that may lead to elevated TG include obesity, physical inactivity, tobacco use, alcohol use, high carbohydrate diets, diabetes, chronic kidney disease, familial disorders, and certain drugs. ATP III adopts the following classification for serum TGs:· Normal TGs: <150 mg/dL· Borderline-high TGs: 150199 mg/dL· High TGs: 200499 mg/dL· Very high TGs: 500 mg/dLNicotinic acid and fibrates have the largest reduction in TG (2530% and 3550%, respectively) and are thus the first-line recommendations in addition to diet modification and exercise in cases of very high TG. Statins reduce TG by roughly 1033%, while bile acid sequestrant can have no effect or even increase TG levels. Fish oils in high doses can be used in recalcitrant cases as they may reduce TG by up to 50%; however GI side effects are common. It is also important to note that active omega-3 fatty acids make up only 3050% of many fish oil supplements, whereas Omacor has 90% omega-3 fatty acids. Although this class of agents can reduce TG effectively, they have the unwanted effect of elevating LDL-C levels.
A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin.Before doing so, you explain to the patient that antibiotics such as gentamicin are often associated with which of the following?
Aminoglycosides such as gentamicin accumulate in the proximal tubular cells of the kidney, resulting in a defect in renal concentrating ability and reduced glomerular filtration after several days. This renal impairment is almost always reversible. Of all the aminoglycosides, gentamicin and tobramycin are the most nephrotoxic. Aminoglycosides may also cause ototoxicity in the form of irreversible auditory or vestibular damage. There is a direct relationship between aminoglycoside dosage and the risk for development of ototoxicity, so doses should be adjusted according to a patient's baseline renal function. Complicated UTIs involve metabolic or hormonal abnormalities such as those seen in M or during pregnancy; the presence of foreign bodies such as calculi, tumors, or catheters; the presence of strictures causing turbulent urine flow or vesicoureteral reflux; incomplete voiding such as that seen in neurogenic bladder, prostate hyperplasia or cancer; and, the presence of unusual infecting microorganisms. A history of recurrent UTI does not in itself lead to the classification of subsequent infections as complicated. Due to anatomic differences in urethral length between males and females, any UTI in a male is considered complicated. A history of recent surgery does not correlate with development of a complicated UTI unless the surgical procedure resulted in the creation of some anatomic abnormality which increased the risk of infection; examples of such abnormalities include adhesions or strictures. Apostvoid residual volume greater than 50100 mL suggests abnormal bladder emptying, which would predispose an individual to development of UTIs.
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