MD 1201-1400 ចម្លើយពេញ

1207 The standard starting regimen for acid-fast bacilli smear-positive active pulmonary tuberculosis is A isoniazid B isoniazid, rifampin C isoniazid, moxifloxacin, pyrazinamide, ethambutol D isoniazid, rifampin, pyrazinamide, ethambutol E rifampin, moxifloxacin, pyrazinamide, ethambutol

D

1208 All the following are common manifestations of cytomegalovirus (CMV) infection following lung transplantation except A bronchiolitis obliterans B CMV esophagitis C CMV pneumonia D CMV retinitis E CMV syndrome (fever, malaise, cytopenias, transaminitis, and CMV viremia)

D

1209 Which of the following statements regarding severe acute respiratory syndrome (SARS) is true? A SARS displays poor human-to-human transmission. B SARS is more severe among children than adults. C The etiologic agent of SARS is in the Adenovirus family. D There have been no reported cases of SARS since 2004. E There is no known environmental reservoir for the virus causing SARS.

D

1210 A 72-year-old woman is admitted to the intensive care unit with respiratory failure. She has fever, obtundation, and bilateral parenchymal consolidation on chest imaging. Which of the following is true regarding the diagnosis of Legionella pneumonia? A Acute and convalescent antibodies are not helpful due to the presence of multiple serotypes. B Legionella can never be seen on a Gram stain. C Legionella cultures grow rapidly on the proper media. D Legionella urinary antigen maintains utility after antibiotic use. E Polymerase chain reaction (PCR) for Legionella DNA is the "gold standard" diagnostic test.

D

1211 Which of the following has resulted in a significant decrease in the incidence of trichinellosis in the United States? A Adequate therapy that allows for eradication of infection in index cases before person-toperson spread can occur B Earlier diagnosis due to a new culture assay C Federal laws limiting the import of foreign cattle D Laws prohibiting the feeding of uncooked garbage to pigs E Requirements for hand-washing by commercial kitchen staff who handle raw meat

D

1217 Helicobacter pylori colonization is implicated in all of the following conditions except A duodenal ulcer disease B gastric adenocarcinoma C gastric mucosa-associated lymphoid tissue (MALT) lymphoma D gastroesophageal reflux disease E peptic ulcer disease

D

1218 A 24-year-old woman presents with diffuse arthralgias and morning stiffness in her hands, knees, and wrists. Two weeks earlier she had a self-limited febrile illness notable for a red facial rash and lacy reticular rash on her extremities. On examination, her bilateral wrists, metacarpophalangeal joints, and proximal interphalangeal joints are warm and slightly boggy. What test is most likely to reveal her diagnosis? A Antinuclear antibody B Chlamydia trachomatis ligase chain reaction of the urine C Joint aspiration for crystals and culture D Parvovirus B19 IgM E Rheumatoid factor

D

1219 Which of the following statements regarding Clostridium difficile-associated disease relapses is true? A A first recurrence does not imply greater risk of further recurrences. B Most recurrences are due to antibiotic resistance. C Recurrent C. difficile-associated disease has been associated with a higher risk of colon cancer. D Recurrent disease is associated with serious complications. E Testing for clearance of C. difficile is warranted after treating recurrences.

D

1223 A 26-year-old woman presents to the emergency department with fever, chills, backache, and malaise. She reports a habit of active IV drug use; last use was 2 days ago. Her vital signs show a temperature of 38.4°C, heart rate of 106/minute, respiratory rate of 22/minute, blood pressure of 114/61 mmHg, and oxygen saturation of 98% on 2 L per nasal cannula. A chest x-ray and subsequent chest CT scan demonstrate multiple peripheral nodular infiltrates with cavitation. Blood cultures are sent to the laboratory and are pending. At this point in the workup, how many minor criteria are met from the Duke criteria for the clinical diagnosis of infective endocarditis? A 0 B 1 C 2 D 3 E 5

D

1226 A patient presents to the clinic complaining of nausea, vomiting, crampy abdominal pain, and markedly increased flatus. The patient has not experienced any diarrhea or vomiting but notes that he has been belching more than usual and he describes a "sulfur-like" odor when he does so. He returned from a 3-week trip to Peru and Ecuador several days ago and notes that his symptoms began about a week ago. Giardiasis is considered in the differential. Which of the following is true regarding Giardia? A Boiling water prior to ingestion will not kill Giardia cysts. B Giardia is a disease of developing nations; if this patient had not travelled, there would be no likelihood of giardiasis. C Hematogenous dissemination and eosinophilia are common. D Ingestion of as few as 10 cysts can cause human disease. E Lack of diarrhea makes the diagnosis of Giardia very unlikely.

D

1228 A 17-year-old woman with a medical history of mild intermittent asthma presents to your clinic in February with several days of cough, fever, malaise, and myalgias. She notes that her symptoms started 3 days earlier with a headache and fatigue, and that several students and teachers at her high school have been diagnosed recently with "the flu." She did not receive a flu shot this year. Which of the following medication treatment plans is the best option for this patient? A Aspirin and a cough suppressant with codeine B Oseltamivir, 75 mg PO bid for 5 days C Rimantadine, 100 mg PO bid for 1 week D Symptom-based therapy with over-the-counter agents E Zanamivir, 10 mg inhaled bid for 5 days

D

1234 A 19-year-old female from Guatemala presents to your office for a routine screening physical examination. At age 4 years she was diagnosed with acute rheumatic fever. She does not recall the specifics of her illness and remembers only that she was required to be on bed rest for 6 months. She has remained on penicillin V orally at a dose of 250 mg bid since that time. She asks if she can safely discontinue this medication. She has had only one other flare of her disease, at age 8, when she stopped taking penicillin at the time of her emigration to the United States. She is currently working as a day care provider. Her physical examination is notable for normal point of maximal impulse (PMI) with a grade III/VI holosystolic murmur that is heard best at the apex of the heart and radiates to the axilla. What do you advise the patient to do? A An echocardiogram should be performed to determine the extent of valvular damage before deciding if penicillin can be discontinued. B Penicillin prophylaxis can be discontinued because she has had no flares in 5 years. C She should change her dosing regimen to IM benzathine penicillin every 8 weeks. D She should continue on penicillin indefinitely as she had a previous recurrence, has presumed rheumatic heart disease, and is working in a field with high occupational exposure to E She should replace penicillin prophylaxis with polyvalent pneumococcal vaccine every 5 years.

D

1235 In a patient with bacterial endocarditis, which of the following echocardiographic lesions is most likely to lead to embolization? A 5-mm mitral valve vegetation B 5-mm tricuspid valve vegetation C 11-mm aortic valve vegetation D 11-mm mitral valve vegetation E 11-mm tricuspid valve vegetation

D

1238 All of the following are clinical manifestations of Ascaris lumbricoides infection except A asymptomatic carriage B fever, headache, photophobia, nuchal rigidity, and eosinophilia C nonproductive cough and pleurisy with eosinophilia D right upper quadrant pain and fever E small-bowel obstruction

D

1239 An 87-year-old nursing home resident is brought by ambulance to a local emergency room. He is obtunded and ill-appearing. Per nursing home staff, the patient has experienced low-grade temperatures, poor appetite, and lethargy over several days. A lumbar puncture is performed, and the Gram stain returns gram-positive rods IV-65. and many white blood cells. Listeria meningitis is diagnosed and appropriate antibiotics are begun. Which of the following best describes a clinical difference between Listeria and other causes of bacterial meningitis? A More frequent nuchal rigidity. B More neutrophils are present on the cerebrospinal fluid (CSF) differential. C Photophobia is more common. D Presentation is often more subacute. E White blood cell (WBC) count is often more elevated in the CSF.

D

1244 A 3-year-old boy is brought by his parents to clinic. They state that he has experienced fevers, anorexia, weight loss, and, most recently, has started wheezing at night. He had been completely healthy until these symptoms started 2 months ago. The family had travelled through Europe several months prior and reported no unusual exposures or exotic foods. They have a puppy at home. On examination, the child is ill-appearing and is noted to have hepatosplenomegaly. Laboratory results show a panic value of 82% eosinophils. Total white blood cells are elevated. A complete blood count is repeated to rule out a laboratory error and eosinophils are 78%. Which of the following is the most likely organism or process? A Cysticercus B Giardiasis C Staphylococcus lugdunensis D Toxocariasis E Trichinellosis

D

1251 A 19-year-old man presents to an urgent care clinic with urethral discharge. He reports three new female sexual partners over the past 2 months. What should his management be? A Nucleic acid amplification test for Neisseria gonorrhoeae and Chlamydia trachomatis and return to clinic in 2 days B Cefpodoxime, 400 mg PO × 1, and azithromycin, 1g PO × 1 for the patient and his partners C Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus cefpodoxime, 400 mg PO × 1, and azithromycin, 1 g PO × 1, for the patient D Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus cefpodoxime, 400 mg PO × 1, and azithromycin, 1g PO × 1, for the patient and his recent partners E Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus cefpodoxime, 400 mg PO × 1, azithromycin, 1g PO × 1, and flagyl, 2 g PO

D

1257 Which clinical entity is the most difficult to distinguish from osteomyelitis in a diabetic foot on any currently available medical imaging (plain film, CT, MRI, ultrasound, and three-phase bone scan)? A Abscess B Cellulitis C Fracture D Neuropathic osteopathy E Tumor

D

1259 Which of the following sexually transmitted infections (STIs) is the most common in the United States? A Gonorrhea B Herpes simplex virus (HSV) 2 infection C HIV-1 infection D Human papilloma virus infection E Syphilis

D

1264 All of the following antifungal medications may be used for the treatment of Candida albicans fungemia except A amphotericin B B caspofungin C fluconazole D terbinafine E voriconazole

D

1284 A 23-year-old previously healthy female letter carrier works in a suburb in which the presence of rabid foxes and skunks has been documented. She is bitten by a bat, which then flies away. Initial examination reveals a clean break in the skin in the right upper forearm. She has no history of receiving treatment for rabies and is unsure about vaccination against tetanus. The physician should A clean the wound with a 20% soap solution B clean the wound with a 20% soap solution and administer tetanus toxoid C clean the wound with a 20% soap solution, administer tetanus toxoid, and administer human rabies immune globulin intramuscularly D clean the wound with a 20% soap solution, administer tetanus toxoid, administer human rabies immune globulin IM, and administer human diploid cell vaccine E clean the wound with a 20% soap solution and administer human diploid cell vaccine

D

1293 A previously healthy 17-year-old woman presents in early October with profound fatigue and malaise, as well as fevers, headache, nuchal rigidity, diffuse arthralgias, and a rash. She lives in a small town in Massachusetts and spent her summer as a camp counselor at a local day camp. She participated in daily hikes in the woods but did not travel outside of the area during the course of the summer. Physical examination reveals a well developed young woman who appears extremely fatigued but not in extremis. Her temperature is 37.4°C; pulse is 86 beats per minute; blood pressure is 96/54 mmHg; respiratory rate is 12 breaths per minute. Physical examination documents clear breath sounds, no cardiac rub or murmur, normal bowel sounds, a nontender abdomen, no organomegaly, and no evidence of synovitis. Several cutaneous lesions are noted on her lower extremities, bilateral axillae, right thigh, and left groin (Figure IV-121, Color Atlas). All of the following are possible complications of her current disease state except A Bell's palsy B large joint oligoarticular arthritis C meningitis D progressive dementia E third-degree heart block

D

1295 IV-123. Which of the following represents an emergent (same day) indication for cardiac surgery in a patient with infective endocarditis? A Culture-proven fungal endocarditis B Culture-proven resistant organism with septic pulmonary emboli C Prosthetic valve endocarditis 4 months after surgery D Sinus of Valsalva abscess ruptured into right heart E Staphylococcus lugdunensis in a patient with previous history of endocarditis

D

1299 A 42-year-old man with poorly controlled diabetes (HbA1C = 13.3%) presents with thigh pain and fever over several weeks. Physical examination reveals erythema and warmth over the thigh with notable woody, nonpitting edema. There are no cutaneous ulcers. CT of the thigh reveals several abscesses located between the muscle fibers of the thigh. Orthopedics is consulted to drain and culture the abscesses. Which of the following is the most likely pathogen? A Clostridium perfringens B Group A Streptococcus C Polymicrobial flora D Staphylococcus aureus E Streptococcus milleri

D

1201 All of the following regarding herpes simplex virus (HSV)-2 infection are true except A Approximately one in five Americans harbors HSV2 antibodies. B Asymptomatic shedding of HSV-2 in the genital tract occurs nearly as frequently in those with no symptoms as in those with ulcerative disease. C Asymptomatic shedding of HSV-2 is associated with transmission of virus. D HSV-2 seropositivity is an independent risk factor for HIV transmission. E Seroprevalence rates of HSV-2 are lower in Africa than in the United States.

E

1204 What is the best method for diagnosis? A Acute and convalescent antibody titers B Demonstration of Norwalk toxin in the stool C Electron microscopy D Isolation in cell culture E Polymerase chain reaction (PCR) to identify the Norwalk-associated calcivirus

E

1206 Which of the following factors is the most important determinant of the rate of disease progression from initial HIV infection to clinical diagnosis of AIDS? A Age B CD4+ lymphocyte count 6 months after infection C Cytomegalovirus (CMV) IgG status D HIV resistance panel at infection E HIV viral load set point 6 months after initial infection

E

1212 A 23-year-old woman is newly diagnosed with genital herpes simplex virus (HSV)-2 infection. What can you tell her that the chance of reactivation disease will be during the first year after infection? A 0.05 B 0.25 C 0.5 D 0.75 E 0.9

E

1214 A patient comes to clinic and describes progressive muscle weakness over several weeks. He has also experienced nausea, vomiting, and diarrhea. One month ago he had been completely healthy and describes a bear hunting trip in Alaska, where they ate some of the game they killed. Soon after he returned, his gastrointestinal (GI) symptoms began, followed by muscle weakness in his jaw and neck that has now spread to his arms and lower back. Examination confirms decreased muscle strength in the upper extremities and neck. He also has slowed extraocular movements. Laboratory examination shows panic values for elevated eosinophils and serum creatine phosphokinase. Which of the following organisms is most likely the cause of his symptoms? A Campylobacter B Cytomegalovirus C Giardia D Taenia solium E Trichinella

E

1215 Abacavir is a nucleoside transcription inhibitor that carries which side effect unique for HIV antiretroviral agents? A Fanconi's anemia B Granulocytopenia C Lactic acidosis D Lipoatrophy E Severe hypersensitivity reaction

E

1221 A 46-year-old veterinary researcher who frequently operates on rats presents to the emergency room with jaundice and scant hemoptysis. She recalls having a fairly deep cut on her hand during an operation about 14 days prior. She has had no recent travel or other animal exposures. Her illness started ~9 days prior with fever, chills, severe headache, intense myalgias, and nausea. She also noted bilateral conjunctival injection. Thinking that she had influenza infection, she stayed home from work and started to feel better 5 days into the illness. However, within a day her symptoms had returned with worsening headache, and soon thereafter she developed jaundice. On initial evaluation, her temperature is 38.6°C, pulse is 105 beats per minute, and blood pressure is 156/89 mmHg with O2 saturations of 92% on room air. She appears acutely ill and is both icteric and profoundly jaundiced. Her liver is enlarged and tender, but there are no palpable masses and she has no splenomegaly. Laboratory results are notable for a BUN of 64, creatinine of 3.6, total bilirubin of 64.8 (direct 59.2), AST = 84, ALT = 103, alkaline phosphatase = 384, white blood cell (WBC) count is 11,000 with 13% bands and 80% polymorphonuclear forms, hematocrit of 33%, and platelets = 142. Urinalysis reveals 20 WBCs/hpf, 3+ protein, and granular casts. Coagulation studies are within normal limits. Lumbar puncture reveals a sterile pleocytosis. CT scan of the chest shows diffuse flamelike infiltrates consistent with pulmonary hemorrhage. What is the likely diagnosis? A Acute interstitial pneumonitis B Acute myeloid leukemia C Polyarteritis nodosum D Rat bite fever (Streptobacillus moniliformis infection) E Weil's syndrome (Leptospira interrogans infection)

E

1229 One month after receiving a 14-day course of omeprazole, clarithromycin, and amoxicillin for Helicobacter pylori-associated gastric ulcer disease, a 44-year-old woman still has mild dyspepsia and pain after meals. What is the appropriate next step in management? A Empirical long-term proton pump inhibitor therapy B Endoscopy with biopsy to rule out gastric adenocarcinoma C H. pylori serology testing D Reassurance E Urea breath test

E

1230 Which of the following medications used as antimycobacterial drugs require dose reduction for patients with an estimated glomerular filtration rate <30 mL/min? A Isoniazid B Pyrazinamide C Rifabutin D Rifampin E Streptomycin

E

1231 Which of the following statements regarding the currently licensed human papillomavirus (HPV) vaccine (Gardasil) is true? A It does not protect against genital warts. B It is an inactivated live virus vaccine. C It is targeted towards all oncogenic strains of HPV but is only 70% effective at decreasing infection in an individual. D Once sexually active, women will derive little protective benefit from the vaccine. E Vaccinees should continue to receive standard Pap smear testing.

E

1233 There is wide concern among many members of the general public regarding which of the following vaccines as a potential cause of autism? A DTap (diphtheria and tetanus toxoid and acellular pertussis) vaccine B Hepatitis B vaccine C Hib (Haemophilus influenza type b) vaccine D Human papilloma virus (HPV) vaccine E Measles-mumps-rubella (MMR) vaccine

E

1237 A 19-year-old man presents to the emergency department with 4 days of watery diarrhea, nausea, vomiting, and low-grade fever. He recalls no unusual meals, sick contacts, or travel. He is hydrated with IV fluid, given antiemetics and discharged home after feeling much better. Three days later two out of three blood cultures are positive for Clostridium perfringens. He is called at home and says that he feels fine and is back to work. What should your next instruction to the patient be? A Return for IV penicillin therapy B Return for IV penicillin therapy plus echocardiogram C Return for IV penicillin therapy plus colonoscopy D Return for surveillance blood culture E Reassurance

E

1240 Which of the following antibiotics has the weakest association with the development of Clostridium difficile- associated disease? A Ceftriaxone B Ciprofloxacin C Clindamycin D Moxifloxacin E Piperacillin/tazobactam

E

1242 A 33-year-old woman is undergoing consolidation chemotherapy for acute myelocytic leukemia with cytarabine plus daunorubicin. She developed a fever 5 days prior which has persisted despite the addition of cefepime and vancomycin to her prophylactic antibiotic regimen of norfloxacin, fluconazole, and acyclovir. Other than diaphoresis and chills during her periodic fevers, she remains largely asymptomatic except for a general sense of malaise and nausea associated with her chemotherapy, as well as oral pain due to mucositis. She remains neutropenic despite administration of hematopoietic growth factors. Blood, urine, and sputum cultures all remain negative. What is the next step in her management? A Addition of metronidazole B Addition of tobramycin C Change fluconazole to caspofungin D Chest roentgenogram E High-resolution CT plus serum galactomannan enzyme immunoassay

E

1243 Which of the following organisms is most likely to cause infection of a shunt implanted for the treatment of hydrocephalus? A Bacteroides fragilis B Corynebacterium diphtheriae C Escherichia coli D Staphylococcus aureus E Staphylococcus epidermidis

E

1252 During the first 2 weeks following solid organ transplantation, which family of infection is most common? A Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) reactivation B Humoral immunodeficiency-associated infections (e.g., meningococcemia, invasive Streptococcus pneumoniae infection) C Neutropenia-associated infection (e.g., aspergillosis, candidemia) D T cell deficiency-associated infections (e.g., Pneumocystis jiroveci, nocardiosis, cryptococcosis) E Typical hospital-acquired infections (e.g., central line infection, hospital-acquired pneumonia, urinary tract infection)

E

1260 A 38-year-old woman presents to the emergency department with severe abdominal pain. She has no past medical or surgical history. She recalls no recent history of abdominal discomfort, diarrhea, melena, bright red blood per rectum, nausea, or vomiting prior to this acute episode. She ate ceviche (lime-marinated raw fish) at a Peruvian restaurant 3 h prior to presentation. On examination, she is in terrible distress and has dry heaves. Temperature is 37.6°C; heart rate is 128 beats per minute; blood pressure is 174/92 mmHg. Examination is notable for an extremely tender abdomen with guarding and rebound tenderness. Bowel sounds are present and hyperactive. Rectal examination is normal and guaiac test is negative. Pelvic examination is unremarkable. White blood cell count is 6738/μL; hematocrit is 42%. A complete metabolic panel and lipase and amylase levels are all within normal limits. CT of the abdomen shows no abnormality. What is the next step in her management? A CT angiogram of the abdomen B Pelvic ultrasonography C Proton pump inhibitor therapy and observation D Right upper quadrant ultrasonography E Upper endoscopy

E

1261 Which of the following clinical features can be used to rule out malaria in favor of another tropical febrile illness in a returning traveler? A Diarrhea B Lack of paroxysmal nature of the fevers C Lack of splenomegaly D Severe myalgias and retroorbital headache E None of the above

E

1266 Which of the following statements regarding prevention of human respiratory syncytial virus (HRSV) infection in children is true? A All children who are admitted to the hospital more than twice a year should be vaccinated against HRSV. B Barrier precautions remain the only effective means of prevention. C Children should be vaccinated at birth. D Inactivated, whole-virus vaccine should be considered in children <2 years old. E RSV immune globulin should be given monthly to children <2 years old who were born prematurely.

E

1277 A 19-year-old woman comes to your office after being bitten by a bat on the ear while camping in a primitive shelter. She is unable to produce a vaccination record. On physical examination, she is afebrile and appears well. There are two small puncture marks on the pinna of her left ear. What is an appropriate vaccination strategy in this context? A Intravenous ribavirin B No vaccination C Rabies immunoglobulins D Rabies inactivated virus vaccine E Rabies inactivated virus vaccine plus immunoglobulins

E

1280 All of the following are associated with increased risk of pelvic inflammatory disease (PID) except A bacterial vaginosis B history of salpingitis C intrauterine device D recent sexual exposure to a man with urethritis E symptoms beginning on days 14-21 of the menstrual cycle

E

1292 Deficits in the complement membrane attack complex (C5-8) are associated with recurrent infections of what variety? A Pseudomonas aeruginosa B Catalase-positive bacteria C Streptococcus pneumoniae D Salmonella spp. E Neisseria meningitis

E

1296 Which of the following pathogens are cardiac transplant patients at unique risk for acquiring from the donor heart early after transplant when compared to other solid organ transplant patients? A Cryptococcus neoformans B Cytomegalovirus C Pneumocystis jiroveci D Staphylococcus aureus E Toxoplasma gondii

E

1254 In addition to antibiotics, which of the following adjunctive therapies should be administered to improve the chance of a favorable neurologic outcome? A Dexamethasone B Dilantin C Gabapentin D L-Dopa E Parenteral nutrition

A

1203 You are a physician working on a cruise ship traveling from Miami to the Yucatán Peninsula. In the course of 24 h, 32 people are seen with acute gastrointestinal illness that is marked by vomiting and watery diarrhea. The most likely causative agent of the illness is A enterohemorrhagic Escherichia coli B norovirus C rotavirus D Shigella E Salmonella

B

1255 Which of the following viruses is the leading cause of respiratory disease in infants and children? A Adenovirus B Enterovirus C Human respiratory syncytial virus D Parainfluenza virus E Rhinovirus

C

1271 A 34-year-old recent immigrant from Burundi presents with fever, headache, severe myalgias, photophobia, conjunctival injection, and prostration. He lived in a refugee camp for the previous 10 years. In the camp, he was treated for several unknown febrile illnesses. Since arriving in the United States 7 years ago, he has worked as a computer analyst and lived only in a metropolitan Northwest city with no significant travel. Initial blood cultures are negative. Five days into the illness he develops hypotension, pneumonitis, encephalopathy, and gangrene of his distal digits as well as a petechial, hemorrhagic rash over his entire body except for his face. A biopsy of his rash reveals immunohistochemical changes consistent with a rickettsial infection. Which of the following rickettsial pathogens is most likely in this patient? A Coxiella burnetii (Q fever) B Rickettsia africae (African tick-borne fever) C Rickettsia prowazekii (Louse-borne typhus) D Rickettsia rickettsii (Rocky Mountain spotted fever) E Rickettsia typhi (Murine typhus)

C

1246 A 35-year-old male is seen 6 months after a cadaveric renal allograft. The patient has been on azathioprine and prednisone since that procedure. He has felt poorly for the past week with fever to 38.6°C (101.5°F), anorexia, and a cough productive of thick sputum. Chest x-ray reveals a left lower lobe (5 cm) nodule with central cavitation. Examination of the sputum reveals long, crooked, branching, beaded gram-positive filaments. The most appropriate initial therapy would include the administration of which of the following antibiotics? A Ceftazidime B Erythromycin C Penicillin D Sulfisoxazole E Tobramycin

D

1294 In the patient described above, which of the following is appropriate therapy? A Azithromycin, 500 mg PO daily B Ceftriaxone, 2 g IV daily C Cephalexin, 500 mg PO bid D Doxycycline, 100 mg PO bid E Vancomycin, 1 g IV bid

D

1253 A 19-year-old college student is brought to the emergency department by friends from his dormitory for confusion and altered mental status. They state that many colleagues have upper respiratory tract infections. He does not use alcohol or illicit drugs. His physical examination is notable for confusion, fever, and a rigid neck. Cerebrospinal fluid (CSF) examination reveals a white blood cell count of 1800 cells/μL with 98% neutrophils, glucose of 1.9 mmol/L (35 mg/dL), and protein of 1.0 g/L (100 mg/dL). Which of the following antibiotic regimens is most appropriate as initial therapy? A Ampicillin plus vancomycin B Ampicillin plus gentamicin C Cefazolin plus doxycycline D Cefotaxime plus doxycycline E Cefotaxime plus vancomycin

E

1279 Per-coital rate of HIV acquisition in a man who has unprotected sexual intercourse with an HIV-infected female partner is likely to increase under which of the following circumstances? A Acute HIV infection in the female partner B Female herpes simplex virus (HSV)-2 positive serostatus C Male nongonococcal urethritis at the time of intercourse D Uncircumcised male status E All of the above

E

1236 Testing for latent Mycobacterium tuberculosis infection is indicated in HIV patients at the time of initial diagnosis for all of the following reasons except A Active tuberculosis treatment success rates are lower in HIV-infected patients compared to HIV-uninfected patients. B Drug interactions between drug regimens for active tuberculosis therapy and highly active antiretroviral therapy are challenging to manage. C HIV-associated active tuberculosis is more likely to be extrapulmonary and can be diagnostically challenging. D HIV-infected patients with active tuberculosis have high 6-month HIV-related mortality rates. E The rate of progression from latent tuberculosis to active tuberculosis is higher in HIV infected persons compared to HIV-uninfected persons.

A

1245 An otherwise healthy 5-year-old child presents with low-grade fevers, sore throat, and red, itchy eyes. He attends summer camp, where several other campers were ill. On examination, the patient is noted to have pharyngitis and bilateral conjunctivitis. Which of the following is the most likely etiologic agent? A Adenovirus B Enterovirus C Influenza virus D Metapneumovirus E Rhinovirus

A

1247 A 53-year-old male with a history of alcoholism presents with an enlarging mass at the angle of the jaw. The patient describes the mass slowly enlarging over a period of 6 weeks with occasional associated pain. He has also noted intermittent fevers throughout this period. Recently, he has developed yellowish drainage from the inferior portion of the mass. He takes no medications and has no other past history. He drinks six beers daily. On physical examination, the patient has a temperature of 37.9°C (100.2°F). His dentition is poor. There is diffuse soft tissue swelling and induration at the angle of the mandible on the left. It is mildly tender, and no discrete mass is palpable. The area of swelling is ~8 × 8 cm. An aspirate is sent for Gram stain and culture. The culture initially grows Eikenella corrodens. After 7 days you receive a call reporting growth of a grampositive bacillus branching at acute angles on anaerobic media. What organism is causing this man's clinical presentation? A Actinomyces B Eikenella corrodens C Mucormycosis D Nocardia E Peptostreptococcus

A

1249 A 40-year-old male smoker with a history of asthma is admitted to the inpatient medical service with fever, cough, brownish-green sputum, and malaise. Physical examination shows a respiratory rate of 15, no use of accessory muscles of breathing, and bilateral polyphonic wheezes throughout the lung fields. There is no clubbing or skin lesions. You consider a diagnosis of allergic bronchopulmonary aspergillosis. All the following clinical features are consistent with allergic bronchopulmonary aspergillosis except A bilateral, peripheral cavitary lung infiltrates B elevated serum IgE C peripheral eosinophilia D positive serum antibodies to Aspergillus species E positive skin testing for Aspergillus species

A

1256 Several family members present to a local emergency room 2 days after a large family summer picnic where deli meats and salads were served. They all complain of profuse diarrhea, headaches, fevers, and myalgias. Their symptoms began ~24 h after the picnic. It appears that everyone who ate Aunt Emma's bologna surprise was afflicted. Routine cultures of blood and stool are negative to date. Which of the following is true regarding Listeria gastroenteritis? A Antibiotic treatment is not necessary for uncomplicated cases. B Carriers are asymptomatic but can easily spread infection via the fecal-oral route. C Gastrointestinal (GI) illness can result from ingestion of a single organism. D Illness is toxin-mediated, and organisms are not present at the time of infection. E Person-to-person spread is a common cause of outbreaks.

A

1262 Which of the following serology patterns places a transplant recipient at the lowest risk of developing cytomegalovirus (CMV) infection after renal transplantation? A Donor CMV IgG negative, recipient CMV IgG negative B Donor CMV IgG negative, recipient CMV IgG positive C Donor CMV IgG positive, recipient CMV IgG negative D Donor CMV IgG positive, recipient CMV IgG positive E The risk is equal regardless of serology results

A

1273 Borrelia burgdorferi serology testing is indicated for which of the following patients, all of whom reside in Lyme-endemic regions? A A 19-year-old female camp counselor who presents with her second episode of an inflamed, red and tender left knee and right ankle B A 23-year-old male house painter who presents with a primary erythema migrans lesion at the site of a witnessed tick bite C A 36-year-old female state park ranger who presents with a malar rash, diffuse arthralgias/arthritis of her shoulders, knees, metacarpophalangeal and proximal interphalangeal joints; pericarditis; and D A 42-year-old woman with chronic fatigue, myalgias, and arthralgias E A 46-year-old male gardener who presents with fevers, malaise, migratory arthralgias/myalgias, and three erythema migrans lesions

A

1275 An HIV-positive patient with a CD4 count of 110/ μL who is not taking any medications presents to an urgent care center with complaints of a headache for the past week. He also notes nausea and intermittently blurred vision. Examination is notable for normal vital signs without fever but mild papilledema. Head CT does not show dilated ventricles. The definitive diagnostic test for this patient is A cerebrospinal fluid (CSF) culture B MRI with gadolinium imaging C ophthalmologic examination including visual field testing D serum cryptococcal antigen testing E urine culture

A

1278 A 26-year-old woman during a clinic is found to have a positive rapid plasmin reagin test (1:4) and a positive fluorescent treponemal antibody-absorption test (FTA-ABS). She has never been treated for syphilis. She recalls a large painless ulcer on her labia 9 months prior, followed about 2 months later by a diffuse rash and oral lesions that also resolved. She has had five sexual contacts in the past year. In addition to treating the patient, all of the following additional interventions should be considered except A echocardiogram looking at the aortic arch B HIV counseling and testing C pregnancy testing D screening and treatment of all recent sexual contacts E screening for other sexually transmitted diseases (STDs)

A

1283 Glucocorticoids have been shown to be of benefit for treatment for all of the following infections except A Aspergillus fumigatus pneumonia B Mycobacterium tuberculosis pericarditis C Pneumocystis carinii pneumonia D severe typhoid fever E Streptococcus pneumoniae meningitis

A

1285 A patient is admitted with fevers, malaise, and diffuse joint pains. His initial blood cultures reveal methicillin-resistant Staphylococcus aureus (MRSA) in all culture bottles. He has no arthritis on examination, and his renal function is normal. Echocardiogram shows a 5-mm vegetation on the aortic valve. He is initiated on IV vancomycin at 15 mg/kg every 12 h. Four days later the patient remains febrile and cultures remain positive for MRSA. In addition to a search for embolic foci of infection, which of the following changes would you make to his treatment regimen? A No change B Add gentamicin C Add rifampin D Check the vancomycin serum peak and trough levels and consider tid dosing E Discontinue vancomycin, start daptomycin

A

1287 A 38-year-old woman is seen in clinic for a decrease in cognitive and executive function. Her husband is concerned because she is no longer able to pay bills, keep appointments, or remember important dates. She also seems to derive considerably less pleasure from caring for her children and her hobbies. She is unable to concentrate for long enough to enjoy movies. This is a clear change from her functional status 6 months prior. A workup reveals a positive HIV antibody by enzyme immunoassay and Western blot. Her CD4+ lymphocyte count is 378/μL with a viral load of 78,000/mL. She is afebrile with normal vital signs. Her affect is blunted, and she seems disinterested in the medical interview. Neurologic examination for strength, sensation, cerebellar function and cranial nerve function is nonfocal. Fundoscopic examination is normal. Mini-Mental Status Examination score is 22/30. A serum rapid plasmin reagin (RPR) test is negative. MRI of the brain shows only cerebral atrophy disproportionate to her age but no focal lesions. What is the next step in her management? A Antiretroviral therapy B Cerebrospinal fluid (CSF) JV virus polymerase chain reaction (PCR) C CSF mycobacterial PCR D CSF VDRL test E Serum cryptococcal antigen

A

1291 A previously healthy 28-year-old male describes several episodes of fever, myalgia, and headache that have been followed by abdominal pain and diarrhea. He has experienced up to 10 bowel movements per day. Physical examination is unremarkable. Laboratory findings are notable only for a slightly elevated leukocyte count and an elevated erythrocyte sedimentation rate. Wright's stain of a fecal sample reveals the presence of neutrophils. Colonoscopy reveals inflamed mucosa. Biopsy of an affected area discloses mucosal infiltration with neutrophils, monocytes, and eosinophils; epithelial damage, including loss of mucus; glandular degeneration; and crypt abscesses. The patient notes that several months ago he was at a church barbecue where several people contracted a diarrheal illness. Although this patient could have inflammatory bowel disease, which of the following pathogens is most likely to be responsible for his illness? A Campylobacter B Escherichia coli C Norwalk agent D Staphylococcus aureus E Salmonella

A

1202 What is the most common manifestation of Coccidioides infection in an immunocompetent host? A Acute pneumonia B Asymptomatic seroconversion C Hypersensitivity phenomena such as erythema nodosum D Meningitis E Self limited flulike illness

B

1220 A 38-year-old man with HIV/AIDS presents with 4 weeks of diarrhea, fever, and weight loss. Which of the following tests makes the diagnosis of cytomegalovirus (CMV) colitis? A CMV IgG B Colonoscopy with biopsy C Serum CMV polymerase chain reaction (PCR) D Stool CMV antigen E Stool CMV culture

B

1222 A 17-year-old boy in Arkansas presents to a clinic in August with fever, headache, myalgias, nausea, and anorexia 8 days after returning from a 1-week camping trip. Physical examination is remarkable for a temperature of 38.6°C and a generally fatigued but nontoxic appearing, well-developed young man. He does not have a rash, and orthostatic vital sign measurements are negative. What would be a reasonable course of action? A Initiate ceftriaxone, 1g IM × 1 B Initiate doxycycline, 100 mg PO bid C Initiate oseltamivir, 75 mg PO qd D Reassure the patient and order a heterophile antibody titer (Monospot) E Reassure the patient and order rickettsial serologies

B

1224 Which of the following is true regarding influenza prophylaxis? A Patients receiving an intramuscular influenza vaccine should be warned of the increased risk of Guillain-Barré syndrome. B Patients with hypersensitivity to eggs should not receive the intramuscular vaccine. C The intramuscular influenza vaccine is a live, attenuated strain of influenza that is based on isolates from the previous year's strains of influenza A and B. D The intramuscular influenza vaccine should not be given to immunocompromised hosts. E The intranasal spray, "Flu-mist," is an inactivated virus preparation based on the previous year's strains of influenza A and B.

B

1227 An 18-year-old man presents with a firm, nontender lesion around his anal orifice. The lesion is about 1.5 cm in diameter and has a cartilaginous feel on clinical examination. The patient reports that it has progressed to this stage from a small papule. It is not tender. He reports recent unprotected anal intercourse. Bacterial culture of the lesion is negative. A rapid plasmin reagin (RPR) test is also negative. Therapeutic interventions should include A IM ceftriaxone, 1g B IM penicillin G benzathine, 2.4 million U C oral acyclovir, 200 mg 5 times per day D observation E surgical resection with biopsy

B

1232 A 25-year-old woman presents with 1 day of fever to 38.3°C (101°F), sore throat, dysphagia, and a number of grayish-white papulovesicular lesions on the soft palate, uvula, and anterior pillars of the tonsils (Figure IV-57, Color Atlas). The patient is most likely infected with which of the following? A Candida albicans B Coxsackievirus C Herpesvirus D HIV E Staphylococcus lugdunensis

B

1258 The human enterovirus family includes poliovirus, coxsackieviruses, enteroviruses, and echovirus. Which of the following statements regarding viral infection with one of the members of this group is true? A Among children infected with poliovirus, paralysis is common. B Enteroviruses cannot be transmitted via blood transfusions and insect bites. C In utero exposure to maternal enteroviral antibodies is not protective. D Infections are most common in adolescents and adults, though serious illness is most common in young children. E Paralysis from poliovirus infection was more commonly seen in developing countries.

B

1263 Which of the following statements regarding liver abscesses is true? A Amebic liver abscess should be ruled out only by direct sampling and culture of pus. B Alkaline phosphatase is the most likely liver function test to be abnormal in the presence of a liver abscess. C Candida species are most commonly isolated from patients with abscesses that develop as a result of peritoneal or pelvic pathology. D Patients with liver abscesses nearly always have right upper quadrant pain. E All of the above are true.

B

1268 A 64-year-old female is admitted to the hospital with altered mental status. She recently returned from a summer white-water rafting trip in Colorado. Her husband reports increasing confusion, alternating lethargy and agitation, and visual hallucinations over the past 3 days. There is no history of drug abuse or psychiatric illness. She takes no medications. Her physical examination is notable for a temperature of 39°C (102.2°F), myoclonic jerks, and hyperreflexia. She is delirious and oriented to person only when aroused. There is no nuchal rigidity. Cerebrospinal fluid (CSF) examination reveals clear fluid with a white blood cell count of 15 cells/μL with 100% lymphocytes, protein of 1.0 g/L (100 mg/dL), and glucose of 4.4 mmol/L (80 mg/ dL). Gram stain of the CSF shows no organisms. You suspect infection with West Nile virus. Which of the following studies will be most useful in making that diagnosis? A CSF culture B CSF IgM antibodies C CNS MRI D CSF PCR E Stool culture

B

1269 Which of the following represents a rare but serious extrapulmonary complication of influenza infection? A Diffuse eczematous rash B Myositis C Oligoarthritis D Purulent conjunctivitis E Secondary bacterial pneumonia caused by Staphylococcus aureus

B

1281 Current Centers for Disease Control and Prevention (CDC) recommendations are that screening for HIV be performed in which of the following? A All high-risk groups (injection drug users, men who have sex with men, and high-risk heterosexual women) B All U.S. adults C Injection drug users D Men who have sex with men E Women who have sex with more than two men per year

B

1282 A 26-year-old woman presents late in the third trimester of her pregnancy with high fevers, myalgias, backache, and malaise. She is admitted and started on empirical broad spectrum antibiotics. Blood cultures return positive for Listeria monocytogenes. She delivers a 5-lb infant 24 h after admission. Which of the following statements regarding antibiotic treatment for this infection is true? A Clindamycin should be used in patients with penicillin allergy. B Neonates should receive weight-based ampicillin and gentamicin. C Penicillin plus gentamicin is first-line therapy for the mother. D Quinolones should be used for Listeria bacteremia in late-stage pregnancy. E Trimethoprim-sulfamethoxazole has no efficacy against Listeria.

B

1286 A 23-year-old woman develops cytomegalovirus (CMV) pneumonitis 5 months after a lung transplant. She developed severe side effects from ganciclovir while receiving prophylaxis. Foscarnet is prescribed for this episode. Which of the following side effects is most likely? A Bone marrow suppression B Electrolyte wasting C Embryotoxic D Lethargy and tremors E Hyperkalemia

B

1290 A person with liver disease caused by Schistosoma mansoni would be most likely to have A ascites B esophageal varices C gynecomastia D jaundice E spider nevi

B

1297 A 68-year-old woman has been in the medical intensive care unit for 10 days with a chronic obstructive pulmonary disease flare and pneumonia, including the initial 6 days on a mechanical ventilator. She just finished a course of moxifloxacin and glucocorticoid taper when she develops abdominal discomfort over 2 days. Vital signs reveal a temperature of 38.2°C, heart rate of 94 beats per minute, blood pressure of 162/94 mmHg, respiratory rate of 18 per minute, and oxygen saturation of 90%. On examination, she is in moderate distress. She is not using accessory muscles but is tachypneic. She has a slight bilateral wheeze with good air movement. Heart sounds are distant and unchanged. Her abdomen is moderately distended and tense, with scant bowel sounds present. There is no guarding or rebound, but she is tender throughout. Review of her records reveals no bowel movement over the past 72 h and no stool is palpable in the rectal vault. White blood cell count has increased from 7100/μL to 38,000/μL over the past 2 days. Abdominal plain film shows what is read as a probable ileus in the right lower quadrant. Aside from nasogastric (NG) tube placement with suction and NPO status, which of the following should your management also include? A Intravenous immunoglobulin (IVIg) B Metronidazole, 500 mg IV tid C Piperacillin/tazobactam, 3.37 g IV q6h D Restart moxifloxacin, 400 PO qd E Vancomycin, 500 mg PO qid

B

1298 A 25-year-old woman presents to the clinic complaining of several days of worsening burning and pain with urination. She describes an increase in urinary frequency and suprapubic tenderness but no fever or back pain. She has no past medical history with the exception of two prior episodes similar to this in the past 2 years. Urine analysis shows moderate white blood cells. Which of the following is the most likely causative agent of her current symptoms? A Candida B Escherichia coli C Enterobacter D Klebsiella E Proteus

B

1205 A 32-year-old man presents with jaundice and malaise. He is found to have acute hepatitis B with positive hepatitis B virus (HBV) DNA and E antigen. Which of the following antiviral agents are approved as part of a therapeutic regimen for monoinfection with hepatitis B? A Efavirenz B Ganciclovir C Lamivudine D Rimantadine E Tenofovir

C

1213 The most common cause of traveler's diarrhea in Mexico is A Campylobacter jejuni B Entamoeba histolytica C enterotoxigenic Escherichia coli D Giardia lamblia E Vibrio cholerae

C

1216 A 30-year-old healthy woman presents to the hospital with severe dyspnea, confusion, productive cough, and fevers. She had been ill 1 week prior with a flulike illness characterized by fever, myalgias, headache, and malaise. Her illness almost entirely improved without medical intervention until 36 h ago, when she developed new rigors followed by progression of the respiratory symptoms. On initial examination, her temperature is 39.6°C, pulse is 130 beats per minute, blood pressure is 95/60 mmHg, respiratory rate is 40, and oxygen saturation is 88% on 100% face mask. On examination she is clammy, confused, and very dyspneic. Lung examination reveals amphoric breath sounds over her left lower lung fields. She is intubated and resuscitated with fluid and antibiotics. Chest CT scan reveals necrosis of her left lower lobe. Blood and sputum cultures grow Staphylococcus aureus. This isolate is likely to be resistant to which of the following antibiotics? A Doxycycline B Linezolid C Methicillin D Trimethoprim/sulfamethoxazole (TMP/SMX) E Vancomycin

C

1225 Which of the following is the most common manifestation of initial (primary) herpes simplex virus (HSV)1 infection? A Asymptomatic infection B Genital ulcers C Gingivostomatitis and pharyngitis D Orolabial ulcers E Trigeminal neuralgia

C

1241 All of the following statements regarding human T cell lymphotropic virus-I (HTLV-I) infection are true except A Acute T cell leukemia is associated with HTLV-I infection. B HTLV-I endemic regions include southern Japan, the Caribbean, and South America. C HTLV-I infection is associated with a gradual decline in T cell function and immunosuppression. D HTLV-I is transmitted parenterally, sexually, and from mother to child. E Tropical spastic paraparesis is associated with HTLV-I infection.

C

1248 What is the most appropriate therapy for this patient? A Amphotericin B B Itraconazole C Penicillin D Surgical debridement E Tobramycin

C

1250 All of the following factors increase the risk for Clostridium difficile-associated disease except A antacids B antecedent antibiotics C difficile colonization D enteral tube feeds E increasing length of hospital stay

C

1265 A 40-year-old male is admitted to the hospital with 2-3 weeks of fever, tender lymph nodes, and right upper quadrant abdominal pain. He reports progressive weight loss and malaise over a year. On examination, he is found to be febrile and frail with temporal wasting and oral thrush. Matted, tender anterior cervical lymphadenopathy <1 cm and tender hepatomegaly are noted. He is diagnosed with AIDS (CD4+ lymphocyte count = 12/μL and HIV RNA 650,000 copies/mL). Blood cultures grow Mycobacterium avium. He is started on rifabutin and clarithromycin, as well as dapsone for Pneumocystis prophylaxis, and discharged home 2 weeks later after his fevers subside. He follows up with an HIV provider 4 weeks later and is started on tenofovir, emtricitabine and efavirenz. Two weeks later he returns to clinic with fevers, neck pain, and abdominal pain. His temperature is 39.2°C, heart rate is 110 beats per minute, blood pressure is 110/64 mmHg, and oxygen saturations are normal. His cervical nodes are now 2 centimeters in size and extremely tender, and one has fistulized to his skin and is draining yellow pus that is acid-fast bacillus stain-positive. His hepatomegaly is pronounced and tender. What is the most likely explanation for his presentation? A Cryptococcal meningitis B HIV treatment failure C Immune reconstitution syndrome to Mycobacterium avium D Kaposi's sarcoma E Mycobacterium avium treatment failure due to drug resistance

C

1267 A 52-year-old woman with alcoholic cirrhosis, portal hypertension, esophageal varices, and history of hepatic encephalopathy presents to the hospital with confusion over several days. Her husband remarks that the patient has been adherent to her medicines. These medicines include labetalol, furosemide, aldactone, and lactulose. Physical examination is notable for temperature of 38.3°C, heart rate of 115 bpm, blood pressure of 105/62 mmHg, respiratory rate of 12 breaths per minute, and oxygen saturation of 96% on room air. The patient is extremely drowsy, only intermittently able to answer questions, and disoriented. She has slight asterixis. Lungs are clear. Cardiac examination is unremarkable. Her abdomen is distended and tense but nontender. She has 3+ lower extremity edema extending to her thighs. She is guaiac negative. Her cranial nerves and extremity strength are symmetric and normal. Laboratory studies reveal a leukocyte count of 4830/μL, hematocrit = 33% (baseline = 30%), and platelet count of 94,000/μL. Basic metabolic panel is unremarkable. What is an essential component of the diagnostic workup? A CT scan of the head B Esophagastroduodenoscopy C Paracentesis D Therapeutic trial of lactulose E Serum ammonia level

C

1270 You are a physician for an undergraduate university health clinic in Arizona. You have evaluated three students with similar complaints of fever, malaise, diffuse arthralgias, cough without hemoptysis, and chest discomfort, and one of the patients has a skin rash on her extremities consistent with erythema multiforme. Chest radiography is similar in all three, with hilar adenopathy and small pleural effusions. Upon further questioning you learn that all three students are in the same archaeology class and participated in an excavation 1 week ago. Your leading diagnosis is A mononucleosis B primary pulmonary aspergillosis C primary pulmonary coccidioidomycosis D primary pulmonary histoplasmosis E streptococcal pneumonia

C

1272 You are the on-call physician practicing in a suburban community. You receive a call from a 28-year-old female with a past medical history significant for sarcoidosis who is currently on no medications. She is complaining of the acute onset of crampy diffuse abdominal pain and multiple episodes of emesis that are nonbloody. She has not had any light-headedness with standing or loss of consciousness. When questioned further, the patient states that her last meal was 5 h previously, when she joined her friends for lunch at a local Chinese restaurant. She ate from the buffet, which included multiple poultry dishes and fried rice. What should you do for this patient? A Ask the patient to go to the nearest emergency department for resuscitation with IV fluids. B Initiate antibiotic therapy with azithromycin. C Reassure the patient that her illness is self-limited and no further treatment is necessary if she can maintain adequate hydration. D Refer the patient for CT to assess for appendicitis. E Refer the patient for admission for IV vancomycin and ceftriaxone because of her immunocompromised state resulting from sarcoidosis.

C

1274 A 39-year-old injection drug user with a history of right-sided endocarditis and HIV infection notes back pain and fevers over the past week. He had an abscess recently on his right arm that he drained on his own. He is part of a needle-exchange program and always cleans his arm before shooting heroin into the vein in his antecubital fossa. On physical examination, he has a temperature of 38.1°C, heart rate of 124 beats per minute, and blood pressure of 75/30 mmHg. He is in a great deal of distress and is slightly confused. He has a 4/6 left lower sternal border murmur that varies with the respiratory cycle. His jugular venous pressure is monophasic and to the jaw when seated at 90 degrees. Lung examination is clear. Abdomen is benign. He is very tender over his lower spine. His extremities are warm. Leg strength is 5/5 on the right, with 4/5 left hip flexion and extension, 3/5 left knee flexion and extension, and 3/5 left foot extension. His Babinski reflex is upgoing on the left and down going on the right. What is the next step in management? A Avoidance of antibiotics until more definitive culture data is obtained; serial neurologic examinations B Urgent MRI and neurosurgical consultation; vancomycin after blood cultures are drawn C Urgent MRI and neurosurgical consultation; vancomycin plus cefepime after blood cultures are drawn D Urgent MRI and neurosurgical consultation; avoidance of antibiotics until more definitive culture data are obtained E Vancomycin plus cefepime after blood cultures are drawn; serial neurologic examinations

C

1276 Which of the following favors a diagnosis of acute bacterial epididymitis? A A solid nontender testicular mass B Absence of blood flow on Doppler examination C Concurrent urethral discharge D Elevation of the testicle within the scrotal sac E Lack of response to ceftriaxone plus doxycycline therapy

C

1288 A 72-year-old male is admitted to the hospital with bacteremia and pyelonephritis. He is HIV-negative and has no other significant past medical history. Two weeks into his treatment with antibiotics a fever evaluation reveals a blood culture positive for Candida albicans. Examination is unremarkable. White blood cell count is normal. The central venous catheter is removed, and systemic antifungal agents are initiated. What further evaluation is recommended? A Abdominal CT scan to evaluate for abscess B Chest x-ray C Funduscopic examination D Repeat blood cultures E Transthoracic echocardiogram

C

1289 A 40-year-old man with HIV (CD4+ lymphocyte count = 180, viral load = 1000 copies/mL) was treated for secondary syphilis based on generalized painless lymphadenopathy, a diffuse maculopapular rash that included his palms and soles, and a preceding primary genital chancre. He reported no neurologic or ophthalmic symptoms at the time and received one dose of IM penicillin G benzathine. At the time of diagnosis, his rapid plasmin reagin (RPR) titer was 1:64 and fluorescent treponemal antibodyabsorption (FTA-ABS) test was positive. He follows up a year later and is found to have an RPR titer of 1:64 and his FTA-ABS remains positive. What is the appropriate intervention at this time? A Aqueous penicillin G 24 mU/d IV given as 4 mU q4h × 10 days B Doxycycline, 100 mg PO bid C Lumbar puncture D Penicillin desensitization E Penicillin G benzathine 2.4 mU IM weekly × 3 doses

C

1300 Regarding the epidemiology of influenza viruses, which of the following is true? A Antigenic drift requires a change in both hemagglutinin (H) and neuraminidase (N) antigens. B Antigenic shift is defined by an exchange of hemagglutinin (H) and neuraminidase (N) antigens between influenza A and influenza B viruses. C Avian influenza outbreaks in humans occur when human influenza A viruses undergo antigenic shifts with influenza A from poultry. D Influenza C virus infections, while uncommon, are more virulent on a population basis due to its increased ability to undergo antigenic shift. E The lethality associated with avian influenza is related to its ability to spread via person-to-person contact.

C