GERM part 1B

A 55-year-old woman presents with a three-week history of low-grade fever, weight loss of 4.5kg (10 lb), and malaise. She is known to have mitral valve prolapse, but is otherwise healthy. She underwent a tooth extraction one month ago. She denies alcohol, tobacco, and illicit drug use. Her temperature is 38.5°C (101.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 145/76 mm Hg. Her chest is clear to auscultation and percussion. Cardiac examination reveals a III/IV holosystolic murmur at the apex that radiates to the axilla. Chest x-ray is normal. Urinalysis is unremarkable. Blood cultures are drawn and empiric antibiotics are started. Echocardiogram shows mitral regurgitation with vegetation on the mitral valve. Which of the following organisms is the most likely cause of this patient's condition?

A 56-year-old man is having intermittent fevers and malaise for the past 2 weeks. He has no other localizing symptoms. Two months ago, he had valve replacement surgery for a bicuspid aortic valve. A mechanical valve was inserted and his postoperative course was uncomplicated. On examination, his temperature is 38°C, blood pressure 124/80 mm Hg, pulse 72/min, and head and neck are normal. There is a 3/6 systolic ejection murmur, the second heart sound is mechanical, and a 2/6 early diastolic murmur is heard. The lungs are clear and the skin examination is normal. Three sets of blood cultures are drawn and an urgent echocardiogram is ordered. Which of the following is the most likely causative organism?

A 57-year-old male presents to your office with a two week history of fever, chills, and generalized weakness. His medical history is significant for a hospitalization for pyelonephritis requiring IV antibiotics six months ago. He also recently underwent cystoscopy for evaluation of persistent dysuria. His past medical history is also significant for an episode of rheumatic fever as a child and Hodgkin's lymphoma treated with chemotherapy 10 years ago. On examination, his temperature is 37.8°C (100°F), blood pressure is 150/86 mmHg, pulse is 98/min and regular, and respirations are 16/min. The patient appears slightly diaphoretic. You note a new II/VI systolic murmur and tender erythematous lesions affecting several fingertips. The remainder of the physical examination is unremarkable. Which of the following bacteria is most likely responsible for his present illness?

A 6-week-old child arrives with a complaint of “breathing fast” and a cough. On examination you note the child to have no temperature elevation, a respiratory rate of 65 breaths per minute, and her oxygen saturation to be 94%. Physical examination also is significant for rales and rhonchi. The past medical history for the child is positive for an eye discharge at 3 weeks of age, which was treated with a topical antibiotic drug. Which of the following organisms is the most likely cause of this child’s condition?

A 60-year-old man comes to the physician because of a 2-day history of fever and left-sided scrotal pain. The pain has progressed in severity and it radiates to the flank. His has also had increased urinary frequency and urgency along with dysuria. His temperature is 38.1°C (100.8°F), blood pressure is 130/75mm Hg, pulse is 86/min, and respirations are 15/min. Physical examination shows left scrotal swelling and a tender scrotal mass; there is no urethral discharge. Rectal examination shows a tender prostate. Laboratory studies show a WBC count of 14,000/microl with a left shift. Urinalysis shows bacteriuria and pyuria. Which of the following is the most likely organism responsible for this patient's findings?

A 60-year-old man presents with fever and malaise 6 weeks after mitral valve replacement. On examination, his temperature is 38°C, blood pressure 130/80 mm Hg, pulse 80/min, and a loud pansystolic murmur at the apex, which radiates to the axilla. He has no skin or neurologic findings. Which of the following is the most likely causative organism?

A 65-year-old female complains of difficulty eating over the last two days. She states that food drops out of her mouth. She has also been having some discharge in her left ear recently. She denies any sore throat, nasal discharge, chest pain, cough, or difficulty breathing. Her past medical history is significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. She has been poorly complaint with follow-up appointments. Her temperature is 38.8°C (101.7°F), pulse is 96/min, blood pressure is 140/90 mmHg, and respirations are 18/min. Examination of the left ear canal shows granulations. There is facial asymmetry, and the angle of the mouth on the left is deviated downward. Which of the following is the most likely causative organism for this patient's condition?

A 65-year-old man comes to the emergency room complaining of 2 days of severe pain and swelling of his right knee. He denies any recent respiratory illness, diarrhea or urinary symptoms. He has a history of severe degenerative joint disease and underwent total knee replacement four years ago. He drinks one can of beer every night and does not use tobacco or illicit drugs. His temperature is 40°C (104°F), blood pressure is 120/60 mmHg, and pulse is 110/min. Examination shows warmth, swelling, and tenderness over the knee. His range of motion is restricted. Synovial fluid white blood cell count is 98,000/microl. Which of the following is the most likely cause of his current condition?

A 65-year-old man comes to the office and complains of pain and a rash with blisters over the left side of his chest. He has experienced pain over the area for the past 2 days. This morning, he noticed blisters while changing his shirt. He also complains of malaise and headache. His pulse is 82/min, blood pressure is 140/90 mmHg, respirations are 14/min and temperature is 36.8°C (98.4°F). Physical examination reveals grouped, tense vesicles arranged in a band along the left side of his chest. Which of the following is the most likely etiology of his condition?

A 73-year-old diabetic man presents with low-grade fever, facial pain over his right maxilla, and bloody nasal discharge for the last three days. For the last day, he has had diplopia. He was diagnosed with diabetes mellitus 10 years ago. For the last year, he has been on insulin. His most recent hemoglobinA1C was 12.0. His temperature is 39.0°C (102.2°F), pulse is 88/min, and blood pressure is 130/76mm Hg. Examination shows right-sided nasal congestion and necrosis of the right nasal turbinate with tenderness over the right maxillary sinus. There is chemosis and proptosis of his right eye. CT scan shows opacification of the right maxillary sinus. Which of the following is the most likely causative organism?

A 73-year-old man from a nursing home develops headache, fever, cough, sore throat, malaise, and severe myalgia during a community outbreak affecting numerous other residents at the home. The symptoms gradually resolve after 3 days, and he starts feeling better but then there is a reappearance of his fever, with cough and yellow sputum production. On examination, his temperature is 38.5°C, pulse 100/min, respiration 24/min, oxygen saturation 88% and crackles in the right lower lung base, bronchial breath sounds and dullness on percussion. CXR reveals a new infiltrate in the right lower lobe. Which of the following is the most likely causative organism?

A 75-year-old female nursing home resident complains of cough and fever. Her past medical history is significant for hypertension, myocardial infarction (experienced two years ago), and a traumatic right foot amputation. Her current medications are atenolol, hydrochlorothiazide, and aspirin. Her temperature is 39.4°C (103°F), pulse is 110/min, respirations are 22/min, and blood pressure is 110/76 mmHg. Crackles are present at right lung base. Chest x-ray reveals a right lower lobe infiltrate. Which of the following pathogens is the most likely cause of this patient's condition?

A husband and wife present to the ED with 1 day of subjective fever, vomiting, watery diarrhea, and abdominal cramps. They were at a restaurant a day before for dinner and both ate the seafood special, which consisted of raw shellfish. In the ED, they are both tachycardic with temperatures of 99.8°F and 99.6°F for him and her, respectively. Which of the following is responsible for the majority of acute episodes of diarrhea?

A previously well 28-year-old female has developed gradual onset of fever and malaise over 2–3 weeks. She also complains of arthralgias and myalgias. Repeated measurement of her temperature reveals a low grade fever between 38°C and 39°C. Physical examination reveals an oval retinal hemorrhage with a clear, pale center; a pansystolic cardiac murmur heard best at the apex; and small, tender nodules on her fingertips. Which of the following is the most likely causative organism?

An 18-year-old man develops fever, neck stiff- ness, and headache. On examination, his blood pressure is 110/80 mm Hg, pulse 100/min, temperature 38.7°C, and neck flexion is very painful. The ears, throat, and sinuses are normal; there are no focal neurologic signs; and the remaining examination is normal. There are no reported similar cases in the community. Which of the following is the most likely causative organism?

An 18-year-old man develops fever, neck stiffness, and headache. On examination, his blood pressure is 105/80 mm Hg, pulse 100/min, temperature 38.7°C, and neck flexion is very painful. The ears, throat, and sinuses are normal; there are no focal neurologic signs, and the remaining examination is normal. His is the second case of meningitis in his university dormitory building. Which of the following is the most likely causative organism?

An 8-year-old sickle-cell patient arrives at the emergency room (ER) in respiratory distress. Over the previous several days, the child has becomeprogressively tired and pale. The child’s hemoglobin concentration in the ER is 3.1 mg/dL. Which of the following viruses commonly causes such a clinical picture?

You are working in the ED on a Sunday afternoon when four people present with acute-onset vomiting and crampy abdominal pain. They were all at the same picnic and ate most of the same foods. The vomiting began approximately 4 hours into the picnic. They deny having any diarrhea. You believe they may have “food poisoning” so you place IV lines, administer IV fluids, and observe. Over the next few hours, the patients begin to improve, the vomiting stops, and their abdominal pain resolves. Which of the following is the most likely cause of their presentation?