USMLE MCQ : 26-28 : An immuno-competent patient develops diarrhea .


Question: 28
An immuno-competent patient develops diarrhea .
The treatment of choice would be
a) antiretroviral therapy
b) metronidazole
c) vancomycin
d) albendazole
e) no antibiotics are necessary

Question: 26
A newly diagnosed patient with depression is treated with serotonin selective reuptake inhibitors. A four week drug trial is performed but the patient shows only a partial response. The physician suspects that this is because the patient is a known 'rapid metabolizer' .
An appropriate next step should now include
a) giving a second larger loading dose and increasing the maintenance dose
b) giving a second larger loading dose only
c) increasing the maintenance dose only
d) stopping the medication
e) decreasing the maintenance dose

Question: 31
A seven year old child with chronic nasal obstruction has persistent disabling dysphagia causing sleep disturbance. On inspection there is an appeareance of a 'clusters of grapes' located in the passage that connects the nasopharynx to the oropharxynx. The most appropriate treatment for this child would be
a) incision and drainage
b) adenoidectomy
c) laser treatment
d) steroids
e) interferon therapy

 Question: 28
 Correct Answer: E

Look at the brush border, there are several small spores
Once believed not to be a pathogen in humans, these little creatures live in the brush border of the gut and are an important cause of diarrhea worldwide. In people who are immunocompromised, it can be hard to shake the infection
The most widely used diagnostic test is the modified acid-fast or Kinyoun stain. It is used to detect Cryptosporidium in stool samples. Several immunofluorescent assays are also available, which test for antibodies to the parasite in the blood. Some pharmaceutical companies have produced rapid-result commercial assays, which are moderately successful (~75% detection rate). Polymerase chain reaction (PCR) techniques might also prove to be effective in diagnosing infection.
Treatment usually is not required for cryptosporidiosis in patients who are immunocompetent, and no clinical trials have convincingly demonstrated the efficacy of antimicrobics.

Question: 26 
Correct Answer: C

If the depressive episode has had a partial response but not a full remission after a 4-week trial, then a dose increase with all of the antidepressants except TCAs is a reasonable approach. This recommendation even holds true for the serotonin selective reuptake inhibitors despite their flat dose-response curve because the patient may be a rapid metabolizer and hence may develop plasma drug levels too low for an optimal response. The patient should receive a 4-week trial of this higher dose, assuming that his/her condition is improved sufficiently to warrant this disciplined approach and that s/he is agreeable to it. An increased maintenance dose would be the most rational drug regimen for fast metabolizers. A loading dose is often given because a drug is heavily bound to plasma proteins; this quickly saturates plasma proteins so that therapeutic levels of free drug will be available rapidly. The amount of plasma protein binding is not affected by the rate of drug metabolism, so increasing the loading dose is unnecessary. The maintenance dose is given to maintain adequate levels of free drug in the plasma. Drug clearance is accelerated in rapid metabolizers, and free drug levels decline quickly. Increasing the maintenance dose can help prevent this decline.

 Question: 31
Correct Answer: B

Clinical Indicators for Tonsillectomy/Adenoidectomy include a) Patient with 3 or more infections of tonsils and/or adenoids per year despite adequate medical therapy. b) Hypertrophy causing dental malocclusion or adversely affecting orofacial growth documented by orthodontist. c) Hypertrophy causing upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications. d) Peritonsillar abscess unresponsive to medical management and drainage documented by surgeon, unless surgery performed during acute stage. e) Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy. f) Chronic or recurrent tonsillitis associated with the streptococcal carrier state and not responding to beta-lactamase-resistant antibiotics. g) Unilateral tonsil hypertrophy presumed neoplastic. h) Recurrent suppurative or otitis media with effusion. (Adenoidectomy alone. Tonsillectomy added requires one of the indications listed above.)


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