101-200

Question 1

A common infectious cause of subacute and chronic meningoencephalitis associated with raised intracranial pressure in immunocompromised patients is

Answer 1

Cryptococcus
neoformans.

Question 2

…………….Herpes simplex virus typically causes acute encephalitis with rapid-onset fever, headache, seizures, focal neurologic signs, and altered consciousness. Neuroimaging typically
shows temporal lobe changes. CSF analysis demonstrates a lymphocytic predominance, frequently with erythrocytes; the glucose level is normal.

Answer 2

Herpes simplex virus

Question 3

Streptococcus pneumoniae, Staphylococcus aureus, and Neisseria meningitidis are common causes of

Answer 3

acute bacterial meningitis. Symptoms include a very rapid onset of
fever, nuchal rigidity, and altered mental status, with a neutrophilic pleocytosis in the CSF

Question 4

A 40-year-old man is admitted to the intensive care unit. He was brought to the
hospital by his wife because of progressive mental status changes during the past 2
days. Four days before admission, he developed a fever, nausea and vomiting, and a
headache that he attributed to “the flu.” During the past 2 days, he has become
increasingly irritable and hostile and has been hearing voices. In the emergency
department, his temperature was 39.4°C. He became increasingly obtunded and
was intubated for airway protection.
A lumbar puncture reveals mild lymphocytic pleocytosis as well as xanthochromia.
MRI shows fluid-attenuated inversion recovery enhancement of his medial temporal
lobes bilaterally.

Answer 4

Encephalitis accompanied by personality changes and temporal-lobe
enhancement on MRI is characteristic of herpes simplex virus encephalitis. The
treatment is intravenous acyclovir.

Cerebrospinal fluid analysis most commonly shows an elevated lymphocyte
count (sometimes with an increased erythrocyte count), mildly elevated protein
levels, and normal or mildly decreased glucose levels. The most frequent findings
on MRI are temporal or inferior frontal-lobe edema (or both) and enhancement on
fluid-attenuated inversion recovery and T2-weighted images. Bilateral temporallobe enhancement is highly suggestive of HSV encephalitis. Diagnosis is made
via cerebrospinal fluid polymerase chain-reaction for HSV-1 and HSV-2. Acyclovir
is the treatment of choice

Question 5

Herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2) are among the most
common causes of

Answer 5

sporadic encephalitis worldwide. Infection can occur in any
age group but is more common in neonates and in adults older than 50 years.
Symptoms in adults include fever, headache, and temporal-lobe symptoms, such
as language difficulties, behavioral disturbances, memory impairment, and
seizures

Question 6

In a patient with suspected Streptococcus pneumoniae meningitis, the most
appropriate regimen to initiate while awaiting antibiotic susceptibilities consists
of

Answer 6

dexamethasone plus both vancomycin and ceftriaxone.

Question 7

In acute bacterial meningitis, the CSF is typically c

Answer 7

loudy with a
neutrophil-predominant pleocytosis, elevated protein levels, and lowered glucose,
with the CSF-to-plasma glucose ratio <0.4. S. pneumoniae is the most common
cause of bacterial meningitis in older adults; it appears as gram-positive lancetshaped diplococci on Gram stain.

Question 8

The most appropriate investigation for a patient with fever, leukocytosis, and
severe back pain is

Answer 8

MRI to evaluate for a suspected spinal epidural abscess.

Question 9

The three most common symptoms of a spinal epidural abscess are

Answer 9

back pain
(about three-quarters of patients), fever (almost half of patients), and neurologic
deficit (about one-third of patients).

Question 10

A high proportion of patients with spinal epidural abscess have one or more
predisposing conditions, including a

Answer 10

potential local or systemic source of
infection (skin and soft-tissue infections, osteomyelitis, urinary tract infection,
indwelling vascular access), intravenous drug use, epidural analgesia, or nerve
block

Question 11

The appropriate antibiotic management for methicillin-susceptible Staphylococcus aureus prosthetic-valve endocarditis is a combination of

Answer 11

nafcillin, rifampin, and gentamicin.

Question 12

Appropriate therapy for methicillin-susceptible Staphylococcus aureus prosthetic-valve endocarditis is a penicillinase-resistant penicillin such as

Answer 12

nafcillin 12 g daily for at least 6
weeks (oxacillin or cefazolin can also be used), in combination with 300 mg of rifampin 3 times daily. Rifampin is added with the hope of penetrating biofilm on the valve
tissue. Intravenous gentamicin should also be included for synergy for the first 2 weeks.

Question 13

is an indication for vaccination against pneumococcus

Answer 13

Current tobacco use

Question 14

In most patients with suspected bacterial meningitis, a lumbar puncture can be
done without any preceding head imaging. However, not all patients can proceed
directly to a lumbar puncture. This procedure carries a risk of

Answer 14

brain stem
herniation and death in those with elevated intracranial pressure; thus, patients at
risk for elevated intracranial pressure should undergo head imaging before
proceeding to lumbar puncture. This includes patients who present with a seizure
(as in this case), those with focal neurologic deficits, those who are
immunocompromised, and those with evidence of papilledema or a moderate-toseverely impaired level of consciousness

Question 15

The most appropriate sequence in managing a patient with suspected bacterial
meningitis and a new-onset, 10-second seizure is

Answer 15

to obtain blood cultures, then
initiate dexamethasone and empiric antimicrobial therapy, and then obtain a CT
scan of the head (before performing a lumbar puncture).

Question 16

The first step in managing cardiac tamponade is

Answer 16

aggressive intravenous fluid
resuscitation, accompanied by a transthoracic echocardiogram to confirm the
diagnosis and, if an effusion is noted, an urgent needle pericardiocentesis or
pericardial window.

Question 17

A specific echocardiographic sign of pericardial tamponade in a patient with a
malignant effusion is

Answer 17

diastolic right ventricular collapse.

Question 18

The physical finding of pulsus paradoxus can be seen in both

Answer 18

constrictive
pericarditis and cardiac tamponade, but it is more common with tamponade than
with constrictive pericarditis. Clinically, patients with constrictive pericarditis tend
to present with fatigue, dyspnea, and peripheral edema. An elevated jugular
venous pressure and pericardial rub may be present as well. Although this
patient’s history of mantle field radiation for lymphoma places her at high risk for
constrictive pericarditis, the early diastolic RV collapse seen on echocardiogram
and the acuity of her symptoms are more consistent with cardiac tamponade

Question 19

Pericardial chest pain is

Answer 19

typically positional (worse when supine,
better when leaning forward) and pleuritic (worse with inspiration), and these
features distinguish it from the pain associated with myocardial ischemia. A
pericardial rub, as heard in this case, classically has three audible components:
atrial systole, ventricular systole, and rapid ventricular filling during early diastole

Question 20

see ecg

Answer 20

this patient’s electrocardiogram shows left ventricular hypertrophy with a left
ventricular strain pattern (downsloping ST–T changes and T-wave inversion in
anterolateral leads, I, aVL, and V4–V6), which is typical of HCM. An
echocardiogram and genetic testing can help to confirm the diagnosis.

Question 21

A fixed, split second heart sound is nearly pathognomonic for a

Answer 21

n atrial septal defect (ASD) and does not occur with other congenital cardiac defects.

Question 22

The electrocardiogram of patients with an atrial septal defect often reveals

Answer 22

an incomplete right bundle-branch block and right-axis deviation due to right ventricular dilatation.

Question 23

A bicuspid aortic valve may cause

Answer 23

a systolic ejection click and murmur but not a fixed, split second heart sound or right ventricular enlargement.

Question 24

A ventricular septal defect creates a

Answer 24

harsh systolic murmur at the lower sternal border — often with an associated thrill — and is not associated with a fixed, split second heart
sound.

Question 25

A patent ductus arteriosus creates a

Answer 25

loud continuous murmur at the upper left sternal border.

Question 26

Ebstein anomaly is associated with a

Answer 26

holosystolic murmur caused by tricuspid regurgitation due to apical displacement of the valve. This may lead to right heart dilatation with
a palpable right ventricular heave. There is usually a split first heart sound due to delayed closure of the tricuspid valve. The second heart sound can be widely split due to a
right bundle-branch block, but it is not a fixed split, such as in ASD

Question 27

In a patient who has mild hypokalemia caused by diarrhea and who can tolerate
food, the optimal management approach is

Answer 27

oral potassium replacement

Question 28

In a patient who has acute kidney injury and rhabdomyolysis secondary to acute
cocaine intoxication, the most appropriate initial step in management is

Answer 28

administration of intravenous isotonic fluid.
Start 0.9% normal saline at 1 liter per hour intravenously

Question 29

The intervention that has been shown to most consistently reduce the risk of contrast-induced acute kidney injury is

Answer 29

infusion of isotonic saline.

Question 30

Amyloidosis refers to the deposition of low-molecular-weight fibrils in
extracellular tissue. The two most common forms of systemic amyloidosis are

Answer 30

primary (AL) amyloidosis and secondary or reactive (AA) amyloidosis. Reactive
systemic (AA) amyloidosis can complicate chronic inflammatory disorders that
are associated with a sustained acute-phase response, such as rheumatoid
arthritis, periodic fever syndromes, inflammatory bowel disease, and tuberculosis
The major sites of amyloid deposition are the kidneys, heart, and liver; however, in
some conditions, amyloid deposition can be limited to one organ, such as the
kidney.

Question 31

Post-infectious glomerulonephritis is usually characterized by

Answer 31

depressed serum complement levels and an active urine sediment, including hematuria, red-cell
casts, and mild-to-moderate proteinuria. Lupus nephritis is unlikely in the setting
of normal complement levels and in the absence of antibodies to double-stranded
DNA.

Question 32

Immunoglobulin A (IgA) nephropathy is typically characterized by

Answer 32

microscopic hematuria. Patients may develop nephrotic-range proteinuria with time, but
nephrotic syndrome is an unusual presentation for IgA nephropathy.

Question 33

Characteristic features of chronic interstitial nephritis include

Answer 33

pyuria and proteinuria that is below 2000 mg per day. Nephrotic syndrome is rarely
associated with interstitial nephritis. An exception is nonsteroidal
antiinflammatory drugs, which can cause concurrent interstitial nephritis and
nephrotic syndrome from either minimal-change disease or membranous
nephropathy

Question 34

In a patient with a chronic inflammatory disorder or a chronic infectious disease,
the most likely cause of nephrotic syndrome is

Answer 34

reactive systemic (AA) amyloidosis.

Question 35

An 83-year-old man with a history of hypertension and dyslipidemia that have been managed with lisinopril, chlorthalidone, and pravastatin for several years presents for
evaluation. Eight days ago, he had symptoms of rhinorrhea, myalgia, and fever, which he self-treated with naproxen and acetaminophen. He also had limited oral intake and
anorexia, all of which had improved until he started to develop fatigue, anorexia, and nausea 2 days ago. At today’s visit, he is found to have a serum creatinine level of 4.6
mg/dL (0.8–1.3; increased from his baseline level of 1.6 mg/dL); a complete blood count is normal, and urinalysis shows granular casts. What is the most likely cause of the
abnormal laboratory results?

Answer 35

In the setting of volume depletion and the use of agents that block the renin–angiotensin–aldosterone axis, the use of nonsteroidal antiinflammatory drugs can precipitate
acute kidney injury.

Question 36

A systolic murmur that worsens with the Valsalva maneuver in a patient with
electrocardiographic evidence of left ventricular strain and hypertrophy is
indicative of

Answer 36

hypertrophic cardiomyopathy.

Question 37

With a chest radiograph showing no evidence of pneumonia or volume overload,
and given the other test results, the most likely diagnosis is an acute exacerbation
of chronic obstructive pulmonary disease (COPD). First-line treatment is

Answer 37

inhaled albuterol and ipratropium to aid in reversing bronchoconstriction. Metered-dose
inhalers or nebulized therapies are equivalent for this purpose. Systemic
glucocorticoids also help attenuate the inflammatory response, improve
symptoms and lung function, and limit the length of hospital stay.

Antibiotics have a role in treating an acute COPD exacerbation, particularly when
the exacerbation warrants admission to the hospital. Current GOLD guidelines
suggest that antibiotics should be reserved for patients with purulent sputum.
Appropriate choices would include doxycycline, azithromycin, or a respiratory
fluoroquinolone. Piperacillin–tazobactam provides broader coverage than is
needed and would not be an appropriate choice even if the patient did have
purulent sputum.
Noninvasive positive-pressure ventilation is an important therapy for many
patients with acute COPD exacerbations, but it is not likely to be necessary in a
patient with a mild-to-moderate exacerbation and no evidence of significant
respiratory acidosis.
Oxygen therapy may be required for some patients with COPD exacerbations, but
it is not necessary if oxygen saturation is adequate, as in this case. In patients
with chronic respiratory acidosis (not the case in this patient), excessive
supplemental oxygen may worsen hypercapnia.

Question 38

Hypersensitivity pneumonitis (HP) is

Answer 38

an interstitial lung condition characterized by
inflammation in response to the inhalation of organic antigens to which the
patient has been previously sensitized. Bronchoalveolar lavage frequently reveals
a lymphocytic predominance but is not a sensitive diagnostic test. Chest imaging
can reveal evidence of fibrosis.
Bird antigens are known to cause HP specifically known as “bird fancier’s lung.”
The most important intervention is to remove the offending exposure. For
patients with symptomatic, progressive disease, initial therapy includes
prednisone 0.5 to 1.0 mg per kilogram of ideal body weight to a maximum of 60
mg daily; this therapy should be tapered slowly over several weeks.
Amoxicillin–clavulanate is not itself a therapy for HP

Question 39

A patient with a symptomatic hemoglobinopathy (“intermedia” implies symptomatic), especially sickle cell disease, alpha-thalassemia, or beta-thalassemia, is

Answer 39

at risk for
pulmonary arterial hypertension. Pulmonary hypertension is one of the most common causes of death in patients with this condition.
A transthoracic echocardiogram is the test of choice for diagnosing pulmonary hypertension

Question 40

Patients who have cryptogenic organizing pneumonia (COP) often present

Answer 40

with
flulike illness, cough, and dyspnea. Radiographic findings are nonspecific and
include patchy bilateral alveolar filling processes. COP is often treated
unsuccessfully with antibiotic courses before further evaluation reveals
organizing pneumonia (i.e., not related to an infection). The histopathologic
pattern of organizing pneumonia is characterized by patchy filling of alveoli and
respiratory bronchioles with loose plugs of granulation tissue. Most patients with
COP respond to a glucocorticoid, such as prednison

Some patients with COP may relapse after initial response to the glucocorticoid,
at which point an alternative immunosuppressive therapy, such as azathioprine,
may be considered.