COMLEX USA LEVEL 3

1.

A 42 year old man with a 20 year hx of Type I DM presents with a dime-sized ulcer on the plantar surface of his left foot. On physical exam you notice a swollen area around the wound that is tender and red. An initial X-ray exam demonstrates no periosteal elevation in any parts of the left lower extremity. What is the next step in the managment of this man's problem?

A.

PO txment with Linezolid
B.

Treatment empirically with IV Vancomycin with culture and sensitivity to follow
C.

IV treatment with Oxacillin 500mg IV q 6 hours for 30 days
D.

Order an MRI
E.

Order a blood culture and a bone scan STAT

Correct Answer
D. Order an MRI

Explanation
D. is the correct answer. A is not correct because if it is osteomyelitis PO administration is not going to attack the problem..B is not correct because at this point its not clear that osteomyelitis is the ddx. Ordering an MRI at this point would be the next best thing..Treatment with OXACILLIN (C) COULD BE RIGHT IF CULTURE AND SENSITIVITY DEMONSTRATE THAT IS OSTEO AND THAT IT IS SENSITIVE. ORDERING A BLOOD CULTURE WOULD BE A DEFINITE STEP BUT NOT INITIALLY. AN MRI IS MUCH MORE SPECIFIC THAN A BLOOD CULTURE AND/OR A BONE SCAN IN GIVING THE DIAGNOSIS.

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2.

A 42 year old man with a 20 year hx of Type I DM presents with a dime-sized ulcer on lateral aspect of his left lower extremity. On physical exam you notice a swollen area around the wound that is tender and red. An initial X-ray exam demonstrates periosteal elevation of the distal fibula of the left lower extremity. If cultures demonstrated MRSA and txment is initiated, of the treatments listed below, which would be the most likely to succeed?

A.

IV Vancomycin for 1 week
B.

IV oxacillin for 4-6 weeks
C.

IV linezolid for 2 weeks
D.

PO daptomycin for 6 months.
E.

BOTH A and C

Correct Answer
E. BOTH A and C

Explanation
E. would be the most correct answer. Most likely A. would be sufficient to treat a MRSA.B would be incorrect because oxacillin does not cover MRSA

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3.

A 42 year old man presents with a painful left leg that has progressively become worse over the last 3 days. An initial cbc shows 18000 wbc. On physical exam a quarter-sized ulcer is noted on the plantar surface of his left foot. On physical exam you notice a swollen area around the wound that is tender and red. An initial X-ray exam demonstrates no periosteal elevation of the distal fibula of the left lower extremity. What is the next step in the managment of this man's problem?

A.

Obtain blood cultures and start IV Vancomycin
B.

Obtain MRI ,order blood cultures and begin IV vancomycin
C.

Obtain a bone scan and start IV Oxacillin
D.

Obtain a bone scan and start IV Vancomycin

Correct Answer
B. Obtain MRI ,order blood cultures and begin IV vancomycin

Explanation
The most specific test for osteomyelitis is an MRI..

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4.

A 49 year old type II diabetic who recently had a knee replacement presents with a very painful erythematous area surrounding his prosthesis. His temp by mouth is 102 F. . What is the next step in the managment of this man's problem? He declares that in no uncertain terms is going to go into surgery again. I'm tired of this whole mess; either fix it or let me die.

A.

Obtain blood cultures and start IV vancomycin
B.

Prepare for immediate surgical removal of prosthesis in spite of his insistence
C.

Obtain blood cultures, obtain X-ray, and start antibiotic therapy with IV Vancomycin
D.

Admit to hospital, start IV vancomycin + Rifampin 300 mg PO

Correct Answer
D. Admit to hospital, start IV vancomycin + Rifampin 300 mg PO

Explanation
The patient's symptoms of a painful erythematous area surrounding the prosthesis and a high fever suggest the possibility of an infection. The next step in managing this patient's problem would be to admit him to the hospital for further evaluation and treatment. Blood cultures should be obtained to identify the causative organism, and antibiotic therapy should be initiated with IV vancomycin to cover for potential methicillin-resistant Staphylococcus aureus (MRSA) infection. Additionally, rifampin can be added orally to provide coverage against other potential pathogens. Surgical removal of the prosthesis may be necessary in the future, but it is not the immediate next step given the patient's refusal for surgery.

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5.

78 year old white male with a history of decubitus ulcers presents with a painful red spot on his left buttock. After obtaining a bone biopsy and culture, you discover the culture you would expect with the presentation as described. What is the most likely diagnosis?

A.

Gram positive cocci in chains
B.

Coagulase positive organisms
C.

Gram negative bacilli
D.

A bacteria that is sensitive to Vancomycin

Correct Answer
C. Gram negative bacilli

Explanation
The most likely diagnosis for a 78-year-old white male with a history of decubitus ulcers presenting with a painful red spot on his left buttock and a culture showing gram-negative bacilli is an infection caused by gram-negative bacilli. Gram-negative bacilli are a group of bacteria that have a characteristic appearance when stained with the Gram stain. They are known to cause various infections, including skin and soft tissue infections. In this case, the presence of gram-negative bacilli in the culture suggests that they are the causative agent of the red spot on the patient's buttock.

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6.

A 7 year old black male who is an avid swimmer at the local Y is brought to the office by his mother after complaints by the child of difficulty hearing from his left ear. On physical exam he is afebrile, of average ht. and weight and has no significant past medical hx including no ear infections in the past. What is the most likely diagnosis?

A.

Otitis Media
B.

Malignant Otitis Externa
C.

Otitis Externa
D.

A viral induced Otitis Media

Correct Answer
C. Otitis Externa

Explanation
Based on the given information, the most likely diagnosis is Otitis Externa. This is because the patient is complaining of difficulty hearing from his left ear, which is a symptom commonly associated with Otitis Externa. Otitis Externa is an infection of the outer ear canal, often caused by bacteria or fungi. The fact that the patient is an avid swimmer at the local Y suggests that he may have been exposed to water, which can contribute to the development of Otitis Externa. The absence of fever and past ear infections also supports this diagnosis.

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7.

A 7 year old black male who is an avid swimmer at the local Y is brought to the office by his mother after complaints by the child of difficulty hearing from his left ear. On physical exam he is afebrile, of average ht. and weight and has no significant past medical hx including no ear infections in the past. What is the best explanation for this infection and what is a good first line treatment?

A.

The ear was infected after swimming because swimming can wash out the acidic environment found in the external auditory canal and the best initial treatment is reassurance it will most likely resolve in 5 days with no treatment
B.

The ear was infected because of the immune compromise that swimming does to the external ear environment and the best initial treatment is PO Metronidazole
C.

Normal Acidity of the external ear gets washed out by swimming and the best treatment is a topical antibiotic along with topical hydrocortisone
D.

Inflammation caused by excessive water in the ear..High dose steroids PO for 5 days and then a taper

Correct Answer
C. Normal Acidity of the external ear gets washed out by swimming and the best treatment is a topical antibiotic along with topical hydrocortisone

Explanation
Correct Answer is C..It is most often caused by some method where the acidic environment in the ear is changed to more of a basic environment and an inflammation develops. Treatment with a topical antibiotic will take care of opportunistic bacteria in the canal until the normal flora are returned and a dose of hydrocortisone will reduce the inflammation...Other answers are incorrect.

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8.

A 78 year old white male with respiratory problems presents with a fever of 102 degrees and abdominal pain of 3 days duration. What is the best choice of treatment to cover anaerobic bacteria.

A.

Clindamycin
B.

Metronidazole
C.

Piperacillin
D.

Aztreonam

Correct Answer
B. Metronidazole

Explanation
In this instance based on his presentation choice B would be the correct answer. the best medication for anaerobes abdominaly is metronidazole. Clindamycin is the best for anaerobic strep. Piperacillin is a good choice but metronidazole is better and Aztreonam is not an option for Abdominal anaerobes.

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COMLEX USA Level 3

78 year old white male with a history of decubitus ulcers presents with a painful red spot on his left buttock. After obtaining a bone biopsy and culture, you discover the culture you would expect with the presentation as described. What is the most likely diagnosis?

A 78 year old white male with respiratory problems presents with a fever of 102 degrees and abdominal pain of 3 days duration. What is the best choice of treatment to cover anaerobic bacteria.