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Thread: MIcro QUEstion

  1. #1
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    Default MIcro QUEstion

    A 42-year-old woman presents to her physician because of recent urinary tract infections (UTIs). She has been on an unknown oral antibiotic chronically. She has a temperature of 99 F, and costovertebral angle tenderness is noted on the left side. A plain film of the abdomen reveals a radiopaque density filling the left renal pelvis and calyces. Which of the following is the most likely pathogen?

    A. Bacteroides fragilis
    B. Clostridium difficile
    C. Escherichia coli

    D. Proteus mirabilis
    E. Streptococcus bovis

  2. #2
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    Description:
    The correct answer is D. The patient is experiencing recurrent UTIs associated with the presence of kidney stones (the radiopaque density in the renal pelvis and calyces). Urease-producing organisms, such as Proteus mirabilis, create a high urinary pH, contributing to the development of struvite kidney stones. The stone may cause obstruction and urinary stress, leading to infection. These stones are relatively soft and are usually amenable to percutaneous nephrostomy. Acetohydroxamic acid is an effective urease inhibitor. Pseudomonas and Providencia are less common urease-producing organisms that may cause struvite calculi. Bacteroides fragilis (choice A) is associated with peritonitis in patients with an intra-abdominal abscess

    .Clostridium difficile (choice B) is associated with pseudomembranous colitis.

    Escherichia coli (choice C) is the most common cause of UTI.

    Streptococcus bovis (choice E) is a nonenterococcal type of group D streptococcus.

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    Default SURGERY qqq

    An otherwise healthy, 65-year-old woman comes to the physician because of bloody discharge from the right nipple for 2 weeks. On examination, no retraction, erosion, or other abnormal change is present. Palpation reveals an ill-defined, 1-cm nodule located deep in the right areola. Which of the following is the most appropriate next step in diagnosis?

    A. Cytologic examination of nipple discharge
    B. Mammography alone
    C. Ultrasonography
    D. Biopsy under mammographic localization
    E. Mammography followed by fine-needle cytology

  4. #4
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    .Description:
    The correct answer is E. Nipple discharge in the nonlactating breast may be the presenting sign of a number of diseases, the most common of which are intraductal papilloma, carcinoma, and fibrocystic changes. Carcinoma is more likely in women older than 50. Regardless of whether this sign is present, a clinically malignant palpable mass in a postmenopausal woman should be investigated with mammography followed by fine-needle cytology (or excisional biopsy). The features suspicious for malignancy in this case include ill-defined margins of the mass and the hemorrhagic nature of the discharge.

    Cytologic examination of nipple discharge (choice A) may reveal malignant cells but is associated too frequently with false negative results to be reliable. Mammography alone (choice B) is adequate if the breast mass appears benign on clinical grounds. Biopsy or fine-needle aspiration may then be carried out depending on the mammographic findings.

    Ultrasonography (choice C) is mainly used to differentiate between solid and cystic masses. However, it does not allow any inference on the malignant versus benign nature of a lesion. If a lesion is cystic, the fluid should be aspirated and examined cytologically.

    Biopsy under mammographic localization (choice D), i.e., a "stereotactic" biopsy, is not necessary in this case because the lesion is palpable and can be easily sampled by fine-needle aspiration or conventional biopsy.

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