MD 1201-1400 ចម្លើយពេញ

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

C Gingivostomatitis and pharyngitis

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

C difficile colonization

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

E None of the above

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

E Piperacillin/tazobactam

1378 All the following types of cancer commonly metastasize to the central nervous system (CNS) except A ovarian B breast C hypernephroma D melanoma E acute lymphoblastic leukemia (ALL)

A ovarian

1343 A 44-year-old man presents to the emergency room for evaluation of a severe sore throat. His symptoms began this morning with mild irritation on swallowing and have gotten progressively severe over the course of 12 h. He has been experiencing a fever to as high as 39°C at home and also reports progressive shortness of breath. He denies antecedent rhinorrhea or tooth or jaw pain. He has had no ill contacts. On physical examination, the patient appears flushed and in respiratory distress with use of accessory muscles of respiration. Inspiratory stridor is present. He is sitting leaning forward and is drooling with his neck extended. His vital signs are as follows: temperature 39.5°C, blood pressure 116/60 mmHg, heart rate 118 beats/min, respiratory rate 24 breaths/ min, SaO2 95% on room air. Examination of his oropharynx shows erythema of the posterior oropharynx without exudates or tonsillar enlargement. The uvula is midline. There is no sinus tenderness and no cervical lymphadenopathy. His lung fields are clear to auscultation, and cardiovascular examination reveals a regular tachycardia with a II/VI systolic ejection murmur heard at the upper right sternal border. Abdominal, extremity, and neurologic examinations are normal. Laboratory studies reveal a white blood cell count of 17,000 μL with a differential of 87% neutrophil, 8% band forms, 4% lymphocytes, and 1% monocytes. Hemoglobin is 13.4 g/dL with a hematocrit of 44.2%. An arterial blood gas on room air has a pH of 7.32, a PaCO2 of 48 mmHg, and PaO2 of 92 mmHg. A lateral neck film shows an edematous epiglottis. What is the next most appropriate step in evaluation and treatment of this individual? A Ampicillin, 500 mg IV q6h B Ceftriaxone, 1 g IV q24h C Endotracheal intubation and ampicillin, 500 mg IV q6h D Endotracheal intubation, ceftriaxone, 1 g IV q24h, and clindamycin, 600 mg IV q6h E Laryngoscopy and close observation

D Endotracheal intubation, ceftriaxone, 1 g IV q24h, and clindamycin, 600 mg IV q6h

1396 A 72-year-old man with chronic obstructive pulmo-nary disease and stable coronary disease presents to the emergency room with several days of worsening productive cough, fevers, malaise, and diffuse muscle aches. A chest x-ray demonstrates a new lobar infiltrate. Laboratory measurements reveal a total white blood cell count of 12,100 cells/μL, with a neutrophilic predominance of 86% and 8% band forms. He is diagnosed with community-acquired pneumonia, and antibiotic treatment is initiated. Under normal, or "nonstress," conditions, what percentage of the total body neutrophils are present in the circulation? A 0.02 B 0.1 C 0.25 D 0.4 E 0.9

A 0.02

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

A A 19-year-old female camp counselor who presents with her second episode of an inflamed, red and tender left knee and right ankle

1359 Which of the following statements regarding incidence of and risk factors for hepatocellular carcinoma is true? A A chemical toxin produced by Aspergillus species, aflatoxin B has a strong association with development of hepatocellular carcinoma and can be found in stored grains in hot, humid places. B In the United States, the incidence of hepatocellular carcinoma is decreasing. C Nonalcoholic steatohepatitis is not associated with an increased risk for hepatocellular carcinogen. D Fewer than 5% of individuals diagnosed with hepatocellular carcinoma in the United States do not have underlying cirrhosis. E The risk of developing hepatocellular carcinoma in individuals with hepatitis C infection is 50%.

A A chemical toxin produced by Aspergillus species, aflatoxin B has a strong association with development of hepatocellular carcinoma and can be found in stored grains in hot, humid places.

1386 Which of the following statements about lead-time bias occurrence is true? A A test does not influence the natural history of the disease; patients are merely diagnosed at an earlier date. B Slow-growing, less aggressive cancers are detected during screening; aggressive cancers are not detected by screening, due to death. C Screening identifies abnormalities that would never have caused a problem during a person's lifetime. D The screened population differs significantly from the general population in that they are healthier. E A test detects disease at an earlier and more curable stage of disease.

A A test does not influence the natural history of the disease; patients are merely diagnosed at an earlier date.

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

A Actinomyces

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

A Active tuberculosis treatment success rates are lower in HIV-infected patients compared to HIV-uninfected patients.

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

A Adenovirus

1354 A 63-year-old man from Mississippi comes to your office for evaluation of a chronic sore on his thigh. He has an open sore on his anterior thigh that has been draining purulent material for many months. The thigh is nontender but is warm to touch. The material is purulent and foul-smelling. He has been given multiple antibiotic courses and recently finished a course of itraconazole without relief of his symptoms. He has an intact neurovascular examination of his lower extremities. His erythrocyte sedimentation rate is 64, white blood cell count is 15,000/μL and hemoglobin is 8 mg/dL. A plain radiograph of the affected thigh shows a periosteal reaction of the femur with osteopenia. There is suggestion of a sinus tract between the femur and the skin. A Gram stain of the pus shows broad-based budding yeast and you make a presumptive diagnosis of blastomyces osteomyelitis. What is the treatment of choice for this patient? A Amphotericin B B Caspofungin C Itraconazole D Moxifloxacin E Voriconazole

A Amphotericin B

1372 Which of the following statements regarding polycythemia vera is correct? A An elevated plasma erythropoietin level excludes the diagnosis. B Transformation to acute leukemia is common. C Thrombocytosis correlates strongly with thrombotic risk. D Aspirin should be prescribed to all these patients to reduce thrombotic risk. E Phlebotomy is used only after hydroxyurea and interferon have been tried.

A An elevated plasma erythropoietin level excludes the diagnosis.

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

A Antibiotic treatment is not necessary for uncomplicated cases.

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

A Antiretroviral therapy

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

A Aspergillus fumigatus pneumonia

1303 A sputum culture from a patient with cystic fibrosis showing which of the following organisms has been associated with a rapid decline in pulmonary function and a poor clinical prognosis? A Burkholderia cepacia B Pseudomonas aeruginosa C Staphylococcus aureus D Staphylococcus epidermidis E Stenotrophomonas maltophilia

A Burkholderia cepacia

1345 A 24-year-old man seeks evaluation for painless penile ulcerations. He noted the first lesion about 2 weeks ago, and since that time, two adjacent areas have also developed ulceration. He states that there has been blood staining his underwear from slight oozing of the ulcers. He has no past medical history and takes no medication. He returned 5 weeks ago from a vacation in Brazil where he did have unprotected sexual intercourse with a local woman. He denies other high-risk sexual behaviors and has never had sex with prostitutes. He was last tested for HIV 2 years ago. He has never had a chlamydial or gonococcal infection. On examination, there are three well-defined red, friable lesions measuring 5 mm or less on the penile shaft. They bleed easily with any manipulation. There is no pain with palpation. There is shotty inguinal lymphadenopathy. On biopsy of one lesion, there is a prominent intracytoplasmic inclusion of bipolar organisms in an enlarged mononuclear cell. Additionally, there is epithelial cell proliferation with an increased number of plasma cells and few neutrophils. A rapid plasma reagin test is negative. Cultures grow no organisms. What is the most likely causative organism? A Calymmatobacterium granulomatis (donovanosis) B Chlamydia trachomatis (lymphogranuloma venereum) C Haemophilus ducreyi (chancroid) D Leishmania amazonensis (cutaneous leishmaniasis) E Treponema pallidum (secondary syphilis)

A Calymmatobacterium granulomatis (donovanosis)

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

A Campylobacter

1315 Caspofungin is a first-line agent for which of the following conditions? A Candidemia B Histoplasmosis C Invasive aspergillosis D Mucormycosis E Paracoccidiomycosis

A Candidemia

1367 A 58-year-old woman presents to the emergency room complaining of jaundice. She first noticed a yellowish discoloration of her skin about 3 days ago. It has become progressively worse since that time. In association with the development of jaundice, she also has noticed clay-colored stools and pruritus. There has been no associated abdominal pain, fever, chills, or night sweats. She has a past medical history of alcohol abuse, but has been abstinent for the past 10 years. She has no known history of cirrhosis. On physical examination, she is afebrile with normal vital signs. She is jaundiced. The bowel sounds are normal. The abdomen is soft and nontender. There is no distention. The liver span is 12 cm to percussion and is palpable at the right costal margin. The spleen tip is not palpable. Liver function testing reveals an AST of 122 IU/L, ALT of 168 IU/L, alkaline phosphatase of 483 U/L, total bilirubin of 22.1 mg/dL, and direct bilirubin of 19.2 mg/dL. On right upper quadrant ultrasound, the gallbladder cannot be visualized, and there is dilatation of the intrahepatic bile ducts but not the common bile duct. What is the most likely diagnosis? A Cholangiocarcinoma B Cholecystitis C Gallbladder cancer D Hepatocellular carcinoma E Pancreatic cancer

A Cholangiocarcinoma

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

A Donor CMV IgG negative, recipient CMV IgG negative

1394 A 68-year-old man seeks evaluation for fatigue, weight loss, and early satiety that have been present for about 4 months. On physical examination, his spleen is noted to be markedly enlarged. It is firm to touch and crosses the midline. The lower edge of the spleen reaches to the pelvis. His hemoglobin is 11.1 g/dL, and hematocrit is 33.7%. The leukocyte count is 6200/μL, and platelet count is 220,000/μL. The white cell count differential is 75% PMNs, 8% myelocytes, 4% metamyelocytes, 8% lymphocytes, 3% monocytes, and 2% eosinophils. The peripheral blood smear shows teardrop cells, nucleated red blood cells, and immature granulocytes. Rheumatoid factor is positive. A bone marrow biopsy is attempted, but no cells are able to be aspirated. No evidence of leukemia or lymphoma is found. What is the most likely cause of the splenomegaly? A Chronic idiopathic myelofibrosis B Chronic myelogenous leukemia C Rheumatoid arthritis D Systemic lupus erythematosus E Tuberculosis

A Chronic idiopathic myelofibrosis

1366 A 73-year-old man is admitted to the hospital with 3 weeks of malaise and fevers. His past medical history is notable only for hypertension controlled with a thiazide diuretic. He smokes one pack of cigarettes per day and works as an attorney. His physical examination is notable only for a new systolic heart murmur heard best in the mitral region. His laboratory examination is notable for mild anemia, an elevated white blood cell count, and occasional red blood cells on clean catch urine. Blood cultures grow Streptococcus bovis and echocardiogram shows a <1-cm vegetation on the mitral valve. What additional evaluation is indicated for this patient? A Colonoscopy B Head CT scan C Pulmonary embolism protocol CT scan D Renal biopsy E Toxicology screen

A Colonoscopy

1364 You are investigating the cause for a patient's anemia. He is a 50-year-old man who was found to have a hematocrit of 25% on routine evaluation. His hematocrit was 47% 1 year ago. Mean corpuscular volume is 80, mean corpuscular hemoglobin concentration is 25, mean corpuscular hemoglobin is 25. Reticulocyte count is 5%. Review of the peripheral blood smear shows marked numbers of polychromatophilic macrocytes. Ferritin is 340 μg/L. What is the cause of this patient's anemia? A Defective erythroid marrow proliferation B Extravascular hemolysis C Intravascular hemolysis D Iron-deficiency anemia E Occult gastrointestinal bleeding

A Defective erythroid marrow proliferation

1350 Which of the following is the most common source of fever in travelers returning from Southeast Asia? A Dengue fever B Malaria C Mononucleosis D Salmonella E Yellow fever

A Dengue fever

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

A Dexamethasone

1397 All of the following laboratory values are consistentwith an intravascular hemolytic anemia except A increased haptoglobin B increased lactate dehydrogenase (LDH) C increased reticulocyte count D increased unconjugated bilirubin E increased urine hemosiderin

A increased haptoglobin

1336 Which single clinical feature has the most specificity in differentiating Pseudomonas aeruginosa sepsis from other causes of severe sepsis in a hospitalized patient? A Ecthyma gangrenosum B Hospitalization for severe burn C Profound bandemia D Recent antibiotic exposure E Recent mechanical ventilation for >14 days

A Ecthyma gangrenosum

1324 A 64-year-old man in Wisconsin develops a high fever and malaise over 2 days. He has spent his weekends over the past month chopping wood in his backyard. Initial laboratory examination reveals a neutrophil count of 1000/μL, platelet count of 84,000/μL, AST of 140 U/L, and ALT of 183 U/L. A peripheral blood smear reveals prominent morulae in neutrophils. What is the most likely diagnosis? A Human granulocytotropic anaplasmosis B Human monocytotropic ehrlichiosis C Lyme disease D Rocky Mountain spotted fever E Systemic lupus erythematosus

A Human granulocytotropic anaplasmosis

1348 A 39-year-old healthy man plans to travel to Malaysia and comes to clinic for appropriate vaccinations. He cannot recall which vaccines he has had in the past, but reports having had "all the usual ones" in childhood. Which of the following represents the most common vaccine-preventable infection in travelers? A Influenza B Measles C Rabies D Tetanus E Yellow fever

A Influenza

1340 A 50-year-old man is admitted to the hospital for active pulmonary tuberculosis with a positive sputum acid-fast bacilli smear. He is HIV positive with a CD4 count of 85/μL and is not on highly active antiretroviral therapy. In addition to pulmonary disease, he is found to have disease in the L4 vertebral body. What is the most appropriate initial therapy? A Isoniazid, rifampin, ethambutol, and pyrazinamide B Isoniazid, rifampin, ethambutol, and pyrazinamide; initiate antiretroviral therapy C Isoniazid, rifampin, ethambutol, pyrazinamide, and streptomycin D Isoniazid, rifampin, and ethambutol E Withhold therapy until sensitivities are available.

A Isoniazid, rifampin, ethambutol, and pyrazinamide

1330 A 45-year-old patient with HIV/AIDS presents to the emergency department. He complains of a rash that has been slowly spreading up his right arm and is now evident on his chest and back. The rash consists of small nodules that have a reddish-blue appearance. Some of them are ulcerated, but there is minimal fluctuance or drainage. He is unsure when these began. He notes no foreign travel or unusual exposures. He is homeless and unemployed, but occasionally gets work as a day laborer doing landscaping and digging. A culture of a skin lesion grows a Mycobacterium in 5 days. Which of the following is the most likely organism? A M. abscessus B M. avium C M. kansasii D M. marinum E M. ulcerans

A M. abscessus

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

A No change

1389 The most common inherited prothrombotic disorder is A activated protein C resistance B prothrombin gene mutation C protein C deficiency D protein S deficiency E antithrombin deficiency

A activated protein C resistance

1335 Rifampin lowers serum levels of all of the following medicines except A amiodarone B anticonvulsants C oyclosporine D hormonal contraceptives E protease inhibitors

A amiodarone

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

A bilateral, peripheral cavitary lung infiltrates

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

A cerebrospinal fluid (CSF) culture

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

A echocardiogram looking at the aortic arch

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

B IM penicillin G benzathine, 2.4 million U

1371 A healthy 62-year-old woman returns to your clinic after undergoing routine colonoscopy. Findings included two 1.3-cm sessile (flat-based), villous adenomas in her ascending colon that were removed during the procedure. What is the next step in management? A Colonoscopy in 3 months B Colonoscopy in 3 years C Colonoscopy in 10 years D CT scan of the abdomen E Partial colectomy

B Colonoscopy in 3 years

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

B Colonoscopy with biopsy

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

B Coxsackievirus

1391 A 65-year-old man is brought to the emergency room by ambulance after his daughter found him to be incoherent earlier today. She last spoke with him yesterday, and at that time, he was complaining of 2 days of myalgias, headache, and fever. He had attributed it to an upper respiratory tract infection and did not seek evaluation from his primary care physician. Today, he did not answer when she called his home, and she found him lying in his bed smelling of urine. He was minimally arousable but appeared to be moving all of his extremities. His past medical history is significant for hypertension, hypercholesterolemia, and chronic obstructive pulmonary disease. He was evaluated 2 weeks previously for a transient ischemic attack after an episode where he had numbness and weakness of his left arm and leg that resolved over 6 h without intervention. His current medications include aspirin, 81 mg daily, clopidogrel, 75 mg daily, atenolol, 100 mg daily, atorvastatin, 20 mg daily, and tiotropium, once daily. He is allergic to lisinopril, which caused angioedema. He is a former smoker and drinks alcohol rarely. On physical examination, he is obtunded and minimally arousable. He is febrile with a temperature of 38.9°C. His blood pressure is 159/96 mmHg, and heart rate is 98 beats/ min. He is breathing at a rate of 24 breaths/min with a room air oxygen saturation of 95%. He has minimal scleral icterus. The oropharynx reveals dry mucous membranes. His cardiovascular, pulmonary, and abdominal examinations are normal. There are no rashes. His neurologic examination is difficult to obtain. There are no cranial nerve findings. He resists movement of his extremities but has normal strength. Deep tendon reflexes are brisk, 3+ and equal. The laboratory values are as follows: hemoglobin 9.3 g/ dL, hematocrit 29.1%, white blood cell count 14,000/μL, and platelets 42,000/μL. The differential demonstrates 83% neutrophils, 2% band forms, 6% lymphocytes, and 9% monocytes. The sodium is 145 meq/L, potassium 3.8 meq/L, chloride 113 meq/L, bicarbonate 19 meq/L, blood urea nitrogen 68 mg/dL, and creatinine 3.4 mg/dL. The bilirubin is 2.4 mg/dL, and lactate dehydrogenase is 450 U/L. A peripheral blood smear shows diminished platelets and many schistocytes. What is the next most appropriate step in this patient's care? A Discontinue clopidogrel. B Discontinue clopidogrel and initiate plasmapheresis. C Initiate therapy with intravenous immunoglobulin. D Obtain a head CT scan and initiate treatment with factor VIIa, if subarachnoid hemorrhage is seen. E Perform a lumbar puncture and start broad-spectrum antibiotic coverage with ceftazidime and vancomycin.

B Discontinue clopidogrel and initiate plasmapheresis.

1341 All of the following individuals receiving tuberculin skin purified protein derivative (PPD) reactions should be treated for latent tuberculosis except A A 23-year-old injection drug user who is HIV negative has a 12-mm PPD reaction. B A 38-year-old fourth grade teacher has a 7-mm PPD reaction and no known exposures to active tuberculosis. She has never been tested with a PPD previously. C A 43-year-old individual in the Peace Corps working in Sub-Saharan Africa has a 10-mm PPD reaction. 18 months ago, the PPD reaction was 3 mm. D A 55-year-old man who is HIV positive has a negative PPD. His partner was recently diagnosed with cavitary tuberculosis. E A 72-year-old man who is receiving chemotherapy for non-Hodgkin's lymphoma has a 16-mm PPD reaction.

B A 38-year-old fourth grade teacher has a 7-mm PPD reaction and no known exposures to active tuberculosis. She has never been tested with a PPD previously.

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

B Alkaline phosphatase is the most likely liver function test to be abnormal in the presence of a liver abscess.

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

B All U.S. adults

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

B Asymptomatic seroconversion

1388 All but which of the following statements about the lupus anticoagulant (LA) are true? A Lupus anticoagulants typically prolong the aPTT. B A 1:1 mixing study will not correct in the presence of lupus anticoagulants. C Bleeding episodes in patients with lupus anticoagulants may be severe and life-threatening. D Female patients may experience recurrent mid-trimester abortions. E Lupus anticoagulants may occur in the absence of other signs of systemic lupus erythematosus (SLE).

C Bleeding episodes in patients with lupus anticoagulants may be severe and life-threatening.

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

B CSF IgM antibodies

1347 A 38-year-old woman with frequent hospital admissions related to alcoholism comes to the emergency room after being bitten by a dog. There are open wounds on her arms and right hand that are purulent and have necrotic borders. She is hypotensive and is admitted to the intensive care unit. She is found to have disseminated intravascular coagulation and soon develops multiorgan failure. Which of the following is the most likely organism to have caused her rapid decline? A Aeromonas spp. B Capnocytophaga spp. C Eikenella spp. D Haemophilus spp. E Staphylococcus spp.

B Capnocytophaga spp.

1349 A 19-year-old man plans on traveling through Central America by bus. He comes to clinic interested in travel advice and any vaccinations he may need. He has no medical history and takes no medicines. In addition to DEET and mosquito netting, which of the following recommendations would be important for prophylaxis against malaria? A Atovaquone B Chloroquine C Doxycycline D Mefloquine E Primaquine

B Chloroquine

1317 A 76-year-old woman is brought in to clinic by her son. She complains of a chronic nonproductive cough and fatigue. Her son adds that she has had low-grade fevers, progressive weight loss over months, and "just doesn't seem like herself." A chest CT reveals bronchiectasis and small (<5 mm) nodules scattered throughout the lung parenchyma. She had a distant history of treated tuberculosis. A sputum sample is obtained, as are blood cultures. Two weeks later, both culture sets grow acid fast bacilli consistent with Mycobacterium avium complex. Which of the following is the best treatment option? A Bronchodilators and pulmonary toilet B Clarithromycin and ethambutol C Clarithromycin and rifampin D Moxifloxacin and rifampin E Pyrazinamide, isoniazid, rifampin, and ethambutol

B Clarithromycin and ethambutol

1326 A patient who has undergone prosthetic valve surgery 6 weeks ago is readmitted with signs and symptoms consistent with infective endocarditis. Which of the following is the most likely etiologic organism? A Candida albicans B Coagulase-negative staphylococci C Enterococcus D Escherichia coli E Pseudomonas aeruginosa

B Coagulase-negative staphylococci

1392 A primary tumor of which of these organs is the least likely to metastasize to bone? A Breast B Colon C Kidney D Lung E Prostate

B Colon

1383 A 70-year-old man is admitted to the cardiac care unit for complaints of chest pressure occurring at rest radiating to his left arm with associated diaphoresis and presyncope. His admission electrocardiogram (ECG) showed ST depressions in V4-V6. The chest pain and ECG changes resolve with sublingual nitroglycerin. He is treated with IV heparin, aspirin, metoprolol, and lisinopril. His cardiac catheterization shows 90% occlusion of the left anterior descending artery, 80% occlusion of the distal circumflex artery, and 99% occlusion of the right coronary artery. He remains in the cardiac care unit awaiting coronary artery bypass. He has a history of rheumatic heart disease and underwent mechanical mitral valve replacement at age 58. On admission, his hemoglobin is 12.2 g/dL, hematocrit 37.1%, white blood cell (WBC) count 9800/μL, and platelet count 240,000/μL. His creatinine is 1.7 mg/dL. On the fourth hospital day, his hemoglobin is 10.0, hematocrit 31%, WBC count 7600/μL, and platelet count 112,000/μL. His creatinine has risen to 2.9 mg/dL after the cardiac catheterization. What is the most appropriate treatment of the patient at this time? A Continue heparin and give a platelet transfusion. B Discontinue heparin infusion and start argatroban. C Discontinue heparin and start lepirudin. D Discontinue heparin and start warfarin. E Send serum to assess for the presence of heparin- platelet factor 4 (PF4) IgG antibody and continue heparin.

B Discontinue heparin infusion and start argatroban.

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

B Electrolyte wasting

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

B Enteroviruses cannot be transmitted via blood transfusions and insect bites.

1307 A 34-year-old injection drug user presents with a 2-day history of slurred speech, blurry vision that is worse with bilateral gaze deviation, dry mouth, and difficulty swallowing both liquids and solids. He states that his arms feel weak as well but denies any sensory deficits. He has had no recent illness but does describe a chronic ulcer on his left lower leg that has felt slightly warm and tender of late. He frequently injects heroin into the edges of the ulcer. On review of systems, he reports mild shortness of breath but denies any gastrointestinal symptoms, urinary retention, or loss of bowel or bladder continence. Physical examination reveals a frustrated, nontoxic appearing man who is alert and oriented but noticeably dysarthric. He is afebrile with stable vital signs. Cranial nerve examination reveals bilateral cranial nerve six deficits and an inability to maintain medial gaze in both eyes. He has mild bilateral ptosis, and both pupils are reactive but sluggish. His strength is 5/5 in all extremities except for his shoulder shrug, which is 4/5. Sensory examination and deep tendon reflexes are within normal limits in all four extremities. His oropharynx is dry. Cardiopulmonary and abdominal examinations are normal. He has a 4 cm × 5 cm well-granulated lower extremity ulcer with redness, warmth, and erythema noted on the upper margin of the ulcer. What is the treatment of choice? A Glucocorticoids B Equine antitoxin to Clostridium botulinum neurotoxin C Intravenous heparin D Naltrexone E Plasmapheresis

B Equine antitoxin to Clostridium botulinum neurotoxin

1318 What is the most common side effect of oral ribavirin when used with pegylated interferon for the treatment of hepatitis C? A Drug-associated lupus B Hemolytic anemia C Hyperthyroidism D Leukopenia E Rash

B Hemolytic anemia

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

B Escherichia coli

1323 A 79-year-old Filipino-American man with diabetes mellitus, coronary artery disease, and emphysema develops the acute onset of low back pain and night sweats. Ten days prior, he underwent a prolonged lithotripsy procedure for septic ureteral stones. He was treated for a positive PPD 23 years ago. He moved to the United States 20 years ago and was a rice farmer in the Philippines prior to moving. Examination reveals tenderness over the lumbar spine. He has 5/5 strength in his lower extremities. MRI shows findings consistent with osteomyelitis of L3 and L4, with narrowing of the disc space and a small contiguous epidural abscess that is not compressing his spinal cord. A needle culture of the epidural abscess drawn prior to administration of antibiotics will most likely reveal which of the following? A Brucella melitensis B Escherichia coli C Mycobacterium tuberculosis D Staphylococcus aureus E Polymicrobial content with gram-positive cocci in chains, enteric gram-negative rods, and anaerobic pleomorphic forms

B Escherichia coli

1387 Which of the following is sufficient to make a definitive diagnosis of porphyria? A Appropriate clinical scenario including positive family history B Evidence of an enzyme deficiency or gene defect C Laboratory measurements in blood indicating accumulation of porphyrin precursors D Laboratory measurements in urine indicating accumulation of porphyrin precursors at the time of symptoms E Laboratory measurements in stool indicating accumulation of porphyrin precursors at the time of symptoms

B Evidence of an enzyme deficiency or gene defect

1333 Patients with which of the following have the lowest risk of invasive pulmonary Aspergillus infection? A Allogeneic stem cell transplant with graft-vs-host disease B HIV infection C Long-standing high-dose glucocorticoids D Post-solid organ transplant with multiple episodes of rejection E Relapsed/uncontrolled leukemia

B HIV infection

1329 A 47-year-old woman with known HIV/AIDS (CD4+ lymphocyte = 106/μL and viral load = 35,000/ mL) presents with painful growths on the side of her tongue (Figure IV- 158, Color Atlas). What is the most likely diagnosis? A Aphthous ulcers B Hairy leukoplakia C Herpes stomatitis D Oral candidiasis E Oral Kaposi's sarcoma

B Hairy leukoplakia

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

B Initiate doxycycline, 100 mg PO bid

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

B Metronidazole, 500 mg IV tid

1363 A 36-year-old African-American woman with systemic lupus erythematosus presents with the acute onset of lethargy and jaundice. On initial evaluation, she is tachycardic, hypotensive, appears pale, is dyspneic, and is somewhat difficult to arouse. Physical examination reveals splenomegaly. Her initial hemoglobin is 6 g/dL, white blood cell count is 6300/μL, and platelets are 294,000/μL. Her total bilirubin is 4 g/dL, reticulocyte count is 18%, and haptoglobin is not detectable. Renal function is normal, as is urinalysis. What would you expect on her peripheral blood smear? A Macrocytosis and PMN's with hypersegmented nuclei B Microspherocytes C Schistocytes D Sickle cells E Target cells

B Microspherocytes

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

B Myositis

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

B Neonates should receive weight-based ampicillin and gentamicin.

1355 A 73-year-old male presents to the clinic with 3 months of increasing back pain. He localizes the pain to the lumbar spine and states that the pain is worst at night while he is lying in bed. It is improved during the day with mobilization. Past history is notable only for hypertension and remote cigarette smoking. Physical examination is normal. Laboratory studies are notable for an elevated alkaline phosphatase. A lumbar radiogram shows a lytic lesion in the L3 vertebra. Which of the following malignancies is most likely? A Gastric carcinoma B Non-small cell lung cancer C Osteosarcoma D Pancreatic carcinoma E Thyroid carcinoma

B Non-small cell lung cancer

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

B Patients with hypersensitivity to eggs should not receive the intramuscular vaccine.

1356 Patients from which of the following regions need not be screened for glucose-6- phosphate dehydrogenase (G6PD) deficiency when starting a drug that carries a risk for G6PD mediated hemolysis? A Brazil B Russia C Southeast Asia D Southern Europe E Sub-Saharan Africa

B Russia

1385 A woman wants your advice regarding Papanicolaou smears. She is 36 years old and is monogamous with her husband since they were married 3 years ago. She has had normal Pap smears every year for the past 6 years. She would like to avoid the yearly test. What is your advice to this patient, based on the current screening guidelines? A She may discontinue screening at age 50 if she has had normal yearly Pap smears for the previous 10 years. B She may extend the screening interval to once every 2-3 years. C She may extend the screening interval to once every 5 years if she agrees to use barrier protection. D She may discontinue Pap screening if she receives the human papilloma virus (HPV) vaccine. E The only indication to cease Pap testing is if she were to have a total hysterectomy.

B She may extend the screening interval to once every 2-3 years.

1312 A 29-year-old man is being initiated on HIV antiretroviral therapy (ART) because of a rising viral RNA. He has no significant past medical or psychiatric history and has never received ART. His viral resistance screening shows no likely resistance mutations. Which of the following is now considered an acceptable first-line regimen of ART for patients being newly treated for HIV infection who have no viral resistance and no other medical or psychiatric problems? A Stavudine (d4T), didanosine (ddI), efavirenz (EFV) B Tenofovir (TDF), emtricitabine (FTC), efavirenz (EFV) C Tenofovir (TDF), emtricitabine (FTC), indinavir D Tenofovir (TDF), lopinavir/ritonavir, atazanavir E Zidovudine (AZT), lamivudine (3TC), abacavir (ABC)

B Tenofovir (TDF), emtricitabine (FTC), efavirenz (EFV)

1319 A previously unvaccinated health care worker incurs a needle stick from a patient with known active hepatitis B infection. What is the appropriate management for the health care worker? A Hepatitis B immunoglobulins B Hepatitis B vaccine C Hepatitis B vaccine plus hepatitis B immunoglobulins D Hepatitis B vaccine plus lamivudine E Lamivudine plus tenofovir

C Hepatitis B vaccine plus hepatitis B immunoglobulins

1398 All the following match the anticoagulant with its correct mechanism of action except A abciximab—GpIIb/IIIa receptor inhibition B clopidogrel—inhibition of thromboxane A2 release C fondaparinux—inhibition of factor Xa D argatroban—thrombin inhibition E warfarin—vitamin K—dependent carboxylation of coagulation factors

B clopidogrel—inhibition of thromboxane A2 release

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

B esophageal varices

1313 All of the following clinical findings are consistent with the diagnosis of molluscum contagiosum except A involvement of the genitals B involvement of the soles of the feet C lack of inflammation or necrosis at the site of the rash D rash associated with an eczematous eruption E rash spontaneously resolving over 3-4 months

B involvement of the soles of the feet

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

B norovirus

1339 Which of the following individuals with a known history of prior latent tuberculosis infection (without therapy) has the greatest likelihood of developing reactivation tuberculosis? A A 28-year-old woman with anorexia nervosa, a body mass index of 16 kg/m2, and a serum albumin of 2.3 g/dL B A 36-year-old intravenous drug user who does not have HIV but is homeless C A 42-year-old man who is HIV-positive with a CD4 count of 350/μL on highly active antiretroviral therapy D A 68-year-old man who worked as a stone mason for many years and has silicosis E A 73-year-old man who was infected while stationed in Korea in 1958

C A 42-year-old man who is HIV-positive with a CD4 count of 350/μL on highly active antiretroviral therapy

1379 A 54-year-old woman with atrial fibrillation is anticoagulated with warfarin, 5 mg daily. She developed a urinary tract infection that her primary care physician has treated with ciprofloxacin, 250 mg orally twice daily for 7 days. She presents to the emergency room today complaining of blood in her urine and easy bruising. Her physical examination shows ecchymoses on her arms. Her urine is bloody in appearance, but no clots are present. After flushing the bladder with 100 mL of sterile saline, the urine returns with a slight pink hue only. A urinalysis shows 3-5 white blood cells per high power field and many red blood cells per high power field. There are no bacteria present. The international normalized ratio (INR) is 7.0. What is the best approach to treatment of this patient's coagulopathy? A Administer vitamin K 10 mg IV. B Administer vitamin K 2 mg SC. C Administer vitamin K 1 mg sublingually. D Hold further warfarin doses until the INR falls to 2.0. E Transfuse four units of fresh-frozen plasma.

C Administer vitamin K 1 mg sublingually.

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

C Avian influenza outbreaks in humans occur when human influenza A viruses undergo antigenic shifts with influenza A from poultry

1369 Which of the following statements describes the relationship between testicular tumors and serum markers? A Pure seminomas produce α fetoprotein (AFP) or beta human chorionic gonadotropin (β-hCG) in more than 90% of cases. B More than 40% of nonseminomatous germ cell tumors produce no cell markers. C Both β-hCG and AFP should be measured in following the progress of a tumor. D Measurement of tumor markers the day after surgery for localized disease is useful in determining completeness of the resection. E β-hCG is limited in its usefulness as a marker because it is identical to human luteinizing hormone.

C Both β-hCG and AFP should be measured in following the progress of a tumor.

1362 A 55-year-old female presents with progressive incoordination. Physical examination is remarkable for nystagmus, mild dysarthria, and past-pointing on finger-to-nose testing. She also has an unsteady gait. MRI reveals atrophy of both lobes of the cerebellum. Serologic evaluation reveals the presence of anti-Yo antibody. Which of the following is the most likely cause of this clinical syndrome? A Non-small cell cancer of the lung B Small-cell cancer of the lung C Breast cancer D Non-Hodgkin's lymphoma E Colon cancer

C Breast cancer

1374 A 34-year-old female with a past medical history of sickle cell anemia presents with a 5- day history of fatigue, lethargy, and shortness of breath. She denies chest pain or bone pain. She has had no recent travel. Of note, the patient's 4-year-old daughter had a "cold" 2 weeks before the presentation. On examination she has pale conjunctiva, is anicteric, and is mildly tachycardic. Abdominal examination is unremarkable. Laboratories show a hemoglobin of 3 g/dL; her baseline is 8 g/dL. The white blood cell count and platelets are normal. Reticulocyte count is undetectable. Total bilirubin is 1.4 mg/dL. Lactic dehydrogenase is at the upper limits of the normal range. Peripheral blood smear shows a few sickled cells but a total absence of reticulocytes. The patient is given a transfusion of 2 units of packed red blood cells and admitted to the hospital. A bone marrow biopsy shows a normal myeloid series but an absence of erythroid precursors. Cytogenetics are normal. What is the most appropriate next management step? A Make arrangements for exchange transfusion. B Tissue type her siblings for a possible bone marrow transplant. C Check parvovirus titers. D tart prednisone and cyclosporine. E Start broad-spectrum antibiotics.

C Check parvovirus titers.

1352 A 68-year-old man is brought to the emergency room with altered mental status, fever, and leg pain. His wife reports that he first complained of pain in his leg yesterday, and there was some slight redness in this area. Over the night, he developed a fever to as high as 39.8°C and became obtunded this morning. At that point, his family brought him to the emergency room. Upon arrival, he is unresponsive to voice and withdraws to pain. The vital signs are: blood pressure 88/40 mmHg, heart rate 126 beats/min, respiratory rate 28 breaths/min, temperature 39.3°C, and SaO2 95% on room air. Examination of the right leg shows diffuse swelling with brawny edema. The patient grimaces in pain when the area is touched. There are several bullae filled with dark blue to purple fluid. Laboratory studies show: pH 7.22, PaCO2 28 mmHg, PaO2 93 mmHg. The creatinine is 3.2 mg/dL. White blood cell count is elevated at 22,660/μL with a differential of 70% polymorphonuclear cells, 28% band forms, and 2% lymphocytes. A bulla is aspirated and the Gram stain shows gram-positive cocci in chains. What is the most appropriate therapy for this patient? A Ampicillin, clindamycin, and gentamicin B Clindamycin and penicillin C Clindamycin, penicillin, and surgical debridement D Penicillin and surgical debridement E Vancomycin, penicillin, and surgical debridement

C Clindamycin, penicillin, and surgical debridement

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

C Concurrent urethral discharge

1381 A 23-year-old woman is diagnosed with a lower extremity deep venous thrombosis. Which of the following medical conditions represents a contraindication to therapy with low-molecular-weight heparin (LMWH)? A Pregnancy B Obesity C Dialysis-dependent renal failure D Uncontrolled diabetes mellitus E Jaundice

C Dialysis-dependent renal failure

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

C Funduscopic examination

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

C HTLV-I infection is associated with a gradual decline in T cell function and immunosuppression

1346 A 75-year-old patient presents with fevers and wasting. He describes fatigue and malaise over the past several months and is concerned that he has been losing weight. On examination, he is noted to have a low-grade fever and a soft diastolic heart murmur is appreciated. Laboratory tests reveal a normocytic, normochromic anemia. Three separate blood cultures grow Cardiobacterium hominis. Which of the following statements is true about this patient's clinical condition? A Antibiotics are not likely to improve his condition. B Echocardiogram will likely be normal. C He has a form of endocarditis with a high risk of emboli. D He will likely need surgery. E The positive blood cultures are likely a skin contaminant.

C He has a form of endocarditis with a high risk of emboli.

1320 Which of the following is not a common feature of severe Plasmodium falciparum malaria? A Acute tubular necrosis B Hematocrit <15% C Hepatic necrosis D Hypoglycemia E Obtundation

C Hepatic necrosis

1375 A 22-year-old pregnant woman of northern European descent presents 3 months into her first pregnancy with extreme fatigue, pallor, and icterus. She reports being previously healthy. On evaluation her hemoglobin is 8 g/dL, reticulocyte count is 9%, indirect bilirubin is 4.9 mg/dL, and serum haptoglobin is not detectable. Her physical examination is notable for splenomegaly and a normal 3-month uterus. Peripheral smear is shown below. What is the most likely diagnosis? (See Figure I21, Color Atlas.) A Colonic polyp B G6PD deficiency C Hereditary spherocytosis D Parvovirus B19 infection E Thrombotic thrombocytopenic purpura

C Hereditary spherocytosis

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

C Human respiratory syncytial virus

1353 In the urgent care clinic, you are evaluating a 47year-old woman with poorly controlled diabetes who has a chief complaint of "sinusitis." She does not have a history of atopy. She first noticed a headache 2 days ago and now feels very congested in her upper nasal passages. She has hyperesthesia over her nasal bridge as well and is inquiring about antibiotics to treat her infection. She has a bloody nasal discharge with occasional black specks. On examination, the sinuses are full and tender. She has a temperature of 38.3°C. Oral examination shows a black eschar on the roof of her mouth surrounded by discolored hyperemic areas on the palate. What is the most appropriate intervention at this time? A Ciprofloxacin and quarantine for possible anthrax B ENT consultation if no improvement with oral antibiotics C Immediate biopsy of the involved areas and lipid amphotericin D Immediate biopsy of the lesion and voriconazole E Intranasal decongestants and close follow-up

C Immediate biopsy of the involved areas and lipid amphotericin

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

C Immune reconstitution syndrome to Mycobacterium avium

1384 A 24-year-old woman presents to the emergency room complaining of a red, tender rash that has been spreading across her arms and legs over the past 2 days. She also describes severe diffuse muscle pain that has worsened over a week's time. She woke up feeling as though she could not catch her breath and has developed a dry cough over the past several days. She is without any significant medical history but recalls that she had similar symptoms several years ago, and was told she was having an allergic reaction. Her symptoms abated with an oral glucocorticoid taper. She takes no prescription medications but takes a number of over-the-counter nutritional supplements daily. She cannot describe any allergic trigger to her previous episode or her current one. Her family history is unremarkable, and her close contacts are not ill. She works in an office, has no pets, and has not travelled internationally. Her laboratory results are remarkable for a leukocyte count of 12,100 cells/ μL and a total eosinophil count of 1100/μL. Which of the following is the most likely cause of her symptoms? A Early stage of systemic lupus erythematosus B Gluten allergy C Ingestion of L-tryptophan D Lactose intolerance E Recent viral upper respiratory tract infection

C Ingestion of L-tryptophan

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

C Lamivudine

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

C Lumbar puncture

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

C Methicillin

1337 Which of the following statements regarding varicella-zoster infection after hematopoietic stem cell transplant is true? A Acyclovir prophylaxis is not warranted for patients with positive varicella-zoster virus serologies pretransplant as the rate of zoster reactivation is low following transplantation. B Herpes zoster resistance is a common problem, and a change from acyclovir to foscarnet is often required. C Multidermatomal and disseminated zoster can occur in transplant patients who do not receive appropriate antiviral therapy. D Zoster occurs more commonly following autologous transplant of stem cells than allogeneic transplant of stem cells. E Zoster occurs most frequently during the first month after transplant.

C Multidermatomal and disseminated zoster can occur in transplant patients who do not receive appropriate antiviral therapy.

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

C Paracentesis

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

C Penicillin

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

C Reassure the patient that her illness is self-limited and no further treatment is necessary if she can maintain adequate hydration.

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

C Rickettsia prowazekii (Louse-borne typhus)

1370 A woman with advanced breast cancer being treated with tamoxifen presents to the emergency department with nausea and vomiting. She has been tolerating her treatment well but in the last 3 days noticed nausea, vomiting, and abdominal pain. Her symptoms are not related to food intake, and she is having normal bowel movements. She has no fevers or rashes. Her medications include tamoxifen, alendronate, megestrol acetate, and a multivitamin. Abdominal examination reveals very mild tenderness diffusely, and there is no rebound tenderness. Bowel sounds are normal. Plain radiographs and a CT scan of the abdomen are unremarkable. Laboratory analysis reveals a normal white blood cell count. Sodium is 130 meq/L, potassium 4.9 meq/L, chloride 99 meq/L, bicarbonate 29 meq/L, BUN 15 mg/dL, creatinine 0.7 mg/ dL. What is the next most appropriate step in this patient's management? A Antiemetics prn B Laparoscopy C Serum cortisol D Small-bowel follow through E Upper endoscopy

C Serum cortisol

1373 A 52-year-old female is evaluated for abdominal swelling with a computed tomogram that shows ascites and likely peritoneal studding of tumor but no other abnormality. Paracentesis shows adenocarcinoma but cannot be further differentiated by the pathologist. A thorough physical examination, including breast and pelvic examination, shows no abnormality. CA-125 levels are elevated. Pelvic ultrasound and mammography are normal. Which of the following statements is true? A Compared with other women with known ovarian cancer at a similar stage, this patient can be expected to have a less than average survival. B Debulking surgery is indicated. C Surgical debulking plus cisplatin and paclitaxel is indicated. D Bilateral mastectomy and bilateral oophorectomy will improve survival. E Fewer than 1% of patients with this disorder will remain disease-free 2 years after treatment.

C Surgical debulking plus cisplatin and paclitaxel is indicated.

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

C primary pulmonary coccidioidomycosis

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

C Urgent MRI and neurosurgical consultation; vancomycin plus cefepime after blood cultures are drawn

1327 A 28-year-old man is diagnosed with HIV infection during a clinic visit. He has no symptoms of opportunistic infection. His CD4+ lymphocyte count is 150/ μL. All of the following are approved regimens for primary prophylaxis against Pneumocystis jiroveci infection except A aerosolized pentamidine, 300 mg monthly B atovaquone, 1500 mg PO daily C clindamycin, 900 mg PO q8h, plus primaquine, 30 mg PO daily D dapsone, 100 mg PO daily E trimethoprim/sulfamethoxazole, 1 single-strength tablet PO daily

C clindamycin, 900 mg PO q8h, plus primaquine, 30 mg PO daily

1332 A 41-year-old man with hepatitis C-associated ascites presents with acute abdominal pain. Physical examination is notable for temperature of 38.3°C, heart rate of 115 beats per minute, blood pressure of 88/48 mmHg, respiratory rate of 16 breaths per minute, and oxygen saturation of 99% on room air. The patient is in moderate discomfort and is lying still. He is alert and oriented. Lungs are clear. Cardiac examination is unremarkable. His abdomen is diffusely tender with distant bowel sounds, mild guarding, and no rebound tenderness. Laboratory studies reveal a leukocyte count of 11,630/μL with 94% neutrophils, hematocrit of 29%, and platelet count of 24,000/μL. Paracentesis reveals 658 PMNs/μL, total protein 1.2 g/dL, glucose 24 mg/dL, and gram stain showing gram-negative rods, gram-positive cocci in chains, gram-positive rods, and yeast forms. All of the following are indicated except A abdominal radiograph B broad-spectrum antibiotics C drotrecogin alfa D intravenous fluid E surgical consultation

C drotrecogin alfa

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

C enterotoxigenic Escherichia coli

1338 All of the following factors influence the likelihood of transmitting active tuberculosis except A duration of contact with an infected person B environment in which contact occurs C presence of extrapulmonary tuberculosis D presence of laryngeal tuberculosis E probability of contact with an infectious person

C presence of extrapulmonary tuberculosis

1321 A 55-year-old male is admitted to the hospital with aspiration pneumonia. Over the past 8 months he has had a relentless neurologic decline characterized by dementia with severe memory loss and decline in intellectual function. These symptoms were preceded by 2-3 months of labile mood, weight loss, and headache. Currently he is awake but unable to answer questions. Neurologic examination is notable for normal cranial nerves and sensation. He has marked myoclonus provoked by startle or bright lights, but it also occurs spontaneously during sleep. Prior evaluation revealed normal serum chemistries, negative serologic tests for syphilis, and normal cerebrospinal fluid (CSF) studies. Head CT scan is normal. The infectious agent that caused his neurologic syndrome is most likely a A DNA virus B fungus C protein-lacking nucleic acid D protozoan E RNA virus

C protein-lacking nucleic acid

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

D 11-mm mitral valve vegetation

1377 A 48-year-old male is referred for evaluation by an acute care center because of a nodule on chest radiography. Three weeks ago he was diagnosed with pneumonia after reporting 3 days of fever, cough, and sputum production. The chest radiogram showed a small right lower lobe alveolar infiltrate and a left upper lobe 1.5-cm round nodule. He was treated with antibiotics and is now asymptomatic. A repeat chest radiogram shows that the right lower lobe pneumonia is resolved, but the nodule is still present. He is asymptomatic. He smoked one pack of cigarettes per day for 25 years and quit 3 years ago. He never had a prior chest radiogram. CT scan shows that the nodule is 1.5 by 1.7 cm and is located centrally in the left upper lobe, has no calcification, and has slightly scalloped edges. There is no mediastinal adenopathy or pleural effusion. Which of the following is the appropriate next step in his management? A Bronchoscopy B Mediastinoscopy C MRI scan D 18FDG PET scan E Repeat chest CT in 6 months

D 18FDG PET scan

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

D 3

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

D CMV retinitis

1380 Which of the following statements about cardiac toxicity from cancer treatment is true? A Doxorubicin-based cardiac toxicity is idiosyncratic and dose-independent. B Anthracycline-induced congestive heart failure is reversible with time and control of risk factors. C Mediastinal irradiation often results in acute pericarditis during the first few weeks of treatment. D Chronic constrictive pericarditis often manifests symptomatically up to 10 years after treatment. E The incidence of coronary atherosclerosis in patients who have a history of mediastinal irradiation is the same as that in age-matched controls.

D Chronic constrictive pericarditis often manifests symptomatically up to 10 years after treatment.

1382 Which of the following pairs of chemotherapy and complication is incorrect? A Daunorubicin—CHF B Bleomycin—interstitial fibrosis C Cyclophosphamide—hematuria D Cisplatin—liver failure E Ifosfamide—Fanconi syndrome

D Cisplatin—liver failure

1311 A 20-year-old female is 36 weeks pregnant and presents for her first evaluation. She is diagnosed with Chlamydia trachomatis infection of the cervix. Upon delivery, what complication is her infant most at risk for? A Jaundice B Hydrocephalus C Hutchinson triad D Conjunctivitis E Sensorineural deafness

D Conjunctivitis

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

D Doxycycline, 100 mg PO bid

1304 Empirical antibiotic therapy for continuous ambulatory peritoneal dialysis (CAPD) patients with peritonitis should be directed towards which organisms? A Enteric gram-negative rods B Enteric gram-negative rods and yeast C Gram-positive cocci D Gram-positive cocci plus enteric gram-negative rods E Gram-positive cocci plus enteric gram-negative rods plus yeast

D Gram-positive cocci plus enteric gram-negative rods

1310 A 27-year-old man presents to your clinic with 2 weeks of sore throat, malaise, myalgias, night sweats, fevers, and chills. He visited an urgent care center and was told that he likely had the flu. He was told that he had a "negative test for mono." The patient is homosexual, states that he is in a monogamous relationship and has unprotected receptive and insertive anal and oral intercourse with one partner. He had several partners prior to his current partner 4 years ago but none recently. He reports a negative HIV-1 test 2 years ago and recalls being diagnosed with Chlamydia infection 4 years ago. He is otherwise healthy with no medical problems. You wish to rule out the diagnosis of acute HIV. Which blood test should you order? A CD4+ lymphocyte count B HIV enzyme immunoassay (EIA)/Western blot combination testing C HIV resistance panel D HIV RNA by polymerase chain reaction (PCR) E HIV RNA by ultrasensitive PCR

D HIV RNA by polymerase chain reaction (PCR)

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

D Human papilloma virus infection

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

D Ingestion of as few as 10 cysts can cause human disease.

1308 In an HIV-infected patient, Isospora belli infection is different from Cryptosporidium infection in which of the following ways? A Isospora causes a more fulminant diarrheal syndrome leading to rapid dehydration and even death in the absence of rapid rehydration. B Isospora infection may cause biliary tract disease, whereas cryptosporidiosis is strictly limited to the lumen of the small and large bowel. C Isospora is more likely to infect immunocompetent hosts than Cryptosporidium. D Isospora is less challenging to treat and generally responds well to trimethoprim/sulfamethoxazole treatment. E Isospora occasionally causes large outbreaks among the general population.

D Isospora is less challenging to treat and generally responds well to trimethoprim/sulfamethoxazole treatment.

1342 A 68-year-old woman seeks evaluation for an ulcerative lesion on her right hand. She reports the area on the back of her right hand was initially red and not painful. There appeared to be a puncture wound in the center of the area, and she thought she had a simple scratch acquired while gardening. Over the next several days, the lesion became verrucous and ulcerated. Now, the patient has noticed several nodular areas along the arm, one of which ulcerated and began draining a serous fluid today. She is also noted to have an enlarged and tender epitrochlear lymph node on the right arm. A biopsy of the edge of the lesion shows ovoid and cigar-shaped yeasts. Sporotrichosis is diagnosed. What is the most appropriate therapy for this patient? A Amphotericin B intravenously B Caspofungin intravenously C Clotrimazole topically D Itraconazole orally E Selenium sulfide topically

D Itraconazole orally

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

D Laws prohibiting the feeding of uncooked garbage to pigs

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

D Legionella urinary antigen maintains utility after antibiotic use.

1316 A 19-year-old college student presents to the emergency room with crampy abdominal pain and watery diarrhea that has worsened over 3 days. He recently returned from a volunteer trip to Mexico. He has no past medical history and felt well throughout the trip. Stool examination shows small cysts containing four nuclei, and stool antigen immunoassay is positive for Giardia. Which of the following is an effective treatment regimen? A Albendazole B Clindamycin C Giardiasis is self-limited and requires no antibiotic therapy D Metronidazole E Paromomycin

D Metronidazole

1322 A previously healthy 19-year-old man presents with several days of headache, cough with scant sputum, and fever of 38.6°C. On examination, pharyngeal erythema is noted and lung fields are clear. Chest radiograph reveals focal bronchopneumonia in the lower lobes. His hematocrit is 24.7%, down from a baseline measure of 46%. The only other laboratory abnormality is an indirect bilirubin of 3.4. A peripheral smear reveals no abnormalities. A cold agglutinin titer is measured at 1:64. What is the most likely infectious agent? A Coxiella burnetii B Legionella pneumophila C Methicillin-resistant Staphylococcus aureus D Mycoplasma pneumoniae E Streptococcus pneumoniae

D Mycoplasma pneumoniae

1305 Indinavir is a protease inhibitor that carries which side effect unique for HIV antiretroviral agents? A Abnormal dreams B Benign hyperbilirubinemia C Hepatic necrosis in pregnant women D Nephrolithiasis E Pancreatitis

D Nephrolithiasis

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

D Neuropathic osteopathy

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

D Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis plus cefpodoxime, 400 mg PO × 1, and azithromycin, 1g PO × 1, for the patient and his recent partners

1393 The triad of portal vein thrombosis, hemolysis, and pancytopenia suggests which of the following diagnoses? A Acute promyelocytic leukemia B Hemolytic-uremic syndrome (HUS) C Leptospirosis D Paroxysmal nocturnal hemoglobinuria (PNH) E Thrombotic thrombocytopenia purpura (TTP)

D Paroxysmal nocturnal hemoglobinuria (PNH)

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

D Parvovirus B19 IgM

1351 A 54-year-old woman presents to the emergency room complaining of pain and redness of her left face and cheek. The area of redness began abruptly yesterday. At that time, the area was about 5 mm2 near the nasolabial fold. There was rapid progression of the redness to an area that is now about 5 cm2. In addition, she is complaining of intense pain in this area. On examination, there is a well-demarcated 5 cm2 area of erythema along her left nasolabial fold. The borders are raised and indurated. The entire area is very tender to touch. Over the next 24 h, the affected area begins to develop a flaccid bullae. What is the most appropriate treatment for this patient? A Acyclovir B Clindamycin C Clindamycin and penicillin D Penicillin E Trimethoprim and sulfamethoxazole

D Penicillin

1361 All of the enzyme deficiencies that lead to porphyrias are inherited either as autosomal dominant (AD) or autosomal recessive (AR) traits with one exception. Which of the following most commonly occurs sporadically? A 5-ALA dehydratase-deficient porphyria B Acute intermittent porphyria C Erythropoietic porphyria D Porphyria cutanea tarda E Variegate porphyria

D Porphyria cutanea tarda

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

D Presentation is often more subacute.

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

D Recurrent disease is associated with serious complications.

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

D Staphylococcus aureus

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

D She should continue on penicillin indefinitely as she had a previous recurrence, has presumed rheumatic heart disease, and is working in a field with high occupational exposure to

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

D Sinus of Valsalva abscess ruptured into right heart

1331 A 25-year-old male is seen in the emergency department for symptoms of fevers and abdominal swelling, early satiety, and weight loss. His symptoms began abruptly 2 weeks ago. He was previously healthy and is taking no medications. He denies illicit drug use and recently immigrated to the United States from Bangladesh. On physical examination, temperature is 39.0°C (102.2°F) and pulse is 120, with normal blood pressure and respiratory rate. The remainder of the exam is notable for cachexia and a distended abdomen with a massively enlarged spleen. The spleen is tender and soft. The liver is not palpable. Mild peripheral adenopathy is present. Which of the following statements is correct regarding this patient with presumed kala azar leishmaniasis? A He probably has normal cell counts on peripheral blood smear. B Leishmania donovani is not endemic in Bangladesh. C Leishmania-specific cell-mediated immunity probably is present. D Splenic aspiration offers the highest diagnostic yield. E Treatment can be delayed until the diagnosis is confirmed.

D Splenic aspiration offers the highest diagnostic yield.

1360 You are asked to review the peripheral blood smear from a patient with anemia. Serum lactate dehydrogenase is elevated and there is hemoglobinuria. This patient is likely to have which physical examination finding? (See Figure I6, Color Atlas.) A Goiter B Heme-positive stools C Mechanical second heart sound D Splenomegaly E Thickened calvarium

D Splenomegaly

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

D Sulfisoxazole

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

D Symptom-based therapy with over-the-counter agents

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

D There have been no reported cases of SARS since 2004.

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

D Toxocariasis

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

D clean the wound with a 20% soap solution, administer tetanus toxoid, administer human rabies immune globulin IM, and administer human diploid cell vaccine

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

D gastroesophageal reflux disease

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

D isoniazid, rifampin, pyrazinamide, ethambutol

1365 All the following are associated with pure red cell aplasia except A anterior mediastinal masses B connective tissue disorders C giant pronormoblasts D low erythropoietin levels E parvovirus B19 infection

D low erythropoietin levels

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

D progressive dementia

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

D right upper quadrant pain and fever

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

D terbinafine

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

E 0.9

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

E All of the above

1306 A 28-year-old woman presents with fevers, headache, diaphoresis, and abdominal pain 2 days after returning from an aid mission to the coast of Papua New Guinea. Several of her fellow aid workers developed malaria while abroad, and she stopped her doxycycline prophylaxis due to a photosensitivity reaction 5 days prior. You send blood cultures, routine labs, and a thick and thin smear to evaluate the source of her fevers. Which of the following statements is accurate in reference to diagnosis of malaria? A A thick smear is performed to increase sensitivity in comparison to a thin smear but can only be performed in centers with experienced laboratory personnel and has a longer processing time. B Careful analysis of the thin blood film allows for prognostication based on estimation of parasitemia and morphology of the erythrocytes. C In the absence of rapid diagnostic information, empirical treatment for malaria should be strongly considered. D Morphology on blood smear is the current criterion used to differentiate the four species of Plasmodium that infect humans. E All of the above are true.

E All of the above are true.

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

E Cefotaxime plus vancomycin

1344 A 45-year-old man from western Kentucky presents to the emergency room in September complaining of fevers, headaches, and muscle pains. He recently had been on a camping trip with several friends during which they hunted for their food, including fish, squirrels, and rabbits. He did not recall any tick bites during the trip, but does recall having several mosquito bites. For the past week, he has had an ulceration on his right hand with redness and pain surrounding it. He also has noticed some pain and swelling near his right elbow. None of the friends he camped with have been similarly ill. His vital signs are: blood pressure 106/65 mmHg, heart rate 116 beats/min, respiratory rate 24 breaths/min, and temperature 38.7°C. His oxygen saturation is 93% on room air. He appears mildly tachypneic and flushed. His conjunctiva are not injected and his mucous membranes are dry. The chest examination reveals crackles in the right mid-lung field and left base. His heart rate is tachycardic but regular. There is a II/VI systolic ejection murmur heard best at the lower left sternal border. His abdominal examination is unremarkable. On the right hand, there is an erythematous ulcer with a punched-out center covered by a black eschar. He has no cervical lymphadenopathy, but there are markedly enlarged and tender lymph nodes in the right axillae and epitrochlear regions. The epitrochlear node has some fluctuance with palpation. A chest x-ray shows fluffy bilateral alveolar infiltrates. Over the first 12 h of his hospitalization, the patient becomes progressively hypotensive and hypoxic, requiring intubation and mechanical ventilation. What is the most appropriate therapy for this patient? A Ampicillin, 2 g IV q6h B Ceftriaxone, 1 g IV daily C Ciprofloxacin, 400 mg IV twice daily D Doxycycline, 100 mg IV twice daily E Gentamicin, 5 mg/kg twice daily

E Gentamicin, 5 mg/kg twice daily

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

E HIV viral load set point 6 months after initial infection

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

E High-resolution CT plus serum galactomannan enzyme immunoassay

1400 Which of the following best describes the mechanism of action of clopidogrel? A Activates antithrombin and inhibits clotting enzymes B Binds to the activated GPIIb/IIIa receptor on the platelet surface to block binding of adhesive molecules C Inhibits cyclooxygenase 1 (COX-1) on platelets to decrease production of thromboxane A2 D Inhibits phosphodiesterase to block the breakdown of cyclic adenosine monophosphate (cAMP) to inhibit platelet activation E Irreversibly blocks P2Y12 to prevent adenosine diphosphate (ADP)-induced platelet aggregation

E Irreversibly blocks P2Y12 to prevent adenosine diphosphate (ADP)-induced platelet aggregation

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

E Measles-mumps-rubella (MMR) vaccine

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

E Neisseria meningitis

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

E Polymerase chain reaction (PCR) to identify the Norwalk-associated calcivirus

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

E RSV immune globulin should be given monthly to children <2 years old who were born prematurely.

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

E Rabies inactivated virus vaccine plus immunoglobulins

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

E Reassurance

1314 A 45-year-old woman with known HIV infection and medical nonadherence to therapy is admitted to the hospital with 2-3 weeks of increasing dyspnea on exertion and malaise. Chest radiograph shows bilateral alveolar infiltrates and induced sputum is positive for Pneumocystis jiroveci. Which of the following clinical conditions is an indication for administration of adjunct glucocorticoids? A Acute respiratory distress syndrome B CD4+ lymphocyte count < 100/μL C No clinical improvement 5 days into therapy D Pneumothorax E Room air PaO2 <70 mmHg

E Room air PaO2 <70 mmHg

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

E Seroprevalence rates of HSV-2 are lower in Africa than in the United States.

1325 A 26-year-old asthmatic continues to have coughing fits and dyspnea despite numerous steroid tapers and frequent use of albuterol over the past few months. Persistent infiltrates are seen on chest roentgenogram. A pulmonary consultation suggests an evaluation for allergic bronchopulmonary aspergillosis. What is the diagnostic test of choice? A Bronchoalveolar lavage (BAL) with fungal culture B Galactomannan enzyme immunoassay (EIA) C High-resolution CT D Pulmonary function tests E Serum IgE level

E Serum IgE level

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

E Severe hypersensitivity reaction

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

E Staphylococcus epidermidis

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

E Streptomycin

1302 A 36-year-old man with a history of hypertension presents complaining of a 3-year history of constant fatigue, diffuse myalgias, and memory deficits. He also notes trouble with routine tasks at work. He was diagnosed with Lyme disease 4 years ago and was briefly admitted to a cardiac care unit for transient third-degree heart block. Symptoms at that time included fever, malaise, arthralgias, diffuse erythema migrans, and facial nerve palsy. He received ceftriaxone, 2 g/d for 28 days, and had complete resolution of symptoms for several months but then developed his new constellation of problems that have gradually worsened over time. Physical examination is totally within normal limits. Which is the appropriate next step in management? A Borrelia burgdorferi enzyme-linked immunosorbent assay B Ceftriaxone, 2 g daily × 1 month C Doxycycline, 100 mg PO daily for life D Prednisone, 60 mg PO daily E Symptomatic treatment

E Symptomatic treatment

1390 A 34-year-old woman presents for evaluation of left lower extremity swelling and pain. She is obese and 8 weeks postpartum. She recently traveled 6 h by airplane to visit her parents with her infant. She has had no dyspnea, palpitations, or syncope. She is currently on no medications except iron tablets. She is otherwise healthy. Her vitals signs are: heart rate 86 beats/min, blood pressure 110/80 mm/Hg, temperature 37.0°C, and respiratory rate 12 breaths/min. Her weight is 98 kg, and height is 170 cm. The left lower extremity is swollen, tender, and warm to touch. A Homan's sign is present, but there are no palpable cords. A lower extremity Doppler shows a thrombosis in the common and superficial femoral veins of the left leg. You are considering outpatient treatment with enoxaparin. All of the following statements regarding low-molecular-weight heparins (LMWH) are true except A In patients with uncomplicated deep venous thrombosis (DVT), LMWH is a safe and effective alternative to IV heparin and is associated with reduced health care costs compared to IV heparin. B LMWH can be safely used in pregnancy, but factor Xa levels should be monitored to ensure adequate anticoagulation. C Monitoring of factor Xa levels is unnecessary in most patients as there is a predictable dose-dependent anticoagulation effect. D There is a decrease in the risk of development of heparin-induced thrombocytopenia with use of LMWH. E This patient's recent pregnancy is a contraindication to use of LMWH because there is a greater risk of bleeding with LWMH compared to IV heparin.

E This patient's recent pregnancy is a contraindication to use of LMWH because there is a greater risk of bleeding with LWMH compared to IV heparin.

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

E Toxoplasma gondii

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

E Trichinella

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

E Typical hospital-acquired infections (e.g., central line infection, hospital-acquired pneumonia, urinary tract infection)

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

E Upper endoscopy

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

E Urea breath test

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

E Vaccinees should continue to receive standard Pap smear testing.

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

E Weil's syndrome (Leptospira interrogans infection)

1328 During the late 1990s, there was a resurgence of all of the following bacterial sexually transmitted infections (STIs) among homosexual men except A chlamydia B gonorrhea C lymphogranuloma venereum D syphilis E all of the above had a resurgence

E all of the above had a resurgence

1399 All the following are late complications of bone marrow transplant preparative regimens except A growth retardation B azoospermia C hypothyroidism D cataracts E dementia

E dementia

1368 An 81-year-old male is admitted to the hospital for altered mental status. He was found at home, confused and lethargic, by his son. His past medical history is significant for metastatic prostate cancer. The patient's medications include periodic intramuscular goserelin injections. On examination he is afebrile. Blood pressure is 110/50 mmHg, and the pulse rate is 110 beats/min. He is lethargic and minimally responsive to sternal rub. He has bitemporal wasting, and his mucous membranes are dry. On neurologic examination he is obtunded. The patient has an intact gag reflex and withdraws to pain in all four extremities. Rectal tone is normal. Laboratory values are significant for a creatinine of 4.2 mg/dL, a calcium level of 12.4 meq/L, and an albumin of 2.6 g/dL. All the following are appropriate initial management steps except A normal saline B pamidronate C furosemide when the patient is euvolemic D calcitonin E dexamethasone

E dexamethasone

1357 All the following are vitamin K-dependent coagulation factors except A factor X B factor VII C protein C D protein S E factor VIII

E factor VIII

1309 In a patient with known HIV infection, all of the following are an AIDS-defining criterion except A active pulmonary tuberculosis B CD4+ lymphocyte count < 200/μL C cryptococcal meningitis D cytomegalovirus (CMV) retinitis E herpes zoster infection involving more than one dermatome

E herpes zoster infection involving more than one dermatome

1376 A patient with acute lymphoid leukemia (ALL) is admitted with respiratory distress and chest pain. The patient reports 1 day of shortness of breath not associated with cough. There have been no sick contacts, and before the onset of the respiratory symptoms, the patient only recalls fatigue. A chest radiograph shows faint diffuse interstitial infiltrates without pulmonary edema. The cardiac silhouette is normal. An arterial blood gas shows a PaO2 = 54 mmHg, while the pulse oximetry is 97% on room air. A carbon monoxide level is normal. All of the following laboratory abnormalities are expected in this patient except A bcr-abl mutation B blast count >100,000/μL C elevated lactate dehydrogenase levels D increased blood viscosity E methemoglobinemia

E methemoglobinemia

1358 A 31-year-old male with hemophilia A is admitted with persistent gross hematuria. He denies recent trauma or any history of genitourinary pathology. The examination is unremarkable. Hematocrit is 28%. All the following are treatments for hemophilia A except A desmopressin (DDAVP) B fresh-frozen plasma (FFP) C cryoprecipitate D recombinant factor VIII E plasmapheresis

E plasmapheresis

1395 The most common cause of high serum calcium in a patient with a known cancer is A ectopic production of parathyroid hormone B direct destruction of bone by tumor cells C local production of tumor necrosis factor and IL-6 by bony metastasis D high levels of 1,25-hydroxyvitamin D E production of parathyroid hormone-like substance

E production of parathyroid hormone-like substance

1334 All the following patient characteristics are included in the calculation of the Pneumonia Patient Outcomes Research Team (PORT) score that is used in the evaluation of patients with community-acquired pneumonia except A age B coexisting illness C laboratory findings D radiographic findings E smoking history

E smoking history

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

E symptoms beginning on days 14-21 of the menstrual cycle

1301 A 62-year-old man returns from a vacation to Arizona with fever, pleurisy, and a nonproductive cough. All of the following factors on history and laboratory examination favor a diagnosis of pulmonary coccidioidomycosis rather than community-acquired pneumonia except A eosinophilia B erythema nodosum C mediastinal lymphadenopathy on chest roentgenogram D positive Coccidioides complement fixation titer E travel limited to Northern Arizona (Grand Canyon area)

E travel limited to Northern Arizona (Grand Canyon area)