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1

65 yo woman presents with ulcer on sole of her good, below the first MTP joint. Diabetic neuropathy. Unsure how long the ulcer has been there. What is best dx test for osteomyelitis?

-PE, vitals, pressure around the ulcer

-blood cultures, culture pus from ulcer

-labs: CBC, ESR, CRP

-MRI of the foot

-plain films of the foot for bony erosion or periosteal elevation.

65 yo woman presents with ulcer on sole of her good, below the first MTP joint. Diabetic neuropathy. Unsure how long the ulcer has been there. What is best dx test for osteomyelitis?

-PE, vitals, pressure around the ulcer

-blood cultures, culture pus from ulcer

-labs: CBC, ESR, CRP

-MRI of the foot

-plain films of the foot for bony erosion or periosteal elevation.

1

To determine the level of immune compromise in a patient with HIV, which of the following cell types is enumerated in the blood?

a. CD3+ lymphocytes

b. CD4+ T cells

c. CD8+ T cells

d. CD19+ B cells

e. CD20+ B cells

To determine the level of immune compromise in a patient with HIV, which of the following cell types is enumerated in the blood?

a. CD3+ lymphocytes

b. CD4+ T cells

c. CD8+ T cells

d. CD19+ B cells

e. CD20+ B cells

1

You should wear an N95 mask when visiting the patient in their negative pressure room to prevent the transmission of tuberculosis and which of the following infections?

  • Chickenpox
  • Influenza
  • Pseudomonas aeruginosa
  • Streptococcus pneumoniae
  • Mycoplasma pneumoniae

chicken pox

also acceptable answers: Pulmonary TB, measles

2

About ten days after symptoms of a febrile cough illness for which you took azithromycin without a chest x-ray, you start feeling sick again: you develop diarrhea and crampy abdominal pain as well as low grade temperatures. You experience a sense of urgency to defecate which is relieved by bowel movements (tenesmus). Which of the following organisms is MOST LIKELY to blame?

Clostridium difficile

Hepatitis A

Bacillus cereus

Clostridium perfringens

Salmonella spp

About ten days after symptoms of a febrile cough illness for which you took azithromycin without a chest x-ray, you start feeling sick again: you develop diarrhea and crampy abdominal pain as well as low grade temperatures. You experience a sense of urgency to defecate which is relieved by bowel movements (tenesmus). Which of the following organisms is MOST LIKELY to blame?

Clostridium difficile

Hepatitis A

Bacillus cereus

Clostridium perfringens

Salmonella spp

2

A 32 year-old medical student notices a painless purple spot on his left calf. “I figured I bumped it while riding,” he says. He is an avid mountain biker. He is surprised when the purple mark does not resolve spontaneously, and comes to see you when additional purple marks appear on his nose. Other than genital herpes for which he takes suppressive valacyclovir, he is completely healthy. Physical examination is normal except for the two mentioned spots (photo). This is the classic presentation for which of the following opportunistic pathogens?

a.Pneumocystis jiroveci

b.Toxoplasma gondii

c.Mycobacterium avium complex

d.Human herpesvirus 8

e.Cytomegalovirus

A 32 year-old medical student notices a painless purple spot on his left calf. “I figured I bumped it while riding,” he says. He is an avid mountain biker. He is surprised when the purple mark does not resolve spontaneously, and comes to see you when additional purple marks appear on his nose. Other than genital herpes for which he takes suppressive valacyclovir, he is completely healthy. Physical examination is normal except for the two mentioned spots. This is the classic presentation for which of the following opportunistic pathogens? 

a.Pneumocystis jiroveci 

b.Toxoplasma gondii 

c.Mycobacterium avium complex 

d.Human herpesvirus 8 

e.Cytomegalovirus

3

•A young mother brings her 6 year-old son into your office for a sore throat. She asks, “Is this strep throat?” Which of the following is NOT suggestive of streptococcal pharyngitis?

A.Abrupt onset.

B.Fever of 102F.

C.Bright red tonsils with tonsillar exudate.

D.Post-tussive emesis.

E.Enlarged, tender cervical lymph nodes.

•A young mother brings her 6 year-old son into your office for a sore throat. She asks, “Is this strep throat?” Which of the following is NOT suggestive of streptococcal pharyngitis? 

A.Abrupt onset. 

B.Fever of 102F. 

C.Bright red tonsils with tonsillar exudate. 

D.Post-tussive emesis. 

E.Enlarged, tender cervical lymph nodes.

3

About twenty-four hours after consuming some cold chicken salad at a picnic, you develop nausea, vomiting and profuse diarrhea. It’s hard to know whether you should be sitting or kneeling for most of the 1-2 day illness, after which you improve back to baseline. Which of the following organisms is MOST LIKELY to blame?

Clostridium difficile

Hepatitis A

Bacillus cereus

Clostridium perfringens

Salmonella spp

About twenty-four hours after consuming some cold chicken salad at a picnic, you develop nausea, vomiting and profuse diarrhea. It’s hard to know whether you should be sitting or kneeling for most of the 1-2 day illness, after which you improve back to baseline. Which of the following organisms is MOST LIKELY to blame?

Clostridium difficile

Hepatitis A

Bacillus cereus

Clostridium perfringens

Salmonella spp

4

Two d ago you took a call from a worried mother who said her 3yo son seems irritable and “keeps itching his behind” On your advice, she applied Scotch tape to the boy’s anus at bedtime last night, and now she brings the evidence to your office. You see little white worms on the tape. Which of the following statements is likely true?


-This is consistent w pinworm (Enterobius vermicularis) and the boy should be treated with mebendazole.

-This is consistent w pinworm (Enterobius vermicularis) and the boy plus his family should be treated with mebendazole.

-This is consistent with strongyloidiasis (strongyloides stercoralis) and the boy should be treated with praziquantel

-This is consistent with strongyloidiasis (strongyloides stercoralis) and the boy plus his mother and maybe other family members should be treated with praziquantel

-This is a classic example of delusions of parasitosis and you should refer the by and his parents to the Division of Children, Youth and Family for a child abuse evaluation

Two d ago you took a call from a worried mother who said her 3yo son seems irritable and “keeps itching his behind” On your advice, she applied Scotch tape to the boy’s anus at bedtime last night, and now she brings the evidence to your office. You see little white worms on the tape. Which of the following statements is likely true?


-This is consistent w pinworm (Enterobius vermicularis) and the boy should be treated with mebendazole.

-This is consistent w pinworm (Enterobius vermicularis) and the boy plus his family should be treated with mebendazole.

-This is consistent with strongyloidiasis (strongyloides stercoralis) and the boy should be treated with praziquantel

-This is consistent with strongyloidiasis (strongyloides stercoralis) and the boy plus his mother and maybe other family members should be treated with praziquantel

-This is a classic example of delusions of parasitosis and you should refer the by and his parents to the Division of Children, Youth and Family for a child abuse evaluation

4

You suspect acute HIV infection in a commercial sex worker with three weeks of mono-like symptoms. Which of the following tests is most likely to confirm your hunch?

a.HIV enzyme linked immunosorbent assay (ELISA)

b.HIV Western blot

c.HIV viral load by PCR

d.CD4+ count

You suspect acute HIV infection in a commercial sex worker with three weeks of mono-like symptoms. Which of the following tests is most likely to confirm your hunch? 

a.HIV enzyme linked immunosorbent assay (ELISA) 

b.HIV Western blot 

c.HIV viral load by PCR 

d.CD4+ count

4

You meet an HIV-infected injection drug user for the first time in clinic so she can establish care in your office. She has no other medical problems, and takes these medications: 
abacavir (a nucleotide reverse transcriptiase inhibitor)
efavirenz (a non-nucleotide reverse transcriptase inhibitor)

Physical examination is normal other than track marks. Her labs reveal CD4 count of 100, and an HIV viral load of 4,000 copies. Which of the following BEST describes what is wrong with her medication list?

-She should be taking trimethroprim/sulfamethoxazole as prophylaxis against Pneumocystis pneumonia.

-She should be taking weekly azithromycin as prophylaxis against Mycobacterium avium complex (MAC).

-She should be taking another antiretroviral agent such as lamivudine (a nucleotide reverse transcriptase inhibitor).

-She should be taking trimethroprim/sulfamethoxazole as prophylaxis against Pneumocystis pneumonia and also another antiretroviral agent such as lamivudine (a nucleotide reverse transcriptase inhibitor).

-She should be taking trimethroprim/sulfamethoxazole as prophylaxis against Pneumocystis pneumonia and weekly azithromycin as Mycobacterium avium complex (MAC) prophylaxis as well as another antiretroviral agent such as lamivudine (a nucleotide reverse transcriptase inhibitor).

You meet an HIV-infected injection drug user for the first time in clinic so she can establish care in your office. She has no other medical problems, and takes these medications: 
abacavir (a nucleotide reverse transcriptiase inhibitor)
efavirenz (a non-nucleotide reverse transcriptase inhibitor)

Physical examination is normal other than track marks. Her labs reveal CD4 count of 100, and an HIV viral load of 4,000 copies. Which of the following BEST describes what is wrong with her medication list?

-She should be taking trimethroprim/sulfamethoxazole as prophylaxis against Pneumocystis pneumonia.

-She should be taking weekly azithromycin as prophylaxis against Mycobacterium avium complex (MAC).

-She should be taking another antiretroviral agent such as lamivudine (a nucleotide reverse transcriptase inhibitor).

-She should be taking trimethroprim/sulfamethoxazole as prophylaxis against Pneumocystis pneumonia and also another antiretroviral agent such as lamivudine (a nucleotide reverse transcriptase inhibitor).

-She should be taking trimethroprim/sulfamethoxazole as prophylaxis against Pneumocystis pneumonia and weekly azithromycin as Mycobacterium avium complex (MAC) prophylaxis as well as another antiretroviral agent such as lamivudine (a nucleotide reverse transcriptase inhibitor).

5

The treatment of furuncles and carbuncles typically involves which of these?

A. Ice packs

B. Steroid treatment

C. Systemic antibiotics for all patients

D. Drainage of large lesions

The treatment of furuncles and carbuncles typically involves which of these?

A. Ice packs

B. Steroid treatment

C. Systemic antibiotics for all patients

D. Drainage of large lesions (What's "large"? greater than 1 cm)

5

Which of the following is the MOST SENSITIVE and SPECIFIC imaging modality for the diagnosis of osteomyelitis?

A. Plain radiography

B. Computed tomography

C. Ultrasonography

D. MRI

Which of the following is the MOST SENSITIVE and SPECIFIC imaging modality for the diagnosis of osteomyelitis?

A. Plain radiography

B. Computed tomography

C. Ultrasonography

D. MRI

5

The daycare calls to let you know your three-year-old otherwise healthy child has to come home because he has developed vomiting and profuse diarrhea. He has a low grade temperature, and doesn’t want to play very much, but is otherwise well with stable vitals per the school nurse. The nurse mentions that three other kids were sent home recently, but “they were both back and doing great after a couple of days at home.” Which of the following is the BEST characterization of the pathophysiology of the likely pathogen?

Viral damage to brush border causes impaired absorption of water and nutrients.

Non-inflammatory bacterial toxin causes cyclic AMP upregulation in enterocytes.

Bacterial cytotoxin can cause bloody diarrhea and hemolytic uremic syndrome.

Intracellular bacterial pathogen passes through intestines into macrophages and causes disseminated infection.

Invasion of colonic epithelial cells causing superficial ulcerations and colitis.

 

The daycare calls to let you know your three-year-old otherwise healthy child has to come home because he has developed vomiting and profuse diarrhea. He has a low grade temperature, and doesn’t want to play very much, but is otherwise well with stable vitals per the school nurse. The nurse mentions that three other kids were sent home recently, but “they were both back and doing great after a couple of days at home.” Which of the following is the BEST characterization of the pathophysiology of the likely pathogen?

Viral damage to brush border causes impaired absorption of water and nutrients.

Non-inflammatory bacterial toxin causes cyclic AMP upregulation in enterocytes.

Bacterial cytotoxin can cause bloody diarrhea and hemolytic uremic syndrome.

Intracellular bacterial pathogen passes through intestines into macrophages and causes disseminated infection.

Invasion of colonic epithelial cells causing superficial ulcerations and colitis.

6

A 26 yo medical student develops acute fever, muscle aches, and exhaustion about 1 w after returning from a 3 m medical rotation in Gabon. She is otherwise healthy, has taken no medicines for “years” and has lived only in the US and Gabon but has traveled widely throughout Africa and Asia as well as Europe. On examination she is febrile, but stable with normal oxygen saturations. Her exam is normal. CBC shows new anemia with hemoglobin of 6 g/dL and mild thrombocytopenia to 120,000. The lab reports parasite forms on peripheral smear, shown in picture. Which of the following is true about this condition?


-Symptoms of this human infection range from none to lethal cerebral edema

-Hypnozoites lodged in liver venules cause congestive hepatitis

-Supportive care is the only treatment for this viral infection

-Cerebral inflammation can arise weeks to years after infection

-Drug resistance to this parasite is most prevalent in North America

A 26 yo medical student develops acute fever, muscle aches, and exhaustion about 1 w after returning from a 3 m medical rotation in Gabon. She is otherwise healthy, has taken no medicines for “years” and has lived only in the US and Gabon but has traveled widely throughout Africa and Asia as well as Europe. On examination she is febrile, but stable with normal oxygen saturations. Her exam is normal. CBC shows new anemia with hemoglobin of 6 g/dL and mild thrombocytopenia to 120,000. The lab reports parasite forms on peripheral smear, shown in picture. Which of the following is true about this condition?

-Symptoms of this human infection range from none to lethal cerebral edema

-Hypnozoites lodged in liver venules cause congestive hepatitis

-Supportive care is the only treatment for this viral infection 

-Cerebral inflammation can arise weeks to years after infection

-Drug resistance to this parasite is most prevalent in North America

 

7

•You are seeing a lot of patients with influenza in your family practice clinic this year, and recently learned from the CDC that a new type of influenza is circulating nationwide. In contrast to last year’s H9N1 now the CDC says circulating influenza virus type is H7N1. What PHRASE is used to describe the emergence of a “new virus” from major changes in the hemaglutinin (H) and/or neuraminidase (N) viral proteins?

A.Antigenic shift.

B.Antigenic drift.

C.Antigenic variation.

D.Antigenic mutation.

E.Antigenic speciation.

•You are seeing a lot of patients with influenza in your family practice clinic this year, and recently learned from the CDC that a new type of influenza is circulating nationwide. In contrast to last year’s H9N1 now the CDC says circulating influenza virus type is H7N1. What PHRASE is used to describe the emergence of a “new virus” from major changes in the hemaglutinin (H) and/or neuraminidase (N) viral proteins? 

A.Antigenic shift. 

B.Antigenic drift. 

C.Antigenic variation. 

D.Antigenic mutation. 

E.Antigenic speciation.

7

A 23 year-old injection drug user presents with cough, dyspnea, and fever to 102 degrees F. He has chronic hepatitis C but no other known medical problems. He takes no medications. Physical examination otherwise reveals bilateral crackles, respiratory distress with a room air oxygen saturation of 72%, and cachexia. His white count is decreased, and an HIV serology comes back positive whereas a serum cryptococcal antigen is negative. A chest x-ray reveals hazy bilateral infiltrates. This is the classic presentation for which of the following opportunistic pathogens?

a.Pneumocystis jiroveci

b.Toxoplasma gondii

c.Mycobacterium avium complex

d.Human herpesvirus 8

e.Cytomegalovirus

A 23 year-old injection drug user presents with cough, dyspnea, and fever to 102 degrees F. He has chronic hepatitis C but no other known medical problems. He takes no medications. Physical examination otherwise reveals bilateral crackles, respiratory distress with a room air oxygen saturation of 72%, and cachexia. His white count is decreased, and an HIV serology comes back positive whereas a serum cryptococcal antigen is negative. A chest x-ray reveals hazy bilateral infiltrates. This is the classic presentation for which of the following opportunistic pathogens? 

a.Pneumocystis jiroveci 

b.Toxoplasma gondii 

c.Mycobacterium avium complex 

d.Human herpesvirus 8 

e.Cytomegalovirus

8

The next inpatient you see on the wards has a fever, a new heart murmur, and painful Osler’s nodes on the right hand. A transesophageal echocardiogram shows a mobile echodensity on the aortic valve that is 0.3 cm in diameter. Which of the following findings would make you call the cardiothoracic surgeon to replace the patient’s aortic valve?

High grade fever and leukocytosis

The presence of a mobile echodensity that is greater than 0.5 cm in diameter

A new stroke attributed to septic emboli

Unquenched bacteremia nine days after starting treatment

Growth of viridans streptococci in the initial blood cultures

The next inpatient you see on the wards has a fever, a new heart murmur, and painful Osler’s nodes on the right hand. A transesophageal echocardiogram shows a mobile echodensity on the aortic valve that is 0.3 cm in diameter. Which of the following findings would make you call the cardiothoracic surgeon to replace the patient’s aortic valve?

High grade fever and leukocytosis

The presence of a mobile echodensity that is greater than 0.5 cm in diameter

A new stroke attributed to septic emboli

Unquenched bacteremia nine days after starting treatment

Growth of viridans streptococci in the initial blood cultures

9

The oral live attenuated typhoid vaccine provides five years of 75% protection from typhoid infection. In the United States, this is commonly given to people who travel to endemic areas. To which of the following people going to an endemic area should your travel clinic NOT give this vaccine? 

  • A 28-year-old with irritable bowel syndrome whose soccer team is traveling to India for an invitational tournament.
  • A 65-year-old presidential candidate with undisclosed multiple sclerosis who is visiting the West Bank for peace talks.
  • A 12-year-old boy with mild autistic spectrum disorder who is traveling to Thailand with his family.
  • A 38-year-old pregnant infectious diseases doctor who will work with the DarDar research program in Tanzania.


A 38-year-old pregnant infectious diseases doctor who will work with the DarDar research program in Tanzania. 



 

live-attenuated vaccines are contraindicated in pregnancy and immunodeficient persons. (just FYI - Jullet wasn't allowed to get the yellow-fever vaccine prior to backpacking in SEA because it is a live-attenuated vaccine!)

10

You are seeing a patient with cough, fever and mild dyspnea in your office. She admits to drinking twelve beers daily, sometimes to the point of blackouts, but otherwise she carries no medical diagnoses. Physical examination reveals T 102, normal vital signs, poor dentition and acne rosacea plus loud wet-sounding crackles in the right lower lung. A chest x-ray confirms an infiltrate without cavitation in the right middle lobe. Which of the following antibiotic regimens would be BEST for this patient?

Vancomycin plus piperacillin/tazobactam

Trimethroprim-sulfamethoxazole plus clindamycin

Ceftriaxone plus azithromycin plus vancomycin

Levofloxacin plus metronidazole

Vancomycin plus piperacillin/tazobactam plus metronidazole

You are seeing a patient with cough, fever and mild dyspnea in your office. She admits to drinking twelve beers daily, sometimes to the point of blackouts, but otherwise she carries no medical diagnoses. Physical examination reveals T 102, normal vital signs, poor dentition and acne rosacea plus loud wet-sounding crackles in the right lower lung. A chest x-ray confirms an infiltrate without cavitation in the right middle lobe. Which of the following antibiotic regimens would be BEST for this patient?

Vancomycin plus piperacillin/tazobactam

Trimethroprim-sulfamethoxazole plus clindamycin

Ceftriaxone plus azithromycin plus vancomycin

Levofloxacin plus metronidazole

Vancomycin plus piperacillin/tazobactam plus metronidazole

11

In those unusual cases when the infectious source of sepsis is not completely obvious, it is helpful to know which sources of infection are most likely and thus worthy of additional diagnostic work up. Which of the following is the MOST COMMON cause of sepsis?

  • Pneumonia
  • Urinary tract infection
  • Primary bloodstream infection
  • Intraabdominal abscess
  • Skin and soft tissue infection

pneumonia

13

You are running a community health clinic in which you see a college student and avid hiker who has had 4 weeks of loose stools. “It’s like water Doc.” Otherwise he feels fine. He is healthy otherwise. A routine stool culture reveals nothing. Which of the following pathogens is the likely culprit?

-Trichomonas
-Cryptosporidium parvum

-Ascaris lumbricoides

-Giardia Lamblia

-Schistsoma mansonii

You are running a community health clinic in which you see a college student and avid hiker who has had 4 weeks of loose stools. “It’s like water Doc.” Otherwise he feels fine. He is healthy otherwise. A routine stool culture reveals nothing. Which of the following pathogens is the likely culprit?

-Trichomonas
-Cryptosporidium parvum

-Ascaris lumbricoides 

-Giardia Lamblia

-Schistsoma mansonii

14

Which oc these bugs is the most common cause of vertebral osteomyelitis?

A. Escherichia coli

B. Streptococcus pyogenes

C. Pasteurella multocida

D. Staphylococcus aureus

Which oc these bugs is the most common cause of vertebral osteomyelitis?

A. Escherichia coli

B. Streptococcus pyogenes

C. Pasteurella multocida

D. Staphylococcus aureus

14

You draw two sets of blood cultures in a patient hospitalized for a GI bleed and who subsequently developed a fever while you are on call. At that point you notice the patient has no indwelling catheter, and no prosthetic joints or other man-made body parts. Three days later, at which point the patient is feeling well and afebrile and nearly ready for discharge, you learn one of the bottles has grown coagulase negative staphylococci. Which of the following is an adequate justification for your decision to disregard this finding as culture contaminant?

GI bleeding is almost never caused by coagulase negative staphylococci.

You can always disregard a blood culture result if only some of the bottles are positive.

The finding of coagulase negative staphylococci on a blood culture is always a culture contaminant.

The patient lacks clinical risk factors that would make coagulase negative staphylococcal bacteremia a likely condition.

The fact that the patient is feeling better off of antibiotics excludes bacteremia from the realm of possibility.

You draw two sets of blood cultures in a patient hospitalized for a GI bleed and who subsequently developed a fever while you are on call. At that point you notice the patient has no indwelling catheter, and no prosthetic joints or other man-made body parts. Three days later, at which point the patient is feeling well and afebrile and nearly ready for discharge, you learn one of the bottles has grown coagulase negative staphylococci. Which of the following is an adequate justification for your decision to disregard this finding as culture contaminant?

GI bleeding is almost never caused by coagulase negative staphylococci.

You can always disregard a blood culture result if only some of the bottles are positive.

The finding of coagulase negative staphylococci on a blood culture is always a culture contaminant.

The patient lacks clinical risk factors that would make coagulase negative staphylococcal bacteremia a likely condition.

The fact that the patient is feeling better off of antibiotics excludes bacteremia from the realm of possibility.

15

Which of the following syndromes is MOST CONSISTENT with the typical presentation of viral encephalitis?

-A 34-year-old injection drug user presents with fever, headache and weakness of the left arm

-An 16-year-old high school girl presents with fever, headache, a petechial rash and sepsis

-A 22-year-old Appalachian trail hiker presents with fever, confusion and seizure

-A 21-year-old otherwise healthy woman from Massachusetts presents with fever, headache, normal vitals, and myalgias in the summer

-A 68-year-old dancer with AIDS presents with ataxia and personality changes

Which of the following syndromes is MOST CONSISTENT with the typical presentation of viral encephalitis?


-A 34-year-old injection drug user presents with fever, headache and weakness of the left arm

-An 16-year-old high school girl presents with fever, headache, a petechial rash and sepsis

-A 22-year-old Appalachian trail hiker presents with fever, confusion and seizure

-A 21-year-old otherwise healthy woman from Massachusetts presents with fever, headache, normal vitals, and myalgias in the summer

-A 68-year-old dancer with AIDS presents with ataxia and personality changes

 

16

An alcoholic hiker from New England presents to the emergency room with profound fatigue and fevers. His evaluation there reveals marked new anemia, with red cell schistocytes on his smear. Some red cells contain ring forms. He has never traveled internationally. Which of the following parasites is likely to blame?


-Toxoplasma

-Schistosoma

-Ascaris

-Babesia

-Trichomonas

An alcoholic hiker from New England presents to the emergency room with profound fatigue and fevers. His evaluation there reveals marked new anemia, with red cell schistocytes on his smear. Some red cells contain ring forms. He has never traveled internationally. Which of the following parasites is likely to blame?


-Toxoplasma

-Schistosoma
-Ascaris

-Babesia

-Trichomonas

16

•A 23 year-old sexually active recent college graduate develops dysuria. His urinalysis shows pyuria but so far nothing has grown in urine culture. Which of the following is true?

A.You should look for congenital abnormalities of the genitourinary tract before treating.

B.A three-day course of trimethoprim-sulfamethoxazole should cover the most likely pathogens.

C.A three-day course of azithromycin should cover the most likely pathogens.

D.You should look for MRSA in culture before treating.

E.You should look for Chlamydia and other sexually transmitted infections before treating. 

•A 23 year-old sexually active recent college graduate develops dysuria. His urinalysis shows pyuria but so far nothing has grown in urine culture. Which of the following is true? 

A.You should look for congenital abnormalities of the genitourinary tract before treating. 

B.A three-day course of trimethoprim-sulfamethoxazole should cover the most likely pathogens. 

C.A three-day course of azithromycin should cover the most likely pathogens.

D.You should look for MRSA in culture before treating. 

E.You should look for Chlamydia and other sexually transmitted infections before treating. 

17

You see a WWII veteran with a long history of episodic abdominal pain and diarrhea. A month ago he was started on a trial of steroids for a reason that is not clear. He now presents with fever and hypotension and a productive cough. Your careful history reveals that he served in the Philippines and has visited there several times over the years. A blood culture grows a gram-negative rod and a sputum exam reveals microscopic worm larvae. The worms are most likely:


-An incidental finding, probably pinworm (Enterobius)

-Ascaris lumbricoides, because it is the most common worm infection worldwide

-Strongyliodes stercoralis in its hyperinfection phase

-Visceral larva migrans (Toxocara) from his pet dog

-Schistosoma japonicum reactivated by the steroids

You see a WWII veteran with a long history of episodic abdominal pain and diarrhea. A month ago he was started on a trial of steroids for a reason that is not clear. He now presents with fever and hypotension and a productive cough. Your careful history reveals that he served in the Philippines and has visited there several times over the years. A blood culture grows a gram-negative rod and a sputum exam reveals microscopic worm larvae. The worms are most likely:

-An incidental finding, probably pinworm (Enterobius)

-Ascaris lumbricoides, because it is the most common worm infection worldwide

-Strongyliodes stercoralis in its hyperinfection phase

-Visceral larva migrans (Toxocara) from his pet dog

-Schistosoma japonicum reactivated by the steroids

18

You have been treating a 62-year-old lawyer for the past several weeks with ciprofloxacin for biopsy-proven lumbar vertebral osteomyelitis from Escherichia coli. Other than some benign prostatic hypertrophy, and high blood pressure, he is a healthy guy who enjoys golfing with his friends on the weekends. Which of the following is an accurate explanation of the pathophysiology of this disease?

(Jen didn't get the answer choices....ECHO cut off)

You have been treating a 62-year-old lawyer for the past several weeks with ciprofloxacin for biopsy-proven lumbar vertebral osteomyelitis from Escherichia coli. Other than some benign prostatic hypertrophy, and high blood pressure, he is a healthy guy who enjoys golfing with his friends on the weekends. Which of the following is an accurate explanation of the pathophysiology of this disease?

He likely developed bacteremia from a urinary infection resulting from his benign prostatic hyperplasia, which in turn led to hematogenous seeding of his vertebrae.

(sorry, Jen didn't get the rest of the answer choices.... ECHO cut off)

19

An AIDS patient with a CD4 count under 100 is admitted to the neurology ward with left sided weakness ascribed to what the radiologist called a ‘ring-enhancing lesion’ in his right motor cortex. He is afebrile, hemodynamically stable and blood cultures show nothing. Which of the following parasites is the most likely cause of this syndrome?


-Toxoplasma

-Schistosoma

-Ascaris

-Babesia

-Trichomonas

An AIDS patient with a CD4 count under 100 is admitted to the neurology ward with left sided weakness ascribed to what the radiologist called a ‘ring-enhancing lesion’ in his right motor cortex. He is afebrile, hemodynamically stable and blood cultures show nothing. Which of the following parasites is the most likely cause of this syndrome?


-Toxoplasma

-Schistosoma 

-Ascaris 

-Babesia 

-Trichomonas

19

About four hours after consuming some reheated fried rice from the local Chinese restaurant, you develop nausea and vomiting that is miserable but lasts only two hours. Which of the following organisms is MOST LIKELY to blame?

1. Clostridium difficile

2. Hepatitis A

3. Bacillus cereus

4. Clostridium perfringens

5. Salmonella spp

 

About four hours after consuming some reheated fried rice from the local Chinese restaurant, you develop nausea and vomiting that is miserable but lasts only two hours. Which of the following organisms is MOST LIKELY to blame?

1. Clostridium difficile

2. Hepatitis A

3. Bacillus cereus

4. Clostridium perfringens

5. Salmonella spp

21

You meet a 42 yo fisherman who emigrated to the US from Guinea Bissau where he worked in the same trade. To date your workup has revealed cirrhosis, portal hypertension, and esophageal varices. Which of the following is true about the parasitic infection causing his liver disease?

-This is consistent with visceral larva migrans (Toxocara spp) and the man should be treated with mebendazole
-This is consistent w pinworm (Enterobius vermicularis) and the man plus his daughter and maybe other family members should be treated with mebendazole.

-This is consistent with schistosomiasis (Schistosoma spp) and the man should be treated with praziquantel

-This is consistent with schistosomiasis (Schistosoma spp) and the man plus his daughter and maybe other family members should be treated with praziquantel

-This is a classic example of migratory Ascaris (Ascaris lumbricoides) but no therapy is indicated because the worms are already dead.

You meet a 42 yo fisherman who emigrated to the US from Guinea Bissau where he worked in the same trade. To date your workup has revealed cirrhosis, portal hypertension, and esophageal varices. Which of the following is true about the parasitic infection causing his liver disease?

-This is consistent with visceral larva migrans (Toxocara spp) and the man should be greated with mebendazole

-This is consistent w pinworm (Enterobius vermicularis) and the man plus his daughter and maybe other family members should be treated with mebendazole.

-This is consistent with schistosomiasis (Schistosoma spp) and the man should be treated with praziquantel

-This is consistent with schistosomiasis (Schistosoma spp) and the man plus his daughter and maybe other family members should be treated with praziquantel 

-This is a classic example of migratory Ascaris (Ascaris lumbricoides) but no therapy is indicated because the worms are already dead.

22

An 18 year-old college student returned from a summer internship in Tanzania two days ago, and now is seeing you in the ER with a high fever, shaking chills and muscle aches. She is otherwise healthy, and takes no medications. She asks, “could this relate to the fact I didn’t take my malaria prophylaxis?” You have ordered a parasite smear of her blood. In the meantime, which of the following lab patterns would be most suggestive of severe malaria from Plasmodium falciparum?

A.Elevated hemoglobin, elevated platelets, and elevated creatinine.

B.Elevated hemoglobin, decreased platelets, and decreased creatinine.

C.Decreased hemoglobin, elevated platelets, and elevated creatinine.

D.Decreased hemoglobin, decreased platelets, and elevated creatinine.

E.Decreased hemoglobin, decreased platelets, and decreased creatinine.

An 18 year-old college student returned from a summer internship in Tanzania two days ago, and now is seeing you in the ER with a high fever, shaking chills and muscle aches. She is otherwise healthy, and takes no medications. She asks, “could this relate to the fact I didn’t take my malaria prophylaxis?” You have ordered a parasite smear of her blood. In the meantime, which of the following lab patterns would be most suggestive of severe malaria from Plasmodium falciparum? 

A.Elevated hemoglobin, elevated platelets, and elevated creatinine. 

B.Elevated hemoglobin, decreased platelets, and decreased creatinine.

C.Decreased hemoglobin, elevated platelets, and elevated creatinine.

D.Decreased hemoglobin, decreased platelets, and elevated creatinine.

E.Decreased hemoglobin, decreased platelets, and decreased creatinine.

24

Osteomyelitis can arise from hematogenous spread, or contiguous inoculation. Which of the following patients is at risk for developing osteomyelitis from hematogenous spread?

A. 34  yo woman with tampon-associated septic shock

B. 66 yo woman with vascular disease and a longstanding diabetic foot ulcer

C. 31 yo man with HIV acquired through injection drug use

D. 81 yo man given rituximab for idiopathic thrombocytopenic purpura

Osteomyelitis can arise from hematogenous spread, or contiguous inoculation. Which of the following patients is at risk for developing osteomyelitis from hematogenous spread?

A. 34  yo woman with tampon-associated septic shock (not the correct answer because this pt will be in shock due to the toxin from the bacteria, not from being bacteremic overall)

B. 66 yo woman with vascular disease and a longstanding diabetic foot ulcer

C. 31 yo man with HIV acquired through injection drug use (Dr. Lahey referred to this guy as "Homeslice" in the review. OMG awesome)

D. 81 yo man given rituximab for idiopathic thrombocytopenic purpura

26

Which of the following statements regarding prevention of HIV transmission is TRUE?



 

1. Antiretroviral therapy protects HIV-positive individuals from the complications of HIV but does not lower the likelihood of HIV transmission.

 

2. Microbicide gels can prevent HIV transmission but are too expensive for all but the most wealthy patients

3. Post-exposure treatment with antiretrovirals doesn’t work because by the time it is given HIV infection has already occurred

4. Condoms are effective at preventing HIV transmission but their efficacy is imperfect due to poor education, imperfect access and patient ambivalence

5. High population rates of circumcision are associated with lower HIV prevalence but this may not reflect a true impact of circumcision of HIV transmission risk

Which of the following statements regarding prevention of HIV transmission is TRUE?



 

1. Antiretroviral therapy protects HIV-positive individuals from the complications of HIV but does not lower the likelihood of HIV transmission.

2. Microbicide gels can prevent HIV transmission but are too expensive for all but the most wealthy patients

3. Post-exposure treatment with antiretrovirals doesn’t work because by the time it is given HIV infection has already occurred

4. Condoms are effective at preventing HIV transmission but their efficacy is imperfect due to poor education, imperfect access and patient ambivalence

5. High population rates of circumcision are associated with lower HIV prevalence but this may not reflect a true impact of circumcision of HIV transmission risk

 

27

Necrotizing fasciitis can kill healthy people in hours. What testing is commonly used to diagnose this condition?

A. Physical exam alone

B. Plain radiography

C. Skin biopsy

D. MRI

Necrotizing fasciitis can kill healthy people in hours. What testing is commonly used to diagnose this condition?

A. Physical exam alone (this can make you very suspicious about necrotizing fasciitis, esp if they have numbness or erythema, or are going into shock. But still want to get MRI to assess the extent of the wound, and before you start deeply debriding tissue)

B. Plain radiography

C. Skin biopsy

D. MRI 

29

For patients with HIV who have access to effective antiretroviral therapy, which of the following statements is true?

a.Antiretroviral therapy is experimental and its impact on infection and longevity are not yet known.

b.Antiretroviral therapy reduces the likelihood of opportunistic infections but does not lengthen life.

c.Antiretroviral therapy reduces the likelihood of opportunistic infections and adds 2-3 years to life expectancy, which is nonetheless reduced in comparison to the HIV-negative population.

d.Antiretroviral therapy reduces the likelihood of opportunistic infections and adds decades to life expectancy, which is nonetheless reduced in comparison to the HIV-negative population.

e.Antiretroviral therapy reduces the likelihood of opportunistic infections and adds decades to life expectancy, which is therefore similar in comparison to the HIV-negative population.

For patients with HIV who have access to effective antiretroviral therapy, which of the following statements is true? 

a.Antiretroviral therapy is experimental and its impact on infection and longevity are not yet known. 

b.Antiretroviral therapy reduces the likelihood of opportunistic infections but does not lengthen life. 

c.Antiretroviral therapy reduces the likelihood of opportunistic infections and adds 2-3 years to life expectancy, which is nonetheless reduced in comparison to the HIV-negative population. 

d.Antiretroviral therapy reduces the likelihood of opportunistic infections and adds decades to life expectancy, which is nonetheless reduced in comparison to the HIV-negative population. 

e.Antiretroviral therapy reduces the likelihood of opportunistic infections and adds decades to life expectancy, which is therefore similar in comparison to the HIV-negative population.

30

A 41 year-old lawyer presents with right sided blindness. She says about two weeks ago she started experiencing “blind spots” on that side which progressed to “total haze” and now complete loss of vision. Otherwise she feels completely fine: no fevers or other symptoms. “I was just too busy to see a doctor.” She has no past medical history, and takes no medications. Physical examination is completely normal except for cotton wool spots obscuring the retinal arteries and the edges of the optic disc. This is the classic presentation for which of the following opportunistic pathogens?

a.Pneumocystis jiroveci

b.Toxoplasma gondii

c.Mycobacterium avium complex

d.Human herpesvirus 8

e.Cytomegalovirus

A 41 year-old lawyer presents with right sided blindness. She says about two weeks ago she started experiencing “blind spots” on that side which progressed to “total haze” and now complete loss of vision. Otherwise she feels completely fine: no fevers or other symptoms. “I was just too busy to see a doctor.” She has no past medical history, and takes no medications. Physical examination is completely normal except for cotton wool spots obscuring the retinal arteries and the edges of the optic disc. This is the classic presentation for which of the following opportunistic pathogens?

a.Pneumocystis jiroveci 

b.Toxoplasma gondii 

c.Mycobacterium avium complex 

d.Human herpesvirus 8 

e.Cytomegalovirus

31

Polly is a loving single mother of three school-aged children and a waitress at a local biker bar. Polly also has HIV infection for which you have prescribed the daily well-tolerated combination pill Complera. Polly’s adherence to this medication, and her engagement with routine medical follow up, are imperfect. She says both are because she is too busy taking care of her kids and “getting the laundry and groceries and taxes done – there’s just no time!” Polly’s CD4 count of 150 cells/mm3 and persistently detectable HIV viral load of 1,200 copies/mL without resistance suggest partial medication adherence. 

Which of the following accurately characterizes the MOST EFFECTIVE approach to helping Polly live to see her children to adulthood?

-Polly has the same opportunity to take her antiretroviral therapy as anybody else. If she makes the bad decision not to, that is her problem.

-Polly is less likely to take antiretroviral therapy than people with fewer social obstacles to good health. Ultimately she needs to pull herself up by the bootstraps; this is not her physician’s job.

-Polly is less likely to take antiretroviral therapy than people with fewer social obstacles to good health. A doctor is responsible for prescription of antiretroviral medications and clinical education and in addition should work with multidisciplinary team to help ameliorate the social determinants of adverse health outcomes for Polly.

-Polly is less likely to take antiretroviral therapy than people with fewer social obstacles to good health. A doctor is responsible for prescription of antiretroviral medications and clinical education, but the remainder of the social determinants of Polly’s adverse health outcomes is outside the scope of physician responsibility.

-Polly is less likely to take antiretroviral therapy than people with fewer social obstacles to good health. A doctor is responsible for prescription of antiretroviral medications and should do what it takes to redress the social determinants of adverse health outcomes for Polly even if that means giving her money, giving her rides to appointments, or letting her live with the doctor’s family.

Polly is a loving single mother of three school-aged children and a waitress at a local biker bar. Polly also has HIV infection for which you have prescribed the daily well-tolerated combination pill Complera. Polly’s adherence to this medication, and her engagement with routine medical follow up, are imperfect. She says both are because she is too busy taking care of her kids and “getting the laundry and groceries and taxes done – there’s just no time!” Polly’s CD4 count of 150 cells/mm3 and persistently detectable HIV viral load of 1,200 copies/mL without resistance suggest partial medication adherence. 

Which of the following accurately characterizes the MOST EFFECTIVE approach to helping Polly live to see her children to adulthood?

-Polly has the same opportunity to take her antiretroviral therapy as anybody else. If she makes the bad decision not to, that is her problem.

-Polly is less likely to take antiretroviral therapy than people with fewer social obstacles to good health. Ultimately she needs to pull herself up by the bootstraps; this is not her physician’s job.

-Polly is less likely to take antiretroviral therapy than people with fewer social obstacles to good health. A doctor is responsible for prescription of antiretroviral medications and clinical education and in addition should work with multidisciplinary team to help ameliorate the social determinants of adverse health outcomes for Polly.

-Polly is less likely to take antiretroviral therapy than people with fewer social obstacles to good health. A doctor is responsible for prescription of antiretroviral medications and clinical education, but the remainder of the social determinants of Polly’s adverse health outcomes is outside the scope of physician responsibility.

-Polly is less likely to take antiretroviral therapy than people with fewer social obstacles to good health. A doctor is responsible for prescription of antiretroviral medications and should do what it takes to redress the social determinants of adverse health outcomes for Polly even if that means giving her money, giving her rides to appointments, or letting her live with the doctor’s family.

 

32

Animal bites can cause deep, polymicrobial infections. Which of the following is a prominent pathogen seen in infections that follow cat bites?

A. Pasteurella

B. Erysipeolthrix

C. Strep pneumoniae

D. Sporothrix

Animal bites can cause deep, polymicrobial infections. Which of the following is a prominent pathogen seen in infections that follow cat bites?

A. Pasteurella

B. Erysipeolthrix

C. Strep pneumoniae

D. Sporothrix (associated with gardeners -- looks nodular, can ulcerate, become nodule)

34

Our understanding of the pathogenesis of the acquired immunodeficiency syndrome (AIDS) has changed recently. Which of the following is the best description of the latest model? (Warner Greene of UCSF published the answer in simultaneous Nature and Science papers in late 2013.)

a.HIV infects T cells and replicates within them, and the replication of HIV within T cells causes their death via lysis, which leads to immunodeficiency

b.HIV infects T cells and replicates within them, and the replication of HIV within T cells causes their death via activation-induced cell death, which leads to immunodeficiency

c.HIV infects T cells abortively, and this abortive infection of HIV in T cells causes their death via lysis, which leads to immunodeficiency

d.HIV infections T cells abortively, and this abortive infection of HIV in T cells causes their death via apoptosis, which leads to immunodeficiency

e.HIV infections T cells abortively, and this abortive infection of HIV in T cells causes their death via pyroptosis, which leads to immunodeficiency

Our understanding of the pathogenesis of the acquired immunodeficiency syndrome (AIDS) has changed recently. Which of the following is the best description of the latest model? (Warner Greene of UCSF published the answer in simultaneous Nature and Science papers in late 2013.) 

a.HIV infects T cells and replicates within them, and the replication of HIV within T cells causes their death via lysis, which leads to immunodeficiency 

b.HIV infects T cells and replicates within them, and the replication of HIV within T cells causes their death via activation-induced cell death, which leads to immunodeficiency 

c.HIV infects T cells abortively, and this abortive infection of HIV in T cells causes their death via lysis, which leads to immunodeficiency 

d.HIV infections T cells abortively, and this abortive infection of HIV in T cells causes their death via apoptosis, which leads to immunodeficiency 

e.HIV infections T cells abortively, and this abortive infection of HIV in T cells causes their death via pyroptosis, which leads to immunodeficiency

35

Despite the availability of effective HIV therapy, many patients with HIV still have poor health outcomes. The figure below shows how many among the total number of HIV patients in the United States (leftmost bar) are actually on fully suppressive antiretroviral therapy (rightmost bar).
 
Please reflect on the social determinants of health that cause patients who have HIV to not be diagnosed, linked to care, retained in care and on effective therapy. These social determinants of health are of course not unique to HIV and influence a host of social outcomes. Which of the following will be your approach to addressing the social determinants of adverse health outcomes?

I plan to recognize and help redress the social determinants of health in my clinical practice.

36

A 34-year-old injection drug user presents with fever, headache and weakness of the left arm. Physical examination shows fever, mild hypotension and a blowing diastolic murmur heard best along the left sternal border when the patient is sitting up and leaning forward. Blood cultures from last night are already growing Gram positive cocci in all four bottles. A CT scan of the head shows a focal collection in the distribution of the right middle cerebral artery. Which of the below cerebrospinal fluid analysis results is MOST CONSISTENT with this syndrome?

-Elevated opening pressure, white cells 50 (85% mononuclear cells), protein 100, Gram stain and culture negative, cryptococcal antigen positive

-Normal opening pressure, white cells 25 (70% neutrophils), protein 100, Gram stain and culture negative

-Normal opening pressure, white cells 923 (96% neutrophils), protein 55, Gram stain and culture positive for Gram positive cocci

-Normal opening pressure, white cells 0 (65% neutrophils), protein 30, Gram stain and culture negative

-Normal opening pressure, white cells 411 (15% neutrophils), protein 51, arboviral encephalitis panel positive for Eastern equine encephalitis virus

A 34-year-old injection drug user presents with fever, headache and weakness of the left arm. Physical examination shows fever, mild hypotension and a blowing diastolic murmur heard best along the left sternal border when the patient is sitting up and leaning forward. Blood cultures from last night are already growing Gram positive cocci in all four bottles. A CT scan of the head shows a focal collection in the distribution of the right middle cerebral artery. Which of the below cerebrospinal fluid analysis results is MOST CONSISTENT with this syndrome?


-Elevated opening pressure, white cells 50 (85% mononuclear cells), protein 100, Gram stain and culture negative, cryptococcal antigen positive

-Normal opening pressure, white cells 25 (70% neutrophils), protein 100, Gram stain and culture negative

-Normal opening pressure, white cells 923 (96% neutrophils), protein 55, Gram stain and culture positive for Gram positive cocci

-Normal opening pressure, white cells 0 (65% neutrophils), protein 30, Gram stain and culture negative

-Normal opening pressure, white cells 411 (15% neutrophils), protein 51, arboviral encephalitis panel positive for Eastern equine encephalitis virus

--Await explanation for the answer!!

37

Which of the following stories is MOST CHARACTERISTIC of infection with the dog hookworm?

Egg ingestion leads to anal pruritis diagnosed via the Scotch tape test.

Larva penetrate skin and make characteristic serpiginous trails through skin.

Cercaria from snails penetrate skin and can cause pipestem fibrosis in the liver.

Oocyst from cat feces wakes up in the brain of immunocompromised patients.

Eggs turn into worms which penetrate the bowel wall causing sepsis.

Which of the following stories is MOST CHARACTERISTIC of infection with the dog hookworm?

Egg ingestion leads to anal pruritis diagnosed via the Scotch tape test.

Larva penetrate skin and make characteristic serpiginous trails through skin.

Cercaria from snails penetrate skin and can cause pipestem fibrosis in the liver.

Oocyst from cat feces wakes up in the brain of immunocompromised patients.

Eggs turn into worms which penetrate the bowel wall causing sepsis.

38

Which of the following statements regarding the likelihood of transmission of tuberculosis by someone with latent tuberculosis infection is TRUE?



 

1. The likelihood of transmission is affected by receipt of prior BCG vaccine

 

2. The likelihood of transmission is affected by receipt of effective therapy

3. The likelihood of transmission of tuberculosis is zero

4. The likelihood of transmission is affected by immunological competency

5. The likelihood of transmission of tuberculosis is very low but non-zero

Which of the following statements regarding the likelihood of transmission of tuberculosis by someone with latent tuberculosis infection is TRUE?



 

1. The likelihood of transmission is affected by receipt of prior BCG vaccine

2. The likelihood of transmission is affected by receipt of effective therapy

3. The likelihood of transmission of tuberculosis is zero

4. The likelihood of transmission is affected by immunological competency

5. The likelihood of transmission of tuberculosis is very low but non-zero

39

Yesterday you notified Joe, a 25 year-old man who has sex with men, that he has HIV infection. He feels well, has no past medical history, and has a normal physical examination. The HIV serology was obtained during routine screening. After he spent a few hours on Google looking up HIV and its complications, Joe has a list of questions for you, including, “When do you think we should start meds, doc?” Joe’s CD4 count is 90. You plan to start prophylactic antibiotics today and then next week you’ll begin antiretroviral therapy. 

What prophylactic antibiotics would you recommend for Joe?

a.Trimethoprim/sulfamethoxazole alone

b.Azithromycin alone

c.Valganciclovir alone

d.Trimethoprim/sulfamethoxazole plus azithromycin

e.Trimethoprim/sulfamethoxazole plus valcanciclovir

•Yesterday you notified Joe, a 25 year-old man who has sex with men, that he has HIV infection. He feels well, has no past medical history, and has a normal physical examination. The HIV serology was obtained during routine screening. After he spent a few hours on Google looking up HIV and its complications, Joe has a list of questions for you, including, “When do you think we should start meds, doc?” Joe’s CD4 count is 90. You plan to start prophylactic antibiotics today and then next week you’ll begin antiretroviral therapy. 

What prophylactic antibiotics would you recommend for Joe?

a.Trimethoprim/sulfamethoxazole alone 

b.Azithromycin alone 

c.Valganciclovir alone 

d.Trimethoprim/sulfamethoxazole plus azithromycin

e.Trimethoprim/sulfamethoxazole plus valcanciclovir

40

•A 23 year-old sexually active recent college graduate develops dysuria. Her urinalysis shows pyuria but so far nothing has grown in urine culture. Which of the following is true of her illness?

A.A three-day course of trimethoprim-sulfamethoxazole should cover the most likely pathogens.

B.A three-day course of gentamicin should cover the most likely pathogens.

C.A three day course of amoxicillin-clavulanate should cover the most likely pathogens.

D.A three-day course of vancomycin should cover the most likely pathogens.

E.A three-day course of azithromycin should cover the most likely pathogens. 

•A 23 year-old sexually active recent college graduate develops dysuria. Her urinalysis shows pyuria but so far nothing has grown in urine culture. Which of the following is true of her illness? 

A.A three-day course of trimethoprim-sulfamethoxazole should cover the most likely pathogens. 

B.A three-day course of gentamicin should cover the most likely pathogens.

C.A three day course of amoxicillin-clavulanate should cover the most likely pathogens. 

D.A three-day course of vancomycin should cover the most likely pathogens. 

E.A three-day course of azithromycin should cover the most likely pathogens. 

42

A 62-year-old man with hemochromatosis and poorly controlled diabetes develops painful sinusitis and a black sore on the roof of his mouth. A tissue biopsy of the oral ulcer shows right angle hyphae. Which of the following is TRUE regarding the diagnosis and management of this condition?

-This is rhinocerebral mucormycosis and should be treated with posaconazole

 

-This is rhinocerebral mucormycosis and should be treated with posaconazole plus surgery with good response rates.

-This is rhinocerebral mucormycosis and should be treated with posaconazole plus surgery with poor response rates.

-This is rhinocerebral aspergillosis and should be treated with voriconazole

-This is rhinocerebral aspergillosis and should be treated with voriconazole plus surgery with good response rates

-This is rhinocerebral aspergillosis and should be treated with voriconazole plus surgery with poor response rates

A 62-year-old man with hemochromatosis and poorly controlled diabetes develops painful sinusitis and a black sore on the roof of his mouth. A tissue biopsy of the oral ulcer shows right angle hyphae. Which of the following is TRUE regarding the diagnosis and management of this condition?

-This is rhinocerebral mucormycosis and should be treated with posaconazole

-This is rhinocerebral mucormycosis and should be treated with posaconazole plus surgery with good response rates.

-This is rhinocerebral mucormycosis and should be treated with posaconazole plus surgery with poor response rates.

-This is rhinocerebral aspergillosis and should be treated with voriconazole

-This is rhinocerebral aspergillosis and should be treated with voriconazole plus surgery with good response rates

-This is rhinocerebral aspergillosis and should be treated with voriconazole plus surgery with poor response rates

 

43

A nurse changing the linen of a known injection drug user suffers a deep puncture from a bloody needle hidden in the bed sheets. Which of the following statements is TRUE?

  • A. Among unvaccinated people, the likelihood of HIV transmission is higher than the likelihood of hepatitis
  • B. Transmission cannot occur unless the needle entered one of the nurse’s veins.
  • C. Post-exposure prophylaxis may be necessary if the patient has HIV infection.
  • D. Cefazolin should be given to reduce the likelihood of bacterial infection.

C

45

•You are a pediatrician seeing a 5 year-old otherwise healthy child for rhinorrhea, irritability and fatigue. On exam, she does not look sick, she has red nostrils, slightly erythematous posterior oropharynx, and clear lungs. You suspect a cold, and are considering non-antibiotic treatments. Beyond extra sleep, which of the following would NOT be a good idea?

A.Ibuprofen

B.Ipratropium

C.Dextromethorphan

D.Aspirin

E.Salt water gargles 

•You are a pediatrician seeing a 5 year-old otherwise healthy child for rhinorrhea, irritability and fatigue. On exam, she does not look sick, she has red nostrils, slightly erythematous posterior oropharynx, and clear lungs. You suspect a cold, and are considering non-antibiotic treatments. Beyond extra sleep, which of the following would NOT be a good idea? 

A.Ibuprofen 

B.Ipratropium 

C.Dextromethorphan 

D.Aspirin 

E.Salt water gargles 

46

A bone marrow transplant recipient develops a cavitary lung lesion while taking high dose corticosteroids and other immunosuppressants for graft versus host disease. Physical examination shows fever and the characteristic rash of graft versus host disease but is otherwise unrevealing. Blood cultures are negative and a serum galactomannan test is positive. Which of the following statements is TRUE about the diagnosis and management of this condition?

1. This is likely pulmonary candidiasis and should respond to fluconazole

2. This is likely pulmonary candidiasis and should respond to voriconazole

3. This is likely pulmonary aspergillosis and should respond to fluconazole

4. This is likely pulmonary aspergillosis and should response to voriconazole

A bone marrow transplant recipient develops a cavitary lung lesion while taking high dose corticosteroids and other immunosuppressants for graft versus host disease. Physical examination shows fever and the characteristic rash of graft versus host disease but is otherwise unrevealing. Blood cultures are negative and a serum galactomannan test is positive. Which of the following statements is TRUE about the diagnosis and management of this condition?

1. This is likely pulmonary candidiasis and should respond to fluconazole

2. This is likely pulmonary candidiasis and should respond to voriconazole

3. This is likely pulmonary aspergillosis and should respond to fluconazole

4. This is likely pulmonary aspergillosis and should response to voriconazole

 

48

Many fungal pathogens can present with a bilateral pneumonia but the geographic location of acquisition can help clinicians to guess which pathogen is most likely. Which of the below pairs a fungus with its stereotypical location properly?



 

1. Bug: Cryptococcus neoformans, Location: Mississippi River Valley and Ohio River Valley

 

2. Bug: Histoplasma capsulatum, Location: Mississippi River Valley and Ohio River Valley

3. Bug: Sporothrix schenckii, Location: San Joaquin Valley and Central Valley, CA

4. Bug: Penicillium marneffei, Location: San Joaquin Valley and Central Valley, CA

5. Bug: Coccidioides immitis, Location: Worldwide

Many fungal pathogens can present with a bilateral pneumonia but the geographic location of acquisition can help clinicians to guess which pathogen is most likely. Which of the below pairs a fungus with its stereotypical location properly?



 

1. Bug: Cryptococcus neoformans, Location: Mississippi River Valley and Ohio River Valley

2. Bug: Histoplasma capsulatum, Location: Mississippi River Valley and Ohio River Valley

3. Bug: Sporothrix schenckii, Location: San Joaquin Valley and Central Valley, CA

4. Bug: Penicillium marneffei, Location: San Joaquin Valley and Central Valley, CA

5. Bug: Coccidioides immitis, Location: Worldwide

50

What percentage of immunocompetent people develop active tuberculosis disease during the first two years after tuberculosis infection and then in the ensuing years of life?



 

1. 5% in the first two years and 5% thereafter, i.e. 10% overall

 

2. 5% in the first two years and 10% thereafter i.e. 15% overall

3. 10% in the first two years and 5% thereafter, i.e. 15% overall

4. 10% in the first two years and 10% thereafter, i.e. 20% overall

What percentage of immunocompetent people develop active tuberculosis disease during the first two years after tuberculosis infection and then in the ensuing years of life?



 

1. 5% in the first two years and 5% thereafter, i.e. 10% overall

2. 5% in the first two years and 10% thereafter i.e. 15% overall

3. 10% in the first two years and 5% thereafter, i.e. 15% overall

4. 10% in the first two years and 10% thereafter, i.e. 20% overall

 

51

The HIV epidemic was first detected in the coastal United States among men who have sex with men (MSM), and MSM remain the predominant demographic group among people with HIV in the United States and Europe. Which of the following is true of HIV epidemiology WORLDWIDE?

a.MSM are the predominant demographic group among people with HIV.

b.Perinatal transmission has been wiped out via preventive antiretroviral therapy.

c.Heterosexual transmission is the most common transmission route.

d.Antiretroviral drugs are widely available to all who need them.

e.Poverty, war, addiction, and sexism play little role in ongoing HIV transmission.

The HIV epidemic was first detected in the coastal United States among men who have sex with men (MSM), and MSM remain the predominant demographic group among people with HIV in the United States and Europe. Which of the following is true of HIV epidemiology WORLDWIDE? 

a.MSM are the predominant demographic group among people with HIV. 

b.Perinatal transmission has been wiped out via preventive antiretroviral therapy. 

c.Heterosexual transmission is the most common transmission route. 

d.Antiretroviral drugs are widely available to all who need them. 

e.Poverty, war, addiction, and sexism play little role in ongoing HIV transmission.

52

Which of the following correctly ranks HIV transmission risk activities from GREATEST TO LEAST likelihood of transmission?

a.Oral intercourse, vaginal intercourse, anal intercourse

b.Vaginal intercourse, anal intercourse, oral intercourse

c.Receptive vaginal intercourse, insertive vaginal intercourse, anal intercourse

d.Receptive anal intercourse without a condom, receptive vaginal intercourse without a condom, insertive vaginal intercourse with a condom

e.Receptive vaginal intercourse, receptive anal intercourse, insertive oral intercourse

Which of the following correctly ranks HIV transmission risk activities from GREATEST TO LEAST likelihood of transmission? 

a.Oral intercourse, vaginal intercourse, anal intercourse 

b.Vaginal intercourse, anal intercourse, oral intercourse 

c.Receptive vaginal intercourse, insertive vaginal intercourse, anal intercourse 

d.Receptive anal intercourse without a condom, receptive vaginal intercourse without a condom, insertive vaginal intercourse with a condom 

e.Receptive vaginal intercourse, receptive anal intercourse, insertive oral intercourse

53

Which of the following syndromes is MOST CONSISTENT with the typical presentation of bacterial meningitis?

-A 34-year-old injection drug user presents with fever, headache and weakness of the left arm

-An 16-year-old high school girl presents with fever, headache, a petechial rash and sepsis

-A 22-year-old Appalachian trail hiker presents with fever, confusion and seizure

-A 21-year-old otherwise healthy woman from Massachusetts presents with fever, headache, normal vitals, and myalgias in the summer

-A 68-year-old dancer with AIDS presents with ataxia and personality changes

Which of the following syndromes is MOST CONSISTENT with the typical presentation of bacterial meningitis?


-A 34-year-old injection drug user presents with fever, headache and weakness of the left arm

-An 16-year-old high school girl presents with fever, headache, a petechial rash and sepsis

-A 22-year-old Appalachian trail hiker presents with fever, confusion and seizure

-A 21-year-old otherwise healthy woman from Massachusetts presents with fever, headache, normal vitals, and myalgias in the summer

-A 68-year-old dancer with AIDS presents with ataxia and personality changes

 

54

Which of the following stories is MOST CHARACTERISTIC of infection with Strongyloides stercoralis?

Egg ingestion leads to anal pruritis diagnosed via the Scotch tape test.

Larva penetrate skin and make characteristic serpiginous trails through skin.

Cercaria from snails penetrate skin and can cause pipestem fibrosis in the liver.

Oocyst from cat feces wakes up in the brain of immunocompromised patients.

Eggs turn into worms which penetrate the bowel wall causing sepsis.

Which of the following stories is MOST CHARACTERISTIC of infection with Strongyloides stercoralis?

Egg ingestion leads to anal pruritis diagnosed via the Scotch tape test.

Larva penetrate skin and make characteristic serpiginous trails through skin.

Cercaria from snails penetrate skin and can cause pipestem fibrosis in the liver.

Oocyst from cat feces wakes up in the brain of immunocompromised patients.

Eggs turn into worms which penetrate the bowel wall causing sepsis.

56

Ova and parasite testing reveals the organism pictured below in the stool of a 45-year-old teetotaler with cirrhosis of the liver and a gastrointestinal bleed from esophageal varices. Which of the following parasites is the MOST LIKELY culprit?

Strongyloides stercoralis

Schistosoma japonicum

Ascaris lumbricoides

Babesia microti

Cryptosporidium parvum

Schistosoma japonicum 

(this is actually a picture of schistosoma haematobium!!)

57

Why is the tuberculin skin test (a.k.a. purified protein derivative or PPD) interpreted differently in different hosts, i.e. with 15 mm positive in some hosts and 5 mm in others?

1. A higher likelihood of being exposed to tuberculosis requires a higher threshold for a positive result, as in the case of contacts of people with diabetes.

2. A higher likelihood of being exposed to tuberculosis requires a lower threshold for a positive result, as in the case of people with diabetes.

3. A higher likelihood of developing active tuberculosis after exposure requires a higher threshold for a positive result, such as in the case of people with HIV co-infection.

4. A higher likelihood of developing tuberculosis after exposure requires a lower threshold for a positive result, such as in the case of people with HIV co-infection.

Why is the tuberculin skin test (a.k.a. purified protein derivative or PPD) interpreted differently in different hosts, i.e. with 15 mm positive in some hosts and 5 mm in others?

1. A higher likelihood of being exposed to tuberculosis requires a higher threshold for a positive result, as in the case of contacts of people with diabetes.

2. A higher likelihood of being exposed to tuberculosis requires a lower threshold for a positive result, as in the case of people with diabetes.

3. A higher likelihood of developing active tuberculosis after exposure requires a higher threshold for a positive result, such as in the case of people with HIV co-infection.

4. A higher likelihood of developing tuberculosis after exposure requires a lower threshold for a positive result, such as in the case of people with HIV co-infection.

58

Osteomyelitis located in a thoracic vertebra in a patient with no antecedent spinal surgery is most suggestive of hematogenous or contiguous spread?

Hematogenous spread

60

You should wear a surgical mask when visiting the patient in their standard room to prevent the transmission of whooping cough and which of the following infections?

  • Chickenpox
  • Influenza
  • Pseudomonas aeruginosa
  • Streptococcus pneumoniae
  • Mycoplasma pneumoniae

Influenza

also acceptable answers: meningitis, pertussis

61

You diagnose a 25-year-old woman with her third Escherichia coli urinary tract infection of the past year. Beyond starting a three-day course of trimethoprim-sulfamethoxazole (TMP/SMX) while awaiting the results of drug susceptibility testing, what additional measures should you take to address her recurrent infections?

  • Educate her about post-coital voiding.
  • Teach her to wipe back to front after bowel movements.
  • Send blood tests for immunoglobulin deficiency testing.
  • Test for co-existing gonorrhea.


Educate her about post-coital voiding.
 

62

•While seeing a patient with a persistent cough and mild dyspnea in your clinic, you hear some crackles on chest exam and so order a chest x-ray. Which of the following statements is TRUE regarding the use of chest x-ray in patients with suspected bronchitis or pneumonia?

A.A normal physical examination excludes the possibility of bacterial pneumonia.

B.You can discriminate between bronchitis and pneumonia via symptoms alone.

C.It is acceptable to give azithromycin to all patients with bronchitis or pneumonia.

D.Patients with bronchitis may have peribronchial cuffing but an infiltrate is rare.

E.Bacteria are the most common cause of acute bronchitis.

•While seeing a patient with a persistent cough and mild dyspnea in your clinic, you hear some crackles on chest exam and so order a chest x-ray. Which of the following statements is TRUE regarding the use of chest x-ray in patients with suspected bronchitis or pneumonia? 

A.A normal physical examination excludes the possibility of bacterial pneumonia. 

B.You can discriminate between bronchitis and pneumonia via symptoms alone. 

C.It is acceptable to give azithromycin to all patients with bronchitis or pneumonia. 

D.Patients with bronchitis may have peribronchial cuffing but an infiltrate is rare. 

E.Bacteria are the most common cause of acute bronchitis.

63

You suspect Amit, a recent emigrated mechanic from India with fever and a right upper lobe cavitary nodule, has active tuberculosis. After putting on your N95 mask, which of the following diagnostic tests should you order in order to confirm your diagnostic suspicion?

  • Placement of a tuberculin skin test (TST) with purified protein derivative (PPD)
  • Interferon gamma release assay (IGRA).
  • Right upper lobe wedge resection to allow pathological analysis of the lung nodule.
  • Sputum collection for acid-fast bacillus staining and mycobacterial culture.
  • Serum galactomannan testing.

 

Sputum collection for acid-fast bacillus staining and mycobacterial culture.
 

 

64

Which of the following scenarios is MOST CONSISTENT with latent tuberculosis infection?



 

1. Symptom: Cough  ---  PPD: Negative  ---  Chest X-ray: Granuloma near the hilum on the right

 

2. Symptom: None  ---  PPD: Negative  ---  Chest X-ray: Normal

3. Symptom: None  ---  PPD: Positive  ---  Chest X-ray: Infiltrate in the left lower lobe

4. Symptom: None  ---  PPD:  Positive  ---  Chest X-ray: Normal

5. Symptom: Cough  ---  PPD: Positive  ---  Chest X-ray: Cavitation in the right upper lobe

Which of the following scenarios is MOST CONSISTENT with latent tuberculosis infection?



 

1. Symptom: Cough  ---  PPD: Negative  ---  Chest X-ray: Granuloma near the hilum on the right

2. Symptom: None  ---  PPD: Negative  ---  Chest X-ray: Normal

3. Symptom: None  ---  PPD: Positive  ---  Chest X-ray: Infiltrate in the left lower lobe

4. Symptom: None  ---  PPD:  Positive  ---  Chest X-ray: Normal

5. Symptom: Cough  ---  PPD: Positive  ---  Chest X-ray: Cavitation in the right upper lobe

 

65

•In comparison to routine community acquired pneumonia, which of the following is true about aspiration pneumonia?

A.Highly resistant Gram positive cocci like MRSA are more likely.

B.Highly resistant Gram negative bacilli like Pseudomonas are more likely.

C.Anaerobic organisms like Peptostreptococcus are more likely.

D.Viruses like herpesviruses are more likely.

E.Atypical bacteria like Mycoplasma are more likely.

•In comparison to routine community acquired pneumonia, which of the following is true about aspiration pneumonia? 

A.Highly resistant Gram positive cocci like MRSA are more likely. 

B.Highly resistant Gram negative bacilli like Pseudomonas are more likely.

C.Anaerobic organisms like Peptostreptococcus are more likely. 

D.Viruses like herpesviruses are more likely. 

E.Atypical bacteria like Mycoplasma are more likely.

66

•Which of the following statements about the intramuscular influenza vaccine is TRUE?

A.Influenza vaccination is associated with a risk of autism.

B.Influenza vaccination is associated with 25% protection from influenza.

C.Influenza vaccination is associated with 75% protection from influenza.

D.Influenza vaccination is contraindicated in people with HIV or other immunocompromise.

E.Influenza vaccination is associated with a risk of multiple sclerosis. 

•Which of the following statements about the intramuscular influenza vaccine is TRUE? 

A.Influenza vaccination is associated with a risk of autism. 

B.Influenza vaccination is associated with 25% protection from influenza.

C.Influenza vaccination is associated with 75% protection from influenza.

D.Influenza vaccination is contraindicated in people with HIV or other immunocompromise. 

E.Influenza vaccination is associated with a risk of multiple sclerosis. 

67

Lacerations, puncture wounds and other breaks in skin integrity can become infected. Which statement about such infections is true?

A. the most common pathogens are Pseudominas and Aeromonase

B. Foot puncture through a sneaker typically causes infection with Vibrio vulnificus

C. Foul-smelling infection with gas in the tissues suggests Clostridium perfringens

D. Staph aureus is an uncommon pathogen in staph infections

Lacerations, puncture wounds and other breaks in skin integrity can become infected. Which statement about such infections is true?

A. the most common pathogens are Pseudominas and Aeromonase

B. Foot puncture through a sneaker typically causes infection with Vibrio vulnificus

C. Foul-smelling infection with gas in the tissues suggests Clostridium perfringens

D. Staph aureus is an uncommon pathogen in staph infections

68

A 32-year-old AIDS patient and political activist with a CD4 count of 41 develops right-sided blind spots and ultimately complete right-sided blindness over the course of a few weeks. The ophthalmologist sees some “cotton wool” spots near the optic disc on the left eye although at this point the patient’s vision is normal on that side. “Doc,” he says, “you’ve got to save my vision. Can you keep my left eye from going dark too?” 

Which of the following medications would help him save his remaining vision?

-Trimethroprim-sulfamethoxazole

-Azithromycin

-Fluconazole

-Acyclovir

-Ganciclovir

A 32-year-old AIDS patient and political activist with a CD4 count of 41 develops right-sided blind spots and ultimately complete right-sided blindness over the course of a few weeks. The ophthalmologist sees some “cotton wool” spots near the optic disc on the left eye although at this point the patient’s vision is normal on that side. “Doc,” he says, “you’ve got to save my vision. Can you keep my left eye from going dark too?” 

Which of the following medications would help him save his remaining vision?

-Trimethroprim-sulfamethoxazole

-Azithromycin

-Fluconazole

-Acyclovir

-Ganciclovir

69

Infection from which of the following pathogens is LEAST LIKELY to cause more than two weeks of diarrhea?

-Cryptosporidium

-Giardia

-Entamoeba histolytica

-Rotavirus

-Clostridium difficile

Infection from which of the following pathogens is LEAST LIKELY to cause more than two weeks of diarrhea?

-Cryptosporidium

-Giardia

-Entamoeba histolytica

-Rotavirus

-Clostridium difficile

 

70

You just learned that four of four blood culture bottles drawn when you admitted a febrile injection drug user last night are now growing Staphylococcus aureus. Which of the following findings would make you MOST CONCERNED she has developed injection drug use-related endocarditis?

Jaundice and spider angiomata

Fever and bloody diarrhea

Pleuritic chest pain and pulmonary nodules

Exposure to parturient livestock

Anemia and elevated erythrocyte sedimentation rate

You just learned that four of four blood culture bottles drawn when you admitted a febrile injection drug user last night are now growing Staphylococcus aureus. Which of the following findings would make you MOST CONCERNED she has developed injection drug use-related endocarditis?

Jaundice and spider angiomata

Fever and bloody diarrhea

Pleuritic chest pain and pulmonary nodules

Exposure to parturient livestock

Anemia and elevated erythrocyte sedimentation rate

 

71

Tina is an exotic dancer in a “gentleman’s club” who developed a rapidly spreading soft tissue infection on her left thigh where a zipper on some tall boots caught. Within hours she was febrile to 40°, her blood pressure was 80/40, heart rate 140, oxygenation normal, and she was receiving many liters of intravenous saline. Labs show an elevated white count with multiple immature forms visible on differential, normal hemoglobin, and a normal serum creatinine. MRI showed necrotizing fasciitis and she was being prepped for operative debridement. Beyond administration of broad spectrum antibiotics aimed at all plausible pathogens, which of the following additional measures is appropriate at this time?

  • Administration of intravenous norepinephrine drip.
  • Administration of intravenous dexamethasone.
  • Administration of packed red blood cell transfusions.
  • Institution of continuous venovenous hemofiltration (CVVH).
  • Institution of intravenous tissue plasminogen activator (tPA).


Administration of intravenous norepinephrine drip.


 

72

Osteomyelitis can arise from hematogenous spread, or contiguous inoculation. Which of the following patients is at risk for developing osteomyelitis from contiguous inoculation?

A. 34  yo woman with tampon-associated septic shock

B. 66 yo woman with vascular disease and a longstanding diabetic foot ulcer

C. 31 yo man with HIV acquired through injection drug use

D. 81 yo man given rituximab for idiopathic thrombocytopenic purpura

Osteomyelitis can arise from hematogenous spread, or contiguous inoculation. Which of the following patients is at risk for developing osteomyelitis from contiguous inoculation?

A. 34  yo woman with tampon-associated septic shock

B. 66 yo woman with vascular disease and a longstanding diabetic foot ulcer

C. 31 yo man with HIV acquired through injection drug use

D. 81 yo man given rituximab for idiopathic thrombocytopenic purpura

73

•You diagnose a patient with community acquired pneumonia. Which of the following statements regarding antibiotic choice is TRUE?

A.Azithromycin covers Gram positives but not Gram negatives so is inadequate alone.

B.Ceftriaxone covers Gram positives and Gram negatives but not atypicals so is inadequate alone.

C.Levofloxacin covers Gram positives and Gram negatives but not atypicals so is inadequate alone.

D.Ciprofloxacin covers Gram positives, Gram negatives and atypicals so is adequate coverage alone.

E.Meropenem covers Gram positives, Gram negatives and atypicals so is adequate coverage alone. 

•You diagnose a patient with community acquired pneumonia. Which of the following statements regarding antibiotic choice is TRUE? 

A.Azithromycin covers Gram positives but not Gram negatives so is inadequate alone. 

B.Ceftriaxone covers Gram positives and Gram negatives but not atypicals so is inadequate alone. 

C.Levofloxacin covers Gram positives and Gram negatives but not atypicals so is inadequate alone. 

D.Ciprofloxacin covers Gram positives, Gram negatives and atypicals so is adequate coverage alone. 

E.Meropenem covers Gram positives, Gram negatives and atypicals so is adequate coverage alone. 

74

Which of the following syndromes is MOST CONSISTENT with the typical presentation of viral meningitis?

-A 34-year-old injection drug user presents with fever, headache and weakness of the left arm

-An 16-year-old high school girl presents with fever, headache, a petechial rash and sepsis

-A 22-year-old Appalachian trail hiker presents with fever, confusion and seizure

-A 21-year-old otherwise healthy woman from Massachusetts presents with fever, headache, normal vitals, and myalgias in the summer

-A 68-year-old dancer with AIDS presents with ataxia and personality changes

Which of the following syndromes is MOST CONSISTENT with the typical presentation of viral meningitis?

-A 34-year-old injection drug user presents with fever, headache and weakness of the left arm

-An 16-year-old high school girl presents with fever, headache, a petechial rash and sepsis

-A 22-year-old Appalachian trail hiker presents with fever, confusion and seizure

-A 21-year-old otherwise healthy woman from Massachusetts presents with fever, headache, normal vitals, and myalgias in the summer

-A 68-year-old dancer with AIDS presents with ataxia and personality changes

 

75

A 60 yo handyman from Egypt has a history of hematuria and then develops bladder cancer. Infection with which of the following pathogens most contributed to these symptoms?

-Toxoplasma gondii

-Toxocara canis

-Schistosoma haematobium

-Trichomonas hominis

-Strongyloides stercoralis

A 60 yo handyman from Egypt has a history of hematuria and then develops bladder cancer. Infection with which of the following pathogens most contributed to these symptoms?

-Toxoplasma gondii

-Toxocara canis

-Schistosoma haematobium

-Trichomonas hominis

-Strongyloides stercoralis

76

Which sexually-transmitted infection whose symptoms are described below is MOST LIKELY to respond to therapy with metronidazole?

1. A college rugby player develops purulent penile discharge.

2. An HIV-positive man who has sex with men has a positive nucleic acid amplification test (NAAT) on routine screening.

3. A female commercial sex worker develops dyspareunia and frothy vaginal discharge.

4. A lawyer notices a painless heaped up sore on the shaft of his penis.

5. A college sophomore develops painful fluid-filled lesions on her upper lip.

Which sexually-transmitted infection whose symptoms are described below is MOST LIKELY to respond to therapy with metronidazole?

1. A college rugby player develops purulent penile discharge.

2. An HIV-positive man who has sex with men has a positive nucleic acid amplification test (NAAT) on routine screening.

3. A female commercial sex worker develops dyspareunia and frothy vaginal discharge.

4. A lawyer notices a painless heaped up sore on the shaft of his penis.

5. A college sophomore develops painful fluid-filled lesions on her upper lip.

77

75 yo man at ED w back pain. Has been feeling unwell for weeks, w poor appetite, occasional sweats and fatigue, but no fever. Comes in now because pain is worse over the past day, and his legs feel weak. Hx notable for diverticulitis and prostatic hypertrophy, which requires intermittent self-catheterization. Retired dairy farmer, served in Vietnam in 1967.

Most urgent concern is:

-degen joint disease and spinal stenosis, for which you prescribe anti-inflammatory agents and arrange for PT

-Recurrent diverticulitis, for which you order an abdominal CT

-UTI, including pyelonephritis, for which you order UA, urine culture, and IV pyelogram

-Spinal TB, for which you do a PPD, get plain films of the spine, order a CXR 

-vertebral osteomyelitis complicated by epidural abscess, for which you order an MRI of the spine 

75 yo man at ED w back pain. Has been feeling unwell for weeks, w poor appetite, occasional sweats and fatigue, but no fever. Comes in now because pain is worse over the past day, and his legs feel weak. Hx notable for diverticulitis and prostatic hypertrophy, which requires intermittent self-catheterization. Retired dairy farmer, served in Vietnam in 1967.

Most urgent concern is:

-degen joint disease and spinal stenosis, for which you prescribe anti-inflammatory agents and arrange for PT

-Recurrent diverticulitis, for which you order an abdominal CT

-UTI, including pyelonephritis, for which you order UA, urine culture, and IV pyelogram

-Spinal TB, for which you do a PPD, get plain films of the spine, order a CXR (possible esp since he served overseas)

-vertebral osteomyelitis complicated by epidural abscess, for which you order an MRI of the spine (key thing you worry about is epidural abscess encroaching on the spinal cord and causeing paralysis – legs feel weak -> might be the start of a cord problem.)

78

Which of the following is the standard approach to treatment of latent tuberculosis infection?



 

1. Six months of isoniazid, rifampin, pyrazinamide and ethambutol

 

2. Nine months of isoniazid

3. Nine months of isoniazid, rifampin, pyrazinamide and ethambutol

4. Six months of isoniazid

Which of the following is the standard approach to treatment of latent tuberculosis infection?



 

1. Six months of isoniazid, rifampin, pyrazinamide and ethambutol

2. Nine months of isoniazid

3. Nine months of isoniazid, rifampin, pyrazinamide and ethambutol

4. Six months of isoniazid

 

79

  Which of the following CORRECTLY describes the preferred approach to hand hygiene in healthcare settings?

  • Alcohol-based hand sanitizer before each patient contact.
  • Alcohol-based hand sanitizer after each patient contact.
  • Alcohol-based hand sanitizer before and after each patient contact.
  • Soap and water before each patient contact.
  • Soap and water after each patient contact.
  • Soap and water before and after each patient contact.


Alcohol-based hand sanitizer before and after each patient contact.
 

80

You are running a community health clinic in which you see a MSM who complains of 3w of crampy abdominal pain and loose stools. “Doc, I am so…. Flatulent” he says. A routine stool culture reveals nothing. Which of the following pathogens is the likely culprit?

-Tricomonas hominis

-Cryptosporidium parvum

-Ascaris lumbricoides

-Giardia lamblia

-Schistosoma mansonii

You are running a community health clinic in which you see a MSM who complains of 3w of crampy abdominal pain and loose stools. “Doc, I am so…. Flatulent” he says. A routine stool culture reveals nothing. Which of the following pathogens is the likely culprit?

-Tricomonas hominis

-Cryptosporidium parvum

-Ascaris lumbricoides

-Giardia lamblia

-Schistosoma mansonii

81

Staphylococcus aureus and Streptococcus pyogenes both cause skin and soft tissue infections. Which of the following about the characteristic patterns of infection they cause is true?

A. Staphylococcus aureus commonly causes spreading soft tissue infections, like cellulitis

B. Streptococcus pyogenes commonly causes spreading soft tissue infections like abscesses

C. Staphylococcus aureus commonly causes abscesses like furuncles and carbuncles

D. Streptococcus pyogenes commonly causes abscesses like fasciitis

Staphylococcus aureus and Streptococcus pyogenes both cause skin and soft tissue infections. Which of the following about the characteristic patterns of infection they cause is true?

A. Staphylococcus aureus commonly causes spreading soft tissue infections, like cellulitis

B. Streptococcus pyogenes commonly causes spreading soft tissue infections like abscesses

C. Staphylococcus aureus commonly causes abscesses like furuncles and carbuncles

D. Streptococcus pyogenes commonly causes abscesses like fasciitis

82

A 58-year-old schoolteacher presents to the emergency room with three weeks of worsening fever, fatigue, and dyspnea. She has no past medical history other than bicuspid aortic valve and antibiotic treatment for a dental abscess 4-6 weeks ago. She takes no medications. Physical examination shows a temperature of 102° F, blood pressure 130/40, and a loud blowing diastolic murmur along the left sternal border. Viridans streptococci are growing in off-antibiotic blood cultures drawn on day 1 and day 2 of hospitalization. Complete blood count, serum creatinine and a urinalysis as well as an EKG are normal. A transthoracic echocardiogram shows a hyperdynamic left ventrical but otherwise no valvular vegetations. Chest x-ray shows mild bilateral vascular congestion. 

Which of the below BEST characterizes the diagnostic findings to date?


-She is unlikely to have endocarditis, and this impression is confirmed by the negative transthoracic echocardiogram.

-She is high likely to have endocarditis but this diagnosis is ruled out by the negative transthoracic echocardiogram.

-She is unlikely to have endocarditis but a transesophageal echocardiogram should be done to confirm this impression.

-She is highly likely to have endocarditis and a transesophageal echocardiogram should be done to confirm this impression.

-She is highly likely to have endocarditis, which makes a transesophageal echocardiogram unnecessary.

A 58-year-old schoolteacher presents to the emergency room with three weeks of worsening fever, fatigue, and dyspnea. She has no past medical history other than bicuspid aortic valve and antibiotic treatment for a dental abscess 4-6 weeks ago. She takes no medications. Physical examination shows a temperature of 102° F, blood pressure 130/40, and a loud blowing diastolic murmur along the left sternal border. Viridans streptococci are growing in off-antibiotic blood cultures drawn on day 1 and day 2 of hospitalization. Complete blood count, serum creatinine and a urinalysis as well as an EKG are normal. A transthoracic echocardiogram shows a hyperdynamic left ventrical but otherwise no valvular vegetations. Chest x-ray shows mild bilateral vascular congestion. 

Which of the below BEST characterizes the diagnostic findings to date?

-She is unlikely to have endocarditis, and this impression is confirmed by the negative transthoracic echocardiogram.

-She is high likely to have endocarditis but this diagnosis is ruled out by the negative transthoracic echocardiogram.

-She is unlikely to have endocarditis but a transesophageal echocardiogram should be done to confirm this impression.

-She is highly likely to have endocarditis and a transesophageal echocardiogram should be done to confirm this impression.

-She is highly likely to have endocarditis, which makes a transesophageal echocardiogram unnecessary.