Board review course badreddine- june 2015 id

1. Board review course
Samar assem Badreddine, MD
Dr Soliman Fakeeh hopsital
June 2015

2. • A 29-year-old male bank employee is referred to you
because of a reactive tuberculin skin test. The test was
obtained as part of new-employee screening He is indian. He
received bacille Calmette-Guerin vaccine but had no previous
tuberculin skin test, and he denied any contact precautions
with tuberculosis patients. He is asymptomatic. Examination is
unremarkable. Chest radiography shows thickening of the left
apical pleura with upper lobe scarring. You repeat the
tuberculin skin test and observe a reaction with 12 mm of
induration. You do which of the following?

3. a. Initiate therapy with isoniazid 300 mg daily for 9 months
b. Initiate therapy with isoniazid 300 mg daily, rifampin 600 mg
daily, pyrazinamide 1500 mg and ethambutol 1,200 mg daily
for 6 months
c. Arrange for annual repeat tuberculin skin testing and Advise
screening all household contact precautionss of the patient
for possible tuberculosis
d. Do not do anything since the positive tuberculin test is due to
prior BCG vaccintion
e. Advise no intervention because the diameter of induration is
less than 15 mm

4. • A 35-year-old Somali woman with diabetes
presents with 4-weeks history of cough and
fatigue. Her chest radiograph shows a
fibronodular infiltrate in the right upper lobe with
a small cavitary lesion. Sputum samples show the
presence of acid-fast bacilli on smear. The
patient is given a clinical diagnosis of pulmonary
tuberculosis and while culture results are
pending, therapy with isoniazid rifampin,
pyrazinamide, and ethambutol is started.

5. • 2 weeks after starting the 4 anti TB medications , she started developing
nausea and RUQ pain. You did liver function tests for her and found that
she had elevated ALT and AST (3.5 times of upper normal) , and alkaline
Phosphatase ( 4 times of upper normal)
• What the most likely offender drug?
a. Rifampicin
b. INH
c. Pyrazinamide
d. Ethambutol
e. A,b,c,
f. A,b
g. A,c

6. • What would be the best next action?
a. Keep all medications since enzymes elevation is less
than 5 times upper normal
b. Stop all medications except ethambutol, and replace
the discontinued ones with second line drugs
c. Stop all medications except ethambutol , add
Moxifloxacin and streptomycin, re-introduce
isoniazid and monitor ALT. if ALT does not rise again
after introduction of INH, then continue on it.
d. Stop all medications except ethambutol , add
Moxifloxacin and streptomycin and continue therapy
on these

7. Introduction of isoniazid did not make ALT rise
again, so you continued your patient on INH,
ethambutol, quinolone and streptomycin. The
duration of therapy is:
a. 6 months
b. 9 months
c. 12 months
d. 18 months

8. • After 1.5 months of therapy, numbness and
tingling involving both feet and lower legs
develop, and these conditions
later become painful. What is the most likely
cause of this patient's symptoms?
a. Isoniazid
b. Rifampin
c. Pyrazinamide
d. Ethambutol

9. • After the second month of therapy, the patient missed her menstrual
period. She is married and is sexually active with her husband of 6 years.
You order a pregnancy test, which is positive. A pregnancy test taken at
the onset of her antituberculosis treatment was negative. She has been
taking all her tuberculosis medications on a daily basis and the oral
contraceptive ethinyl estradiol and norethindrone (Ortho-Novum 1/35).
She reports no dietary changes and has not started taking any additional
medications during the past month. Which
one of the following is the most likely cause of the failure of her oral
contraceptive?
a. Isoniazid
b. Rifampin
c. Pyrazinamide
d. Ethambutol
e. Noncompliance with taking the birth control pills

10. • Answer b.
Rifampin induces hepatic microsomal cytochrome P 450-mediated
enzyme activity, which can profoundly decrease the serum levels of
other drugs metabolized by this pathway Rifampin interaction with
more than 100 drugs, including oral contraceptive agents, has been
described. Additionally, rifampin may alter intestinal flora that, in
turn, alter the enterohepatic circulation of oral contraceptives. In
the treatment of HTV and tuberculosis coinfection, rifampin will
induce the metabolism of protease inhibitors, reducing their
antiviral activity. Other side effects of rifampin include
hepatotoxicity. Cytopenia (decreased leukocyte and platelet
counts), orange discoloratio of body fluids, and hypersensitivity
reactions.

11. 27 year old Patient has 5 weeks history of cough,
hemoptysis, night sweats and weight loss. Chest X-ray
shows that patient has cavitary lesions in right upper
lung. What tests are best to make a timely diagnosis:
a. GenXpertb
b. Sputum AFB
c. Sputum for TB Culture
d. Sputum for TB PCR
e. a,b,c
f. All of the above

12. • GenXpert TB result comes as follows:” MTB
detected, Rifampicin resistance detected”.
What would be the best treatment regimen:
a. INH, Rif, pyrazinamide and ethambutol
b. INH, pyrazinamide and ethambutol
c. INH, pyrazinamide , Moxifloxacin and
ethambutol
d. Pyrazinamide, moxifloxacin, streptomycin and
ethambutol

13. • What transmission based precautions you
must apply when dealing with this patient?
a. Airborne precautions
b. standard and Airborne precautions
c. standard and droplet precautions
d. No need for precautions since the patient is
already started on therapy

14. • When to stop precautions?
a. After 48 hours of starting therapy
b. After 2weeks of starting therapy
c. After 2 weeks of starting therapy AND patient
showing clinical improvement AND 3 samples of
sputum are negative for AFB
d. After 2 months of starting therapy

15. 47 year old patient, admitted to ICU because of acute anterior wall MI.
4 days after being in ICU, the patient started developing fever and
chills.
Physical exam is negative including exam of the insertion site of right
Internal jugular vein that was inserted for him upon admission to ICU.
Physician suspects Central line associated blood stream infection
(CLABSI). What is the best way to make the diagnosis?
a. Since physical exam of insertion site is negative, then the possibility
of CLABSI shall not be considered.
b. Draw Blood cultures both from central line and from peripheral
veins
c. Remove central line and send tip for culture

16. • Blood culture came positive for MRSA. What is
the best management approach?
a. Start patient on Vancomycin, remove central line
and place the patient on contact precautions
precautions.
b. Start patient on Vancomycin, remove central line
and no need to place the patient on any precautions
since line is removed.
c. Start patient on Vancomycin, Do NOT remove the
central line and place the patient on contact
precautions precautions.

17. CALBSI diagnosis is confirmed. What measures
could have prevented this hospital acquired
infection?
a. Use of Chlorhexidine for skin prep during
insertion of central line
b. Apply Maximum barrier precautions during the
insertion of the central line
c. The nurse shall “Scrub the hub” when accessing
the IV port/ hub
d. All of the above

18. When do you stop the contact precautions
precautions?
a. After obtaining 3 nasal swabs that are negative
for MRSA
b. After the repeat blood culture becomes negative
c. After removal of the line and completion of 14
days of IV antibiotics
d. Continue precautions as long as the patient is
hospitalized, and precautions shall be stopped
upon discharge from the hospital

19. CAUTI
Patient is 79 years old, admitted for acute stroke.
Developed fever on day 5 after admission. Had a
foley catheter on 1st day of admission. No dysuria.
Urine culture grew ESBL positive E.Coli. What
precautions you will place the patient on?
a. contact precautions
b. contact precautions
c. Droplet precautions
d. Airborne precautions

20. Duration of precautions
You will continue the patient in transmission
based precautions until:
a. Patient received the full course of antibiotics
b. Repeat urine culture shows no growth
c. Continue on precautions as long as the patient is
admitted even if this is more than 1 month

21. This was confirmed as catheter associated UTI
(CAUTI). What measures could have prevented this
hospital acquired infection?
a. Not inserting a foley catheter unless clinically
indicated
b. Removing the foley catheter as soon as clinically
indicated
c. Full aseptic techniques during insertion of foley
catheter
d. Keep foley catheter as closed system with dependent
drainage
e. All of the above

22. A 20 years old women presents with 1 day history of fever,
cough and shortness of breath. She lives in Jeddah. No contact
precautions with camels. She has SLE and is on chronic
steroids. Chest X-ray showed bilateral interstitial lung
infiltrates. She received influenza vaccine at the beginning of
the fall season. Wbc was 6.2, 78% segmented. The differential
diagnosis includes which of the following:
a. Mers CoV
b. Legionella
c. Influenza virus
d. Mycoplasma pneumonia
e. PCP
f. All of the above

23. What transmission based precautions you shall
apply awaiting the final diagnostic results?
a. contact precautions
b. Droplet and standard precautions
c. contact precautions, droplet and standard
precautions
d. Airborne , and contact precautions
e. No need for precautions before the result is back

24. Nasopharyngeal swab PCR comes positive for
Mers CoV . What transmission based
precautions you keep your patient on and for
how long?
a. contact precautions, droplet and standard
precautions until patient is asymptomatic
b. contact precautions, droplet ad standard
precautions until repeat PCR is negative
c. a and b

25. Patient clinical condition deteriorated and he got intubated.
3days after being on the mechanical ventilation, he started
spiking fever and developed right middle lung consolidation.
Sputum culture grew MDR acinetobacter. Ventilator associated
pneumonia was diagnosed. What measures could have
prevented this hospital acquired infection ?
a. Keeping head of patient elevated to 45 degrees while on the
ventilator
b. Giving peptic ulcer disease prophylaxis
c. Giving DVT prophylaxis
d. Giving patient some time of sedation vacation every day
e. Doing daily mouthwash with chlorhexidine
f. All of the above

26. Patient is 35 year old female, started 5 days ago
on ciprofloxacin 500 mg Bid for UTI. Today
presented to ER with bloody diarrhea and
abdominal cramps. No fever. You suspect that
this could be clostridium difficile colitis. What is
the best way to confirm the diagnosis?
a. Stool for Toxin antigen detection
b. Stool for B toxin PCR
c. a,and b

27. What precautions you have to put your patient on?
a. contact precautions, and use alcohol based
antiseptics after finishing interaction with the patient
b. contact precautions, and wash your hands with soap
and water after finishing interaction with the patient
c. Contact and droplet precautions, and wash your
hands with soap and water after finishing interaction
with the patient

28. Which of the following diagnoses does not
mandate putting your patient on transmission
based precautions.
a. Pneumococcal meningitis
b. Tuberculous arthritis
c. HIV
d. Brucellosis
e. Dengue fever
f. All of the above