NP Cert Exam - Eye, Ear, Nose, and Throat Problems

1. A 29-year-old woman presents with a chief complaint of a red, irritated right eye for the past 48 hours with eyelids that were "stuck together" this morning when she awoke. Examination reveals injected palpebral and bulbar conjunctiva and reactive pupils; vision screen with the Snellen chart evaluation reveals 20/30 in the right eye (OD), left eye (OS), and both eyes (OU), and purulent eye discharge on the right only. This presentation is most consistent with: A. suppurative or bacterial conjunctivitis. B. viral conjunctivitis. C. allergic conjunctivitis, D. mechanical injury,

1. Correct: A. suppurative or bacterial conjunctivitis. Suppurative conjunctivitis is the most likely diagnosis due to the unilateral nature of the condition and the presence of purulent eye discharge. Incorrect: Viral conjunctivitis (B) and allergic conjunctivitis (C) are typically bilateral conditions. Additicnally, viral conjunctivitis is associated with clear, watery discharge. There is no mention of injury in the patient history in order to consider a mechanical injury diagnosis (D).

10. In caring for Ms. Levine, the most appropriate next action is: A. prompt referral to an ophthalmologist. B. to provide analgesia and repeat the evaluation when the patient is more comfortable. C. to instill a corticosteroid ophthalmic solution. D. to patch the eye and arrange for follow-up in 24 hours.

10. Correct: A. prompt referral to an ophthalmologist. For a patient diagnosed with angle-closure glaucoma, prompt referral to ophthalmology is needed to confirm diagnosis and initiate therapy to preserve vision. If the IOP is not lowered within a few hours (with IOP- lowering medications and/or laser or incisional surgical therapy), permanent vision loss is possible. Incorrect: As such, treating the symptoms, such as with an anal- gesic (B), and delaying treatment (D) to reduce IOP are not appropriate. The use of a topical corticosteroid (C) is not warranted for angle-closure glaucoma.

100. Which of the following represents an oral therapeutic option for ABRS in a 25-year-old woman with well-controlled asthma, using an inhaled corticosteroid daily and a beta-2 agonist as needed, with no recent antimicrobial use and with treatment failure after 72 hours of appropriate-dose oral doxycy- cline therapy? A. clindamycin B. clarithromycin C. TMP-SMX D. high-dose amoxicillin with clavulanate

100. Correct: D. high-dose amoxicillin with clavulanate Doxycycline exhibits effective activity against certain gram-positive and gram-negative pathogens but is not effective against DRSP, which is the likely pathogen in this patient. Among the choices, high-dose amoxicillin with clavulanate represents the best option to overcome resistance. Incorrect: TMP-SMX (C) and the macrolides (B) are not rec- ommended for DRSP, and clindamycin (A) is not rec- ommended for ABS. A respiratory fluoroquinolone would be another appropriate option for this patient.

101. A 34 year-old man with penicillin allergy with a history of hive-form reaction and difficulty breathing presents with ABRS. Three weeks ago, he was treated with doxycycline for "bronchitis." You now prescribe: A. standard-dose clarithromycin. B. standard-dose moxifloxacin C. standard-dose cephalexin. D. high-dose amoxicillin.

101. Correct: B. standard-dose moxifloxacin. Because of a recent history of antimicrobial use, this patient is at risk of infection by DRSP. A respiratory fluoroquinolone (i.e., moxifloxacin) is the preferred choice when DRSP is suspected. Incorrect: The macrolides (i.e., clarithromycin [A]) and first- generation cephalosporins (i.e., cephalexin [C]) are not recommended for the treatment of DRSP. High-dose amoxicillin (D) should be avoided in this patient due to penicillin allergy.

102. A 45-year-old man with ABRS has shown no clinical improvement after a total of 10 days of oral anti microbial therapy. Initially treated with doxycycline for 5 days, he was then switched to levofloxaci for the past 5 days. This is his third episode of ABRS in the past 12 months. You consider: A. initiating a course of oral corticosteroid. B. switching treatment to oral moxifloxacin. C. prompt referral for sinus imaging with a CT scan. D. discontinuing antimicrobial therapy, performing a nasal swab for culture and sensitivity, and treat- ment dependent on these results.

102. Correct: C. prompt referral for sinus imaging with a CT scan. For the patient who has experienced treatment failure with antimicrobials that should have been effective, imaging will likely help with rethinking the original diagnosis. A CT scan can help identify a sinus struc- tural abnormality or possibly a complication such as extension of infection beyond the sinus space. ENT consultation should also be considered. Incorrect: With treatment failure with moxifloxacin, prescribing a second fluoroquinolone (B) would not be appropriate as it would likely result in the same clinical response. A nasal swab (D) can be useful in identifying the caus- ative organism, but appropriate management should not be delayed for culture results, which can take 1 to 2 days. An oral corticosteroid (A) is not warranted. particularly when a definitive diagnosis with imaging studies has not been made.

103. All of the following have demonstrated efficacy in relieving symptoms of ABRS except: A. saline nasal spray. B. nasal corticosteroid. C. oral decongestant. D. oral acetaminophen.

103. Correct: C. oral decongestant Adjunctive treatments should be considered to reduce the symptoms associated with ABS. Decongestants, either oral or nasal, are not recommended as adjunc- tive therapy in patients with ABRS as they do not sub- stantially impact outcomes. Incorrect: Saline nasal spray (A) or neti pot can be used to rinse nasal passages. Nasal corticosteroids (B) can be effec- tive in reducing inflammation. Analgesics such as acet- aminophen (D) or ibuprofen can help alleviate pain.

104. You inspect the oral cavity of a 72-year-old man who has an 80 pack-year cigarette smoking history as well as a history of alcohol abuse for 20 years, currently with 10 years of sobriety. You find an oral lesion suspicious for malignancy and describe it as: A. a raised, red, painful shallow ulcer. B. a denuded patch with a removable white coating. C. an ulcerated lesion with indurated margins. D. a painful vesicular-form lesion with macerated margins.

104. Correct: C. an ulcerated lesion with indurated margins. An ulcerated lesion with indurated margin is the classic presentation of oral SCC. Oral cancer is typically pain- less, while other self-limiting conditions can be at min- imum uncomfortable (candidiasis) with an irritated feeling to painful (herpetic lesion, aphthous stomatitis). Incorrect: A raised, red, painful shallow ulcer (A) best describes a self-limiting aphthous stomatitis. A denuded patch with a removable white coating best (B) describes oral candidiasis. A painful vesicular-form lesion (D) is likely due to herpes infection.

105. Firm, painless, relatively fixed anterior cervical nodes would mos likely be seen in the diagnosis of A. herpes simplex. B. AOM. C. bacterial pharyngitis. D. oral cancer.

105. Correct: D. oral cancer. Lymphadenopathy associated with oral cancer consists of immobile nodes that are nontender when palpated. Incorrect: In infection (herpes simplex [A], AOM [B], bacterial pharyngitis [C]), the associated lymphadenopathy fol- lows drainage tracks and is characterized by tenderness and mobility.

106. Which of the following is the most common form of oral cancer? A. adenocarcinoma B. sarcoma C. SCC D. basal cell carcinoma

106. Correct: C. SCC SCC is by far the most common cause of oral cancer, accounting for over 90% of cancers in the oral cavity and oropharynx. Incorrect: Other types of oral cancer include verrucous carci- noma, adenocarcinoma (A), sarcoma (B), basal cell carcinoma (D), minor salivary gland carcinoma, and lymphomas, which occur much less frequently than SCC.

107. One of the risk factors of oral cancer is infection with: A. human herpes virus type 1. B. HPV16. C. adenovirus type 16. D. EBV.

107. Correct: B. HPV16. There is a growing body of evidence supporting the increasing role of HPV16 in oral cancers, particu- larly among young, nonsmoking oral cancer patients, Among people under the age of 50 years, HPV16 will likely replace tobacco as the leading cause of initiation of the cancer process. With the availability and growing utilization of the HPV vaccine that protects against HPV16, it is hoped that the incidence of oral cancers will decrease in the future. Incorrect: Other virus types, including human herpes virus type 1 (or the "cold sore" virus) (A) and EBV (common cause of mononucleosis) (D) are not typically associated with oral cancer formation. Though adenovirus has been implicated in certain cancers, adenovirus type 16 (C) has not been identified as a risk factor for oral cancer.

108 to 114. Matching Questions 108. Correct: E 109. Correct: G 110. Correct: C 111. Correct: A 112. Correct: B 113. Correct: F 114. Correct: D The preauricular nodes are located just anterior to the ears and drain lymph fluid from the eyes, cheeks, and scalp. The posterior cervical nodes are located along the back of the neck, while the anterior cervical nodes are located along the front part of the neck, in front of the sternocleidomastoid muscle. Supraclavicular nodes are located on either side of the hollow of the clavicle near the sternoclavicular joint. The submandibular nodes are located between the submandibular salivary glands and along the underside of the jaw. The submental nodes are located under the chin and drain the anterior mandible and associated structures. The tonsillar nodes are located just below the angle of the mandible.

108 to 114. See the following image and match the nodes with their respective letters. 108. Preauricular nodes 109. Posterior cervical nodes 110. Anterior cervical nodes 111. Supraclavicular nodes 112. Submandibular nodes 113. Submental nodes 114. Tonsillar nodes

11. Johnathan is a 38-year-old man with spondyloarthropathy and presents with a new-onset right eye vision change accompanied by dull pain, tearing, and photophobia. The right pupil is small, irregular, and poorly reactive. Vision testing obtained by using the Snellen chart is 20/30 OS and 20/80 OD. He states he usually does not wear glasses and had a recent vision evaluation that was reported as normal. The most likely diagnosis is: A. unilateral heretic conjunctivitis. B. OAG. C. angle-closure glaucoma. D. anterior uveitis.

11. Correct: D. anterior uveitis. This patient presents the classic signs and symptoms of anterior uveitis, particularly dully painful red eye with vision changes and a pupil that is constricted, nonre- active, and irregularly shaped. Furthermore, anterior uveitis occurs in a large percentage of patients with spondyloarthropathy, particularly in persons with the HLA-B27 allele. Incorrect: Angle-closure glaucoma (C) is characterized by eye pain, a firm eyeball, visual changes, and dilated and unreac- tive pupil. OAG (B) is associated with painless, slowly progressive vision loss. Herpetic conjunctivitis (A) is characterized by itching and redness of the eye, eye pain and inflammation of the eyelids, and continuous watery discharge.

115. An 18-year-old woman has a chief complaint of a "sore throat and swollen glands" for the past 3 days. Her physical examination includes a temperature of 101°F (38.3°C), exudative pharyngitis, and tender anterior cervical lymphadenopathy. Right and left upper quadrant abdominal tenderness is absent. The most likely diagnosis is: A. S pyogenes pharyngitis. B. infectious mononucleosis. C. viral pharyngitis. D. Vincent angina.

115. Correct: A. S pyogenes pharyngitis. Classic symptoms of S pyogenes pharyngitis or strep throat include sore throat, fever, enlarged tonsils that are usually covered with exudate, and anterior cervical lymphadenopathy. Incorrect: Viral pharyngitis (C) is accompanied by cough, nasal discharge, hoarseness, and pharyngeal ulcerations. The presentation of infectious mononucleosis (B) includes fatigue, exudative pharyngitis with tonsillar enlargement, fever, headache, and anterior and pos- terior cervical lymphadenopathy. Vincent angina (D) is associated with infection of the gums and tooth margins.

116. Treatment options for streptococcal pharyngitis for a patient with severe penicillin allergy include all of the following except: A. azithromycin. B. TMP-SMX. C. clarithromycin. D. clindamycin.

116. Correct: B. TMP-SMX. TMP-SMX is not typically used for the treatment of strep throat but can be considered for other infections caused by a susceptible organism. Incorrect: For patients with penicillin allergy, strep throat can be treated with a macrolide (azithromycin [A], clarithro- mycin [C]) or clindamycin [D], though there is a risk of bacterial resistance to these agents.

117. S pyogenes is transmitted primarily through: A. sexual contact. B. skin-to-skin contact. C. saliva and droplet contact. D. contaminated surfaces.

117. Correct: C. saliva and droplet contact. S pyogenes is primarily transmitted via saliva and drop- let contact. Incorrect: Knowledge of the mode of transmission can be an important step in minimizing risk of transmission and should be an essential part of patient education. Sexual contact (A), skin-to-skin contact (B), or exposure to contaminated surfaces (D) are not the primary trans- mission vehicles for this pathogen.

118. You are seeing a 25-year-old man with S pyogenes pharyngitis. He asks whether he can get a "shot of penicillin" for therapy. He has no history of drug allergy. You consider the following when counseling about the use of intramuscular penicillin: A. Injectable penicillin formulation is stable in the presence of beta-lactamase. B. This is a treatment option when nonadherence to oral therapy is a possibility. C. This is the preferred agent in treating group G streptococcal infection. D. Injectable penicillin has a superior spectrum of antimicrobial coverage compared with the oral version of the drug.

118. Correct: B. This is a treatment option when nonad- herence to oral therapy is a possibility. The oral formulation of penicillin is preferred over par- enteral formulations for the treatment of strep throat due to cost, convenience, and safety factors. The inject- able version can be considered if there is concern with patient adherence to the oral therapy. Incorrect: The oral and injectable forms of penicillin exhibit an identical spectrum of activity (D), including group G streptococci (C), and both are susceptible to beta- lactamase (A). However, the disadvantages of the intramuscular formulation include a greater risk of severe allergic reaction, higher cost, and injection site pain.

119. The incubation period for infection with S pyogenes is usually: A. 1 to 3 days. B. 3 to 5 days. C. 6 to 9 days. D. 10 to 13 days.

119. Correct: B. 3 to 5 days. The incubation period of S pyogenes lasts an average of 3 to 5 days but can be up to 3 months. Knowledge of the incubation period of an organism is important in helping identify exposure and pre-illness onset and also to let patients know when they could have passed on the organism to others. This is particularly helpful when the patient is a member of a household or in other situations where individuals are in close physical contact. Incorrect: The incubation period of S pyogenes lasts an average of 3 to 5 days but can be up to 3 months.

12. Mrs. Sanchez is a 77-year-old woman with type 2 diabetes and history of bilateral cataract extraction who complains of new onset of "light flashes and floaters" with documented decreased visual acuity in her left eye. Examination reveals reduced visual field on the left and 20/30 vison on right, 20/90 vision on left with corrective lenses. The most likely diagnosis is: A. OAG. B. central retinal artery occlusion. C. anterior uveitis. D. retinal detachment.

12. Correct: D. retinal detachment. This patient presents with the typical symptoms of ret- inal detachment, including an increasing number of floaters and decreased visual acuity. She is also at higher risk of retinal detachment due to her older age and his- tory of cataract surgery. Incorrect: OAG (A) is associated with painless, slowly progressive vision loss associated with elevated IP. Anterior uveitis (C) is characterized by a dully painful red eye and a con- stricted, irregularly shaped pupil. Central renal artery occlusion (B) is associated with sudden, severe vision loss.

120. You see a patient with a positive rapid strep screen. Antimicrobial therapy has been initiated. This person can be cleared to return to work or school after hours of antimicrobial therapy. A. 12 B. 24 C. 36 D. 48

120. Correct: B. 24 Patients are no longer contagious within 24 hours of initiation of antimicrobial therapy and without fever. Patients should be educated on when they are no longer contagious as this will dictate when they can return to work or school. A premature return to work or school can increase contagion risk through droplet transmission. Incorrect: Patients are no longer contagious within 24 hours of initiation of antimicrobial therapy and without fever. Patients should be educated on when they are no lon- ger contagious as this will dictate when they can return to work or school.

13. For Mrs. Sanchez, the most appropriate next course of action is: A. placement of an eye shield and follow-up in 48 hours. B. to initiate treatment with an ophthalmic antimicrobial solution. C. to initiate treatment with a corticosteroid ophthalmic solution. D. immediate referral to an ophthalmologist.

13. Correct: D. immediate referral to an ophthalmologist. In primary care, a high index of suspicion is needed for vision-threatening conditions. For retinal detachment, early diagnosis and treatment by an ophthalmologist are needed to prevent permanent vision loss. Incorrect: There is no sign of infection or localized inflammation; thus, treatment with an antimicrobial (B) or topical corticosteroid (C) is not necessary. Delaying treatment with the use of an eye shield (A) causes pupillary dila- tion that can worsen IP and lead to permanent vision loss.

14. A 45-year-old man presents with eye pain and redness. He reports that he was cutting a tree with a chain saw when some wood fragments hit his eye. You consider all of the following except: A. educating the patient on the use of appropriate eye protection for primary prevention of eye trauma. B. immediately removing any protruding foreign body from the eye. C. using fluorescein staining to detect small objects in the eye. D. prompt referral to an eye care specialist.

14. Correct: B. immediately removing any protruding for- eign body from the eye. In primary care, it is best not to attempt removal of a foreign body from the eye globe. The patient should be referred immediately to an ophthalmologist. Incorrect: The patient should be referred immediately to an ophthalmologist (D). Fluorescein staining (C) can be helpful in identifying corneal injury including corneal abrasion and small foreign body fragments. Primary prevention through patient education on appropriate eye protection (A) can help prevent future eye trauma events.

15. Which of the following is a common vision problem in the person with untreated POAG? A. peripheral vision loss B. blurring of near vision C. difficulty with distant vision D. need for increased illumination

15. Correct: A. peripheral vision loss Although all of these changes can be seen in patients with advanced POAG, peripheral vision loss is specific to POAG. Incorrect: New onset of difficulty with distance vision (C) can be found in patients with cataracts or with age-related ocu- lar changes. Changes in near vision (B) are a common part of the aging process because of hardening of the lens (i.e., presbyopia) and the need for increased illumi- nation (D).

16. POAG is primarily caused by: A. hardening of the lens. B. elevated intraocular pressure. C. degeneration of the optic nerve. D. hypotension in the anterior maxillary artery.

16. Correct: B. elevated intraocular pressure. All forms of glaucoma are caused by elevated IOP. Incorrect: Knowledge of the pathophysiology of disease is key to appreciating its clinical presentation and rationale for treatment. Hardening of the lens (A) is an age-related process, while degeneration of the optic nerve (C) and hypotension in the anterior maxillary artery (D) are not causes of POAG.

17. Which of the following is most likely to be found on the funduscopic examination in a patient with untreated POAG? A. excessive cupping of the optic disk B. arteriovenous nicking C. papilledema D. flame-shaped hemorrhages

17. Correct: A. excessive cupping of the optic disk Excessive IOP results in an optic disk and cup that are "pushed in," creating a classic finding called glaucoma- tous cupping. Incorrect: Papilledema (C), in which the optic disk bulges and the margins are blurred, is seen when there is excessive pres- sure behind the eye, as in increased intracranial pressure (Fig. 5-6). Flame-shaped hemorrhage (D) and arteriove- nous nicking (B), which is an indentation of retinal veins by stiff retinal arteries, are most commonly seen in the presence of chronic hypertension.

18. Risk factors for POAG include all of the following except: A. African ancestry. B. type 2 diabetes mellitus. C. advanced age. D. blue eye color.

18. Correct: D. blue eye color. The presence of one or more risk factors for a given disease increases the likelihood of a condition being present. However, the absence of risk factors does not necessarily eliminate disease risk. Blue eye color is not a known risk factor for POAG. Incorrect: Risk factors for POAG include African ancestry (A), diabetes mellitus (B), family history of POAG, history of certain eye trauma or uveitis, and advancing age (C). Therefore, patients with one or more of these factors should be prioritized for screening for POAG.

19. Key diagnostic findings in POAG include which of the following? A. intraocular pressure greater than 25 mm Hg B. papilledema C. cup-to-disk ratio less than 0.3 D. sluggish pupillary response

19. Correct: A. intraocular pressure greater than 25 mm Hg All forms of glaucoma are caused by elevated IOP (greater than 25 mm Hg). As a result of the increased IOP, the optic disk and cup are "pushed in" and create a cup-to-disk ratio typically greater than 0.3. Incorrect: Papilledema (B), in which the optic disk bulges and the margins are blurred, is seen when there is excessive pressure behind the eye, as in increased intracranial pressure. Change in pupillary response (D) is not a key diagnostic finding for POAG and can be indicative of other ophthalmological conditions. In POAG, the optic disk and cup are "pushed in" and create a cup-to-disk ratio typically greater than 0.3 (C).

2. A 39-year-old man presents with a complaint of bilaterally itchy, red eyes with tearing that occurs inter- mittently throughout the year and is often accompanied by a rope-like eye discharge and clear nasal discharge. This is most consistent with conjunctival inflammation caused by: A. a bacterium. B. a virus. C. an allergen. D. an injury.

2. Correct: C. an allergen Bilateral, itchy eyes on an intermittent basis throughout the year points to allergic conjunctivitis. Incorrect: Bacterial (suppurative) conjunctivitis (A) is typically associated with unilateral involvement, while viral infection (B) is associated with a clear, watery discharge; neither of which would occur on an intermittent basis throughout the year. There is no mention of injury in the patient history to consider this diagnosis (D)

20. Who is at highest risk for the development of POAG? A. a 22-year-old woman of Asian ancestry with type 1 diabetes mellitus B. a 54-year-old man of European ancestry with bilateral cataracts C. a 68-year-old man of African ancestry with type 2 diabetes mellitus D. a 36-year-old woman of Native American ancestry with asthma

20. Correct: C. a 68-year-old man of African ancestry with type 2 diabetes mellitus Knowing risk factors for a given disease can help guide clinicians in making a differential diagnosis. Risk factors for POAG include African ancestry, diabetes mellitus, family history of POAG, history of certain eye trauma or uveitis, and advancing age. Therefore, among the choices given, the elderly man of African ancestry and type 2 diabetes is likely to be at greatest risk of POAG. Incorrect: Knowing risk factors for a given disease can help guide cli- nicians in making a differential diagnosis. Risk factors for POAG include African ancestry, diabetes mellitus, family history of POAG, history of certain eye trauma or uveitis, and advancing age. The 22-year-old (A) has one major risk factor for POAG (diabetes), bilateral cataracts are not a risk factor for POAG (B), and being of Native American ances- try or having asthma are not risk factors for POAG (D).

21. Treatment options for POAG include all of the following topical ocular agents excr A. beta-adrenergic antagonists. B. a2-agonists. C. prostaglandin analogues. D. mast cell stabilizers.

21. Correct: D. mast cell stabilizers. Treatment of POAG is aimed at reducing IOP to normal levels. Mast cell stabilizers halt the degradation or mast cells and the subsequent release of histamine and other inflammatory mediators. These agents are typically used to treat allergic conjunctivitis but have no role in the treatment of POAG. Incorrect: Treatment of POAG is aimed at reducing IP to nor- mal levels. Topical beta-adrenergic antagonists (A) and az-agonists (B) can be used to reduce the production of intraocular fluid. Topical prostaglandin analogues (C) increase the outflow of intraocular fluid.

22. A 44-year-old man presents with a chief complaint of a "white bump that is a little sore" on the left eyelid. Examination reveals a 2-mm nondraining pustule on the lateral border of the left eyelid margin. The remainder of the ocular examination is within normal limits. This description is most consistent with: A. a chalazion. B. a hordeolum. C. blepharitis. D. cellulitis.

22. Correct: B. a hordeolum. A pustule is a small, raised lesion filled with purulent fluid. This is most consistent with a hordeolum or stye, which is an acute, localized swelling of the eyelid (inter- nal or external) usually caused by infection. Incorrect: A chalazion (A) is an inflammatory condition char- acterized by a hard, nontender swelling of the upper or lower eyelid. Blepharitis (C) is an inflammatory condition associated with lid redness, crusting, and flaking. Cellulitis (D), when noted in the ocular region, is typically caused by an acute bacterial infection and is characterized by a warm, red, edematous area with sharply demarcated borders. This is a rare complication of hordeolum.

23. A 22-year-old woman presents with a "bump on her right eyelid that has been present for a number of weeks. She states the lesion is not painful and is not draining. Examination reveals a 2-mm firm, nontender, nondraining swelling on the lateral border of the right eyelid margin. The remainder of the ocular examination is within normal limits. This presentation is most consistent with: A. a chalazion. B. a hordeolum. C. blepharitis. D. cellulitis.

23. Correct: A. a chalazion. A chalazion is an inflammatory condition characterized by a hard, nontender swelling of the upper or lower eyelid Incorrect: A hordeolum (B) is acute, localized swelling of the eyelid (internal or external) usually caused by infection form- ing a pustule or abscess. Blepharitis (C) is an inflamma- tory condition associated with lid redness, crusting, and flaking When noted in the ocular region, cellulitis (D) is typically caused by an acute bacterial infection and is characterized by a warm, red, edematous area with sharply demarcated borders.

24. First-line treatment for uncomplicated hordeolum is: A. topical corticosteroid applied to the lid margin. B. warm compresses multiple times a day to the affected area. C. referral to ophthalmology for incision and drainage. D. oral antimicrobial therapy with S aureus coverage.

24. Correct: B. warm compresses multiple times a day to the affected area. Warm compresses are effective in treating hordeolum as this lesion usually opens spontaneously due to a thin pustular wall and then heals rapidly. Incorrect: Risk of secondary infection is low; therefore, antimi- crobial therapy (D) (topical/ocular or systemic) is not warranted. Incision and drainage (C) are rarely indi- cated. Topical corticosteroid (A) is not recommended for hordeolum and can increase the risk of secondary infection.

25. A potential complication of hordeolum is: A. conjunctivitis. B. cellulitis of the eyelid. C. corneal ulceration. D. sinusitis.

25. Correct: B. cellulitis of the eyelid. On rare occasions, hordeolum will progress to celluli- tis of the eyelid. If cellulitis occurs, ENT consultation is warranted. S aureus is the most common causative organism. Incorrect: Hordeolum or stye is localized and does not result in insult to the conjunctiva (A) or cornea (C). On rare occasions, hordeolum will progress to cellulitis of the eyelid but will not cause sinusitis (D).

26. Initial treatment for a chalazion is: A. topical fluoroquinolone. B. topical corticosteroid. C. warm compresses of the affected area. D. surgical excision.

26. Correct: C. warm compresses of the affected area. Initial treatment for a chalazion includes frequent warm soaks of the area. Incorrect: Since chalazion is an inflammatory condition and not infectious, antimicrobial therapy (A) is not warranted. If the condition fails to resolve with warm soaks, then refer- ral to an ophthalmologist for intralesional corticosteroid injection or excision (D) is recommended, particularly if the chalazion impairs lid closure or presses on the cornea. Topical corticosteroid (B) is not recommended and can increase the risk of secondary infection.

27. A 37-year-old man presents complaining of a 3-day history of a burning, itchy eyelid. Examination reveals a red, crusty eyelid. This is most consistent with: A. a chalazion. B. a hordeolum. C. blepharitis. D. cellulitis.

27. Correct: C. blepharitis. Blepharitis is an inflammatory condition associated with lid redness, crusting, and flaking and is often accom- panied by burning, itching, or a grainy sensation. The condition is caused by bacteria and inflammation due to congested oil glands at the base of each eyelash. Incorrect: A chalazion (A) is an inflammatory condition char- acterized by a hard, nontender swelling of the upper or lower eyelid. A hordeolum (B) is acute, localized swelling of the eyelid usually caused by infection forming a pustule or abscess. Cellulitis (D), typically caused by an acute bacterial infection, is characterized by a warm, red, edematous area with sharply demar- cated borders.

28. Treatment for a blepharitis can include all of the following except: A. topical antimicrobial. B. intralesional corticosteroid injection. C. warm compresses of the affected area. D. gentle cleansing of the area with diluted baby shampoo.

28. Correct: B. intralesional corticosteroid injection. Intralesional corticosteroid injection is not warranted for blepharitis. Incorrect: Treatment of blepharitis includes warm compresses (C) several times per day and gentle cleansing with diluted baby shampoo (D) to remove any crust and flakes in the area. This can be followed with application of a topical antimicrobial (A). Blepharitis is frequently a recurring condition that requires chronic treatment. Poorly con- trolled blepharitis can lead to lid deformity.

29. A 27-year-old woman presents with otitis externa . Likely causative pathogens include all of the follow ing except : A. Pseudomonas spp B. S epidermidis C. S aureus D. Moraxella catarrhalis

29. Correct: D. Moraxella catarrhalis Though M catarrhalis is a common pathogen for AOM, it is not a common pathogen for OE. Incorrect: It is important for health-care providers to recognize the most likely causative organisms in order to select appropriate initial empirical therapy. The most common pathogens for E include gram-positive bacteria (S epi- dermidis [B] [46%] and S aureus [C] [11%]) as well as gram-negative Pseudomonas species (A) (11%).

3. Common causative organisms of acute suppurative or bacterial conjunctivitis include all of the follow- ing except: A. S aureus. B. H influenzae. C. S pneumoniae. D. Pseudomonas aeruginosa.

3. Correct: D. Pseudomonas aeruginosa. In outpatient infections, P aeruginosa is an uncommon cause of infection inciding bacterial conjunctivitis. Incorrect: Bacterial or suppurative conjunctivitis is caused by select gram-positive (S pneumoniae [C] or S aureus (A]) or gram-negative (H influenzae [B]) organisms. Knowledge of the most likely causative organisms in infectious dis- eases is critical in selecting appropriate initial empirical antimicrobial therapy.

30. Which of the following individuals is least likely to develop OE? A. a 22-year-old who travels frequently by airplane B. a 32-year-old who frequently cleans the ear canals with a hair pin C. a 16-year-old who is on the high school varsity swim team D. a 36-year-old man with recurrent cerumen impaction

30. Correct: A. a 22-year-old who travels frequently by airplane Risk factors for OE include a history of recent ear canal trauma, vigorous use of a cotton swab or other device to clean the ear canal, conditions in which moisture is frequently held in the ear canal (such as with cerumen impaction), and frequent swimming. Frequent air travel is not a risk factor for OE but can be a risk factor for AOM. Incorrect: Risk factors for OE include a history of recent ear canal trauma, vigorous use of a cotton swab or other device to clean the ear canal (B), conditions in which moisture is frequently held in the ear canal (such as with cerumen impaction) (D), and frequent swimming (C).

31. Appropriate antimicrobial therapy for uncomplicated O in a 45-year-old with hypertension and dyslipidemia includes a course of: A. an oral macrolide. B. a parenteral cephalosporin. C. fluoroquinolone otic drops. D. aminoglycoside otic drops.

31. Correct: C. fluoroquinolone otic drops. Antimicrobial otic drops are the preferred treatment choice for OE as these provide highly effective localized therapy. Fluoroquinolones are the preferred first-line agent. Incorrect: Systemic antimicrobial therapy (A, B) can be considered in OE if the ear canal is sufficiently swollen to prevent proper distribution of the otic drops, or in complicated cases such as malignant/necrotizing OE. Aminoglyco- side otic drops (D) are not the preferred first-line agent due to spectrum of activity and should not be used in the presence of a ruptured tympanic membrane.

32. Physical examination findings in OE in a 38-year-old include: A. tympanic membrane immobility. B. increased ear pain with tragus pull. C. tympanic membrane erythema. D. tympanic membrane bullae.

32. Correct: B. increased ear pain with tragus pull. The clinical presentation of E includes the hallmark findings of pain on tragus palpation or with the applica- tion of traction to the pinna. Incorrect: Tympanic membrane immobility (A), erythema (C), and bullae (D) are all consistent with AOM, and recognizing these differences is an important aspect of making the differential diagnosis.

33. An important risk factor for malignant/necrotizing OE includes: A. the presence of an immunocompromised condition. B. age younger than 21 years. C. a history of a recent URI. D. a complicated course of otitis media with effusion (OME).

33. Correct: A. the presence of an immunocompromised condition. Those at risk for malignant or necrotizing OE include patients who are immunocompromised or who have received radiotherapy to the skull base. Incorrect: Malignant/necrotizing OE can occur at any age though it is more common in older adults (B). A history of URI (C) or a complicated course of OME (D) are risk factors for AOM.

34. Clinical presentation of malignant/necrotizing E usually includes: A. foul-smelling discharge from the ear canal. B. pain disproportionate to the clinical presentation. C. increase in discomfort with manipulation of pinna. D. marked ear canal edema.

34. Correct: B. pain disproportionate to the clinical presentation. The clinical presentation of malignant or necrotizing OE includes the usual features of OE with the addition of pain disproportionate to clinical findings. Incorrect: The usual features of OE include purulent or serous dis- charge (A), pain on application of traction to the pinna (C), and marked ear canal edema (D). The presence of these findings would not necessarily indicate malignant or necrotizing OE.

35. During a clinical visit with an NP where malignant OE is being considered, the next best steps in care include all of the following except: A. prompt otolaryngology consultation. B. oral or parenteral antimicrobial therapy. C. imaging to determine degree of bony erosion or other complications. D. use of analgesic otic drops.

35. Correct: D. use of analgesic otic drops. While management of pain through the use of analgesic otic drops is an important part of malignant OE therapy, choosing this option does not set the priorities of care, including ENT consult, appropriate systemic antimi- crobial therapy, and imaging to detect complications. In addition, topical analgesia will likely be inadequate to control the severe pain usually noted with this condition. Incorrect: Setting the priorities of care for the person with malig- nant E would include performing imaging studies (C), initiating systemic antimicrobial therapy (B), and mak- ing prompt referral to a specialist (A).

36 to 39. Indicate (Yes or No) which of the following viruses are implicated in causing AOM. 36. RSV 37. herpes simplex virus 2 38. influenza virus 39. rhinovirus

36 to 39. Yes or No 36. Correct: Yes 37. Correct: No 38. Correct: Yes 39. Correct: Yes Understanding the likely causative pathogens of infection is important in safe practice and guiding management decisions. Common viral pathogens in AM include RSV, influenza virus, and rhinovirus. Herpes simplex virus 2 is not a common cause of AOM. Viral AOM typically presents with milder symptoms compared to bacterial infections and usually resolves within 7 to 10 days with supportive care alone (antimicrobials not needed).

4. Keeping in mind patterns of bacterial resistance, currently recommended treatment options in suppu- rative or bacterial conjunctivitis include an ophthalmological preparation containing: A. tobramycin. B. levofloxacin. C. gentamicin. D. azithromycin.

4. Correct: B. levofloracin. Ocular solutions of flucroquinolones (e.g., levofloxacin, moxifloxacin) are considered first-line therapy as they remain highly effective against the most common caus- ative organisms. Incorrect: Empirical treatment of suppurative conjunctivitis should provide coverage against common gram-positive (S pneu- moniae or S aureus) and gram-negative (H influenzae) organisms. Macrolides (e.g., azithromycin) (D), tobramy- cin (A), or gentamicin (C) are not preferred due to high rates of resistance exhibited by S pneumoniae.

40 to 43. Indicate (Yes or No) which of the following bacteria are commonly implicated in causing AOM. 40. S pneumoniae 41. H influenzae 42. Escherichia coli 43. M. catarrhalis

40 to 43. Yes or No 40. Correct: Yes 41. Correct: Yes 42. Correct: No 43. Correct: Yes Common bacterial pathogens that cause AM include S pneumonia (gram-positive pathogen) and the gram- negative pathogens H influenza and M catarrhalis. These are also the leading pathogens of ABRS. E coli, a gram-negative bacterium, is not typically implicated in AOM.

44. Risk factors for AOM include all of the tollowing except: A. URI. B. untreated allergic rhinitis. C. tobacco use. D. aggressive ear canal hygiene.

44. Correct: D. aggressive ear canal hygiene. Eustachian tube dysfunction contributes to the devel- opment of AOM. As such, upper respiratory infection, allergic rhinitis, and tobacco use are risk factors for AOM. Aggressive ear canal hygiene can increase the risk of OE but not AOM. Incorrect: Eustachian tube dysfunction contributes to the devel- opment of AOM. As such, URI (A), allergic rhinitis (B), and tobacco use (C) are risk factors for AOM.

45. An 18-year-old high school senior presents with a 4-day history of left-sided otalgia and fullness, despite use of oral decongestants and ibuprofen. When considering a diagnosis of AOM, expected findings include: A. prominent tympanic membrane bony landmarks. B. tympanic membrane immobility. C. itchiness and crackling in the affected ear. D. submental lymphadenopathy on the affected side.

45. Correct: B. tympanic membrane immobility. In AOM, the tympanic membrane may be retracted or bulging and is typically reddened with loss of translu- cency and immobility on insuflation. Incorrect: Prominent tympanic membrane bony landmarks (A) are usually not visual in AOM as the middle ear is filled with purulent discharge. Crackling and itchiness in the affected ear (C) are often reported following AOM, during OME that is usually noted for a number of weeks after acute infection. Lymphadenopathy of the anterior cervical nodes on the ipsilateral side are often noted in AOM, but the submental node (D) is not part of the middle ear's drain- age tract and, thus, will not be involved in AOM findings.

46. A 35-year-old man has a 3-day history of left ear pain that began after 1 week of URI symptoms. On physical examination, you find that he has AOM. He took an oral antimicrobial for the treatment of a skin and soft tissue infection 2 weeks ago. The most appropriate oral antimicrobial option for this patient is: A. standard-dose azithromycin. B. high-dose cephalexin. 110 1890S C. high-dose amoxicillin. D. standard-dose TMP-SMX.

46. Correct: C. high-dose amoxicillin. This patient is at risk of infection with drug-resistant S pneumonia due to recent use of an antimicrobial. As such, high-dose amoxicillin will be an appropriate choice Incorrect: Azithromycin (A) is not recommended due to high rates of resistance by S pneumonia, and high-dose amoxicil- lin provides better coverage compared to cephalexin (B) (first-generation cephalosporin) and TMP-SMX (D).

47. A reasonable treatment option for AOM in an adult who reports a penicillin allergy, stating, "I just had a fine pink rash on my trunk, is: A. cefpodoxime. B. erythromycin. C. cephalexin. D. TMP-SMX.

47. Correct: A. cefpodoxime. With milder forms of penicillin allergy, a second- or third-generation cephalosporin (e.g., cefpodoxime) can be considered due to a lower risk of cross-reactivity compared to first-generation agents (e.g., cephalexin) and robust coverage. Incorrect: There is higher risk of cross-reactivity between penicil- lins and first-generation cephalosporins (C) compared to second-generation cephalosporins. Erythromycin (B) offers poor coverage against S pneumonia, a leading cause of AOM. Cefpodoxime also provides more robust S pneumonia coverage compared to TMP-SMX (D).

48. Drug-resistant S pneumonia is least likely to exhibit resistance to which of the following antimicrobial classes? A. advanced macrolides such as azithromycin B. tetracycline forms such as doxycycline C. first-generation cephalosporins such as cephalexin D. respiratory fluoroquinolones such as levofloxacin

48. Correct: D. respiratory fluoroquinolones such as levofloxacin Among the answer choices, the respiratory fluoroquino- lones provide the best coverage against S pneumoniae with relatively low rates of resistance. These agents are recommended for the treatment of infection when DRSP is suspected. Incorrect: S pneumonia exhibits higher rates of resistance to the macrolides (A), doxycycline (B), and first-generation cephalosporins (C) compared to the respiratory fluoroquinolones.

49. Which of the following is absent in OME? A. fluid in the middle ear B. sensation of middle ear fullness C. fever D. itch

49. Correct: C. fever Since OME marks the resolution of acute infection, fever is not an anticipated finding. Incorrect: With resolution of AOM, tympanic membrane mobil- ity returns to normal within 1 to 2 weeks, but fluid in the middle ear (A) remains for several weeks. This can result in a sensation of ear fullness (B) and itching (D) or crackling in the ear.

5. Treatment options in acute and recurrent allergic conjunctivitis include all of the following except: A. cromolyn ophthalmic drops. B. oral antihistamines. C. ophthalmological antihistamines. D. corticosteroid ophthalmic drops.

5. Correct: D. corticostercid ophthalmic drops. The use of ophthalmic corticosteroid solution increases the risk of eye infection, particularly among patients wearing contact lenses. Other adverse effects with the use of corticosteroid eye drops include increased risk of cat- aracts and a rise in intraocular pressure that can lead to optic disk and visual field damage similar to open-angle glaucoma. Incorrect: Treatment of allergic disorders includes the use of medi- cations to reduce production of inflammatory mediators, such as the mast cell stabilizer cromolyn (A), and medi- cations that block the action of inflammatory mediators, such as antihistamines (B, C).

50. Treatment of OME usually includes: A. advising that this condition self-resolves. B. antimicrobial therapy. C. an antihistamine. D. a mucolytic.

50. Correct: A. advising that this condition self-resolves. With resolution of AOM, the tympanic membrane mobility returns to normal within 1 to 2 weeks, but fluid in the middle ear remains for several weeks. Thus, time is the best intervention for the resolution of OME. Incorrect: Repeating a course of antimicrobial therapy (B) or the use of antihistamines (C) or a mucolytic agent (D) will not be effective in hastening symptom resolution and, thus, is not recommended.

51 to 53. Indicate whether each case represents Ménière's disease (D) or Ménières syndrome (S): 51. A 44-year-old woman with a history of head trauma after a motor vehicle accident 52. A 55-year-old woman who has osteoarthritis of the knees 53. A 27-year-old woman with rheumatoid arthritis who remains significantly symptomatic despite optimized therapy

51 to 53. Matching Questions 51. Correct: Syndrome (S) 52. Correct: Syndrome (S) 53. Correct: Syndrome (S) Ménière's disease is idiopathic in origin without a clearly identifiable underlying cause. Ménière's syndrome pre- sents with identical signs as Ménière's disease but with an identified underlying cause. Ménière's syndrome is usually secondary to various processes that interfere with normal production or resorption of endolymph, and can include endocrine dysfunction, trauma, electrolyte imbalance, autoimmune dysfunction, medications, infection, or hyperlipidemia. For each of the examples, an underlying cause is present that can contribute to the condition (i.e., trauma, osteoarthritis, and rheumatoid arthritis).

54. Which of the following is true concerning Ménière's disease? A. Neuroimaging helps locate the offending cochlear lesion. B. Associated high-frequency hearing loss is common. C. This is largely a diagnosis of exclusion. D. Tinnitus is rarely reported.

54. Correct: C. This is largely a diagnosis of exclusion. Ménières disease is idiopathic in origin without a clearly identifiable underlying cause, thus, it is largely a diagno- sis of exclusion. The tetrad of symptoms includes fluctu- ating hearing loss, episodic vertigo, tinnitus, and aural fullness. Incorrect: Neuroimaging (A) is not warranted, and hearing loss (B) is usually in the low-frequency range. Tinnitus (D), or ringing in the ears, is usually present and is part of the four components of the disease.

55 to 59. Indicate (Yes or No) whether each of the following clinical findings would be present in a patient with Ménière's disease. 55. The Weber tuning test lateralizes to the affected ear. 56. The Rinne test reveals that air exceeds bone conduction. 57. Pneumatic otoscopy in the affected ear can elicit symptoms or cause nystagmus. 58. The Romberg test is negative. 59. The Fukuda marching step test is positive.

55. Correct: No The Weber tuning test evaluates the nature of hearing loss. A vibrating tuning fork is placed in the middle of the patient's forehead, and the patient is asked to identify in which ear the sound is louder. A normal Weber test has the patient reporting the sound is heard equally on both sides. During Ménière's disease, the Weber tuning test usually lateralizes to the unaffected ear.

56. Indicate (Yes or No) whether each of the following clinical findings would be present in a patient with Ménière's disease. 56. The Rinne test reveals that air exceeds bone conduction.

56. Correct: Yes The Rinne test is performed by placing a vibrating tun- ing fork against the patient's mastoid bone and asking the patient to indicate when the sound is no longer audible (bone conduction). Once the patient reports the sound is no longer heard, then the fork is quickly moved 1 to 2 cm from the auditory canal and the patient is again asked if he or she can hear it (air conduction). A normal finding shows that air conduction exceeds bone conduction, which is what is observed with Ménière's disease.

57. Indicate (Yes or No) whether each of the following clinical findings would be present in a patient with Ménière's disease. 57. Pneumatic otoscopy in the affected ear can elicit symptoms or cause nystagmus.

57. Correct: Yes During pneumatic otoscopy, an otoscope is fitted snugly on the patient's external auditory canal to produce an airtight chamber. Gently squeezing a rubber bulb in rapid succession allows observation of the eardrum mobility. Performing this on the affected ear of a patient with Ménière's disease can elicit symptoms and/or cause nys- tagmus (repetitive, uncontrolled movements of the eyes).

58. Indicate (Yes or No) whether each of the following clinical findings would be present in a patient with Ménière's disease. 58. The Romberg test is negative.

58. Correct: No The Romberg test evaluates a patient's ability to main- tain balance by having the patient stand erect with feet together and eyes closed and observing movement for a minute. A positive sign is observed with swaying, irregular swaying, or toppling over. This test is usually positive in patients with Ménière's disease.

59. Indicate (Yes or No) whether each of the following clinical findings would be present in a patient with Ménière's disease. 59. The Fukuda marching step test is positive.

59. Correct: Yes The Fukuda marching step test has the patient perform a march step with the eyes closed. Patients with Ménière's disease generally have a positive result where there is directional drift, usually toward the affected ear.

6. The most common virological cause of conjunctivitis is: A. coronavirus. B. adenovirus. C. rhinovirus. D. human papillomavirus.

6. Correct: B. adenovirus. Adenovirus is the most common virological cause of conjunctivitis. Incorrect: Coronavirus (A), rhinovirus (C), and human papilloma- virus (D) are not typical causes of conjunctivitis. In viral conjunctivitis, the patient often exhibits signs and symp- toms of a viral upper respiratory tract infection. Trans- mission of virus to the eye can occur through accidental inoculation of viral particles from the patient's hands or by contact with infected upper respiratory droplets.

60. When evaluating a patient with Ménière's disease, the procedure of observing for nystagmus while moving the patient from sitting to supine with the head angled 45° to one side and then the other is called the: A. Romberg test. B. Dix-Hallpike test. C. Rinne test. D. Fukuda test.

60. Correct: B. Dix-Hallpike test. The Dix-Hallpike test evaluates the ability to elicit nystagmus while moving the patient from sitting to supine with the head angled 45° to one side and then the other. Incorrect: The Romberg test (A) evaluates a patient's ability to maintain balance by having the patient stand erect with feet together and eyes closed and observing movement for a minute. The Fukuda marching step test (D) has the patient perform a march step with the eyes closed. The Rinne test (C) uses a tuning fork to determine if air con- ductance exceeds bone conductance.

61. Prevention and prophylaxis in Ménières disease include all of the following except: A. avoiding ototoxic drugs. B. protecting the ears from loud noise. C. limiting sodium intake. D. restricting fluid intake.

61. Correct: D. restricting fluid intake. Measures to decrease fluid pressure load in the inner ear can help prevent symptoms. However, these measures do not include fluid restriction. Incorrect: Risk factors for Ménière's disease include the use of ototoxic drugs (A), long-term high-dose salicylate use, certain cancer chemotherapeutics, and exposure to loud noise (B). Triggers of attacks can include certain foods and drinks, mental and physical stress, and variations in the menstrual cycle. Measures to decrease fluid pressure load in the inner ear can also help prevent symptoms, such as the use of thiazide diuretics or limiting sodium intake (C).

62 to 65. Match the following to the lettered descriptions: 62. Dizziness 63. Vertigo 64. Nystagmus 65. Tinnitus A. perception that the person or the environment is mov B. subjective perception of altered equilibrium C. rhythmic oscillations of the eyes D. perception of abnormal hearing or head noises

62 to 65. Matching Questions 62. Correct: B. subjective perception of altered equilibrium 63. Correct: A. perception that the person or the environ- ment is moving 64. Correct: C. rhythmic oscillations of the eyes 65. Correct: D. perception of abnormal hearing or head noises Dizziness can include the perception of an altered equilibrium that can include unsteadiness, lighthead- edness, or a feeling of impending fainting (B). Possible causes of dizziness can include hypotension or postural hypotension as well as hyperventilation and anxiety. Vertigo is a sense of spinning or whirling when the person is not actually moving (A) and is usually caused by a disorder of the vestibular system (structures of the inner ear, vestibular nerve, brainstem, and cerebellum). Nystagmus is characterized by rhythmic, uncontrolled oscillations of the eye (C), often found in persons with Ménière's disease. Movements can be side to side, up and down, or circular in motion and can affect vision, depth perception, balance, and coordination. Tinnitus is the perception of noise or ringing in the ears (D). Tinnitus is typically a symptom of an underlying condition, such as age-related hearing loss or injury to the ear.

66. Who is most likely to present with anterior epistaxis? A. a 72-year-old woman, blood pressure of 178/102, who ran out of blood pressure medication 3 days ago B. a 32-year-old woman with Von Willebrand's disease C. a 42-year-old man who works outdoors during the months of December to March in the northeast- ern United States D. a 30-year-old with nasal polyps

66. Correct: C. a 42-year-old man who works outdoors during the months of December to March in the northeastern United States Anterior epistaxis is most commonly the result of local- ized nasal mucosa dryness or trauma. Nosebleeds tend to increase in the winter months due to lower humidity. Incorrect: Hypertension (A) and coagulation disorders (B) are uncommon reasons for nosebleeds in the outpatient setting, while the presence of nasal polyps is not a risk factor for epistaxis (D).

67. First-line intervention for anterior epistaxis includes: A. nasal packing. B. application of topical thrombin or vasoconstrictor. C. firm pressure in an "entire nose pinched" position for a minimum of 10 minutes. D. chemical cauterization.

67. Correct: C. firm pressure in an "entire nose pinched" position for a minimum of 10 minutes. Most episodes of anterior epistaxis can be easily managed with simple pressure as first-line therapy, either with firm pressure to the area superior to the nasal alar cartilage or an "entire nose pinched closed" approach for at least 10 minutes; often up to 30 minutes of pressure is needed. Incorrect: If simple pressure is ineffective, second-line approaches can include nasal packing (A) and cautery (D). Topical antifibrinolytic agents can be used when other methods are unsuccessful (B).

68. In an older adult with refractory epistaxis resistant to standard therapies, an underlying diagnosis occa- sionally found is: A. poorly controlled type 2 diabetes mellitus. B. accelerated hypertension. C. acute bacterial sinusitis. D. thrombocytopenia.

68. Correct: B. accelerated hypertension. Though hypertension is not a common reason for acute anterior epistaxis, poorly controlled hypertension is among the more common reasons for epistaxis that is refractory to first-line therapies. Incorrect: Diabetes mellitus (A), acute bacterial sinusitis (C), and thrombocytopenia (D) are not commonly associated with protracted nasal bleeding.

69. A 55-year-old man with atrial fibrillation who is taking multiple medications including DOAC pre- sents with anterior epistaxis. He fails to respond to first-line therapy. Additional therapeutic approaches include all of the following except: A. initiating systemic prothrombotic therapy. B. nasal packing. C. nasal cautery. D. topical antifibrinolytic agents.

69. Correct: A. initiating systemic prothrombotic therapy. The use of systemic prothrombotic therapy is not recom- mended for recurrent epistaxis. Incorrect: Epistaxis is nearly always treated with localized therapy, including pressure, nasal packing (B), cautery (C), and/ or topical antifibrinolytic agents (D). For refractory cases, arterial embolization or surgical therapy can be considered.

7. Treatment of viral conjunctivitis can include: A. moxifloxacin ophthalmic drops. B. polymyxin B ophthalmic drops. C. oral acyclovir. D. cool artificial tear solution.

7. Correct: D. cool artificial tear solution. Treatment should focus on relieving irritative symptoms, such as with the use of cold artificial tear solution. Incorrect: Viral conjunctivitis is most often self-limiting and will resolve without the use of antibiotics over days to weeks. The use of antibacterials, such as moxifloxacin (A) or polymyxin (B), or antivirals such as acyclovir (C) are not warranted. The development of a secondary bacterial ophthalmological infection after viral con- junctivitis is rare.

70. A 45-year-old man who works as a landscaper has seasonal AR. He asks you when the pollen count likely to be the lowest. You respond: A. "Early in the morning." B. "During breezy times of the day? C. "After a rain shower." D. "When the sky is overcast."

70. Correct: C. "After a rain shower.?" Pollens are major triggers in seasonal AR and allergic conjunctivitis and are likely at the lowest levels after a rain shower. Incorrect: Pollen counts are generally the highest early in the morning (A) as they are released shortly after dawn. Pollen travels best on warm, dry, breezy days (B) and lowest during chilly, wet periods. Overcast skies (D) have no effect on pollen counts in the absence of precipitation.

71 to 74. Match each allergen with the appropriate characteristic. (An answer can be used more than once.) 71. Pollens 72. Pet dander 73. Dust mites 74. Mold spores en forinos agleri (InovoTA) A. most common perennial allergen B. most common seasonal allergen C. common indoor allergen

71. Correct: B. most common seasonal allergen 72. Correct: C. common indoor allergen 73. Correct: A. most common perennial allergen 74. Correct: C. common indoor allergen Pollens are major triggers in seasonal AR and allergic conjunctivitis and achieve highest levels early in the morning. Dust mites are the most common trigger for perennial allergy symptoms. Pet dander, cockroaches, and mold spores are other indoor allergens found to cause nasal and ocular allergy symptoms. Some outdoor mold spores can also cause allergy symptoms.

75. You prescribe a nasal corticosteroid for a 28-year-old woman with perennial AR. When advising her about the onset of symptom relief, the NP states that she will notice improvement: A. immediately with the first spray. B. in 1 to 2 days. C. in a few days to a week. D. in 2 or more weeks.

75. Correct: C. in a few days to a week. Unlike a topical nasal decongestant that can provide an immediate effect, the use of a nasal corticosteroid can take a few days to a week before symptom relief is achieved. Incorrect: When prescribing these agents, patient education is needed to ensure consistent use to achieve the desired effect. Patients initiating nasal corticosteroid therapy should be advised that effects will not be immediate (A) or even within 1 to 2 days (B). If no effects are observed after 1 to 2 weeks (D), treatment approaches should be reevaluated.

76. Which of the following medications is most appropriate for AR therapy in an acutely symptomatic 24-year-old machine operator? A. nasal cromolyn B. oral diphenhydramine C. flunisolide nasal spray resilidsla D. oral loratadine

76. Correct: D. oral loratadine Due to this patient's symptoms and occupation, he requires a rapid reliever that is nonsedating. Loratadine, a second-generation antihistamine, is recommended as first-line therapy due to its effectiveness in providing rapid relief and nonsedating quality. Incorrect: Nasal cromolyn (A) is not recommended as first-line treatment, and diphenhydramine (B), a first-generation antihistamine, is sedating. Nasal corticosteroids, such as flunisolide (C), can be used as controller medications but will not provide immediate relief.

77. Antihistamines work primarily through: A. vasoconstriction. B. action on the histamine-1 (H,) receptor sites. C. inflammatory mediation. D. peripheral vasodilation.

77. Correct: B. action on the histamine-1 (H,) receptor sites. Antihistamines work by blocking the H, receptor sites and preventing the action of histamines, a potent inflammatory mediator. These agents can be used to treat acute allergy symptoms. Second-generation products such as lorata- dine (Claritin®) can be given as first-line treatment. First- generation products, such as diphenhydramine, should be avoided due to their sedative and anticholinergic effects. Incorrect: Antihistamines work by blocking the H, receptor sites and prevent the action of histamines. This action pre- vents inflammatory mediation (C) and has no clinically significant impact on vasoconstriction (A) or peripheral vasodilation (D).

78. Decongestants work primarily through: A. vasoconstriction. B. action on the H, receptor sites. C. inflammatory mediation. D. peripheral vasodilation.

78. Correct: A. vasoconstriction. Decongestants act as vasoconstrictors, opening edem- atous nasal passages and relieving congestion. These agents only provide relief of nasal congestion. Topical decongestants should be limited to use for less than 5 days, and use should be avoided in preschoolers. Regu- lar use of oral decongestants should be avoided due to potential adverse effects, including tachycardia, hyper- tension, dizziness, and sedation. Incorrect: Decongestants act as vasoconstrictors rather than vaso- dilators (D) and have no impact on H, receptor sites (B) or inflammatory mediation (C).

79. Which of the following medications affords the best relief of acute nasal itch? A. anticholinergic nasal spray B. oral decongestant C. corticosteroid nasal spray D. oral antihistamine

79. Correct: D. oral antihistamine An oral second-generation antihistamine can be used as first-line therapy to treat acute symptoms of AR, includ- ing nasal itch. Incorrect: The use of an anticholinergic nasal spray (A) should be limited to the relief of refractory rhinorrhea. Oral decongestants (B) should be avoided in AR, while cor- ticosteroid nasal spray (C) can be used as a controller agent, though its effect may not be achieved until consis- tent use for several days to a week.

8. All of the following are components of the classic ophthalmological emergency except: A. eye pain. B. nausea and vomiting. C. red eye. D. new-onset change in visual acuity.

8. Correct: B. nausea and vomiting. Nausea, vomiting, and even headache can occur in select emergency conditions, such as angle-closure glaucoma, but are not considered the classic symptoms for an oph- thalmological emergency. Incorrect: Severe eye pain (A), red eye (C), and new-onset change in visual acuity (D) are the major classic signs/symp- toms of ophthalmological emergency. In more limiting eye problems, such as viral or bacterial conjunctivitis, there are no visual changes (once eye discharge is wiped away), and the eye can be irritated but not pain- ful and can have a slightly red "pink eye" appearance.

80. Which of the following medications affords the best relief of acute nasal congestion? A. anticholinergic nasal spray B. oral leukotriene modifier C. nasal decongestant D. oral antihistamine

80. Correct: C. nasal decongestant A nasal decongestant can be used for rescue therapy and symptom relief of nasal congestion. However, these agents should not be used for prolonged periods of time (less than 5 days). Incorrect: Leukotriene modifiers (B), such as montelukast, can be considered for treatment of AR. However, these agents are generally not preferred as they tend to be more expensive with similar or less effectiveness compared with other products. The use of anticholinergic nasal spray (A) should be limited to the relief of refractory rhinorrhea. An oral first-generation antihistamine (D) is not recommended as treatment for AR because of sedation effects, though a nasal antihistamine has first-line benefits for seasonal AR associated with nasal congestion.

81. Which of the following medications is preferred to treat acute rhinorrhea associated with AR? A. anticholinergic nasal spray B. oral antihistamine C. corticosteroid nasal spray D. oral leukotriene modifier

81. Correct: B. oral antihistamine The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) recommends the use of an oral antihistamine to treat rhinorrhea associated with AR. Incorrect: Leukotriene modifiers (D), such as montelukast, can be considered for treatment of AR. However, these agents are generally not preferred as they tend to be more expensive with similar or less effectiveness compared with other products. The use of anticholinergic nasal spray (A) should be limited to the relief of refractory rhinorrhea. Corticosteroid nasal spray (C) can be used as controller therapy, though relief can take several days of consistent use.

82. Ipratropium bromide (Atrovent®) helps control nasal secretions through: A. antihistaminic action. B. anticholinergic effect. C. vasodilation. D. vasoconstriction.

82. Correct: B. anticholinergic effect. Ipratropium bromide is an anticholinergic that can be useful as part of rescue therapy for patients with both- ersome nasal discharge. These agents work by inhibiting the parasympathetic transmission to submucosal glands. Incorrect: Ipratropium bromide works as an anticholinergic with no or minimal vasodilation (C), vasoconstriction (D), or antihistaminic (A) action.

83. Oral decongestant use should be discouraged in patients with: A. AR. B. migraine headache. C. cardiovascular disease. D. chronic bronchitis.

83. Correct: C. cardiovascular disease. Oral decongestants have the potential for vasoconstric- tion and increased blood pressure and heart rate. These agents should be avoided in patients with hypertension and cardiovascular disease. As decongestants are a common ingredient in many OTC medications, patient education is important to raise awareness of the possible risks when considering these medications. Incorrect: In general, regular use of oral decongestants should be avoided due to potential adverse effects, including tachy- cardia, hypertension, dizziness, and sedation. There are no warnings or precautions with their use associated with AR (A), migraine headache (B), or chronic bron- chitis (D).

84. Cromolyn's mechanism of action is as: A. an anti-immunoglobulin E antibody. B. a vasoconstrictor. C. a mast cell stabilizer. D. a leukotriene modifier.

84. Correct: C. a mast cell stabilizer. Cromolyn is a mast cell stabilizer used as a nasal spray to treat AR. Mast cells are involved in the inflammatory process through the release of mediators, including his- tamines. Cromolyn stabilizes the mast cells and prevents the release of inflammatory mediators and can be used as controller therapy for AR. Incorrect: Cromolyn is a mast cell stabilizer and thus does not work as an anti-immunoglobulin E antibody (A), vaso- constrictor (B), or leukotriene modifier (D).

85. In the treatment of AR, a leukotriene modifier should be used as: A. an agent to relieve nasal itch. B. an inflammatory inhibitor. C. a rescue drug. D. an intervention in acute inflammation.

85. Correct: B. an inflammatory inhibitor. Leukotrienes are inflammatory chemicals that are released upon exposure to an allergen. Upon release, these chemicals cause airway constriction and mucus production. Leukotriene modifiers work by blocking the action of leukotriene that can cause nasal conges- tion and rhinorrhea. These agents are typically used as controller therapy in AR by blocking the inflammatory process. Incorrect: Leukotriene modifiers are typically used as controller therapy in AR and thus would not be used as a rescue drug (C) or to treat acute inflammation (D) or acute nasal itch (A).

86. Allergen subcutaneous or oral immunotherapy should be considered in all of the following except: A. when allergy symptoms are controlled with environmental management. B. when allergy symptoms persist despite optimal use of appropriate medications. C. when there is a desire to reduce the use of allergy medications. D. to prevent progression or development of asthma.

86. Correct: A. when allergy symptoms are controlled with environmental management. Allergen immunotherapy can be helpful in managing persistent AR and conjunctivitis and should be con- sidered in patients with multiorgan symptoms of IgE- mediated allergic sensitization (e.g., asthma). Allergen immunotherapy would not be appropriate for patients whose allergy symptoms can be controlled with simple environmental management. Incorrect: Allergen immunotherapy can be helpful in managing persistent AR and conjunctivitis and should be con- sidered in patients with multiorgan symptoms of IgE- mediated allergic sensitization (e.g., asthma) (D). This method can be highly effective in select patients and should be considered when other treatments fail (B) or if the patient desires to reduce the use of allergy medica- tions (C).

87. Which of the following is most appropriate for the treatment of moderate-to-severe AR when symp toms are not controlled with intranasal antihistamine? A. initiation of daily oral corticosteroids B. single dose of a long-acting parenteral or intramuscular corticosteroids C. initiation of daily intranasal corticosteroids D. immediate initiation of allergy immunotherapy

87. Correct: A. initaon or day oral corticosteroias. A short course of oral corticosteroids is recommended in moderate-to-severe AR and conjunctivitis when symptoms are not controlled with current therapy. Incorrect: Daily intranasal corticosteroids (C) as well as mast cell stabilizers (D) can be used as controller therapy once symptoms are managed. Parenteral or intramus- cular corticosteroids (B) are not preferred over oral corticosteroids, and repeated doses are needed for full effect.

88. Which of the following medications is not a penicillin form? A. amoxicillin B. ampicillin C. dicloxacillin D. imipenem

88. Correct: D. imipenem Safe practice involves recognizing the properties and characteristics of drug classes and knowing to which class each medication belongs. Imipenem belongs in the carbapenem drug class, which typically has a "penem" suffix. Incorrect: The prefix or suffix of generic drug names can be helpful in recognizing the drug class. Agents in the penicillin drug class typically have the "cillin" suffix and include ampicillin (B), amoxicillin (A), and diclox- acillin(C).

89. A cutaneous reaction nearly always occurs with the use of oral amoxicillin in the presence of infection with: A. human herpes virus type 1. B. human papillomavirus type 11. 1 nommos rom sri C. adenovirus type 20. D. Epstein-Barr virus (EBV).

89. Correct: D. Epstein-Barr virus (EBV). EBV is the leading causative organism in mononucle- osis. When certain penicillin forms, such as ampicillin and amoxicillin, are administered to a person with EBV infection, a cutaneous reaction (rash) nearly always occurs. Though the mechanism is not entirely known, the rash is thought to be the result of altered immune status during the infection and not indicative of penicil- lin allergy. Incorrect: Other than the reaction between certain penicillins and EBV infection, there are no other known reactions between antibiotic use and other select pathogens, including infections caused by human herpes virus type 1 (A), human papilloma virus type 11 (B), and adenovi- rus type 20 (C).

9. Ms. Levine is a 48-year-old woman with hypertension and depression, taking an oral angiotensin- converting enzyme (ACE) inhibitor and sertraline, presenting with a sudden left-sided headache that is most painful in and behind her left eye. Her vision is blurred, and the left pupil is slightly dilated and poorly reactive. The left conjunctiva is markedly injected, with ciliary flush, and the eyeball is firm. Vision screen with the Snellen chart is 20/30 OD and 20/90 OS. The most likely diagnosis is: A. unilateral heretic conjunctivitis. B. open-angle glaucoma (OAG). C. angle-closure glaucoma. D. anterior uveitis.

9. Correct: C. angle-closure glaucoma. This patient has multiple risk factors for angle-closure glaucoma (i.e., female gender, systamric anticholinergic use), plus the classic presentation for this diagnosis including unilateral headache, visuai changes, firm eye- ball, and poorly reactive pupil. Incorrect: OAG (B) is associated with painless, slowly progres- sive peripheral vision loss. Anterior uveitis (D) is characterized by a constricted, irregularly shaped pupil and no change in IP. Herpetic conjunctivitis (A) is characterized by itching and redness of the eye, eye pain and inflammation of the eyelids, and continuous watery discharge.

90. In a person with a well-documented history of systemic cutaneous reaction without airway impir ment following penicillin use, the use of which of the following cephalosporins is most likely to re in an allergic response? A. cephalexin B. cefprozil C. cefuroxime D. cefpodoxime

90. Correct: A. cephalexin The greatest rate of cross-reactivity to the penicillins appears to arise from use of the first-generation cephal sporins (e.g., cephalexin and cefadroxil). Incorrect: There is less cross-reactivity with second-generation (e.g., cefprozil [B]), third-generation (e.g. cefpodox- ime [D]), and fourth-generation (e.g., cefuroxime [C]) agents, with a cross-reactivity rate of less than 1%.

91. Which of the following antimicrobial classes is associated with the highest rate of allergic reaction? A. the macrolides B. the beta-lactams C. the fluoroquinolones D. the sulfonamides

91. Correct: B. the beta-lactams The beta-lactam class (e.g., penicillin, amoxicillin, ceph- alosporins) is associated with the highest rate of allergic reactions, with about 10% of the population reporting a penicillin allergy. However, the rate is likely not as high as reported in the past. Incorrect: Approximately 3% to 6% report an allergy to sulfon- amides (D) (e.g., TMP-SMX). Allergic reaction to the macrolides (A) (e.g., azithromycin, clarithromycin) is relatively uncommon (0.4% to 3%), as well as imme- diate allergic reactions to fluoroquinolones (C) (e.g., ciprofloxacin, levofloxacin), with rates ranging from 0.4% to 2%.

98. Which of the following patients is least likely to develop ABRS? A. a 22-year-old with a 2-week history of viral URI symptoms B. a 35-year-old with allergic rhinitis who is currently not using controller or rescue medications C. a 38-year-old who has a 40 pack-year cigarette smoking history, currently smoking 2 packs per day D. an 18-year-old with a history of recurrent epistaxis

98. Correct: D. an 18-year-old with a history of recurrent epistaxis Risk factors for ABS include any condition that alters the normal cleansing mechanism of the sinuses. Recur- rent epistaxis is not a risk factor for ABRS. Incorrect: Risk factors for ABS include any condition that alters the normal cleansing mechanism of the sinuses. These can include viral URI (A), poorly controlled allergic rhinitis (B), cigarette smoking (C), and abnormalities of sinus structure.

92. A 36-year-old man presents for his initial visit to become a patient in a primary care practice. generally in good health with a history of hyperlipideria and is currently taking an HMG-COAr tase inhibitor (statin). He reports that he is "allergic to just about every antibiotic" and reports a ety of reactions including diffuse urticaria, gastrointestinal upset, and fatigue but without respir involvement. He is unclear as to which antibiotics have caused these reactions and states that mu what he knows is from his mother who "told me I always got sicker instead of better when I tor antibiotic." His last use of an antimicrobial was more than 10 years ago when he was treated for a infection" and was without reaction and does not recall the name of this medication. The next appropriate step in his care is to: A. advise the patient to obtain a more detailed history of what antibiotics he was given during his childhood. B. refer to allergy and immunology for further evaluation. C. inform the patient to start an antihistamine whenever he is given an antibiotic. D. provide a prescription for a systemic corticosteroid to take if he develops a reaction to his next antimicrobial course.

92. Correct: B. refer to allergy and immunology for fur- ther evaluation. Safe practice dictates that the exact nature of this patient's allergy, if any, be determined by a specialist. This information will be essential if antimicrobial ther- apy is needed for this patient in the future. Incorrect: The use of antihistamines (C) or corticosteroids (D) as a measure to help avoid an allergic reaction is not appro- priate. It is also important to note that family reports (A) of allergies can often be inaccurate. Antimicrobial allergy does not appear to have a strong genetic or famil- ial tendency.

93. Serious allergic reactions caused by the use of TMP-SMX include all of the following except: A. anaphylaxis. B. Stevens-Johnson syndrome. C. toxic epidermal necrolysis. D. fixed drug eruptions.

93. Correct: D. fixed drug eruptions. Fixed drug eruptions are the development of one or more erythematous patches. The condition associ- ated with the use of TMP-SMX is usually mild and self-limiting. Incorrect: Use of TMP-SMX can on occasion lead to serious reac- tions including anaphylaxis (A) (overreaction of the immune system) that can lead to hypotension, vomiting, syncope, and upper airway edema. Stevens-Johnson syn- drome (B) and toxic epidermal necrolysis (C) are severe skin reactions that eventually cause the skin to blister and peel, leaving raw areas.

94. A 37-year-old man presents with acute bacterial rhinosinusitis (ABRS) that has failed to respond to 5 days of treatment with amoxicillin. He reports that he experienced an allergic reaction to ciprofloxacin a few years ago that caused a rash as well as swelling of the lips and tongue. In deciding on a new anti- microbial, you consider avoiding the use of: A. amoxicillin-clavulanate. B. azithromycin. C. moxifloxacin. D. cefpodoxime.

94. Correct: C. moxifloxacin. Though a respiratory fluoroquinolone, such as moxi floxacin or levofloxacin, would be appropriate due to the likely presence of a beta-lactamase-producing organism or drug-resistant S pneumoniae, a history of facial edema with ciprofloxacin is problematic given the risk for potential respiratory distress. Thus, the use of another fluoroquinolone should be avoided for this patient. Incorrect: Given the report of facial edema with prior use of a fluo- roquinolone, an antimicrobial from another class would be most appropriate, including beta-lactams (D), macro- lides (A), and cephalosporins (B).

95. You prescribe a regimen of oral doxycycline to treat an acute exacerbation of chronic obstructive pulmonary disease for a 56-year-old man. This is his first exposure to this antimicrobial. You advise that: A. he should not experience an allergic reaction because he has no reported penicillin allergy. B. if he experiences any allergic reaction, he should stop taking the antibiotic and seek appropriate health care. C. if he experiences an allergic reaction, he should continue taking the medication until he meets with a health-care provider to avoid resistance development. D. any allergic reaction will eventually resolve once the regimen is complete.

95. Correct: B. if he experiences any allergic reaction, he should stop taking the antibiotic and seek appropriate health care. When taking an antimicrobial for the first time, the patient should be instructed that if an allergic reaction occurs, he should stop taking the medication and imme- diately contact a health-care provider. This is generally true for all medications as the allergic reaction can worsen with continued use. Incorrect: The absence of a penicillin allergy (A) does not necessarily predict the absence of a reaction to doxycycline since they belong to different drug classes. With the development of an allergic reaction, the patient should not continue tak- ing the medication (C) as the reaction can worsen rather than resolve with continued use (D).

96. A 45-year-old otherwise well woman presents with a chief complaint of a "sinus infection." In evaluating her for this problem, which of the following findings is most supportive of the diagnosis of ABRS? A. upper respiratory tract infection-like symptoms persisting beyond 7 to 10 days B. mild midfacial fullness and tenderness C. bilateral cervical lymphadenopathy D. purulent nasal discharge for the past 4 days

96. Correct: A. upper respiratory tract infection-like symptoms persisting beyond 7 to 10 days Patient history of present illness, especially the length of symptoms, is more sensitive and specific for ABRS than is physical examination. Symptoms that persist beyond 7 to 10 days, especially with a report of double sickening, is most indicative of ABRS. Incorrect: ABRS can include symptoms of facial fullness and ten- derness (B), cervical lymphadenopathy (C), and nasal discharge (D). However, these conditions can also occur in the presence of a viral upper respiratory infection, allergic rhinitis, and a variety of other conditions. Having symptoms that persist beyond 7 to 10 days, especially with a report of double sickening, is most indicative of ABRS.

97. The most common causative bacterial pathogen in ABRS in a 40-year-old adult with type 2 diabetes mellitus and AlC of 8.2% is: A. M pneumoniae. B. S pneumoniae. C. M catarrhalis. D. E coli.

97. Correct: B. S pneumoniae. Understanding the common pathogens of infection is helpful in deciding appropriate initial empiric therapy. The gram-positive bacteria S pneumonia is the most common causative pathogen of ABRS and is most likely to cause the most significant symptoms. Incorrect: H influenzae and M catarrhalis (C) are common gram- negative organisms that cause ABRS. M pneumoniae (A) and E coli (D) are not typically found in ABRS.

99. Which of the following is a first-line therapy for the treatment of ABRS in a 32-year-old adult with hypertension, taking an ACE inhibitor and thiazide diuretic, who has no allergies and last took an antimicrobial approximately 2 years ago? A. amoxicillin-clavulanate B. TMP-SMX C. clarithromycin D. moxifloxacin

99. Correct: A. amoxicillin-clavulanate The most common pathogens for ABRS include S pneu- moniae (gram-positive), H influenza (gram-negative), and M catarrhalis (gram-negative). Amoxicillin- clavulanate exhibits activity against these pathogens and is considered an appropriate first-line agent. Incorrect: A respiratory fluoroquinolone (D) can be considered in the presence of risk factors for DRSP; however, hypertension is not a comorbid condition associated with DRSP risk, and there has been no recent use of antimicrobials for this patient. TMP-SMX (B) and clar- ithromycin (C) are not preferred due to elevated rates of S pneumonia resistance to these agents.