On July 21, a 78-year-old woman sought treatment in the emergency room of a hospital in central Ohio because of dysphagia. On examination, she had slightly slurred speech, but no difficulty breathing. A wood splinter from a forsythia bush had been lodged in her left shin for approximately 1 week; the wound site was mildly erythematous and there was a little pus around the splinter. The woman's breath smelled strongly of alcohol and she had many carious lesions of her teeth. The splinter was extracted, her wound was cleaned and she was sent home and told to sober up. She returned the next day with the same symptoms only slightly worse. Her speech was still slurred although she says she had not had a drink since yesterday. She now had trouble opening her mouth and was drooling heavily. She had no fever or headache and had a normal heart rate. Her blood pressure was slightly low, but not dramatically so. No redness nor pus were seen in her throat. Results of a Gram stain of the pus taken the day before from her wound showed a predominance of Gram positive cocci in bunches and a very few Gram positive rods with terminal spores. There were also some rods that looked just like the Gram positive ones, but they were red.
Question 1 - Single Best Answer
What is dysphagia? Bugs Database
A) difficulty swallowing
B) no phagocytes in the blood
C) pain on urination
D) a stumbling gait
E) blurred vision
Question 2 - Single Best Answer
What are some problems that you might want to consider? Bugs Database
A) chronic alcoholism
B) tetanus
C) toxic shock syndrome
D) diphtheria
E) all of the above
Question 3 - Single Best Answer
Diphtheria could cause dysphagia but is probably not a reasonable diagnosis because? Bugs Database
A) the woman is too old
B) her throat looked normal
C) diphtheria is not associated with wounds
D) alcoholics do not get diphtheria because the Corynebacteria are Gram negative and are killed by alcohol
E) diphtheria is a toxigenic infection
Question 4 - Single Best Answer
Meningitis could be excluded on the grounds that? Bugs Database
A) the woman is too old
B) there is no fever or headache
C) her throat is normal
D) her blood pressure was normal
E) meningitis does not produce dysphagia
Question 5 - Single Best Answer
Toxic shock syndrome IS possible but not probable because? Bugs Database
A) 78-year-old women do not menstruate
B) her blood pressure is only slightly low
C) she has an infected wound
D) her throat is normal
E) there are no signs of pyogenic infection
Question 6 - Single Best Answer
What microbiological evidence, as opposed to clinical signs, would make you think of Toxic Shock? Bugs Database
A) the Gram positive rods
B) the Gram negative rods
C) the terminal spores
D) the Gram positive cocci
Question 7 - Single Best Answer
Because you considered tetanus what must be done immediately? Bugs Database
A) tetanus toxoid
B) tetanus antibodies (tetanus immune globulin)
C) penicillin
Because you considered tetanus you give the woman 3000 units of tetanus immune globulin (tetanus antitoxin) and 0.5 cc of tetanus toxoid. You also prescribe a course of penicillin and also vancomycin. The patient's clinical status gradually deteriorated, and mechanical ventilation was required because of increasing generalized rigidity. During the ensuing 2-week period, she was treated for tremors, muscle spasms, abdominal rigidity, apnea, pneumonia, and local infection from her leg wound. Despite aggressive therapy, the woman died.
Question 8 - Single Best Answer
You feel positive that you know what the woman died from. What would it be? Bugs Database
A) wound botulism
B) tetanus
C) gangrene
D) bacteroides infection
E) pneumonia due to neurotoxin-producing mycoplasma
Question 9 - Single Best Answer
Why do you favor a diagnosis of tetanus instead of wound botulism? Bugs Database
A) botulism is a food poisoning - there is no such thing as wound botulism
B) she would have diarrhea if it was wound botulism
C) botulism produces flaccid paralysis- not spastic (rigid) paralysis
D) tetanus is much more common than wound botulism
E) only young boys get wound botulism
Question 10 - Single Best Answer
The woman was treated aggressively for tetanus, but she died anyway. What is the most likely reason? Bugs Database
A) she didn't have tetanus, but wound botulism
B) the tetanus bacilli are not affected by penicillin because they are Gram negative
C) not enough toxoid was given
D) the antibodies to the toxin can't neutralize the cell bound toxin
Question 11 - Single Best Answer
If the woman had come to you right after injuring herself, what one question that you could have asked might have saved her life? Bugs Database
A) Did you fertilize the bush with cow manure?
B) Have you been vaccinated?
C) Have you had a fever?
D) Did you clean the wound?
E) Are you allergic to penicillin?
The patient had no history of any previous tetanus vaccinations. She had been treated about 20 years ago for an infected wound associated with a fractured ankle. In addition, she had sought medical care periodically for treatment of hypertension and other medical problems.
Question 12 - Single Best Answer
Which of the following tests would conclusively prove that the woman died of tetanus? Bugs Database
A) gram stain of the pus from the wound on the second day
B) growth of the organism on blood agar in an aerobic incubator and inoculation into mice
C) analysis of serum taken when she first presented to the Emergency Room with symptoms
D) growth of the organism anaerobically and injection into immunized and unimmunized mice
Question 13 - Single Best Answer
Was the woman's age a factor in her death? Bugs Database
A) yes, directly
B) yes, indirectly
C) no