Upper Respiratory Tract Infections

Question 1

1. ML is a 14-month-old girl diagnosed with acute otitis media. She presented to the pediatric clinic today with a fever of 102.4°F (39.1°C) and tugging of her right ear for the past 24 hours. She developed rhinorrhea, nasal congestion, and sneezing approximately 3 days ago, but those
   symptoms have improved. She attends daycare 3 days a week and has a 4-year-old brother who attends preschool. This is her first episode of acute otitis media. She had a urinary tract infection when she was 10 months old, which was treated with amoxicillin successfully. What risk factor(s) for otitis media is/are present in ML?

A. Female sex
B. Daycare attendance
C. Young sibling
D. Antibiotic therapy 4 months ago
E. B and C are both risk factors

Answer 1

E

Question 2

2. ML has been vaccinated appropriately according to recommended childhood immunization schedules. The most likely bacterial pathogen causing her infection is:

A. Streptococcus pneumoniae
B. Streptococcus pyogenes
C. Moraxella catarrhalis
D. Staphylococcus aureus
E. Influenza

Answer 2

A

Question 3

3. Acute otitis media should be diagnosed in a child with which of the following
   signs/symptoms?

A. Middle ear effusion only
B. Middle ear effusion and mild erythema of the tympanic membrane
C. Moderate bulging of the tympanic membrane and otalgia
D. Mild erythema of the tympanic membrane, middle ear effusion, and hearing
impairment for at least 72 hours
E. None of these signs/symptoms are consistent with acute otitis media

Answer 3

C

Question 4

4. JJ is a 13-month-old boy with bilateral acute otitis media that is not severe. He was treated for a similar episode 4 months ago with amoxicillin and developed a nonurticarial rash. Which of the following is the most appropriate treatment approach for JJ?

A. Amoxicillin-clavulanate
B. Azithromycin
C. Cefdinir
D. Clindamycin
E. Observation option

Answer 4

C

Question 5

5. Adjunctive therapies for acute otitis media that are effective for reducing symptoms include:

A. Analgesics
B. Antihistamines
C. Decongestants
D. Corticosteroids
E. All of the above

Answer 5

A

Question 6

6. Which patient is most likely to have acute bacterial rhinosinusitis?

A. 6-year-old boy with nasal discharge for 5 days and congestion for 4 days whose
symptoms are improving
B. 18-year-old woman with persistent rhinorrhea and cough for 5 days and headache for 2 days
C. 42-year-old man with nasal congestion and nasal discharge for 5 days that became
purulent on day 3
D. 35-year-old woman with nasal congestion and postnasal discharge for 5 days that was initially improving but now has headache, increased discharge, and cough
E. 55-year-old man with rhinorrhea and postnasal discharge for 4 weeks

Answer 6

D

Question 7

7. Risk factors for acute bacterial rhinosinusitis include all of the following except:

A. Viral upper respiratory tract infection
B. Asthma
C. Cigarette smoke exposure
D. Perennial allergic rhinitis
E. Intranasal medication use

Answer 7

B

Question 8

8. A 39-year-old woman presents to an ambulatory care clinic with a 5-day history of nasal congestion and postnasal discharge. She tried oral phenylephrine for the last 2 days with very little relief of her congestion. Over the last 2 days, she developed right maxillary facial pain, a fever of 100.4°F (38.0°C), and a cough that is most pronounced in the morning. She reports an allergy to penicillin (“abdominal pain and diarrhea”) and she has not been treated with any antibiotics for the past 5 years. What is the most appropriate antibiotic for this patient?

A. Amoxicillin for 7 days
B. Moxifloxacin for 5 days
C. Azithromycin for 5 days
D. Cefdinir for 7 days
E. None of the above; she is not a candidate for antibiotics at this time

Answer 8

A

Question 9

9. Adherence to prescribed antibiotic therapy can reduce bacterial resistance. Which antibiotic regimen would you consider using in a 10-year-old boy with acute bacterial rhinosinusitis to promote adherence?

A. Levofloxacin 500 mg every day for 5 days.
B. Clarithromycin 500 mg twice a day for 5 days.
C. Amoxicillin 500 mg twice a day for 3 days.
D. Azithromycin 500 mg every day for 3 days.
E. None of these are appropriate options for this patient.

Answer 9

E

Question 10

10. Which of the following is not a goal of antibiotic therapy for streptococcal pharyngitis?

A. Minimize spread of infection to close contacts
B. Prevention of rheumatic fever
C. Prevention of postinfectious glomerulonephritis
D. Reduce the duration of symptoms
E. None of the above; they are all goals of antibiotic therapy

Answer 10

C

Question 11

11. Which patient most likely has streptococcal pharyngitis?

A. A 12-month-old boy with a 1-day history of rhinorrhea, vomiting, and a temperature
of 101.3°F (38.5°C) and evidence of pharyngeal erythema upon physical examination
B. A 6-year-old girl with a 2-day history of sore throat, fever of 101.5°F (38.6°C), pain
upon swallowing, poor oral intake, and tonsillar erythema with exudates
C. A 10-year-old girl with a 2-day history of sore throat, pain upon swallowing,
postnasal drip, and pharyngeal erythema
D. A 21-year-old male college student with a 3-day history of rhinorrhea, 2 days of
cough and sore throat, and temperature of 100.1°F (37.8°C)
E. A 34-year-old woman with a 2-day history of fatigue, 1-day history of sore throat, and temperature of 99.3°F (37.4°C)

Answer 11

B

Question 12

12. A 7-year-old girl is diagnosed with streptococcal pharyngitis. She developed a non-urticarial rash after receiving amoxicillin for sinusitis last year. What antibiotic regimen is most
    appropriate for this child?

A. Penicillin VK for 10 days
B. Azithromycin for 5 days
C. Cephalexin for 10 days
D. Trimethoprim-sulfamethoxazole for 10 days
E. Clindamycin for 5 days

Answer 12

C

Question 13

13. A 10-year-old girl presents to her pediatrician’s office with a 2-day history of throat pain, poor appetite, fever of 100.3°F (37.9°C), and fatigue. Her mother reports that “strep throat” has been identified at her school recently. Physical examination reveals pharyngeal and tonsillar erythema without exudates. What is the most appropriate course of action?

A. Perform a rapid streptococcal antigen detection test and treat with antibiotics if the test is positive
B. Perform a throat culture and immediately initiate antibiotics because this patient is likely to have streptococcal pharyngitis
C. Perform a throat culture; if it is negative, perform a follow-up rapid antigen detection test and treat with antibiotics if this test is positive
D. Initiate antibiotics without any diagnostic testing since her symptoms and possible exposure to streptococcal disease are sufficient to make the diagnosis
E. Diagnose her with a viral upper respiratory tract infection and send her home without performing any diagnostic testing

Answer 13

A

Question 14

14. A 44-year-old man presents to the pharmacy with complaints of nasal congestion, thick nasal discharge, cough, and headache for 4 days. He has a past medical history that is significant for seasonal allergies to grass and ragweed and he has had “sinus infections in the past.” What should you recommend for him?

A. Echinacea, diphenhydramine, and pseudoephedrine
B. Acetaminophen, nasal saline spray, and phenylephrine
C. Ibuprofen, vitamin C, and dextromethorphan
D. Intranasal oxymetazoline for up to 7 days; if he is still symptomatic in a week, he
should contact a health care provider
E. Refer him to a health care provider for an antibiotic prescription

Answer 14

B

Question 15

15. A 2-year-old girl’s mother calls her health care provider’s office for advice. Her daughter has had cold symptoms (rhinorrhea, nonproductive cough, and temperature of 100.2°F [37.9°C]) for the past 2 days. She asks what she can give to her to help her feel better so she can go back to daycare. Which of these is the best therapeutic recommendation?

A. Diphenhydramine and acetaminophen
B. Dextromethorphan and guaifenesin
C. Echinacea
D. Air humidification and nasal saline drops
E. Pseudoephedrine and ibuprofen

Answer 15

D

Question 16

1. A 14-month-old girl is diagnosed with acute otitis media. She has been vaccinated according to recommended childhood immunization schedules. The most likely organism causing her infection is:

A. Streptococcus pyogenes
B. Streptococcus pneumoniae
C. Haemophilus influenzae
D. Moraxella catarrhalis

Answer 16

C

Question 17

2. A 10-month-old African-American boy is diagnosed with acute otitis media. He and his mother both have upper respiratory tract infection symptoms. He lives with his mother and grandparents who care for him while his mother works. She used to smoke but quit when she learned that she was pregnant with him. This is his first episode of acute otitis media. He has no
   other past medical history and his growth and development have been normal. What risk factor for otitis media is present in this child?

A. Race
B. Daycare attendance
C. Passive smoke exposure
D. Upper respiratory tract infection

Answer 17

D

Question 18

3. Which of the following signs and symptoms is most indicative of AOM?

A. Middle ear effusion and hearing impairment
B. Mild erythema of the tympanic membrane
C. Middle ear effusion and ear tugging
D. Moderate bulging of the tympanic membrane and otalgia

Answer 18

D

Question 19

4. Available nonprescription medications for acute otitis media that are effective for reducing symptoms are:

A. Oral analgesics
B. Antihistamines
C. Decongestants
D. Topical anesthetic drops

Answer 19

A

Question 20

5. A 13-month-old girl is diagnosed with bilateral acute otitis media that is not severe. She is able to eat and drink, but her intake is somewhat reduced as compared to normal. She was treated for AOM 5 months ago with amoxicillin and developed an urticarial rash. Which of the following is the most appropriate treatment approach for this child?

A. Observation option
B. Cefdinir
C. Ceftriaxone
D. Azithromycin

Answer 20

B

Question 21

6. Select the patient below in whom the observation option is the most appropriate approach for AOM.

A. A 6-month-old child with severe unilateral AOM
B. A 12-month-old child with nonsevere bilateral AOM
C. A 2-year-old child with severe unilateral AOM
D. A 4-year-old child with nonsevere bilateral AOM

Answer 21

D

Question 22

7. Risk factors for acute bacterial rhinosinusitis include all of the following except:

A. Upper respiratory tract infection
B. Cigarette smoke exposure
C. Asthma
D. Allergic rhinitis

Answer 22

C

Question 23

8. Which description of symptoms is most consistent with acute bacterial rhinosinusitis?

A. Clear rhinorrhea for 2 days that became yellow colored and thick on day 3
B. Nasal congestion, postnasal discharge, and cough for 4 days and headache for 2 days
C. Purulent nasal/postnasal discharge for 7 days with mild improvement in the past 1 to 2 days
D. Nasal congestion and purulent postnasal discharge for 10 days without improvement

Answer 23

D

Question 24

9. Which antibiotic is considered a first-line choice for adult patients with acute bacterial rhinosinusitis?

A. Amoxicillin-clavulanate
B. Azithromycin
C. Cefpodoxime
D. Moxifloxacin

Answer 24

A

Question 25

10. A 33-year-old woman presents to her primary care provider with a 5-day history of nasal congestion and purulent nasal discharge. She tried oral phenylephrine for the last 2 days with some relief of her congestion. This morning, her congestion significantly worsened, and she is not able to breathe through her nose. She also developed bilateral maxillary facial pain and a fever of 101F (38.3C). She reports an allergy to penicillin (hives) that occurred 7 years ago when she had streptococcal pharyngitis. The last time she received antibiotics (trimethoprim- sulfamethoxazole) was 2 years ago for a urinary tract infection. What is the most appropriate antibiotic for this patient? A. Amoxicillin for 7 days B. Azithromycin for 5 days C. Doxycycline for 5 days D. Levofloxacin for 10 days

Answer 25

C

Question 26

11. A 6-year-old girl is diagnosed with streptococcal pharyngitis after developing a sore throat, fever, and abdominal pain and having a positive rapid diagnostic test at her pediatrician’s office. She is allergic to amoxicillin-clavulanate (erythema multiforme) and cefdinir (hives). She is currently in first grade and she attends before- and after-school programs 5 days a week because both of her parents work full time outside of the home. What antibiotic regimen is most appropriate at this time? A. Penicillin G benzathine IM × one dose B. Azithromycin once daily for 5 days C. Clindamycin three times daily for 10 days D. None of these; she should have a confirmatory throat culture first before starting antibiotics

Answer 26

B

Question 27

12. A 9-year-old boy presents to an urgent care clinic with a 12-hour history of throat pain, temperature of 38.8C (101.8F), headache, cough, and vomiting (three times in the past 3 hours). Physical examination reveals pharyngeal erythema and exudates, mild-to-moderate tonsillar hypertrophy, and bilateral cervical lymphadenopathy. He has no known drug allergies, but his mother is allergic to penicillin (hives). He has no known sick contacts. His rapid PCR test is positive for group A streptococci. What antibiotic regimen is most appropriate at this time? A. Amoxicillin once daily for 10 days B. Ceftriaxone IM × one dose C. Penicillin G benzathine IM × one dose D. Cephalexin twice daily for 10 days

Answer 27

C

Question 28

13. Which of these treatments is best suited for a 15-year-old female with cold symptoms that include nasal discharge, nasal congestion, and a nonproductive cough for the past 2 days? A. Diphenhydramine and ibuprofen B. Air humidification and nasal saline spray C. Dextromethorphan and guaifenesin D. Oxymetazoline and pseudoephedrine

Answer 28

B

Question 29

14. Which of the following patients is the most likely to have the common cold? A. A 15-month-old girl with a 2-day history of fever (T 39.3C [102.8F]), right ear tugging, irritability, and poor sleep B. A 9-year-old boy with fever (T 38.7C [101.6F]), abdominal pain, headache, sore throat, and limited oral intake for 36 hours C. A 16-year-old girl with nasal congestion, purulent nasal/postnasal discharge, fatigue, and a nonproductive cough for 11 days with maxillary tenderness for the past 3 days D. A 20-year-old man with rhinorrhea, nonproductive cough, headache, and sore throat for 2 days

Answer 29

D

Question 30

15. A 56-year-old man presents to the pharmacy with complaints of nasal congestion, nasal/postnasal discharge, and nonproductive cough that have developed over the last 3 days. He has a past medical history that is significant for hypertension, type 2 diabetes, and obesity (current medications: lisinopril 40 mg daily, metformin 1000 mg twice daily). He thinks he is developing a “sinus infection,” but he would like to try treating his symptoms with over-the- counter medications. His blood pressure today is 150/90 and he states that his blood sugars are usually 180 to 220 mg/dL. Which of the following is the best recommendation for him? A. Diphenhydramine, pseudoephedrine, and guaifenesin B. Nasal saline spray and nonpharmacologic measures (eg, air humidification, nasal strips) C. Intranasal oxymetazoline until his congestion is gone D. Refer him to a health care provider for an antibiotic prescription

Answer 30

B