American College of Physicians: Internal Medicine — Doctors for Adults ®



From the May ACP Observer, copyright © 2004 by the American College of Physicians.


1. A 23-year-old groundskeeper for a university in Michigan is evaluated because of a series of ulcerating nodules on his right forearm.

The first nodule appeared five days ago, and since that time two more nodules just proximal to the first nodule have appeared. Yesterday, the first second nodule developed small ulcers.

The ulcers and nodules are mildly painful. The patient reports having a low-grade fever, but otherwise is in good health. He has not traveled outside of the Midwest.

On physical examination, his temperature is 99° F (37.2° C). There are a series of nodules arranged in a linear pattern extending proximally from the mid-volar aspect of the right forearm to the elbow.

The distal nodule is the largest, measuring 3x2 cm, and it and the subsequent nodule are ulcerated, showing a red granular base. There are tender, enlarged lymph nodes in the right axilla.

Which of the following is the most likely diagnosis?

A. Cutaneous anthrax
B. Sporotrichosis
C. Cutaneous leshmaniasis
D. Tularemia


2. A 37-year old, previously healthy postal worker in New Jersey is evaluated because of an enlarging sore on his right arm for 10 days. He denies trauma to the arm.

The sore began as a painless, itchy papule that enlarged over one to two days, with small blisters forming on top of the papule that filled with clear fluid. As the blisters enlarged, extensive swelling developed around the sore. The blister broke down, forming a painless ulcer covered by a black scab. His symptoms include low-grade fever and malaise. He has not traveled outside of the mid Atlantic area.

On physical examination the patient is not in any obvious distress. Temperature is 99° F (37.2° C). There is a 3 cm ulcer located on the upper, outer aspect of the right arm. A black, adherent eschar covers the ulcer. The ulcer and eschar are surrounded by extensive non-pitting edema. Lymphadenopathy is present in the right axilla.

Which of the following is the most likely diagnosis?

A. Cutaneous anthrax
B. Cat-scratch disease
C. Tularemia
D. Herpes simplex infection


3. A previously healthy 16-year-old boy is evaluated in the office for dysphagia.

Starting this morning he had difficulty swallowing, with fluid regurgitating out of his nose when he tried to swallow milk. He also reported having "double-vision" while reading the morning newspaper.

On physical examination, he is afebrile, his blood pressure is 120/70 mm Hg, and pulse is 70/min. He has bilateral ptosis and enlarged, sluggishly reactive pupils. The mouth is dry and the pharynx is injected. Muscle strength is good with normal deep tendon reflexes, and there are no sensory changes. The mental status examination is unremarkable.

A patient with similar symptoms was evaluated yesterday. This patient was found to have diplopia, dysarthria, dysphonia and dysphagia as well as hypotonia of the neck muscles.

Which of the following is the most likely diagnosis?

A. Botulism
B. Guillain-Barré polyradiculopathy
C. Myasthenia gravis
D. Poliomyelitis


4. A previously healthy 23-year-old woman residing in Washington is admitted to the hospital with a 2-day history of cough, substernal chest pain, fever (40° C), headache, chills, rigors, myalgias, coryza and sore throat.

On chest X-ray, she has patchy, nodular infiltrates and a pleural effusion. The sputum reveals numerous gram-negative coccobacilli. Despite empiric treatment with a beta-lactam antibiotic, she continues to deteriorate over the next 48 hours.

On the second hospital day, three of her co-workers are admitted to the hospital with similar symptoms. The possibility of a deliberate epidemic is considered, and the differential diagnosis is broadened to include inhalational anthrax, pneumonic plague and inhalation tularemia.

Which of the following communications to the public health system is most appropriate?

A. Immediately inform the CDC
B. Confirm the diagnosis and inform the CDC
C. Immediately inform the local or state public health organization
D. Confirm the diagnosis and inform the local or state public health organization


5. A 37-year-old woman from New Mexico is admitted to the hospital with a rapidly progressive bronchopneumonia.

She was feeling well until two days ago when she developed fever, cough, hemoptysis, dyspnea and chest pain. Within hours of admission to the hospital, gram-negative bacilli are identified in a sputum sample. Two days after admission she is placed on a ventilator to manage respiratory failure.

Which of the following most strongly suggests the possibility that this patient's illness is the result of a bioterrorist attack?

A. Isolation of Yersina pestis from the sputum and blood
B. The presence of inguinal buboes
C. A cluster of similar cases in previously healthy people
D. Respiratory failure


6. A 37-year-old man who is HIV positive is evaluated because of fever and a generalized rash.

He has been in his usual state of health until five days ago when he suddenly developed a fever, headache, myalgias, and a painful, generalized eruption. The patient has been HIV positive for one year, and because he was asymptomatic, elected to postpone antiretroviral medications.

On physical examination, his temperature is 104° F (40° C), blood pressure is 140/86 mm Hg and pulse rate is 100/min. There is a generalized vesicular-pustular eruption that is most prominent over his right shoulder, right arm and right upper back, but several lesions are also evident over the rest of his thorax, face, and extremities.

On any one part of this body, papules, vesicles, pustules, and scabs are present. Six weeks ago his CD4 lymphocyte count was 300 /µL, and his most recent plasma viral load was 200,000 copies/mL.

Which of the following is the most likely diagnosis?

A. Disseminated herpes zoster
B. Erythema multiforme
C. Molluscum contagiosum
D. Smallpox


7. Twelve patients with fever and a generalized vesicular or pustular eruption were admitted to the hospital over the previous two days. After an initial investigation, it is deemed that the cases are highly suspicious for smallpox.

Which of the following smallpox vaccination strategies is most likely to have the best risk/benefit ratio?

A. National mass vaccination program
B. Ring vaccination and containment
C. Vaccination of immediate family only
D. Vaccination of the index cases


8. A 38-year-old woman is evaluated in the emergency department because of fever and a generalized rash. She was in her usual state of good health until seven days ago.

At that time, she rapidly developed a high fever, headache, backache, chills and abdominal pain with occasional vomiting. Four days ago she developed a rash. It started as a red, flat rash, then evolved into small papules, and now consists entirely of vesicles. She takes no medications. She recalls having chickenpox as a child.

On physical examination, her temperature is 104° F (40° C), blood pressure is 148/90 mm Hg and pulse is 112/minute. She appears acutely ill and is possibly confused. She has a generalized vesicular eruption on her face, extremities (including the palms and soles), thorax and abdomen. The vesicles are well circumscribed, round and firm to palpation.

Which of the following management options should be done next?

A. Collect fluid from the vesicles for culture
B. Have the patient wear a mask at all times
C. Institute airborne and contact precautions
D. Report the case to the CDC


9. Over a four-day period, five men, four women and six children are admitted to Philadelphia metropolitan hospitals with fever, prostration, hypotension and various degrees of mucosal bleeding. All patients have thrombocytopenia, leukopenia, and elevated liver and renal function tests. None of the patients have traveled outside the mid-Atlantic area in the past three months. A viral hemorrhagic fever is suspected.

Which one of the following epidemiological clues most strongly suggests that the outbreak is the result of a deliberate epidemic?

A. Multiple simultaneous epidemics of different diseases
B. Unusual age distribution of a common disease
C. Unusual antibiotic resistance pattern
D. Unusual geographic clustering of disease
E. Unusual route of exposure


Self-Assessment answers:

1. B
2. A
3. A
4. C
5. C
6. A
7. B
8. C
9. D


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