Infectious Disease

A 23-year-old man presents with a 2-day history of burning urine. He also reports a slight purulent urethral discharge. He denies any fever, malaise, or chills. He smokes 1 pack of cigarettes daily and drinks socially; he has multiple sexual partners. On exam, his vitals are normal and lungs are clear; abdominal exam is unremarkable, without any renal angle or suprapubic tenderness, and external genitals reveal only slight urethral discharge. Labs show WBC of 6500/uL, and urinalysis has 5-10 WBC and 0 RBC. Gram stain of the urethral discharge shows neutrophils and intracellular gram-negative diplococci. Question What is the best treatment regimen for this patient? Answer Choices 1 Ceftriaxone 250 mg IM plus azithromycin 1g PO each single dose 2 Ofloxacin 400 mg BID for 7 days 3 Trimethoprim-sulfamethoxazole for 3 days 4 Doxycycline 100 mg daily for 7 days 5 Ceftriaxone 125 mg IM single dose

1 Ceftriaxone 250 mg IM plus azithromycin 1g PO each single dose

A 32-year-old Latinx woman, previously in good health, was brought to the emergency department by paramedics after she was found unresponsive in her home. It is unknown if she had a seizure. Past medical history is not significant, and she has no known allergies. She is not on any medications and is Gravida 4, Para 4, Ab 0. She is married and recently emigrated to the US from Central America. Vital signs: temperature 100.4°F, pulse 112, respirations 24, blood pressure 110/62, O2 sat 96% on room air. Physical exam reveals a well-developed woman with obtunded mental status. Cardiac exam reveals normal S1 and S2 without rub, murmur, or gallop. Lungs are clear to auscultation and percussion. Spinal tap is thought to be contraindicated. The patient is admitted to the ICU. After consultation with specialists, a tentative diagnosis is made; the patient is treated with a therapeutic trial of medication. The following morning, the patient is found to be alert, oriented, and afebrile. Lab and imaging studies show: WBC 17.2 K/mcL ESR 25 mm/hr Hgb 12.4 gm/dL Electrolytes normal Hct 37% BUN 12 mg/dL Platelets 305 K/mcL Creatinine 1.2 mg/dL Neutrophils 68% Pregnancy test Negative Lymphocytes 20% HIV immunoassay Negative Monocytes 2% Blood cultures No growth (preliminary) Eosinophils 10% EKG NSR, 1 PAC Basophils 1% Transthoracic echocardiogram Normal heart size and structure. Chest X-ray Normal heart size. No infiltrates or edema. CT Brain without contrast Multiple cystic lesions. Cyst with dot sign noted. MRI Brain with contrast Multiple cystic lesions. Cyst with dot sign present. Question What is the treatment of choice (the successful therapeutic trial) for this patient's disease? Answer Choices 1 Albendazole with IV prednisolone 2 Heparin IV 3 Interferon alfa 2-b 4 Isoniazid, rifampin, pyrazinamide, and ethambutol 5 Pyrimethamine with sulfadiazine

1. Albendazole with IV prednisolone

A 30-year-old woman presents because she recently had a PPD skin test; the transverse diameter of the induration was 14 mm. The patient denies ever having tuberculosis and she is asymptomatic now, but she expresses some anxiety about the result of the skin test. For the last 6 months, she has worked as a nurse for a long-term care facility. Her patient is a vent-dependent tetraplegic. On clinical examination, there are no abnormalities. Question What is the most appropriate next step? Answer Choices 1 Chest X-ray 2 Isoniazid prophylaxis 3 Reassurance 4 Respiratory isolation 5 Sputum examination

1. Chest X-ray

Your patient is a 1-day-old "floppy baby"; he was born full term by normal vaginal delivery in the hospital. Birth weight was 2.4 kg; Apgar scores were 6 (1 min), 8 (5 min), and 8 (10 min). His mother had a normal pregnancy, except for an episode of a mononucleosis-like illness, but her heterophile antibodies were negative. On examination today, the patient is febrile, with a heart rate of 130/min, shallow breathing, and bilateral fine crepitations. You notice petechial purpura. He has hepatosplenomegaly and generalized lymphadenopathy (cervical, axillary, and inguinal). Neurological examination reveals hypotonia and bulging anterior fontanelles; there are no meningeal signs. Ophthalmological examination reveals multiple foci of chorioretinitis on both eyes. He is polypneic and hypoxic; nasal oxygen therapy and wide-spectrum antibiotic therapy is introduced (ampicillin, gentamycin, and cefotaxime). Labs are listed below. Value Finding Normal for 12-24 hr old, full term Hb (g/L) 95 184 WBC x 109/L 29 18.9 (9.4-34) Neutro x 109/L 16 11.5 (5-21) Lymph x 109/L 12.9 5.8 (2-11.5) Platelets103/mm3 120 150-350 Cerebrospinal fluid (CSF) Value Finding Normal for 12-24 hr old, full term WBC (mm3) 10 5 (0 - 30) RBC (mm3) 10 9 (0 - 50) Protein (g/L) 8 0.6 (0.3 - 2.5) Glucose (millimol/L) 45 (blood sugar 48 mg/dL) >2/3 of the blood sugar level The rest of his laboratory values, including liver function tests, are normal. Chest X-ray reveals interstitial pneumonia. CT shows intracranial diffuse calcifications. Question What behavior should you ask the mother about? Answer Choices 1 Eating undercooked meat during the pregnancy 2 Being in contact with febrile children during the pregnancy 3 Having unprotected sex during the pregnancy 4 Drinking alcohol during the pregnancy 5 Receiving rubella vaccine before the pregnancy

1. Eating undercooked meat during the pregnancy

A 17-year-old boy presents with pain in his wrists, elbows, and knees bilaterally. He has felt fatigued, and he has been unable to work his summer job as a cashier and bagger in his family's community grocery store for the past 2 weeks. He also reports intermittent fevers and a large rash on his back in the area of his right shoulder. All of these symptoms have emerged in the last 4 weeks after a week-long backpacking trip in upper state New York. He has no significant past medical history. His only medication is acetaminophen daily for joint pain. He does not use tobacco, alcohol, or illicit drugs. He has no known allergies. Physical examination reveals a thin male adolescent in no acute distress. Temp 99.1°F, P 100 bpm, RR 14, BP 120/70 mm Hg. Small non-tender mobile lymph nodes are palpable in the neck and axilla bilaterally. There is a large warm erythematous patch with central clearing at the patient's posterior right shoulder region; it extends across the arm and axilla and measures approximately 25 cm in diameter. There is limited range of motion in his right wrist and left elbow. There were no gross focal neurologic deficits. Question What is the most likely cause of these symptoms? Answer Choices 1 Lyme disease 2 Pityriasis rosea 3 Pityriasis versicolor 4 Rocky Mountain spotted feverSecondary syphilis

1. Lyme disease

A 38-year-old male patient with HIV develops diabetes; he takes stavudine. What diabetes medication is most likely to exacerbate potential acid-base disorders of his antiviral therapy? Answer Choices 1. Metformin 2. Glyburide 3. Glipizide 4. Exenatide 5. Insulin

1. Metformin (Lactic acidosis is a serious and potential complication of both metformin and stavudine use)

A 24-year-old man with HIV-positive status for 2 years presents due to an ongoing chronic cough for the past 8 months. He admits to a mild fever that comes and goes during that period. A 5 lb unintentional weight loss is also discovered since his last visit to your office, which was approximately 9 months ago. He states he has noted an increased amount of breathlessness with simple activities that were never bothersome before the cough began. The patient denies smoking, and his TB test is negative. Question What organism is most likely causing this patient's signs and symptoms? Answer Choices 1 Mycobacterium avium complex 2 Mycobacterium bovis 3 Mycobacterium chelonae 4 Mycobacterium haemophilum 5 Mycobacterium leprae

1. Mycobacterium avium complex

A 55-year-old male firefighter suddenly develops fever, palpitations, and shortness of breath 7 days after skin transplant for severe facial burns. He also has fever resistant to intravenous antibiotics therapy introduced at the onset of fever. Because of oropharyngeal lesions, he is on parenteral nutrition. On examination, transplant shows neither signs of infections nor signs of rejection. Patient appears lethargic, with a blood pressure of 80/40, pulse rate of 120, respiratory rate of 18, and temperature of 103.4°F. Stat CBC shows neutropenia and eosinophilia. Question Why would you order a blood culture for systemic fungal infection? Answer Choices 1 Neutropenia 2 Intravenous antibiotics 3 Parenteral nutrition 4 Facial surgery 5 Age

1. Neutropenia

A 43-year-old man visits the internal medicine clinic of a university hospital presenting with a 3-week history of shortness of breath, fever, and chills. Examination shows a temperature of 38.0°C. Laboratory results suggest hypoxemia with PO2 of 74. Previous history shows the patient has been HIV-1 positive for 4 years and presently has a CD4+ T-cell count of 50/mm3. A presumptive diagnosis of Pneumocystis carinii pneumonia (PCP) is made, which is confirmed by bronchoalveolar lavage. Question What would be expected from chest auscultation in this patient? Answer Choices 1 No findings 2 Tactile fremitus 3 Bilateral rales 4 Egophony 5 Prolonged expiration

1. No findings

A 31-year-old man presents with a tick bite. He describes locating a tick in the left axillary area while showering in the evening, and he denies that the tick was present the previous evening. He removed the tick with forceps and cleaned the wound with alcohol. Examination of the bite shows local erythema and mild induration 3-5 mm diameter. The tick is identified as an adult female Ixodes scapularis. Question What is the recommended course of management for this patient? Answer Choices 1 No treatment needed 2 Test tick for Borrelia burgdorferi 3 Prophylaxis with doxycycline 4 Lyme disease serology 5 Urine antigen test

1. No treatment needed

A 6-year-old boy presents with a 2-day history of fever followed by cough, coryza, and conjunctivitis. He has also developed a rash that started behind the ear and is starting to spread downwards towards the trunk. On examination, you notice erythematous maculopapular blanching rash with coalescence in some areas. The palm and soles are spared. On oral examination, you notice 1-3 mm bluish lesions surrounded by an erythematous base. He is not up to date with his immunizations. Question What virus is most likely responsible for this patient's condition? Answer Choices 1. Paramyxovirus 2. Togavirus 3. Human parvovirus B19 4. Human herpesvirus 6 5. Varicella virus

1. Paramyxovirus

A 26-year-old woman presents for her second obstetric visit in the first trimester. Routine screening tests (blood typing, testing for syphilis, hepatitis, rubella immunity, and HIV) are performed; the test returns positive for HIV. She is counseled to start antiretroviral therapy and to have a cesarean delivery. Question To reduce the risk of mother-to-newborn transmission, the best drug treatment is a drug that prevents what mechanism of the infection? Answer Choices 1. Virus replication 2. Viral assembly 3. Fusion of virus with the host cell 4. Integration of HIV genetic material into the host chromosome 5. Binding of the HIV virion to the surface of the cells

1. Virus replication (Zidovudine only anti-HIV drug that is fully approved for use during pregnancy)

A healthy couple presents for an evaluation before traveling to the Dominican Republic; they leave in 1 month and will stay for 4 weeks. The CDC lists the Dominican Republic as a malaria-endemic area, but it is not considered to have a resistant strain of Plasmodium falciparum. Question What is the best advice for this couple? Answer Choices 1 "You should both take chloroquine weekly starting 1 week before travel." 2 "If you get any mosquito bites, return to the US immediately for malaria treatment." 3 "Be aware that malaria typically causes a mild 3-4 day self-limiting diarrheal illness." 4 "If you take prophylactic medications for malaria, you can discontinue them upon arrival if you have no symptoms." 5 "You should both pack prescriptions of high-dose amoxicillin in case malarial symptoms begin."

1. You should both take chloroquine weekly starting 1 week before travel

A 13-year-old girl presents to the emergency department with febrile episodes (Tmax 102°F), joint aches in her knees and wrists, chest pain, and a raised red rash. She denies sexual activity or intravenous drug use. Vital signs are BP 90/60 mm Hg, HR 115/min, T 101°F, RR 25/min. Physical exam is remarkable for diffuse scattered ring-shaped macules on her extremities, a III/VI systolic ejection murmur, and guarded passive range of motion in wrists and knees bilaterally with no apparent swelling. Laboratory findings: WBC 16,000 mcL, Hematocrit 35%, Platelets 350,000 mcL, ESR 65 mm/h, positive antistreptolysin O titer. Question What is the most likely diagnosis? Answer Choices 1 Systemic onset juvenile idiopathic arthritis 2 Acute rheumatic fever 3 Septic arthritis 4 Systemic lupus erythematosus 5 Lyme disease

2 Acute rheumatic fever

A 25-year-old sexually active woman presents with a 2-day history of pain and swelling of her dorsal right wrist and fingers. For the past week, the pain and swelling have been in different joints of her body, including her left knee, left elbow, and right ankle. On exam, you note edema, effusion, and erythema over the dorsal right wrist with the wrist held in 15° of extension. It is very tender on palpation and has virtually no range of motion secondary to the pain. You aspirate synovial fluid for lab studies. The lab studies reveal the following information: Synovial fluid: WBCs - 57,000 cells/mcL Gram stain: too numerous to count WBCs with no bacteria seen Culture: pending Question Based on this history, physical, and lab findings thus far, what should be the initial treatment for this woman? Answer Choices 1 Prescribe oral doxycycline for 10 days. 2 Admit to the hospital for IV ceftriaxone. 3 Wait for the results of the synovial fluid culture. 4 Admit for immediate surgical arthroscopic irrigation. 5 Admit for IV penicillin.

2 Admit to the hospital for IV ceftriaxone.

An 8-year-old girl presents with a 3-day history of fever, generalized muscle weakness, bilateral knee pain, and chest pain. You suspect acute rheumatic fever (ARF). Question What illness, contracted about 1 month ago, would support your suspicion? Answer Choices 1 Proteus mirabilis infection 2 Group A Streptococcus infection 3 Helicobacter pylori infection 4 Haemophilus influenza infection 5 E. coli infection

2 Group A Streptococcus infection

A 6-month-old infant is brought in for routine vaccination. The mother saw information about a measles outbreak online. There is no known measles outbreak in the state. The mother is asking for more information about this vaccine. She would like her child to receive it now. Question What ages of administration are appropriate to advise the mother about for this vaccine? Answer Choices 1. 6-8 months, 10 years 2. 12-15 months, 4-6 years 3. 1 month, 2 months, 6 months 4. 11-12 months, 12-14 years 5. 2 months, 4 months, 6 months

2. 12-15 months, 4-6 years

A 31-year-old HIV-positive woman presents for ongoing care. She was diagnosed with HIV 2 years ago, and she began antiretroviral therapy. Her CD4 T cell count is 400 cells/mL, and she has a history of oral candidiasis. As part of her evaluation, a tuberculin skin test (TST) is performed using 5 TU of purified protein derivative (PPD). The test site is examined 48 hours later and the skin reaction is measured. Question What is the minimum diameter of induration at which this test result should be considered positive in this patient? Answer Choices 1 2 mm 2 5 mm 3 10 mm 4 15 mm 5 20 mm

2. 5 mm

During a routine X-ray examination for employment insurance purposes, the radiologist notices a rounded lesion in a pulmonary cavity on the right upper lobe of the pulmonary X-ray of a middle-aged man. The patient was treated for pulmonary cavitary tuberculosis (TB) 2 years ago; he has completed treatment, and he has not had any problems since. Question What late complication of TB is seen in this patient? Answer Choices 1 Fibrothorax 2 Aspergilloma 3 Broncholithiasis 4 Reactivation of TB 5 Bronchiectasis

2. Aspergilloma

A 28-year-old man presents with a 2-week history of a non-painful non-pruritic rash. He is negative for any other rashes, dysuria, urinary frequency, penile discharge, erectile dysfunction, diarrhea, constipation, change in stool, nausea, or vomiting. He does recall having had a penile "scab" approximately 4 weeks ago that healed; he never sought medical attention. He is not aware of having been exposed to anyone with any illnesses in the past few months. Social history is positive for unprotected anal sex with multiple male partners in the past 6 months, with the last sexual encounter occurring 4 days ago. He states that he has not engaged in any recreational drug use or cigarette smoking. Skin exam reveals a pink-red papulosquamous eruption with scattered discrete coppery papules on the palms of his hands. Question What treatment is the best choice for the patient's condition? Answer Choices 1 Ceftriaxone 150 mg IM once 2 Benzathine penicillin G 2.4 million units IM once 3 Azithromycin 250 mg daily for 7 days 4 Doxycycline 100 mg twice daily for 7 days 5 Ciprofloxacin 500 mg twice daily for 7 days

2. Benzathine penicillin G 2.4 million units IM once

A 9-year-old boy presents with burning during urination and a creamy white penile discharge. The grandmother is concerned about sexual abuse by a female caregiver. Question What is the most likely diagnosis? Answer Choices 1 Candidal urethritis 2 Chlamydia urethritis 3 Glans-Balanitis 4 Gonococcal urethritis 5 Human papillomavirus

2. Chlamydia urethritis

A 33-year-old woman comes to your office after a 6-month sabbatical working in caves in the eastern part of the South America. Upon questioning, the patient reports fever, chills, productive cough, and joint stiffness that started 1 month before her return. Physical exam reveals 3 ulcerated lesions on her inner cheek. Question What is your treatment recommendation? Answer Choices 1 Corticosteroid 2 Itraconazole 3 Penicillin 4 Amphotericin B 5 Supportive treatment

2. Itraconzaole

A 24-year-old man presents with a 2-day history of skin rash on his back. He notes pain in his joints and tiredness. He has just returned from a camping trip. Vital signs are normal. Examination reveals an expanding lesion with a concentric circle of erythema. Question If left untreated, what is a complication of early dissemination of this condition? Answer Choices 1 Endocarditis 2 Myocarditis 3 Restrictive cardiomyopathy 4 Fibromyalgia 5 Endarteritis obliterans

2. Myocarditis

A 50-year-old man presents for the evaluation of a 1-year history of progressive cognitive, motor, and behavioral problems. He complains of inattention, reduced concentration, slowing of processing, and difficulty changing mental sets. What started as slow movements now is clumsiness and problems with coordination. His friend states that the patient is "not himself anymore" and has become apathetic, non-communicative, and "down." He is HIV-positive and was diagnosed with AIDS 2 years ago because of the presence of Pneumocystis carinii with CD4 of 100. He had an excellent response to antiretroviral therapy, however, and his last CD4+ lymphocyte counts were normal and viral load undetectable. On examination, you find an apathetic male in mild distress. Neurological exam shows loss of coordination, unsteadiness, generalized weakness (more pronounced in legs), ataxia, and tremor. Question What should be the next diagnostic step in this patient? Answer Choices 1. Neuropsychological testing 2. Neuroimaging methods 3. Electroencephalography 4. Cerebrospinal fluid examination 5. CD4+ lymphocyte counts

2. Neuroimaging methods

A 13-month-old boy presents with a rash. The mother reports that he has had high fevers over the past 4 days, but he has not had a fever for the past 24 hours. The rash began 6 hours ago, startingt on his chest and back, spreading to his neck, face, and arms. The child does not appear to be itchy, and he has been acting normally since the fever subsided. The mother denies cough, runny nose, vomiting, and diarrhea. The only medication that the child has taken is acetaminophen. On examination, the child is happy and playful. The only physical finding is a blanching macular rash noted on the mentioned areas. Question What is the most likely diagnosis? Answer Choices 1. Rubella 2. Roseola 3. Measles 4. Drug hypersensitivity 5. Varicella

2. Roseola

A 4-year-old boy presents with a 1-month history of weight loss, fevers, cough, and night sweats. He and his family moved to the United States from Africa 3 months ago. He is a thin pale boy in no acute distress. His heart rate and rhythm are regular, his lungs are clear to auscultation, and he has no organomegaly. Question What initial test would most likely have the most value? Answer Choices 1 Hepatitis B surface antigen 2 Tuberculin skin test 3 Serum blood culture 4 Rapid plasma reagin (RPR) 5 Schistomsoma serologic testing

2. Tuberculin skin test

A 10-year-old boy presents with a 1-week history of progressing joint pain. The pain started in his ankles, and then progressed to his knees; his hips are now starting to hurt. His ankles feel slightly better. He had contact with someone who had strep throat within the past couple of weeks. The patient's heart rate is 130. On exam, there is erythema and edema over the knees and hips as well as minimal edema over the ankles. A high-pitched holosystolic murmur is noted over the apex and radiates to the axilla with a noted friction rub. Question Based on the above history and physical exam, what is the most likely diagnosis? Answer Choices 1 Juvenile idiopathic arthritis 2 Systemic lupus erythematosus 3 Acute rheumatic fever 4 Kawasaki disease 5 Septic arthritis

3. Acute rheumatic fever

You have been asked to do a house call on an 88-year-old woman who is bed-bound and lives at home with her private home health aide. She has had no medical follow-up for the past year. Approximately 3 weeks ago, she appeared to be having "headaches." 2 weeks ago, she developed a rash on the left of her forehead that developed into "little blisters that popped and crusted over." She has a history of coronary artery disease and was diagnosed with "senile dementia" 6 years ago. The home health aide says she is occasionally combative and resistant to care. On exam, she is awake and mumbles several words but is not responsive to verbal commands. BP is 118/68 mm Hg, P 84/min R 20/min. Skin exam reveals clusters of vesicles with crusts on her left forehead. There are no other significant lesions noted on the body. Question What is the most appropriate treatment? Answer Choices 1. Acyclovir ointment 2. Permethrin cream 3. Aluminum acetate solution 4. Capsaicin cream 5. Metronidazole lotion

3. Aluminum acetate solution

A nurse in your office may have been exposed to blood from a patient with AIDS. She was administering an antibiotic injection intramuscularly to an HIV-positive patient and accidentally sustained a needle prick injury. As part of her post-exposure prophylaxis therapy, you instruct her to begin daily tenofovir. Question What is the mode of action of this medication? Answer Choices 1 Cannot be phosphorylated by host cell enzymes 2 Inhibits the host cell RNA polymerase 3 Blocks the viral enzyme in reverse transcriptase 4 Incorporates into viral DNA as purine analog causing chain termination 5 Prevents the virus from entering the cells

3. Blocks the viral enzyme in reverse transcriptase

A 52-year-old man stepped on a piece of glassyesterday. On exam, his wound appears clean, and it is not infected. He has never had the primary series of tetanus immunization. The patient asks if he needs tetanus immunization. Question What should you recommend? Answer Choices 1 No tetanus immunization needed 2 Tetanus booster 3 Complete tetanus immunizations plus TIG 4 Check in 24 hours to determine if immunization 5 Adult tetanus and diphtheria toxoid

3. Complete tetanus immunizations plus TIG

A 25-year-old Caucasian male landscaper presents with a 2-week history of generalized malaise and an "unusual rash" on his right thigh. The patient reports that this rash has been widening, but he denies any pruritus or pain in association with his complaints. In the past week, he has also noticed a constant headache and mild fever. The past medical history is unremarkable. The physical exam reveals vital signs within the normal limits, enlarged non-tender diffuse lymph nodes in cervical and inguinal areas, and an erythematous rash with central clearing and few satellite lesions. Question Given this patient's diagnosis, how would this patient's clinical stage be defined? Answer Choices 1 Early disseminated 2 Latent 3 Early localized 4 Late 5 Tertiary

3. Early localized

A 26-year-old HIV-positive man presents after a series of strange dreams and lack of concentration. He started on antiretrovirals 1 week ago. For his HIV infection, he takes zidovudine, lamivudine, and efavirenz. For pneumocystosis prophylaxis, he takes trimethoprim/sulfamethoxazole. He also takes a multivitamin. Question What medication is probably causing the patient's symptoms? Answer Choices 1. Zidovudine 2. Lamivudine 3. Efavirenz 4. Multivitamin 5. SMX-TMP

3. Efavirenz

A 2-year-old boy presents to your office. He is from a poor rural family and has not had regular healthcare since birth. He is experiencing a childhood exanthematous disease that involves a maculopapular rash and a fever. It started 7 days ago. He now has corneal ulcers and pneumonia. Question What are the classic prodromal signs of his suspected diagnosis? Answer Choices 1. Fever, barky cough, otalgia, conjunctivitis, and maculopapular rash 2. Rash on hands and feet, sore throat, coryza, fever, and cough 3. Koplik's spots, coryza, fever, cough, and conjunctivitis 4. Herald's patch, fever, hematuria, pruritic rash, and conjunctivitis 5. Slapped cheek appearance, coryza, fever, malaise, and maculopapular rash

3. Koplik's spots, coryza, fever, cough, and conjunctivitis (Measles - Rubeola)

A 17-year-old girl presents with a sore throat and weakness; she has a fever of 100°F. There is cervical lymphadenopathy on physical exam, and the Monospot test is positive. After 14 days, the patient develops acute abdominal pain. During the abdominal examination, guarding is noted in the upper left quadrant. The patient is becoming increasingly pale, sweaty, and cold. Question What is the proper management in this case? Answer Choices 1. Intravenous fluids and observation 2. Urgent gastroscopy 3. Laparotomy 4. Colonoscopy 5. Double-contrast barium enema

3. Laparotomy (Patient is unstable and may have a splenic rupture)

A 49-year-old man presents with chronic fatigue, headache, fevers, and muscle and joint pain. He describes the initial rash occurred on his arm with a red circular rash with central clearing. He describes transient "reddish spots" that can be quite large and have appeared on his skin then faded away. His symptoms developed about 4 months ago with no apparent cause; they have gradually gotten worse with the recent addition of the musculoskeletal pains. He is married and monogamous, and he lives in a small rural community; nevertheless, he is concerned that he may have somehow contracted a communicable STD. Question What condition is causing the patient's symptoms? Answer Choices 1 Acute rheumatic fever 2 Alcoholic cirrhosis 3 Lyme disease 4 Malaria 5 Polymyalgia rheumatica

3. Lyme disease

A 32-year-old Latinx woman, previously in good health, was brought to the emergency department by paramedics after she was found unresponsive in her home. It is unknown if she had a seizure. Past medical history is not significant, and she has no known allergies. She is not on any medications and is gravida 4, para 4, Ab 0. She is married and recently emigrated to the US from Central America. Vital signs: temperature 100.4°F, pulse 112, respirations 24, blood pressure 110/62, O2 sat 96% on room air. Physical exam reveals a well-developed woman with obtunded mental status. Cardiac exam reveals normal S1 and S2 without rub, murmur, or gallop. Lungs are clear to auscultation and percussion. Spinal tap is thought to be contraindicated. Patient is admitted to the ICU. After consultation with specialists, a tentative diagnosis is made; the patient is treated with a therapeutic trial of medication. The following morning, the patient is found to be alert, oriented, and afebrile. Lab and imaging studies show: WBC 17.2 K/mcL ESR 25 mm/hr Hgb 12.4 gm/dL Electrolytes normal Hct 37% BUN 12 mg/dL Platelets 305 K/mcL Creatinine 1.2 mg/dL Neutrophils 68% Pregnancy test Negative Lymphocytes 20% HIV immunoassay Negative Monocytes 2% Blood cultures No growth (preliminary) Eosinophils 10% EKG NSR, 1 PAC Basophils 1% Transthoracic echocardiogram Normal heart size and structure. Chest X-ray Normal heart size. No infiltrates or edema. CT brain without contrast Multiple cystic lesions. Cyst with dot sign noted. MRI brain with contrast Multiple cystic lesions. Cyst with dot sign present. Question What is the primary diagnosis? Answer Choices 1 CVA secondary to embolic shower 2 Metastatic cancer with multiple brain metastases 3 Neurocysticercosis 4 Toxoplasmosis 5 Tuberculous meningitis

3. Neurocysticerosis

A 9-month-old female infant presents with an acute onset of a rash on her trunk. She has a 4-day history of fever up to 104°F, but the mother states her daughter has no fever today. She has had some diarrheal stools, but no vomiting. No coughing or nasal congestion has been noted. The child has previously been well. Her past medical history is unremarkable, and she is up to date on her immunizations. She attends daycare, and her mother notes that some children have been ill with non-specific febrile illnesses over the past 2 weeks. Her only medication has been ibuprofen for the fever. Physical exam shows a temperature of 98.8°F, pulse of 124 bpm, and respiratory rate of 28/min. She is alert and shows no other abnormalities. Her exam shows normal tympanic membranes in the ear and normal conjunctivae in the eye. The neck shows some shotty anterior cervical adenopathy; a normal appearing pharynx, and the skin appears with an erythematous maculopapular rash most pronounced on the trunk. Her chest is clear to auscultation, heart rhythm is regular without murmurs, abdomen is soft and non-tender, and her neurological exam is normal. Question What is the most appropriate intervention for this patient? Answer Choices 1. Draw measles titers of acute and convalescent sera. 2. Administer oral acyclovir. 3. Observe the child and reassure the parent. 4. Draw a complete blood count and blood cultures. 5. Treat presumptively with oral antibiotics.

3. Observe the child and reassure the parent.

A 52-year-old man is hospitalized for a left lower lobe pneumonia. The patient is HIV positive with a CD4 count <100/uL and is known to be neutropenic. He also has type 2 diabetes mellitus and diabetic nephropathy. He is started on ciprofloxacin, ceftriaxone, and clindamycin. During treatment, the physician notes a white coating of the tonsils and oropharynx. The physician obtains scrapings of the white coating. The sample is observed microscopically and confirms the presence of fungal hyphae and budding. The physician suspects a candidal infection of the oropharynx. Question What is the next step in patient management? Answer Choices 1 Oral metronidazole 2 Oral amphotericin B 3 Oral fluconazole 4 Topical nystatin 5 Oral itraconazole

3. Oral fluconazole

A 21-year-old man presents with acute onset of pleuritic chest pain accompanied by 2-3 days of fever, chills, arthralgias, and myalgias. Upon further questioning, the patient notes that he had a severe sore throat and fever 4 weeks ago, but he was not evaluated for these symptoms. Physical examination reveals a febrile patient in mild distress. A systolic murmur is noted in the left fourth/fifth intercostal space that radiates to the left axilla. A friction rub is also appreciated on exam. Laboratory results reveal an elevated erythrocyte sedimentation rate (ESR) and antistreptolysin antibodies. Question What is the most appropriate initial management of this patient? Answer Choices 1 Tetracycline 2 Ciprofloxacin 3 Amantadine 4 Aspirin 5 Prednisone

4 Aspirin

A healthy mother with no known medical illnesses presents her 6-month-old male infant due to a 1-day history of poor feeding, lethargy, and weak cry. At first, the infant had difficulty sucking and swallowing and was not opening his eyes. This was followed by loss of head control, weakness of the trunk, arms, and then legs. The infant is constipated and has had decreased tears and saliva since yesterday. The infant was healthy before the onset of these symptoms. There is no history of fever, vomiting, cough, seizures, or difficulty in breathing. The infant has weak gag and pupillary reflexes, generalized hypotonia, loss of head control, ptosis, and diminished deep tendon reflexes. Blood counts and CSF examination are within normal limits. Question What is the most likely diagnosis? Answer Choices 1 Myasthenia gravis 2 Spinal muscular atrophy 3 Guillain-Barré syndrome 4 Botulism 5 Tick paralysis

4 Botulism

A 23-year-old man presents with burning on urination and a light greenish-yellow penile discharge. He is afebrile but otherwise well. He admits to having unprotected anal sex with a man. Question According to the Centers for Disease Control, what treatment is most appropriate? Answer Choices 1 Ciprofloxacin 500 mg now and azithromycin 1 g now 2 Ciprofloxacin 500 mg now and doxycycline 100 mg every 12 hours for 7 days 3 Penicillin G 1.2 M Units IM now and azithromycin 1 g now 4 Ceftriaxone 250 mg IM once and azithromycin 1 g now 5 Ceftriaxone 125 mg IM now and penicillin G 1.2 M units IM now

4 Ceftriaxone 250 mg IM once and azithromycin 1 g now

A 15-year-old girl presents with a 2-day history of excessive vaginal discharge. She had unprotected sex with a boyfriend 4 days ago, and he later informed her that he has gonorrhea. On speculum exam, the girl is found to have a moderate amount of off-white and frothy vaginal secretions. The appearance of the cervix is normal. A cervical swab reveals copious gram-negative intracellular diplococci. Question What should be the first step in the management of this patient? Answer Choices 1 Obtain written or oral parental consent to treat. 2 Ask the patient to return with a parent or adult guardian. 3 Request permission to treat from the Department of Health. 4 Counsel the patient about safer sex and treat. 5 Ask the patient to provide a list of sexual contacts

4 Counsel the patient about safer sex and treat.

A 29-year-old man presents 1 hour after stepping on a sharp nail. The nail penetrated deep into his foot; his last tetanus immunization was at age 6. Question What treatment would be most appropriate? Answer Choices 1 Tetanus immunoglobulin only 2 Tetanus toxoid only 3 Tetanus immunoglobulin plus toxoid 4 Tdap vaccine plus antibiotics 5 Antibiotics only

4 Tdap vaccine plus antibiotics

A 33-year-old man presents with a 2-day history of severe diarrhea and vomiting. He had been on a business trip to Asia 3 days ago, and he reports eating food bought from street vendors. He describes his stools as watery and not bloodstained. He is allergic to seafood, and he takes antacids for peptic ulcers. On examination, he is moderately dehydrated; temperature is 37°C, PR is 100, and BP is 120/60 mm Hg. Question What pathogenic organism is most likely causing his symptoms? Answer Choices 1 Staphylococcus aureus 2 Bacillus cereus 3 Escherichia coli serotype O157:H7 4 Vibrio cholera 5 Vibrio parahaemolyticus

4 Vibrio cholera

A 5-year-old Latino boy with acute lymphoblastic leukemia presents with fever and rash. He is currently on induction chemotherapy that includes dexamethasone. He was exposed to a friend with varicella 2 weeks ago; he has never had the varicella vaccination and his mother cannot recall that he ever had a varicella infection. Blood tests prior to initiation of chemotherapy showed the absence of antibody to the varicella virus. He now has 10 small vesicles and several red macules on his face and chest. Temperature is 38.5°C. Exam is otherwise normal. Question What is the most appropriate immediate treatment for this patient? Answer Choices 1. Acetaminophen as needed 2. Varicella-zoster immune globulin 125 units/10 kg IM 3. Varicella vaccine 0.5 mL IM 4. Acyclovir 500 mg/m2 IV every 8 hours 5. Acyclovir 200 mg/m2 PO 5 times a day

4. Acyclovir 500 mg/m2 IV every 8 hours

A 15-year-old girl presents due to a rash. She does not take any over-the-counter or prescription medications and she does not have any pertinent medical history or drug allergies. She denies known exposure to any sick contacts in the last several days, but she admits to traveling to Tennessee and hiking in the Smoky Mountains last week. Further questioning reveals that the patient admits to feeling feverish (although the patient has not formally taken her temperature), headache, lack of appetite, and muscle pain. Physical examination reveals a rash on her bilateral wrists, forearms, and bilateral ankles; it consists of numerous small flat pink macules that are non-pruritic and non-scaly. Question Highlights What treatment regimen is most appropriate for this patient? Answer Choices 1. Amoxicillin 2. Amoxicillin/clavulanic acid 3. Azithromycin 4. Doxycycline 5. Sulfamethoxazole/trimethoprim

4. Doxycycline

A 10-year-old boy presents with swelling on his face that has been progressively increasing in size. He is an immigrant from East Africa. On examination, he has mild pallor and large swelling involving his right maxilla. A biopsy taken reveals a starry sky pattern of lymphocytes. Question What organism is associated with his condition? Answer Choices 1. Hepatitis B virus 2. Human papilloma virus 3. Schistosoma hematobium 4. Epstein Barr virus (EBV) 5. Human T-cell lymphotropic virus type 1

4. Epstein Barr Virus (EBV) (Burkitt's lymphoma and common in Central and East Africa)

A 3-year-old girl tells her parents that she has itching in what seems to be the perianal area. The itching is something that wakes her at night, and this is when she has complained most to her parents. Her pediatrician performs an anal swab, and microscopic examination reveals ova. Question What is the most likely recommended treatment for this patient? Answer Choices 1 Cefdinir (Omnicef) 2 Miconazole (Oravig) 3 Doxycycline (Vibramycin) 4 Mebendazole (Vermox) 5 Metronidazole (Flagyl)

4. Mebendazole (Vermox)

A 32-year-old Hispanic woman presents with a 3-day history of vaginal pruritus. She is worried she has another infection. She was treated with penicillin 2 weeks ago for group A Streptococcus pharyngitis. The patient reports occasional sinus and urinary tract infections and always struggles with vaginal symptoms afterward. She has episodes of vaginal pruritus and thick white discharge approximately 3 times per year. She usually returns to her urgent care clinic for evaluation and treatment, then her symptoms resolve. She has no chronic medical conditions. She is non-obese and is not pregnant. On exam, the vaginal mucosa is inflamed and coated with thick clumpy white discharge. On a wet mount slide treated with potassium hydroxide, you see pseudohyphae. The patient would like treatment for her current vaginal symptoms and advice in preventing her symptoms in the future. Question What is the best intervention for prevention of the patient's current condition? Answer Choices 1 Advise the patient to drink cranberry juice. 2 Advise the patient to eat yogurt. 3 Avoid prescribing antibiotics for this patient in the future. 4 Offer fluconazole in combination with antibiotics if indicated. 5 Prescribe nitrofurantoin for use after intercourse

4. Offer fluconazole in combination with antibiotics if indicated

An 18-month-old infant presents with a 5-day history of fever of 104°F. On physical examination, you note a mildly irritable infant who has not been feeding well. There are no other clinically significant findings. You prescribe acetaminophen (Children's Tylenol) and tell the mother to monitor the infant's fever for the next few days; if the fever goes down, everything should be fine. The mother calls the next day and says that the fever has stopped, but a rash has developed, and she is concerned. The infant examination reveals a diffuse fine maculopapular rash. Presently, the child does not appear ill. Question What is the most likely diagnosis? Answer Choices 1. Rubella 2. Rubeola 3. Erythema infectiosum 4. Roseola 5. Chickenpox

4. Roseola

A 27-year-old man presents with the "flu." He says that he has felt feverish, tired, and mildly nauseated for the past few weeks. He mentions a headache and non-pruritic rash. He denies any past medical history or medication use. On exam, he is afebrile. Examination reveals diffuse mild lymphadenopathy with mild hepatosplenomegaly; his soft palate has a few scattered shallow ulcerations. The palmar and plantar surfaces have a scattered papular rash that is copper colored, with a few papules on the flexor surfaces of the arms, legs, and trunk. Laboratory evaluation reveals hemoglobin of 12.8 g/dL, hematocrit of 38%, and white blood cell count of 11.1 x 103/ìL. Question What is the most likely diagnosis? Answer Choices 1 Influenza 2 Rocky Mountain spotted fever 3 Hand-foot-and-mouth disease 4 Secondary syphilis 5 Streptococcal pharyngitis

4. Secondary syphilis

A 26-year-old pregnant woman diagnosed with primary tuberculosis and wants to discuss treatment options. Initial labs come back with mild anemia, positive HCG, and elevated cholesterol. All other labs are within normal range. Question What drug should be avoided in this patient? Answer Choices 1 Isoniazid 2 Rifampin 3 Ethambutol 4 Streptomycin 5 Pyrazinamide

4. Streptomycin

A 27-year-old woman who is 18 weeks pregnant states that her 3-year-old daughter was just diagnosed with erythema infectiosum (Fifth disease). An antibody test is ordered, and the woman is found to be seronegative. She is healthy and has no signs or symptoms of parvoviral infection. 2 weeks later, the test is repeated and the patient is IgM-positive. Question What is the significance of this test result with regard to the patient's fetus? Answer Choices 1. The patient has developed protective immunity that will also protect the fetus. 2. There is a 75% chance the fetus has been or will become infected during pregnancy. 3. The patient should undergo amniocentesis to determine if the virus has crossed the placenta. 4. The patient should undergo serial fetal ultrasounds to monitor for signs of hydrops fetalis. 5. The fetus is not at risk of becoming infected because the virus cannot cross the placenta.

4. The patient should undergo serial fetal ultrasounds to monitor for signs of hydrops fetalis.

A 32-year-old woman is brought to the emergency room with sudden onset of fever, headache, sore throat, profuse watery diarrhea, vomiting, and lethargy; symptoms started in the morning. On physical examination, she is slightly confused; her temperature is 39°C (103°F), her blood pressure is 100/50 mm Hg, and she has diffuse sunburn like an erythematous rash. When the emergency doctor is trying to find out if she is pregnant, she mentions that her period started 2 days ago. Question What is the most likely diagnosis? Answer Choices 1. Scarlet fever 2. Rocky Mountain spotted fever 3. Meningococcemia 4. Toxic shock syndrome 5. Food poisoning

4. Toxic Shock Syndrome

A 20-year-old primigravida woman at 12 weeks gestation presents with a 2-day history of low-grade fever and swelling in her neck. She does not have any significant medical history and denies previous blood transfusion. On questioning, she states that she is not sexually promiscuous and that she is living with her husband and their pet cat. She is a homemaker and spends her free time gardening. She has received all immunizations, and they are up-to-date. She also states that she has abstained from sex since learning of her pregnancy 2 months ago. On examination, her vitals are temp 99°F, PR 88/min, BP 110/70 mm Hg, RR 20/min. She also has painless prominent cervical lymph nodes. Abdominal examination reveals a just-palpable uterus. Question The fetus is at increased susceptibility to what infection? Answer Choices 1 Treponema pallidum 2 Cytomegalovirus 3 Rubella 4 Toxoplasma gondii 5 Herpes simplex virus

4. Toxoplasma gondii

A 25-year-old man develops clinical signs of bacteremia in the hospital. Examination reveals erythema, tenderness, and a slight purulent discharge around the insertion site of a central venous catheter. Gram stain of discharge shows gram-positive cocci in grape-like clusters. Culture sensitivity of the fluid showed methicillin-resistant Staphylococcus epidermidis. Question What is the most appropriate antibiotic therapy? Answer Choices 1 Cloxacillin 2 Cefazolin 3 Sulfamethoxazole/trimethoprim 4 Vancomycin 5 Penicillin

4. Vancomycin

A 28-year-old woman presents with malaise. She is known to be HIV positive. Her CD4 count is unchanged at 350 cells/field, and her viral count is undetectable. She is afebrile and has a normal exam. She takes zidovudine, indinavir, potassium, hydrochlorothiazide, and glyburide. Workup shows: Serum bicarbonate 20 meq/L Serum sodium 140 meq/L Serum chloride 100 meq/L Serum lactate 6 mmol/L Serum potassium 4.2 meq/L Whole blood glucose 85 mg/dL HemoglobinA1C 6.2% Hemoglobin 13.5 g/dL( unchanged) Question What medication is likely causing her elevated lactate? Answer Choices 1. Hydrochlorothiazide 2. Glyburide 3. Indinavir 4. Zidovudine 5. Potassium

4. Zidovudine

A 10-year-old girl presents with chest pain and joint aches. Her mother says that about 2 weeks ago, her daughter had a sore throat with fevers and pus around her tonsils. She was prescribed a 14-day course of penicillin on the initial visit, but her mother stopped the medications after 2 days because the fever subsided. She also experienced chest pain and recurrence of fever. Her vital signs: blood pressure 120/80 mm Hg, heart rate 110 beats/min, temperature 102.3°F. On physical examination, normal S1/S2 and a II/VI short mid-diastolic murmur are heard. Her EKG shows a sinus tachycardia with a prolonged PR interval. Question What would have been the best way to prevent this disease? Answer Choices 1 Steroid therapy 2 Saltwater gargles 3 Acetaminophen 4 Aspirin 5 Antibiotic compliance

5 Antibiotic compliance

A 17-year-old boy presents with a 5-day history of intermittent fever, joint pain, and redness and swelling of the joints. The patient gives a history of pain in the right knee and ankle. 3 days ago, he had pain and swelling in his left knee, but now it has improved. On examination, temperature is 102°F, pulse is 108/min, RR is 20/min, and BP is 110/80 mm Hg. The patient's right knee is swollen, tender, and warm. There is a limitation of range of motion due to pain. The right ankle appears swollen and warm. Other system exams are normal. Lab tests are ordered; during the follow-up exam, you note elevated erythrocyte sedimentation rate (ESR) and rising ASO titers. Question How long should the patient receive secondary prophylactic antibiotics? Answer Choices 1 10 days 2 1 month 3 6 months 4 1 year 5 5 years

5. 5 years

A 17-year-old male football player is being evaluated for fatigue and a sore throat. He denies coughing or fevers. He does not smoke or drink. In addition, he denies blood in his stool or urine and any dysuric symptoms. He practices safe sexual intercourse with his girlfriend. Physical exam demonstrates a blood pressure of 130/65 mm Hg, a pulse of 72/minute, respirations of 16/minute, and a temperature of 98°F (36.6°C). Lung and heart sounds are normal. There is no cervical adenopathy. When you look at the pharynx, there is tonsillar enlargement with evidence of exudates. The abdominal exam demonstrates a spleen tip that is easily palpable 1.5 cm below the left costal margin. Results of a Monospot test are positive. Question What management scheme is best for this patient? Answer Choices 1. Empiric antibiotic treatment 2. Intravenous acyclovir therapy 3. Oral acyclovir therapy 4. Oral steroids for 5 days 5. Acetaminophen or NSAIDs

5. Acetaminophen or NSAIDs

A 2-month-old girl presents with rapid breathing and a staccato cough, appearing otherwise well; she is afebrile. Physical examination detects fine rales over the lungs and a thickened red tympanic membrane. A chest X-ray shows bilateral patchy interstitial infiltrates. Laboratory studies indicate eosinophilia. Her mother received limited prenatal care. Question What is the likely causative organism? Answer Choices 1 Haemophilus influenzae 2 Escherichia coli 3 Streptococcus pneumoniae 4 Mycobacterium tuberculosis 5 Chlamydia trachomatis

5. Chlamydia trachomatis

A 3-year-old boy is admitted to the emergency room in acute respiratory distress. The patient has a body temperature of 40°C, a respiratory rate of 70/min, and a pulse of 130/min. Auscultations of the lungs are unremarkable. An examination of the throat reveals an exudate in the posterior pharynx that is yellowish and membranous. Bleeding occurrs when it is scraped and removed. The parents of the child reveal that the child has no prior immunizations. A throat culture was ordered and worked up specifically for an organism that selectively grows on cystine tellurite agar. Question What organism is causing this child's disease? Answer Choices 1 Respiratory syncytial virus 2 Bordetella pertussis 3 Haemophilus influenzae Type b 4 Streptococcus pyogenes 5 Corynebacterium diphtheriae

5. Corynebacterium diphtheriae

A 30-year-old man presents with a 2-month history of coughing and a 2-day history of coughing blood. He has been losing weight and sweating at night. On physical examination, the patient appears wasted and tachypneic with bronchial breath sounds in the right upper lobe and crepitations in the left upper lobe and right mid-zone. His direct sputum result comes back positive for acid-fast bacilli with Ziehl-Neelsen stain. His sputum is sent for culture and treatment is started for his condition. After starting the medication, he notices he is unable to distinguish between red and green colors. Question What treatment medication for his condition would cause this? Answer Choices 1 Isoniazid 2 Rifampin 3 Pyrazinamide 4 Streptomycin 5 Ethambutol

5. Ethambutol

A 24-year-old man is brought to the emergency room in shock. A quick history from his girlfriend reveals that he has had a "blister on his left foot" for the past couple of days. According to the girlfriend, the patient developed a fever earlier in the day; he felt weak and eventually collapsed. He last passed urine the evening prior to presentation. On examination, his BP is 70/40 and pulse is 130/minute; his hands feel cold and clammy. Except for a swollen left foot, systemic examination is normal. His lab values are as follows: Total WBC count: 21,000/mm3 Neutrophils: 55% Lymphocytes: 25% Hemoglobin: 11.0 g/dL CRP: 165 mg/L Serum Creatinine: 2.3 mg/dL Urine Myoglobin: positive Serum K: 5.9 Meq/dL Serum Na: 133 Meq/dL ECG: sinus tachycardia Question What is the critical component in management of this patient? Answer Choices 1 Administration of IV calcium gluconate 2 Low-dose dopamine infusion 3 Broad-spectrum antibiotics 4 Tetanus prophylaxis with immunoglobulin administration 5 Extensive early surgical debridement

5. Extensive early surgical debridement (necrotizing fasciitis)

A 30-year-old immigrant worker presented 4 weeks ago with a chronic cough, blood-stained sputum, and night sweats. His PPD was 15 mm and pulmonary tuberculosis was diagnosed. Treatment was started at that time and today he is back for a checkup with the complaint of "pins and needles" sensation in his hands. Question What drug is causing this type of side effect? Answer Choices 1 Pyrazinamide 2 Ethambutol 3 Rifampicin 4 Streptomycin 5 Isoniazid

5. Isoniazid

You are covering a weekend shift at a local inner-city free clinic. A 41-year-old woman presents with what she describes as "a cough." The patient states that this cough will not go away and has been present for several months, to the point that the patient is coughing up blood for the last 4 days. She admits to unintentionally losing about 10 pounds in the last 2 months. Progressively worsening fatigue, night sweats, and chills are also present. She is a non-smoker and lives in a rent-controlled apartment with 3 adults and 4 kids. Question Given the most likely diagnosis and need for confirmation of the diagnosis, what laboratory study is viewed as the gold standard and most sensitive for confirming the diagnosis? Answer Choices 1 QuantiFERON-TB Gold 2 Tuberculin skin test 3 Chest radiograph 4 Acid-fast bacilli smear 5 TB culture

5. TB culture

A 54-year-old man presents after having a generalized seizure. The patient is HIV-positive, but he has been unable to afford antiretroviral therapy since losing his job 2 years ago. Other than cachexia, the physical exam is unremarkable. Upon further inquiry, the patient also notes that he has become short-tempered and hypercritical; at times he seems confused. An MRI of the brain is performed, and it reveals several cortical ring-enhancing lesions. Question What is the most likely diagnosis? Answer Choices 1. AIDS dementia complex 2. Cryptococcal meningitis 3. Cytomegalovirus encephalitis 4. Progressive multifocal leukoencephalopathy 5. Toxoplasma encephalitis

5. Toxoplasma encephalitis

Case An 18-month-old child presents with a 2-day history of fever that is currently 101°F rectally. You symptomatically treat the patient and ask the mother to return if the condition worsens. The mother returns 2 days later because the child has developed small red spots that became bumps and are now blisters. The mother also noted the child was scratching the lesions. Physical exam reveals macules, papules, and vesicles are on the face and thorax bilaterally. Each vesicle resides on its own erythematous base. Question What is the most likely diagnosis? Answer Choices 1. Shingles 2. Ramsey-Hunt Syndrome 3. Erythema infectiosum 4. Primary herpes simplex 5. Varicella

5. Varicella