Sunday, June 17, 2012

Asthma Action Plan

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Nephrotic Syndrome


Nephrotic Syndrome

Nephrotic syndrome is a clinical disorder characterised by oedema, proteinuria, hypoalbuminaemia and hypercholesterolaemia. Minimal change glomerulonephritis accounts for 80 - 85% of nephrotic syndrome in childhood.

Presentation

  • Oedema is the primary feature. This may be subtle (peri-orbital region, scrotum or labia) or gross and include in addition, peripheral oedema of the limbs and sacrum. Ascities and pleural effusions may be present when oedema is gross.
  • History is often of weight gain, poor urine output and sometimes of discomfort as a result of the oedema. A history of preceding upper respiratory tract infection or diarrhoea may be present.
  • Examination should confirm the presence of oedema, assess peripheral perfusion and blood pressure. Examination should include a search for signs suggesting the onset of complications such as infected ascites, renal vein thrombosis (eg enlarged renal mass, loin tenderness and marked heamaturia) and cerebral vein thrombosis.
  • Urinalysis should always be included to make the diagnosis as other causes of oedema such as protein losing enteropathy or cardiac failure may occur.
  • Infections The altered immune system in patients with nephrotic syndrome is responsible for their enhanced risk of infection. Penicillin during oedematous phases is effective prophylaxis.
  • Thrombosis Renal, femoral, cerebral, pulmonary thrombosis may occur in nephrotic patients due to hypovolaemia, high platelet counts and loss of antithrombin III. Thus low dose aspirin is recommended in oedematous nephrotic patients.
  • Acute renal impairment This is due to renal hypoperfusion. Albumin is the treatment (see below).

Investigation

  1. Urinalysis
    A finding of +++ or ++++ is usual on dipsticks. The degree of proteinuria is variable. Proteinuria is usually of the selective type. Microscopic haematuria is present in 15 - 20% of patients with minimal change nephrotic syndrome. Red blood cells and granular casts may suggest the alternative diagnosis of chronic glomerulonephritis as the underlying cause for nephrotic syndrome.
  2. Estimating proteinuria
    A timed collection of urine for protein excretion is not necessary when the diagnosis is clear.
  3. Routine biochemistry
    Urea and electrolytes, creatinine, total protein, albumin, globulin, cholesterol.

Treatment

  1. Admit to hospital for first presentation. In the case of relapses consult with treating physician.
  2. Intravenous albumin is indicated for anuria, hypotension, poor skin perfusion with skin mottling or poor capillary return. These are all indicators of a depleted vascular space. Give only in consultation with treating consultant. Give 20% albumin 5 ml/kg (1 g/kg) over 4 hr i.v. Beware of the possibility of hypertension and pulmonary oedema. Frusemide should only be given if the peripheral perfusion markedly improves following the albumin or there are signs of pulmonary oedema or hypertension.
  3. Gross genital oedema causing discomfort may also be an indication for albumin. Frusemide 1 mg/kg i.v. should be given 2 hr later.
  4. Free fluid intake.
  5. Diet with no added salt.
  6. Oral penicillin 12.5 mg/kg/dose bd (prophylaxis) while oedematous. If the child is profoundly ill or appears to have sepsis use cefotaxime 50 mg/kg/dose 6-hourly to a maximum of 2 g/dose (to cover Strep pneumoniae, H influenzae and E coli).
  7. Low dose aspirin (10 mg/kg alternate days).
  8. Strict fluid balance.
  9. Daily weight.
  10. Corticosteroids

Prednisolone

  • 60 mg/m2 per day as a single dose up to (max 80 mg/day) for 4 weeks. Then:
  • 40 mg/m2 alternate day for 4 weeks.
  • 20 mg/m2 per alternate day for 4 weeks.
  • 15 mg/m2 per alternate day for 4 weeks.
  • 10 mg/m2 per alternate day for 4 weeks.
  • 5 mg/ m2 per alternate day for 4 weeks.

Relapses

Over 75% of patients will experience at least one relapse, usually in the setting of an intercurrent illness.
A relapse is defined as proteinuria ++++ or +++ for 4 days. Lower levels of transient proteinuria with fever do not require re-treatment. 
  • prednisolone 60 mg/m2 per day till proteinuria dip test result in 0, trace or +. Then:
  • 40 mg/m2 alternate day for 2 weeks.
  • 20 mg/m2 alternate day for 2 weeks.
  • 15 mg/m2 alternate day for 2 weeks.
  • 10 mg/m2 alternate day for 2 weeks.
  • 5 mg/m2 alternate day for 2 weeks.
If oedema recurs also restart penicillin and aspirin.
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Saturday, June 16, 2012

Model Exam for PG Medical Entrance Answers 17-06-2012


1.                  E
2.                  C
3.                  D
4.                  C
5.                  E
6.                  D
7.                  D
8.                  E
9.                  C
10.              D
11.              A
12.              E
13.              D
14.              D
15.              D
16.              C
17.              B
18.              E
19.              E
20.              B
21.              E
22.              E
23.              D
24.              D
25.              A
26.              A
27.              E
28.              E
29.              D
30.              C
31.              D
32.              D
33.              A
34.              D
35.              D
36.              E
37.              B
38.              A
39.              A
40.              C
41.              A
42.              C
43.              E
44.              C
45.              D
46.              A
47.              D
48.              E
49.              C
50.              A
51.              C
52.              B
53.              I
54.              E
55.              C
56.              B
57.              B
58.              C
59.              B
60.              B
61.              B
62.              B
63.              C
64.              D
65.              C
66.              B
67.              C
68.              E
69.              D
70.              D
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Model Exam for PG Medical Entrance Question Paper 17-06-2012


1.         Histologic sections from an irregular, enlarging brown lesion on the left forearm of a 23-year-old male who is HIV-positive would most likely reveal which of the following?
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A.
Irregular vascular spaces lined by nests of uniform cells
B.
Multiple dilated endothelial-lined vessels that lack red blood cells
C.
Numerous neutrophils, nuclear dust, and purple granules
D.
Proliferating blood vessels, endothelial cells, and fibroblasts
E.
Proliferating spindle stromal cells with slitlike spaces and extravasation of erythrocytes
2. A patient with the Marfan's syndrome is evaluated at a clinic. He is noted to have a tall, thin body habitus, loose joints, and arachnodactyly (spider fingers). Ophthalmologic examination reveals lens dislocation. Echocardiogram reveals dilation of the aortic root. A family history reveals that the patient's parents are medically normal, but that his paternal grandfather and great-grandfather died in their forties with lens dislocation and dissecting aortic aneurysms. A sister is found to have a similar body habitus, dilation of the aortic root, and normal lenses. The different findings in these different family members with the same disease are best described by which of the following terms?
A.
Pleiotropy
B.
Founder effect
C.
Variable expressivity
D.
Incomplete penetrance
E.
Genetic heterogeneity
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3.         Which of the following is a highly selective inhibitor of cyclooxygenase II?
A.
Aspirin
B.
Acetaminophen
C.
Ibuprofen
D.
Celecoxib
E.
Piroxicam
4.         The gross appearance of the kidney showed -dilation of the renal pelvis, clubbing of the calyces, and irregular reduction in parenchymal mass . Microscopically, there is atrophy and dilation of tubules with colloid in some tubules.The cortex and medulla showed inflammation and fibrosis –It  is most compatible with which of the following conditions?
A.
Cystic renal dysplasia
B.
Acute pyelonephritis
C.
Chronic pyelonephritis
D.
Acute glomerulonephritis
E.
Chronic glomerulonephritis
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5.         Which of the following is seen most commonly in association with primary biliary cirrhosis (PBC)?
A.
Positive antinuclear antibody (ANA)
B.
Increased ceruloplasmin
C.
Increased ferritin
D.
Positive hepatitis B surface antigen
E.
Positive antimitochondrial antibody (AMA)
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6.         The velocity of nerve conduction is increased with a decrease in the which of the following?
A.
Diameter of the nerve fiber
B.
Degree of myelinization
C.
Space constant of the nerve fiber
D.
Capacitance of the nerve fiber membrane
E.
Resting membrane potential
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7.         It has been noted that infants placed on extremely low-fat diets for a variety of reasons often develop skin problems and other symptoms. This is most often due to
A.
Lactose intolerance
B.
Glycogen storage diseases
C.
Antibody abnormalities
D.
Deficiency of fatty acid desaturase greater than 9
E.
Deficiency of chylomicron and VLDL production
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8.         A 32-year-old male presents with scrotal enlargement. Physical examination, including scrotal transillumination, reveals the presence of a testicular cyst containing clear fluid. This abnormality most likely results from fluid accumulating within which of the following structures?
A.
Ampulla of the ductus deferens
B.
Appendix testis
C.
Epididymis
D.
Seminal vesicles
E.
Tunica vaginalis
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9.         Which of the following arterial pulse waveforms is consistent with severe left ventricular impairment?
A.
Parvus et tardus pulse
B.
Bisferiens pulse
C.
Pulsus alternans
D.
Hyperkinetic pulse
E.
Dicrotic pulse
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10.       A long-lasting depletion of norepinephrine can be produced by administration of which of the following?
A.
Amphetamine
B.
Apomorphine
C.
Clonidine
D.
Reserpine
E.
Yohimbine
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11.       An apathetic male infant is found to have peripheral edema, a “moon” face, and an enlarged, fatty liver. Which one of the following mechanisms is involved in the pathogenesis of this child’s abnormalities?
A.
Decreased protein intake leads to decreased lipoproteins
B.
Decreased caloric intake leads to hypoalbuminemia
C.
Decreased carbohydrate intake leads to hypoglycemia
D.
Decreased fluid intake leads to hypernatremia
E.
Decreased fat absorption leads to hypovitaminosis
12.       A 3-year-old child presents at the physician’s office with symptoms of coryza, conjunctivitis, low-grade fever, and Koplik’s spots. The causative agent of this disease belongs to which group of viruses?
A.
Adenovirus
B.
Herpesvirus
C.
Picornavirus
D.
Orthomyxovirus
E.
Paramyxovirus
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13.       A man breathing room air at sea level has a PaCo2 of 48 mmHg. Which of the following is his alveolar oxygen tension (PaO2)?
A.
150 mmHg
B.
110 mmHg
C.
100 mmHg
D.
90 mmHg
E.
60 mmHg
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14.       Lack of glucocorticoids and mineralocorticoids might be a consequence of which of the following defects in the adrenal cortex?
A.
Androstenedione deficiency
B.
17-hydroxyprogesterone deficiency
C.
Estrone deficiency
D.
C-21-hydroxylase deficiency
E.
Testosterone deficiency
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15.       Neutral protamine Hagedorn (NPH) differs from extended insulin Zn suspension in which of the following actions?
A.
It activates receptor tyrosine kinases
B.
It causes movement of intracellular glucose transporters to the cell membrane
C.
Following subcutaneous injection, it reaches peak plasma concentrations in 6 to 10 h
D.
It has a shorter duration of action
E.
It increases lipogenesis
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16.       The screening test for phenylketonuria (PKU) is called the Guthrie test. Based on this screening method, which of the following is the most likely explanation of a false-negative screen in a newborn?
A.
Bacteria placed on the agar plate
B.
Excess infant blood on the agar plate
C.
Sampling of infant blood before adequate dietary intake
D.
Sampling of infant blood after the newborn period
E.
Adding an inhibitor of bacterial growth to the plate
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17.       An increase in the P50 of an oxyhemoglobin curve would result from a decrease in which of the following?
A.
Metabolism
B.
pH
C.
Temperature
D.
Oxygen
E.
2,3-DPG
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18.       A 55-year-old man who has worked for many years as a stevedore (stevedore = person employed in loading and unloading ships.) develops pain and weakness in the lower back that radiates down the posterolateral thigh and lower aspect of the leg. This is characterized as which of the following?
A.
Mononeuropathy
B.
Brown-Séquard's syndrome
C.
Polyneuropathy
D.
Mononeuropathy multiplex
E.
Radiculopathy
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19.       Which of the following compounds serves as a primary link between the citric acid cycle and the urea cycle?
A.
Malate
B.
Succinate
C.
Isocitrate
D.
Citrate
E.
Fumarate
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20.       Which one of the following individuals is most likely to have a tumor that has a histologic appearance characterized by undifferentiated mesenchymal cells with immature tubules and abortive glomerular formation?
A.
A 2-week-old infant with a mid-epigastric mass, projectile vomiting, and normal urinary hydroxy-indoleacetic acid (HIAA)
B.
An 8-month-old infant with an abdominal mass and normal urinary vanillylmandelic acid (VMA)
C.
A 14-month-old infant with an abdominal mass and increased urinary VMA
D.
A 13-year-old child with basophilic stippling of erythrocytes and increased urinary aminolevulinic acid (ALA)
E.
A 39-year-old female with abdominal cramps, watery diarrhea, periodic facial flushing, wheezing, and increased urinary HIAA
21.       At delivery, caudal analgesia is induced by administration of anesthetic into the epidural space in the sacral region. The needle is introduced via which of the following?
A.
Anterior sacral foramina
B.
Dural sac
C.
Intervertebral foramina
D.
Posterior sacral foramina
E.
Sacral hiatus
22.       Which of the following is the single most important bacteria that causes diarrhea world-wide?
A.
Helicobacter pylori
B.
Staphylococcus aureus
C.
Salmonella spp.
D.
Shigella spp.
E.
E. coli
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23.       Sympathetic and parasympathetic nerves reach the pelvic plexus by different pathways. If, during surgical resection of the rectum, the sympathetic nerves were excised bilaterally, which of the following complications would ensue?
A.
A dilated and neurogenic bladder
B.
Loss of control of the external urethral sphincter
C.
Impotence (inability to obtain erection)
D.
Inability to ejaculate
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24.       A diabetic teenager is found to have a pH of 7.1 and normal electrolyte levels (Na+ = 140 mM, K+ = 4 mM, Cl– = 103 mM) except for a bicarbonate of 11 mM (normal 22 to 28 mM). The urine tests positive for ketone bodies, mostly due to acetoacetic acid and acetoacetate (CH3C=OCH2COOH and CH3C=OCH2COO–), which have a pK of 4.8. In this case, it is assumed that acetoacetate is the only significant anion in the blood besides chloride, and that each acetoacetate anion binds and removes one sodium cation during excretion by the kidney. Given that the patient has a normal glomerular filtration rate of about 7 L of blood per hour without any retention of acetoacetate/acetoacetic acid, the rates of sodium, acetoacetate, and acetoacetic acid loss will be
A.
10 mmol/h of each species
B.
50 mmol/h of sodium and acetoacetate, virtually no acetoacetic acid excretion
C.
100 mmol/h of sodium and acetoacetic acid, virtually no acetoacetate excretion
D.
200 mmol/h of sodium and acetoacetate, virtually no acetoacetic acid excretion
E.
300 mmol/h of each species
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25.       A patient with chronic autoimmune (Hashimoto's) thyroiditis develops a rapidly enlarging thyroid mass. Which of the following is the most likely diagnosis?
A.
Thyroid lymphoma
B.
Medullary thyroid carcinoma
C.
Papillary thyroid carcinoma
D.
Anaplastic thyroid carcinoma
E.
Follicular thyroid carcinoma
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26.       Following release of norepinephrine by sympathetic nerves and epinephrine by the adrenal medulla, which of the following metabolic processes is decreased?
A.
Glycolysis
B.
Lipolysis
C.
Gluconeogenesis
D.
Glycogenolysis
E.
Ketogenesis
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27.       A patient tells you that he had an episode of vomiting bright red blood twice in 1 day about 1 week ago, followed the next day by three or four episodes. Vomitus looked like coffee powder. He did not seek medical help then and he said that "it got better except for the pain." The past 3 days he noticed black "sticky" stools and he finally came to see you. Which of the following should be your first concern?
A.
Bleeding colon cancer
B.
Bleeding from lung cancer
C.
Crohn's disease
D.
Cirrhosis
E.
Bleeding peptic ulcer
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A child is evaluated by an ophthalmologist and is found to have retinitis pigmentosa, a disorder characterized by pigmentary granules in the retina and progressive vision loss. The pedigree below is obtained and the family comes in for counseling. What is the risk for individual II-2 of having an affected child if he marries an unrelated woman?




A.
100%
B.
75%
C.
50%
D.
25%
E.
Virtually 0
29.       A 5-year-old boy presents with clumsiness, a waddling gait, and difficulty climbing steps. Physical examination reveals that this boy uses his arms and shoulder muscles to rise from the floor or a chair. Additionally, his calves appear to be somewhat larger than normal. Which of the following is the most likely diagnosis?
A.
Inclusion body myositis
B.
Werdnig-Hoffmann disease
C.
Dermatomyositis
D.
Duchenne’s muscular dystrophy
E.
Myotonic dystrophy
30. Which of the listed types of cells found within the liver is the major source of the excess collagen deposited in cirrhosis?
A.
Hepatocytes
B.
Kupffer cells
C.
Ito cells
D.
Endothelial cells
E.
Bile duct epithelial cells
31.       Which of the following is the proper cytogenetic notation for a female with Down's syndrome mosaicism?
A.
46,XX,+21/46,XY
B.
47,XY,+21
C.
47,XXX/46,XX
D.
47,XX,+21/46,XX
E.
47,XX,+21(46,XX)
32.       A 2-day-old neonate becomes lethargic and uninterested in breast-feeding. Physical examination reveals tachypnea (rapid breathing) with a normal heartbeat and breath sounds. Initial blood chemistry values include normal glucose, sodium, potassium, chloride, and bicarbonate (HCO3–) levels; initial blood gas values reveal a pH of 7.53, partial pressure of oxygen (PO2) normal at 103 mmHg, and partial pressure of carbon dioxide (PCO2) decreased at 27 mmHg. Which of the following is the most appropriate treatment?
A.
Administer alkali to treat metabolic acidosis
B.
Administer alkali to treat respiratory acidosis
C.
Decrease the respiratory rate to treat metabolic acidosis
D.
Decrease the respiratory rate to treat respiratory alkalosis
E.
Administer acid to treat metabolic alkalosis
33.       Coenzymes derived from the vitamin shown below are required by enzymes involved in the synthesis of which of the following?

 Vitamin folic acid
A.
ATP
B.
UTP
C.
CTP
D.
NADH
E.
NADPH
34.       A 45-year-old male with an artificial heart valve is given oral coumadin (Warfarin) to prevent the formation of thrombi on his artificial valve. Which combination of laboratory tests is most likely to be found in this individual?


Tourniquet Test
Bleeding Time
Platelet Count
PTT
PT

A
Positive
Prolonged
Normal
Normal
Normal

B
Normal
Normal
Normal
Prolonged
Normal

C
Positive
Prolonged
Decreased
Normal
Normal

D
Normal
Normal
Normal
Normal
Prolonged

E
Normal
Prolonged
Normal
Prolonged
Normal
A.
A

B.
B

C.
C

D.
D

E.
E

35        A 34-year-old male patient visits a physician with complaints of fatigue, weight loss, night sweats, and "swollen glands." The physician also observes that he has an oral yeast infection.
The figure demonstrates a Western blot for HIV. Based on these results, and assuming a repeatedly reactive ELISA HIV screening test, which of the following is the best course of action?




A.
Repeat the test immediately
B.
Inform the patient that the test is falsely positive
C.
Wait 6 weeks and repeat the test
D.
Consider anti-HIV therapy
E.
Order an HIV RNA test
36.       A 30-year-old male, requests a routine HIV test. The HIV ELISA was weakly positive and is repeated with the same results. The Western blot result is shown below. The patient denies any risk factors for HIV. Which of the following is the most likely cause of a falsely positive HIV test?




A.
A yeast infection
B.
Test cross-reactivity with HTLV
C.
Test cross-reactivity with Epstein-Barr virus
D.
Naturally occurring HIV antibody
E.
A recent "flu" shot
37.       A 59-year-old man presents with heat intolerance and tremor. Thyroid function testing reveals a free T4 of 3.0 (0.7 to 2.0) and TSH of 6.0 (0.5 to 5). Which of the following is the next best diagnostic test?
A.
Thyroid scan and uptake
B.
MRI of the pituitary
C.
Prolactin
D.
Thyroid autoantibodies
E.
T3
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38.       A 37-year-old woman presents with a recurrent swelling in her left upper eyelid. The lesion is biopsied by an ophthalmologist, and a section from that specimen, showed chronic inflammatory reaction with giant cells that surround empty spaces where the lipid vacuoles from the sebaceous glands had been located. Which of the following is the diagnosis?

A.
Chalazion
B.
Hordeolum
C.
Xanthelasma
D.
Hydrocystoma
E.
Sebaceous carcinoma
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39.       A 16-year-old boy presents without pubertal development or development of secondary sexual characteristics. He cannot smell (anosmia). The baseline testosterone and the LH response to LHRH most likely are which of the following?
A.
Low testosterone and normal LHRH response
B.
Normal testosterone and normal LHRH response
C.
High testosterone and normal LHRH response
D.
Low testosterone and no LHRH response
E.
Low testosterone and exaggerated LHRH response
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40.       Mr. Gopalan Nair is affected with Crouzon's syndrome (123500) and has craniosynostosis (i.e., premature closure of the skull sutures) along with unusual facies that includes proptosis secondary to shallow orbits, hypoplasia of the maxilla, and a prominent nose. His son and brother are also affected, although two daughters and his wife are not. Mr. and Mrs. Gopalan Nair are considering having another child. What is the risk that the child will be affected with Crouzon's syndrome?

A.
100%
B.
67%
C.
50%
D.
25%
E.
Virtually 0
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41.       A 7-year-old boy presents with bilateral swelling around his eyes. His parents state that the child's eyes have become "puffy" over the past several weeks, and his urine has become cocoa-colored. Physical examination reveals bilateral periorbital edema, but peripheral edema is not found. The boy is afebrile and his blood pressure is slightly elevated. A urinary dipstick reveals mild proteinuria, while microscopic examination of the boy's urine reveals hematuria with red blood cell casts. Laboratory tests reveal increased ASO titers and decreased serum C3 levels, but C2 and C4 levels are normal. A throat swab for streptococci is negative. A microscopic section from the kidney reveals increased numbers of cells within the glomeruli. An electron microscopic section of the kidney reveals large electron-dense deposits in the glomeruli that are located between the basement membrane and the podocytes. The foot processes of the podocytes are otherwise unremarkable. Which one of the following renal diseases most likely produce the abnormalities in
this young boy?
A.
Acute post-streptococcal glomerulonephritis
B.
Focal segmental glomerulonephritis
C.
Focal segmental glomerulosclerosis
D.
Membranous glomerulonephritis
E.
Minimal change disease


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42        Which of the following regulators are said to act in "cis"?
A.
The lac repressor and mammalian transcription factors
B.
The lac repressor and the lac operator
C.
The lac operator and mammalian enhancers
D.
The lac operator and mammalian transcription factors
E.
Mammalian transcription factors and enhancers
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43.       Hyperkalemia is a contraindication to the use of which of the following drugs?
A.
Acetazolamide
B.
Chlorothiazide
C.
Ethacrynic acid
D.
Chlorthalidone
E.
Spironolactone
44.       A 65-year-old female receives digoxin and furosemide for CHF. After several months, she develops nausea and vomiting. Serum K+ is 2.5 mEq/L.  Electrocardiogram (EKG) reveals an AV conduction defect. What cellular effect is causing these new findings?
A.
Increased intracellular K+
B.
Increased intracellular cyclic guanosine 5''-monophosphate (cGMP)
C.
Increased intracellular Ca2+
D.
Increased intracellular norepinephrine
E.
Increased intracellular nitric oxide (NO)
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45.       Which one of the following proteolytic enzymes is activated by acid hydrolysis of the proenzyme form?
A.
Trypsin
B.
Chymotrypsin
C.
Elastase
D.
Pepsin
E.
Carboxypeptidase
46.       During the course of an evaluation for thyroid function, a 33-year-old man who is infertile, is found to have very low levels of luteinizing hormone. Which of the following is the likely site of his infertility?
A.
Pretesticular
B.
Testicular
C.
Posttesticular
D.
Idiopathic
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47.       For the severe form of nodulocystic acne vulgaris, the first line of therapy is the systemic use of which of the following agents?
A.
Vitamin A
B.
Retinol
C.
Tetracycline
D.
Isotretinoin (13-cis-retinoic acid)
E.
Ciprofloxacin
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48.       Certain amino acids are not part of the primary structure of proteins but are modified after translation. In scurvy, which amino acid that is normally part of collagen is not synthesized?


A.
Hydroxytryptophan
B.
Hydroxytyrosine
C.
Hydroxyhistidine
D.
Hydroxyalanine
E.
Hydroxyproline
49.       A 40-year-old female with duodenal ulcers is treated with a combination of agents that includes clarithromycin. Of the following enzymes, which is inactivated by clarithromycin?
A.
Dihydrofolate reductase
B.
Glucose-6-phosphate dehydrogenase
C.
Cytochrome P450
D.
Na+,K+-ATPase
E.
Na+,K+,Cl- co-transporter
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50.       A patient complained to his dentist about a draining lesion in his mouth. A Gram''s stain of the pus showed a few Gram-positive cocci, leukocytes, and many branched Gram-positive rods. Which of the following is the most likely cause of the disease?
A.
Actinomyces israelii
B.
Actinomyces viscosus
C.
Corynebacterium diphtheriae
D.
Propionibacterium acnes
E.
S. aureus

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