ID

Question 1

A 25-year-old male presents to your office after recently being diagnosed with HIV infection at the health department. You obtain blood work and note that his CD4+ count is 180 cells/mm3.

This patient should receive prophylaxis against which one of the following opportunistic infections? (check one)
Histoplasma capsulatum
Microsporidiosis
Mycobacterium avium-intracellulare complex
Pneumocystis
Toxoplasma g

Answer 1

Pneumocystis

Patients with HIV infection and severe immunodeficiency are at risk for certain opportunistic infections. Susceptibility to opportunistic infections can be measured by CD4+ T lymphocyte counts. Patients with a CD4+ count <200 cells/mm3 should receive trimethoprim/sulfamethoxazole for prevention of Pneumocystis pneumonia, and prophylaxis against Toxoplasma gondii should also be given if the CD4+ level is <100 cells/mm3. Azithromycin is used to prevent infection with Mycobacterium avium-intracellulare complex when CD4+ counts are <50 cells/mm3. Itraconazole is used to prevent Histoplasma capsulatum infection when the CD4+ count is :150 cells/mm3 if the patient is at risk due to occupational exposure or living in a community with a hyperendemic rate of histoplasmosis (>10 cases per 100 patient years). There is no recommendation for prophylaxis against microsporidiosis.

Question 2

A 6-year-old male is diagnosed with acute bacterial sinusitis. He has a previous history of a rash 5 days after beginning penicillin treatment.

Which one of the following medications is most appropriate for this patient? (check one)
Amoxicillin/clavulanate (Augmentin)
Trimethoprim/sulfamethoxazole (Bactrim)
Cefuroxime (Ceftin
Doxycycline
Azithromycin (Zithromax)

Answer 2

Cefuroxime (Ceftin

Recent reports indicate that the risk of a serious allergic reaction to second-and third-generation cephalosporins in patients with penicillin or amoxicillin allergy appears to be almost nil, and no greater than the risk among patients without such allergies. While patients with a history of a serious type I immediate or accelerated (anaphylactoid) reaction to amoxicillin can be safely treated with cefdinir, cefuroxime, or cefpodoxime, some physicians may wish to recommend an allergy referral to determine tolerance before initiation of therapy. Pneumococcus and Haemophilus influenzae are often resistant to trimethoprim/sulfamethoxazole and azithromycin, and these agents are therefore not recommended for the treatment of acute bacterial sinusitis in the penicillin-allergic patient. Doxycycline should not be used in children younger than 8 years of age except for anthrax and some tickborne infections. Amoxicillin/clavulanate is contraindicated in a penicillin-allergic patient.

Question 3

A 3-week-old male is brought to your office because of a fever and increasing fussiness. He had
a rectal temperature at home earlier today of 101.5°F (38.6°C). The mother reports that he is
not breastfeeding as often as usual and has had fewer wet diapers. He has no nasal congestion
and no cough. There are no recent sick contacts or known exposures.
On examination you note a fever of 39.2°C (102.5°F) and a pulse rate of 200 beats/min. The
remainder of his examination is normal. You order a full sepsis workup and admit him to the
hospital.

Which one of the following is the best intravenous antibiotic regimen for empiric coverage at
this point?
(check one)
Ampicillin and cefotaxime (Claforan)
Ampicillin and clindamycin (Cleocin)
Ciprofloxacin (Cipro)
Gentamicin
Vancomycin

Answer 3

Ampicillin and cefotaxime (Claforan)

Any child younger than 29 days with a fever should undergo a complete sepsis workup and be admitted
for observation until culture results are obtained or the source of the fever is found and treated (SOR A).
The most common bacterial organisms in this age group are group B Streptococcus and Escherichia coli.
However, many other pathogens have been known to cause sepsis; therefore, broad empiric coverage with
ampicillin and cefotaxime is recommended (SOR B). Gentamicin is commonly used, but should be used
in combination with ampicillin. Vancomycin is not recommended as first-line treatment unless the child
has evidence of a soft-tissue infection suspected to be methicillin resistant (SOR C). Ciprofloxacin and
clindamycin are not indicated treatments in this case.

Question 4

A 34-year-old male who recently immigrated to the United States from Mexico comes to your clinic to complete a comprehensive health evaluation for a custodial job at a hospital, and he must be screened for tuberculosis. He recalls getting many vaccines as a child, including one for tuberculosis.

Which one of the following screening tests for tuberculosis is preferred for this patient? (check one)
A stained sputum culture for acid-fast bacilli
Skin testing
Serology
Nucleic acid amplification testing
Interferon-gamma release assays

Answer 4

Interferon-gamma release assays

Most Hispanic immigrants have received the bacille Calmette-Guérin (BCG) vaccine. Although past practice has been to interpret skin test results without regard to BCG status, false-positive tests in this population are common. Interferon-y release assays are preferred to tuberculin skin testing in immigrants who have been vaccinated with BCG.

Question 5

An 18-month-old male is brought to your office by his parents for a well child check. The child was born at 28 weeks gestation and had a month-long NICU stay but has remained healthy and out of the hospital since that time. He is up to date on vaccines and his growth and development are appropriate. He was on omeprazole (Prilosec) for GERD but the parents have recently stopped the medication and he is doing well. He received palivizumab (Synagis) monthly last year during respiratory syncytial virus (RSV) season and never developed a respiratory infection. His parents are hoping that he can receive palivizumab again this year to prevent complications if he develops RSV. He recently started attending day care and they are worried about his exposure risk.

Which one of the following would you recommend this year for chemoprophylaxis against RSV in this patient? (check one)
No chemoprophylaxis
A single dose of palivizumab only if RSV exposure is confirmed
A single dose of palivizumab prior to RSV season
Monthly administration of palivizumab during RSV season

Answer 5

No chemoprophylaxis

With the increasing shortage of pediatric providers, especially in rural areas, family physicians need to be comfortable managing the care of premature infants. Palivizumab is recommended for all infants born before 29 weeks gestational age who are less than 1 year of age at the beginning of respiratory syncytial virus season, or for those born at less than 32 weeks gestational age who develop chronic lung disease of prematurity. After 1 year of age, palivizumab is only recommended for infants with chronic lung disease of prematurity who continue to require medical intervention for their lung disease. Therefore, this child should not receive palivizumab.

Question 6

An 18-month-old male with a history of prematurity at 36 weeks gestation but no baseline lung disease is brought to the emergency department with a fever of 38.3°C (100.9°F), rhinorrhea, cough, wheezing, mild tachypnea, and an oxygen saturation of 88%. A chest radiograph reveals perihilar infiltrates, and a nasal swab is positive for respiratory syncytial virus (RSV) antigen.

Which one of the following management options has evidence of benefit for this patient? (check one)
Aerosolized ribavirin
Supplemental oxygen
Intravenous corticosteroids
Macrolide antibiotics

Answer 6

Supplemental oxygen

Respiratory syncytial virus (RSV) bronchiolitis is responsible for approximately 2.1 million health care encounters annually in the United States. The child in this case has a typical presentation of RSV bronchiolitis. The diagnosis can be made clinically, although specific testing for RSV is often used in the hospital setting to segregate RSV-infected patients from others. Management is primarily supportive, especially including maintenance of hydration and oxygenation. Bronchodilators, corticosteroids, and antiviral agents do not have a significant impact on symptoms or the disease course. Ribavirin is not recommended for routine use due to its expense, conflicting data on effectiveness, and potential toxicity to exposed health care workers. Antibiotics are of no benefit in the absence of bacterial superinfection.

Question 7

An 18-month-old male is brought to your office by his mother. The patient is tugging at both ears and has a temperature of 39.0°C (102.2°F). You diagnose bilateral acute otitis media for the third time in the last 6 months. The most recent infection was 3 weeks ago and resolution of the infection was documented after 10 days of treatment with amoxicillin.

Which one of the following antibiotic regimens would be most appropriate at this time? (check one)
Amoxicillin, 45 mg/kg/day for 10 days
Amoxicillin, 90 mg/kg/day for 10 days
Amoxicillin, 90 mg/kg/day for 10 days followed by prophylactic treatment with amoxicillin for 6 months
Amoxicillin/clavulanate (Augmentin), 90 mg/kg/day for 10 days
Amoxicillin/clavulanate, 90 mg/kg/day for 10 days followed by prophylactic treatment with amoxicillin for 6 months

Answer 7

Amoxicillin/clavulanate (Augmentin), 90 mg/kg/day for 10 days

Although high-dose amoxicillin (90 mg/kg/day) is recommended as the antibiotic of choice for acute otitis media (AOM) in the nonallergic patient, amoxicillin/clavulanate is recommended if a child has received antibiotic therapy in the previous 30 days. Prophylactic antibiotics are not recommended, as harms outweigh benefits. Tympanostomy tubes are an option if a child has had three episodes of AOM in the past 6 months or four episodes in the past year with at least one episode in the past 6 months.

Question 8

To reduce overuse of antibiotics, the CDC promotes antibiotic stewardship. The recommended intervention is the implementation of an antibiotic time-out to improve outcomes when prescribing antibiotics in hospitals.

When should an antibiotic time-out be scheduled when prescribing an antibiotic at the time a patient is admitted to the hospital? (check one)
Before starting the initial antibiotic order
12–24 hours after the initial antibiotic order
48 hours after the initial antibiotic order
5–7 days after the initial antibiotic order
Prior to an antibiotic order at discharge

Answer 8

48 hours after the initial antibiotic order

For patients started on empiric antibiotic therapy at hospital admission, the CDC recommends an antibiotic
time-out 48 hours after the initial order to determine if it can be stopped or needs to be changed. The dose,
route, and duration should also be reviewed. The rationale is that antibiotics are often ordered empirically
at the time of admission, while cultures and other studies are also being ordered. The original empiric
order should be reassessed, incorporating the results of these studies while considering the evolving clinical
status of the patient. Studies show this reassessment with antibiotic modification does not reliably occur.

Question 9

A 62-year-old female presents to your office with diarrhea and signs and symptoms of
dehydration. She has a temperature of 38.6°C (101.5°F) and a WBC count of 17,000/mm3 (N
5300–10,800). You admit her to the hospital, and a Clostridium difficile toxin assay is positive.
Because of the severity of her infection, you initiate oral vancomycin (Vancocin), 125 mg 4
times daily. She has a poor clinical response and you decide to alter the antibiotic regimen to
include intravenous coverage.

Which one of the following intravenous antibiotics would be most appropriate?
(check one)
Ciprofloxacin (Cipro)
Imipenem/cilastatin (Primaxin)
Meropenem (Merrem)
Metronidazole
Vancomycin

Answer 9

Metronidazole

Metronidazole, vancomycin, and fidaxomicin are the three medications recommended for treatment of
Clostridium difficile colitis infections. Only metronidazole is effective intravenously, because its biliary
excretion and possibly exudation through the colonic mucosa allows it to reach the colon via the
bloodstream. Treatment for this condition with vancomycin and fidaxomicin is oral. Imipenem/cilastatin,
ciprofloxacin, and meropenem have not been shown to be effective for C. difficile infection.

Question 10

A 69-year-old female presents with her first episode of Clostridium difficile colitis, which is
characterized as severe. Which one of the following is the most appropriate initial therapy?
(check one)
Oral metronidazole (Flagyl)
Intravenous metronidazole
Oral vancomycin (Vancocin)
Intravenous vancomycin
Rifaximin (Xifaxan)

Answer 10

Oral vancomycin (Vancocin)

Vancomycin, 125 mg orally 4 times daily for 10–14 days, is recommended for the first severe episode of
Clostridium difficile colitis (SOR B). If the first episode is mild to moderate, oral metronidazole, 500 mg
3 times daily for 10–14 days, would be preferred. Intravenous vancomycin is not effective in the treatment
of colitis. Rifaximin is not well studied and is not recommended in any current guidelines.

Question 11

A 5-year-old female is brought to the emergency department by her parents after her temperature increases to 104°F. On examination she has noticeable inspiratory stridor. She is restless and drooling, and her voice is muffled. In spite of the nurse’s repeated efforts to get the child to lie back, the patient continues to sit forward in a sniffing position. Her parents indicate that they have declined vaccinations for the patient since leaving the hospital after delivery.

Which one of the following is the most important next step in management? (check one)
Supplemental oxygen by nasal cannula
Intravenous fluids
Arterial blood gas measurement
A CBC
Direct visualization of the epiglottis in the operating room

Answer 11

Direct visualization of the epiglottis in the operating room

The most likely diagnosis is epiglottitis. Inflammatory edema of the epiglottis and surrounding tissues is potentially life-threatening, as this edema can lead to complete airway obstruction. The epiglottis must be visualized in the operating room in case of life-threatening spasms that can lead to airway obstruction. The surgeon must be prepared to perform tracheostomy if airway obstruction develops.

Supplemental oxygen, intravenous fluids, and laboratory studies are reasonable supportive and diagnostic options. However, immediate intervention in the operating room is the most important next step to prevent airway obstruction.

Question 12

A 25-year-old male has developed a painless ulcer on the glans of his penis. After an appropriate examination and testing you diagnose primary syphilis and treat him with 2.4 million units of benzathine penicillin intramuscularly in a single dose. Eight hours later, while you are working the evening clinic, he returns because he has a fever of 100.6°F and a bad headache, which he rarely gets. He says he “aches all over.”

Which one of the following would be most appropriate at this time?
(check one)
Three blood cultures from different sites at 30-minute intervals
CT of the head
A lumbar puncture
Doxycycline, 100 mg orally twice a day for 14 days
Reassurance and antipyretics

Answer 12

Reassurance and antipyretics

This patient is experiencing the Jarisch-Herxheimer reaction—an acute, transient, febrile reaction that occurs within the first few hours after treatment for syphilis. The condition peaks at 6–8 hours and disappears within 12–24 hours after therapy. The temperature elevation is usually low grade, and there is often associated myalgia, headache, and malaise. It is usually of no clinical significance and may be treated with salicylates in most cases. The pathogenesis of the reaction is unclear, but it may be due to liberation of antigens from the spirochetes.

Question 13

A 54-year-old female presents with painful sores in her mouth that appeared a few days ago. She has had some trouble eating due to the pain, but she is able to swallow without difficulty. She also began to have some pain around her right ear today. She has no fever, chills, nasal congestion, cough, or difficulty hearing. Her medical history is significant only for an anxiety disorder treated with sertraline (Zoloft). On examination her vital signs are all normal. You see vesicles on the right side of the hard palate and she has a swollen, red right pinna, with vesicles in the external auditory canal.

The organism responsible for this condition is (check one)
coxsackievirus
Epstein-Barr virus
group A Streptococcus
herpes simplex virus
varicella zoster virus

Answer 13

varicella zoster virus

This patient has herpes zoster oticus, which is also known as Ramsay Hunt syndrome when associated with a facial nerve palsy. It is caused by reactivation of the varicella-zoster virus (VZV) in the geniculate ganglion of the facial nerve. Typical symptoms include painful vesicles on one side of the palate and the ipsilateral ear. When the reactivation involves other branches of the facial nerve it can result in a unilateral facial herpetiform rash that may also involve the anterior two-thirds of the tongue, taste disturbance, and reduced lacrimation. If the nearby cochlear and vestibular nerves become involved, patients may also experience hearing loss, tinnitus, nausea, vomiting, and vertigo. The diagnosis is usually made clinically, but if confirmation is needed polymerase chain reaction testing of vesicular fluid or of a swab of the base of an ulcer may be done. Treatment includes antivirals (acyclovir, valacyclovir) and prednisone, and is more effective when started sooner in the course of illness.

Herpes simplex virus (HSV) can cause oral vesicles and ulcers, but the distribution of vesicles in the ear and the mouth of this patient is not typical for HSV. Epstein-Barr virus can cause leukoplakia of the mouth but not vesicles and is typically associated with systemic signs of illness. Group A Streptococcus causes throat pain and fever, not vesicles. Coxsackievirus causes oral vesicles and ulcers but is usually associated with fever and does not typically involve the ear.

Question 14

A 26-year-old male presents to the emergency department with a fever, and he appears acutely ill. After a previously undocumented grade 3 murmur is detected on examination, a transthoracic echocardiogram is ordered and reveals a 1.5-cm vegetation on the tricuspid valve.

Which one of the following is the most likely causative organism?
(check one)
Cardiobacterium hominis
Enterococcus faecalis
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus viridans

Answer 14

Staphylococcus aureus

Staphylococcus aureus is the most common cause of acute infectious endocarditis worldwide. Additionally, the most common cause of tricuspid valve endocarditis is intravenous drug abuse, and Staphylococcus aureus is the infecting organism in 80% of tricuspid valve infections. Streptococcus viridans is also a frequent cause of infectious endocarditis, with Enterococcus, Pseudomonas, and Cardiobacterium being less likely causes.

Question 15

Which one of the following is the usual reservoir for hantavirus?

(check one)
Prairie dogs
Jackrabbits
Deer mice
Ground squirrels

Answer 15

Deer mice

Up through July of 2013, the Centers for Disease Control and Prevention had logged 624 cases of hantavirus pulmonary syndrome in residents of 34 states. The infection killed more than a third of the victims. The virus is usually spread by inhalation of dried aerosolized deer mouse urine or droppings. Infected deer mice usually have few outward signs. Other hosts include the white-footed mouse, the rice rat, and the cotton rat. Other rodents have not been shown to carry the virus.

Question 16

The scabies mite is predominantly transmitted by: (check one)
Bedclothes
Personal contact
Hats
Pets

Answer 16

Personal contact

The scabies mite is predominantly transmitted by direct personal contact. Infestation from indirect contact with clothing or bedding is believed to be infrequent. Hats are frequent transmitters of head lice, but not scabies.

Question 17

The CDC has designated several diseases as neglected parasitic infections in the United States.
Which one of these, if untreated, has potential consequences that include cardiomyopathy, heart
failure, and fatal cardiac arrhythmias?
(check one)
Trichomoniasis
American trypanosomiasis (Chagas disease)
Toxoplasmosis
Cysticercosis
Toxocariasis

Answer 17

American trypanosomiasis (Chagas disease)

Chagas disease is caused by Trypanosoma cruzi, and is estimated to infect some 300,000 persons in the
United States. Potential consequences include cardiomyopathy, heart failure, and fatal cardiac arrhythmias.
The CDC has designated Chagas disease as a neglected parasitic infection, based on the number of people
estimated to be infected in the United States, the potential severity of the illness, and the ability to prevent
and treat this disease. This infection is considered neglected because relatively little attention has been
devoted to its surveillance, prevention, and/or treatment. It is most common in those who live in rural,
impoverished areas in Mexico or central America, where the vector of the disease, the kissing bug, is
found.

Trichomoniasis can lead to infertility and poor birth outcomes. Toxocariasis and toxoplasmosis cause
developmental defects in children. Cysticercosis can lead to epilepsy in young adults. Some of these
sequelae develop years after an initial mild infection.

Question 18

Which one of the following is the most effective initial treatment of head lice in an 8-year-old child? (check one)
Lindane (Kwell)
Wet combing every 4 days, to continue for 2 weeks after any louse is found
Head shaving
Nightly application of petrolatum to the scalp, covered by a shower cap
Malathion (Ovide)

Answer 18

Malathion (Ovide)

Malathion is currently the most effective treatment for head lice and is less toxic than lindane. Permethrin and pyrethrins are less effective than malathion, although they are acceptable alternatives. These insecticides, as well as lindane, are not recommended in children 2 years of age or younger. Wet combing may be effective, but is less than half as effective as malathion. Head shaving is only temporarily effective and is traumatic. Petrolatum is not proven to be effective.

Question 19

In early February, you receive a call from your office nurse. Her 5-month-old daughter has been ill for several days. What started as a mild upper respiratory infection has progressed and she now has profuse rhinorrhea, a temperature of 100.2° F (37.9° C), and audible wheezing. In spite of an almost nonstop cough, she does not appear acutely ill. The organism responsible for this child’s illness is most likely to be: (check one)
Group B Streptococcus
Mycoplasma pneumoniae
Bordetella pertussis
Parainfluenza virus 3
Respiratory syncytial virus

Answer 19

Respiratory syncytial virus

The most common cause of pneumonia in children age 4 months to 4 years is respiratory syncytial virus. Other viruses may cause pneumonia as well. The peak incidence of respiratory syncytial virus is between 2 and 7 months of age. Wheezing and profuse rhinorrhea are characteristic and the disease typically occurs in mid-winter or early spring epidemics. Parainfluenza 3 typically affects older infants and is not common in winter. Mycoplasma tends to affect older children and children with bacterial illnesses; those infected with this organism generally appear more acutely ill.

Question 20

A 32-year-old female contacts you through the patient portal regarding a 5-day history of symptoms consistent with acute rhinosinusitis. Which one of the following treatment recommendations would be in alignment with current recommendations from the Infectious Diseases Society of America? (check one)
Symptomatic treatment only
Amoxicillin
Amoxicillin/clavulanate (Augmentin)
Azithromycin (Zithromax)
Levofloxacin

Answer 20

Symptomatic treatment only

The Infectious Diseases Society of America guidelines recommend observation and symptomatic treatment for acute rhinosinusitis until after 7 days, at which point antibiotics are recommended. However, the number needed to treat to achieve clinical cure is 17 and the number needed to harm is 8. About 64% of patients will reach clinical cure at 14 days without antibiotics. When antibiotic treatment is warranted, amoxicillin/clavulanate rather than amoxicillin alone is recommended as empiric therapy for children and adults. Macrolides such as azithromycin are not recommended for empiric therapy due to high rates of resistance. Levofloxacin or doxycycline are recommended as an alternative agent in adults who are allergic to penicillin.

Question 21

A 30-year-old female reports that a new male sex partner told her that he has a urethral chlamydial infection. She has no symptoms, but testing with an endocervical swab confirms that she is also infected with Chlamydia. No other sexually transmitted infections are identified. She is not allergic to any medications.

Which one of the following would be the most appropriate treatment regimen for her? (check one)
Oral azithromycin (Zithromax), 1 g once
Oral cefixime (Suprax), 800 mg once
Oral doxycycline, 100 mg twice daily for 7 days
Oral levofloxacin, 500 mg daily for 7 days
Abdominal/pelvic CT

Answer 21

Oral doxycycline, 100 mg twice daily for 7 days

The current recommendation for the treatment of uncomplicated urogenital chlamydial infections is oral doxycycline, 100 mg twice daily for 7 days. Single-dose azithromycin may be considered if compliance is a concern, but the increasing resistance to macrolides is a potential problem. Levofloxacin is another alternative, but it is more costly and side effects may be an issue. Cefixime and ceftriaxone are used to treat gonococcal infections, not Chlamydia.

Question 22

A 45-year-old female who lives in southern Florida presents to the urgent care clinic after a suspected spider bite. She was cleaning up some debris on her patio when she felt a pinprick on her right lower extremity and saw a spider crawl off her leg. The spider was shiny, with a dark-colored body and a red hourglass shape on its abdomen. She developed pain around the bite area. She applied ice to the wound, but the pain has persisted and comes in waves. She currently rates her pain as 4 points on a 10-point scale.

The patient is up to date on her tetanus vaccination and is unaware of any allergies. Her vital signs are stable. She is not experiencing any chest pain, chest tightness, tachycardia, abdominal pain, or muscle spasms. A physical examination reveals a small target lesion on her right lateral malleolus, with some erythema and swelling at the site. The remainder of the physical examination is unremarkable.

The most appropriate initial step in management would be: (check one)
oral analgesia with NSAIDs
calcium and magnesium
parenteral opioids
antivenom
hospital admission

Answer 22

oral analgesia with NSAIDs

While they are rarely life-threatening, there are two medically relevant spiders in the United States: the recluse spider and the widow spider. The patient in this case likely has a widow bite. These are medium-sized spiders, reaching up to 4 cm (2 in). They have shiny, dark-colored bodies with a characteristic red hourglass marking. Widow spiders are rarely found inside the home, but rather in shady, enclosed spaces outdoors such as in a shed, under gardening equipment, and amid yard debris. Latrodectism, a systemic envenomation caused by excessive acetylcholine release that results in muscle spasm and diaphoresis of the affected extremity, is rare. Envenomation severity can be graded to help determine treatment. Mild presentations can be treated with oral nonopioid pain medications such as NSAIDs. Calcium and magnesium have not demonstrated any benefit in spider bites. Parenteral opioids are sometimes indicated for poorly controlled pain, and benzodiazepines can be used for painful muscle spasms. This patient is not experiencing these effects. The use of antivenom is controversial, especially because widow spider bites are rarely life-threatening. Antivenom may decrease pain duration, but there is a risk of allergic reaction in up to 5% of patients. Hospital admission is reserved for grade 3 clinical presentations with generalized muscular pain in the chest, abdomen, and back; diaphoresis of the bite site; headache; nausea; vomiting; and abnormal vital signs.

Question 23

A 35-year-old female presents to your office after a recent trip to Brazil. She tells you that she has developed an extremely pruritic rash that started on her face and has spread to her trunk and limbs. In addition, she reports a headache, arthralgias, and myalgias. On examination you note a diffuse scarlatiniform rash, conjunctivitis, and small petechiae on the palate. She is afebrile.

Which one of the following is the most likely diagnosis? (check one)
Chikungunya virus
Dengue virus
West Nile virus
Yellow fever
Zika virus

Answer 23

Zika virus

Zika virus, an RNA virus belonging to the Flaviviridae family, is most frequently found in tropical regions and is spread by the female Aedes species mosquito. While Zika virus infection shares many of the same symptoms as the other viruses listed, it often has no fever and the rash is accompanied by severe pruritus and conjunctivitis. Zika virus infection typically develops 3–12 days following a bite by the Aedes species mosquito and the symptoms last between a few days to 1 week. The disease is typically self-limited and does not require hospitalization. Zika virus infection during pregnancy can cause infants to be born with microcephaly and other congenital malformations, known as congenital Zika syndrome. Infection with Zika virus is also associated with miscarriage and preterm birth. Diagnosis is usually based on clinical presentation but may be confirmed with serologic testing. Chikungunya virus, dengue virus, West Nile virus, and yellow fever are also spread by mosquitos but have slightly different clinical presentations.

Chikungunya virus is an RNA virus in the Togaviridae family that is characterized by an abrupt onset of high fever, and is frequently accompanied by debilitating joint pain that usually lasts for a few days, but may prolong for weeks, months, or even years.

Like Zika virus, dengue virus is an RNA virus belonging to the Flaviviridae family spread by the Aedes species mosquito. The incubation period varies from 4 to 10 days and common symptoms include a high fever (40°C [104°F]) that is usually accompanied by at least two of the following symptoms: headaches, pain behind the eyes, nausea, vomiting, swollen glands, joint, bone or muscle pains, and rash.

West Nile virus is an RNA virus in the Flaviviridae family and is the leading cause of mosquito-borne disease in the continental United States. The incubation period varies from 3 to 14 days. Symptoms include fever, headache, tiredness and body aches, nausea, vomiting, swollen lymph glands, and sometimes a skin rash on the trunk.

Yellow fever is an RNA virus in the Flaviviridae family. Incubation time for the virus is 3–6 days. The most common symptoms are fever, muscle pain with prominent backache, headache, loss of appetite, and nausea or vomiting. In most cases, symptoms disappear after 3–4 days, but a small minority of patients become quite ill.

Question 24

You diagnose hand-foot-and-mouth disease in a 5-year-old male. His parents ask when he can return to kindergarten.

You advise that if he feels well enough to participate, he may return (check one)
5 days after the onset of symptoms
when afebrile and there are no mouth sores causing drooling
when afebrile as long as all skin lesions can be covered with a dressing
when afebrile and all skin lesions have crusted over

Answer 24

when afebrile and there are no mouth sores causing drooling

Hand-foot-and-mouth disease (HFMD) is very common among children younger than 10 years of age, and is very easily spread by fecal-oral, oral-oral, and respiratory droplet routes. As the disease is ubiquitous and has a very low complication rate, the CDC recommends allowing children to return to school or day care when they are afebrile, feel well enough to participate, and are not actively drooling with mouth lesions. There is no specific time course that must be followed, and the status of skin lesions does not affect return to school.

Question 25

A 47-year-old male presents to your office concerned about his “ugly” toenails. On examination you note that all of his toenails are discolored, thickened, and brittle. He was evaluated by a dermatologist and has been using topical ciclopirox 8% for 7 months. He does not recall any allergies to any medications.

After confirming your suspected diagnosis with a sample from the affected toenails, which one of the following would be the most appropriate oral pharmacotherapy? (check one)
Fluconazole (Diflucan)
Griseofulvin
Pulse dosing with itraconazole (Sporanox)
Continuous itraconazole
Terbinafine

Answer 25

Terbinafine

Onychomycosis, a chronic fungal infection affecting the toenail and fingernail beds, leads to discolored, brittle, and thickened nails. This is not just a cosmetic problem, but can cause discomfort, pain, and physical impairment affecting the quality of life. Obtaining an accurate diagnosis prior to initiating treatment is important to avoid adverse effects caused by lengthy treatment. Dermatophytes are the cause of 70% of onychomycosis. Risk factors include age older than 60; trauma; tobacco use; and comorbidities such as diabetes mellitus, peripheral vascular disease, HIV, malignancy, and obesity. Onychomycosis is classified into several subtypes based on nail invasion. Treatment includes topical and oral options. Terbinafine is the most effective oral agent for this patient who did not benefit from topical therapy and has all toenails affected. Fluconazole may be used off-label as an alternative or if a patient cannot tolerate terbinafine. Griseofulvin is rarely used due to its long treatment duration, lower cure rates, and higher risk of adverse reactions. A pulse-dosing regimen of itraconazole is used for the treatment of fingernails. Continuous itraconazole has a higher relapse rate than terbinafine.

Question 26

A 3-week-old infant is brought to your office with a fever. He has a rectal temperature of 38.3°C (101.0°F), but does not appear toxic. The remainder of the examination is within normal limits. Which one of the following would be the most appropriate management for this patient? (check one)
Admit to the hospital; obtain urine, blood, and CSF cultures; and start intravenous antibiotics
Admit to the hospital and treat for herpes simplex virus infection
Follow up in the office in 24 hours and admit to the hospital if not improved
Order a CBC and urinalysis with urine culture, and send the patient home if the results are normal

Answer 26

Admit to the hospital; obtain urine, blood, and CSF cultures; and start intravenous antibiotics

Any child younger than 29 days old with a fever and any child who appears toxic, regardless of age, should undergo a complete sepsis workup and be admitted to the hospital for observation until culture results are known or the source of the fever is found and treated (SOR A). Observation only, with close follow-up, is recommended for nontoxic infants 3-36 months of age with a temperature <39.0°C (102.2°F) (SOR B). Children 29-90 days old who appear to be nontoxic and have negative screening laboratory studies, including a CBC and urinalysis, can be sent home with precautions and with follow-up in 24 hours (SOR B). Testing for neonatal herpes simplex virus infection should be considered in patients with risk factors, including maternal infection at the time of delivery, use of fetal scalp electrodes, vaginal delivery, cerebrospinal fluid pleocytosis, or herpetic lesions. Testing also should be considered when a child does not respond to antibiotics (SOR C).

Question 27

Which one of the following is most appropriate for treatment of respiratory syncytial virus (RSV) bronchiolitis in otherwise healthy hospitalized infants? (check one)
Supportive care including as-needed oxygen and frequent nasal hygiene
Inhaled bronchodilators
Nebulized hypertonic saline every 4 hours
Systemic corticosteroids
Chest physiotherapy three times a day

Answer 27

Supportive care including as-needed oxygen and frequent nasal hygiene

Supportive care including as-needed oxygen and frequent nasal hygiene, in addition to hydration with intravenous fluids if indicated, are the mainstays of treatment in otherwise healthy infants hospitalized with respiratory syncytial virus (RSV) bronchiolitis. Inhaled bronchodilators, nebulized hypertonic saline, systemic corticosteroids, and chest physiotherapy do not reduce the length of hospitalization and are not indicated as first-line treatment in infants hospitalized with RSV bronchiolitis.

Question 28

A previously healthy 29-year-old pediatric nurse has a 3-day history of malaise, arthralgias, and a nonpruritic rash. The rash is a faint, maculopapular, irregular, reticulate exanthem that covers her thighs and the inner aspects of her upper arms. Symmetric synovitis is present in several distal and proximal interphalangeal joints and in her metacarpophalangeal joints. Small effusions, warmth, and tenderness are noted in her left wrist and right elbow. No other joints are affected.

The most likely cause of this problem is:
(check one)
Varicella-zoster virus
Measles (rubeola) virus
Parvovirus B19
Human immunodeficiency virus (HIV)

Answer 28

Parvovirus B19

Also known as erythema infectiosum or fifth disease, parvovirus B19 infection is a fairly common cause of an exanthematous rash and arthritis in younger women. This infection should be particularly suspected in health-care workers who have frequent contact with children. The specific characteristics of the rash, the pattern of joint involvement, and the place of employment in an otherwise healthy person all offer clues suggesting parvovirus B19 as the infecting agent. Measles virus, adenovirus, and HIV rarely cause arthritis, although HIV infection can cause a musculoskeletal syndrome later in the disease. Varicella-zoster virus may cause large-joint arthritis, but the rash is distinctively vesicular and pruritic.

Question 29

You have diagnosed a Chlamydia infection in a 24-year-old male. He reports having three sexual partners in the last month. He does not feel comfortable revealing their names or genders at this time.

In almost all U.S. states, which one of the following would be the most appropriate plan for timely treatment of the involved parties with azithromycin (Zithromax) as a single dose? (check one)
One prescription in the patient’s name
One prescription in the patient’s name and instructions to the patient to inform his partners
One prescription in the patient’s name with three refills
One prescription in the patient’s name and three prescriptions for expedited partner therapy
One prescription in the patient’s name and three blank prescriptions

Answer 29

One prescription in the patient’s name and three prescriptions for expedited partner therapy

Expedited partner therapy (EPT) is the clinical practice of treating the sex partners of patients diagnosed
with Chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her
partner without the health care provider first examining the partner. When patients have been diagnosed
with gonorrhea or Chlamydia, EPT has been shown to reduce the overall burden of disease in a given
population when the partners cannot be linked to care. In this case, as the partners’ identities are unknown,
it is impossible for the clinician to examine them or even contact them, so four prescriptions should be
written, one with the patient’s name and the other three for EPT. The CDC states that EPT is particularly
effective in treating the female partners of infected males. The CDC considers having the partners visit
a health care provider to be the optimal course of treatment but this is not often practically feasible due to
a lack of resources or social factors.
Although conventional practice is to treat only the patient, this does not provide timely treatment for the
patient’s partners. A prescription written to “EPT” can be filled at the pharmacy without the individual’s
name or date of birth. Kentucky and South Carolina are the only states that do not allow this practice. A
prescription with three refills would be unethical, as presumably the physician would be advising the
patient to distribute medications that had been prescribed to only the patient. Blank prescriptions would
require the partners to reveal their identities, which may lead to a reluctance to fill the prescriptions.

Question 30

One day after a nurse performs CPR on an emergency-department patient, she learns that the patient had meningococcal meningitis. Which one of the following is the most appropriate chemoprophylaxis for this condition? (check one)
Penicillin G benzathine (Bicillin LA), 1.2 million units intramuscularly
Rifampin, 600 mg every 12 hours for 2 days
Oral prednisone, 40 mg daily for 5 days
Quadrivalent meningococcal vaccine
No prophylaxis

Answer 30

Rifampin, 600 mg every 12 hours for 2 days

Health-care workers exposed to a patient with meningococcal meningitis are at increased risk of developing systemic disease and should receive chemoprophylaxis, especially if the contact is intimate. Secondary cases usually occur within 4 days of the initial case. Therefore, prophylactic treatment should begin as soon as possible. Rifampin has been shown to be 90% effective in eliminating meningococcus from the nasopharynx. Other appropriate chemoprophylactic agents include minocycline and ciprofloxacin. Even high doses of penicillin may not eradicate nasopharyngeal meningococci. Prednisone has no place in chemoprophylaxis. Meningococcal vaccine appears to have clinical efficacy, but it usually takes more than 5 days to become effective.

Question 31

A 3-year-old male was treated for acute otitis media last month. His mother brings him in for follow-up because she believes his hearing has not been normal since then. He attends day care and has had several upper respiratory infections. On examination the tympanic membranes are not inflamed, but the membrane is retracted on the right side. An office tympanogram shows a normal peak (type A) on the left side, but a flat tracing (type B) on the right side. Which one of the following would be the most appropriate recommendation? (check one)
Audiometry
Observation with follow-up
An antihistamine/decongestant combination
Intranasal corticosteroids
Systemic corticosteroids

Answer 31

Observation with follow-up

This patient has unilateral serous otitis and is unlikely to have delayed language from decreased hearing on one side. The patient should be observed for now. Hearing loss of longer than 3 months may indicate a need for tympanostomy tubes. Surgical treatment has been shown to be helpful, but should be reserved for patients with chronic effusion. Audiometry is not needed to make a decision about surgery at this point. The mother’s judgment is likely correct about his current hearing loss, so a hearing test most likely would not add any useful information. Numerous studies have shown that all medical treatments for serous otitis are ineffective, including antihistamine and decongestant therapy, and corticosteroids by any route.

Question 32

Which one of the following skin infections should initially be treated with oral antifungal therapy? (check one)
Tinea capitis
Tinea corporis
Tinea cruris
Erythrasma
Mycosis fungoides

Answer 32

Tinea capitis

Most tinea infections respond to topical therapy, but oral therapy is required for tinea capitis so that the drug will penetrate the hair shafts (SOR B). Tinea corporis may require oral therapy in severe cases, but usually responds to topical therapy (SOR A). Oral therapy has a higher likelihood of side effects. Erythrasma and mycosis fungoides are not fungal diseases.

Question 33

A 37-year-old male presents for a physical evaluation prior to starting a new job in a hospital. He recently immigrated from Uganda. An interferon-gamma release assay (IGRA, QuantiFERON-TB Gold) is positive. He is otherwise healthy. He has not had any cough, fever, unintended weight loss, or night sweats.

Which one of the following is the most appropriate next step? (check one)
Tuberculin skin testing
Inducing sputum for mycobacterial culture
Chest radiography
Proceeding with treatment for latent tuberculosis
Proceeding with treatment for active tuberculosis

Answer 33

Chest radiography

This patient’s tuberculosis (TB) screening test is positive, and the next step in the evaluation involves determining whether he has a latent infection or active disease. Diagnosis of latent TB requires ruling out active disease by assessing the patient clinically with a history, physical examination, and chest radiograph. If this evaluation does not suggest active disease, sputum studies are not needed. Interferon-gamma release assays (IGRA), which are blood tests used to screen for TB infection, are more accurate than tuberculin skin testing, so a tuberculin skin test is not needed. Treatment should not be started until a determination of latent versus active TB is made.

Question 34

A healthy 23-year-old presents for a physical examination required for entrance to nursing school. The patient’s vital signs and a physical examination are unremarkable. To complete the immunization requirements, you administer Tdap and varicella vaccines. The nursing school requests tuberculosis (TB) test results.

Which one of the following would be most appropriate regarding TB testing? (check one)
No testing because the patient is asymptomatic
A sputum culture
A tuberculin skin test
An interferon-gamma release assay (IGRA, QuantiFERON-TB Gold)
A chest radiograph

Answer 34

An interferon-gamma release assay (IGRA, QuantiFERON-TB Gold)

Initial tuberculosis screening is recommended for all health care providers upon hire and extends to health care students. Recommended tests for initial screening include the interferon-gamma release assay (IGRA, QuantiFERON-TB Gold) and tuberculin skin testing (TST). TST can be affected by live virus vaccines given within the previous 4 weeks. Since this patient received a live virus vaccine (varicella), a TST may be falsely negative. The IGRA, which is not affected by prior live vaccines, would be most appropriate for this patient. Additional advantages to the assay test include higher sensitivity and specificity than the TST, the need for only one visit, and objective results. While the TST is less expensive, there is risk for subjective or misread results and a requirement of two clinic visits. A sputum culture and a chest radiograph are only indicated in the setting of positive screening results with the above-mentioned tests.

Question 35

A 62-year-old male with a history of COPD sees you because of fever, chills, and redness and swelling in his right lower extremity that has been progressing. He has a temperature of 38.0°C (100.4°F), a blood pressure of 112/72 mm Hg, and a pulse rate of 94 beats/min. The physical examination is remarkable for an erythematous area with increased warmth that extends approximately 18 cm (7 in) between the knee and ankle. You note no apparent abscess formation. The patient does not recall any specific injury that could have caused this problem.

According to the guidelines of the Infectious Diseases Society of America, which one of the following would be the most appropriate antibiotic regimen for this patient? (check one)
Ceftriaxone (Rocephin)
Piperacillin/tazobactam (Zosyn)
Vancomycin (Vancocin)
Vancomycin plus ceftriaxone
Vancomycin plus piperacillin/tazobactam

Answer 35

Ceftriaxone (Rocephin)

The most common pathogen for nonpurulent cellulitis is β-hemolytic streptococci. Guidelines from the Infectious Diseases Society of America recommend treating moderate nonpurulent cellulitis with penicillin, ceftriaxone, cefazolin, or clindamycin alone. Vancomycin would be indicated if the patient had a history of illicit drug use, purulent drainage, concurrent evidence of MRSA infection elsewhere, nasal colonization with MRSA, or severe cellulitis.

Question 36

A 50-year-old male comes to your office for a “doctor’s excuse” for days of work he missed last week. He attended a picnic where he and other guests developed nausea and vomiting 2 hours after eating. Within 48 hours, the symptoms had resolved.

The most likely etiology of the illness is which one of the following?
(check one)
Staphylococcus
Clostridium botulinum
Clostridium perfringens
Clostridium difficile
Actinomycosis

Answer 36

Staphylococcus

This is a typical presentation of staphylococcal food poisoning. The symptoms usually begin 1–6 hours after ingestion and resolve within 24–48 hours. Foodborne botulism is most commonly found in homecanned foods, and symptoms begin 18–36 hours after ingestion. Clostridium perfringens is transmitted in feces and water, and symptoms begin 6–24 hours after ingestion. Clostridium difficile is associated with antibiotic use. Actinomycosis causes local abscesses, not gastroenteritis.

Question 37

Which one of the following treatment regimens is most appropriate for an HIV-positive 42-year old who has latent tuberculosis infection? (check one)
Isoniazid daily for 9 months
Rifampin (Rifadin) daily for 4 months
Rifampin plus pyrazinamide daily for 2 months
Combination therapy with isoniazid, rifampin, pyrazinamide, and ethambutol (Myambutol) for 2 months

Answer 37

Isoniazid daily for 9 months

Latent tuberculosis infection carries a risk of progression to active disease, especially among patients who are immunosuppressed. Isoniazid monotherapy is the treatment of choice for most patients with latent tuberculosis infection. Rifampin is not recommended as monotherapy in patients with HIV infection because of increased rates of resistance and drug interactions with many antiretrovirals. Rifampin plus pyrazinamide is no longer recommended for treatment of latent tuberculosis infection because cases of significant hepatotoxicity have occurred with preventive therapy. Combination drug therapy is reserved for treatment of active tuberculosis in order to prevent drug resistance.

Question 38

Which one of the following oral conditions shows the most significant response to oral antivirals? (check one)
Behçet’s syndrome
Hand-foot-and-mouth disease
Herpangina
Herpes gingivostomatitis
Vincent’s angina

Answer 38

Herpes gingivostomatitis

Herpes gingivostomatitis is the enanthem associated with a primary herpes simplex virus 1 infection, and it is the only condition listed here that is treated with antivirals such as acyclovir or valacyclovir. Behçet’s syndrome is an inflammatory condition presenting with oral and genital aphthous ulcerations. The cause is unknown and it is frequently managed with topical or systemic corticosteroids or colchicine. Hand-foot-and-mouth disease and herpangina are caused by coxsackie or enterovirus and supportive care is most appropriate for both of these. Vincent’s angina (also known as trench mouth or necrotizing ulcerative gingivitis) is a bacterial infection of the gingiva associated with poor hygiene. It is treated with systemic antibiotics such as metronidazole or amoxicillin/clavulanate.

Question 39

A 30-year-old female presents with an episode of recurrent, painful vesicular lesions on the labia. She noted a tingling, burning sensation a few days before the lesions appeared. A few years ago she had a similar outbreak just before the birth of her second child.

Which one of the following is indicated for this patient? (check one)
Doxycycline
Fluconazole (Diflucan)
Metronidazole
Penicillin G benzathine (Bicillin L-A)
Valacyclovir (Valtrex)

Answer 39

Valacyclovir (Valtrex)

This patient has a recurrent outbreak of genital herpes, and valacyclovir is the preferred treatment. Penicillin G benzathine is a treatment for syphilis, which usually begins as a painless papule that transforms into the classic chancre. Fluconazole and metronidazole are treatments for yeast vaginitis and bacterial vaginitis; these conditions present with itching and a vaginal discharge but not vesicular lesions. Doxycycline is a treatment for Chlamydia infection, which is often completely asymptomatic and detected only with screening.

Question 40

You admit a previously healthy 62-year-old female to the hospital for intractable nausea and vomiting with intravascular volume depletion and hypotension. She lives in rural northern New Mexico. Prior to the onset of her symptoms she had been gardening and cleaning out a chicken coop, where she encountered several rodents. She is febrile and you obtain blood and urine cultures. Two out of four blood culture bottles are positive for gram-negative rods.

Which one of the following is the most likely pathogen? (check one)
Brucella melitensis
Coxiella burnetii
Escherichia coli
Listeria monocytogenes
Yersinia pestis

Answer 40

Yersinia pestis

Yersinia pestis is an aerobic fermentative gram-negative rod. It causes a zoonotic infection with humans as the accidental host. The disease is spread by a bite from a flea vector, direct contact with infected tissue, or inhalation of infectious aerosols from a person with pulmonary plague. Plague occurs in two regions in the western United States. One region includes northern New Mexico, northern Arizona, and southern Colorado, and the other region includes California, southern Oregon, and far western Nevada.

Escherichia coli is also an aerobic fermentative gram-negative rod but it generally causes symptoms of gastroenteritis, hemolytic-uremic syndrome, urinary tract infection, intra-abdominal infection, and meningitis. E. coli infection does not have a specific regional distribution. Listeria monocytogenes is a gram-positive rod and causes an influenza-like illness with or without gastroenteritis in adults. Infection occurs through ingestion of contaminated food products such as milk, cheese, processed meats, and raw vegetables. Outbreaks can occur in any geographic distribution.

Coxiella burnetii is a gram-negative intracellular bacterium that causes Q fever. Human infections are associated with contact with infected cattle, sheep, goats, dogs, and cats. Brucella melitensis is a gram-negative coccobacilli that causes brucellosis. Humans are accidental hosts who can develop the disease from contact with tissues rich in erythritol, and from shedding of organisms in milk, urine, and birth products from goats and sheep.

Question 41

A 52-year-old male smoker presents to your office in January with worsening respiratory symptoms over the past 24 hours, along with a rapid onset of fever and chills, nausea, myalgias, and sore throat. He has a history of mild chronic bronchitis and hypertension, and his medications include tiotropium (Spiriva) inhaled daily; lisinopril/hydrochlorothiazide (Zestoretic), 20/12.5 mg daily; and albuterol (Proventil, Ventolin) as needed.

On examination the patient has a temperature of 38.8°C (101.8°F), a heart rate of 102 beats/min, a respiratory rate of 24/min, and an oxygen saturation of 94% on room air. He is ill-appearing and pale. Examination of his throat reveals mild erythema, and chest auscultation reveals bilateral bronchovesicular breath sounds with no crackles or wheezing. The examination is otherwise unremarkable. Laboratory and radiology services are not available.

Which one of the following would be most appropriate at this point? (check one)
Observation only, with follow-up in a few days
Azithromycin (Zithromax)
Oseltamivir (Tamiflu)
Penicillin VK
Prednisone

Answer 41

Oseltamivir (Tamiflu)

This patient has findings consistent with influenza, including a rapid onset of fever, nausea, and sore throat, and negative pulmonary findings. Influenza is considered a clinical diagnosis and confirmation of the diagnosis with laboratory testing is not required. Treatment of influenza is recommended for individuals at a high risk of influenza-related complications. High-risk individuals include those with chronic lung disease; cardiovascular (excluding hypertension), renal, hepatic, hematologic, or neurologic disease; or age >65. Children on long-term aspirin therapy, and pregnant and postpartum women are also considered high risk. This patient should be treated with antiviral medication because of his chronic pulmonary disease. While pneumonia and streptococcal pharyngitis should be considered in the differential diagnosis, these are less likely given the examination findings, and antibiotics are not recommended. Prednisone is not indicated for influenza-like illness and may cause harm.

Question 42

A 7-month-old male is admitted to the hospital for respiratory syncytial virus bronchiolitis. His temperature is 37.9°C (100.2°F), pulse rate 160 beats/min, respiratory rate 70/min, and oxygen saturation 92% on room air. Auscultation of the lungs reveals diffuse wheezing and crackles accompanied by nasal flaring and retractions.

Which one of the following interventions would most likely be beneficial? (check one)
Bronchodilators
Corticosteroids
Epinephrine
Nasogastric fluids
Oxygen supplementation to maintain O2 saturation above 95%

Answer 42

Nasogastric fluids

The mainstay of therapy for acute respiratory syncytial virus bronchiolitis is supportive care, and maintaining hydration is important. Infants with respiratory rates >60/min may have poor feeding secondary to difficulty breathing and oral rehydration may increase the risk of aspiration. In these cases, nasogastric or intravenous fluids should be administered. Oxygen saturation of 90% or more on room air is sufficient for infants with bronchiolitis, and using supplemental oxygen to maintain higher oxygen saturations only prolongs hospitalization because of an assumed need for oxygen. Bronchodilators should not be administered to infants with bronchiolitis, because they have not been shown to have any effect on the need for hospitalization, oxygen saturation, or disease resolution. In addition, there is no evidence to support the use of epinephrine or corticosteroids in the inpatient setting.

Question 43

A 34-year-old male has a 3-day history of a runny nose, postnasal drainage, sinus congestion, and left-sided facial pain. He also reports a mild cough and difficulty sleeping due to the congestion. He is afebrile and the examination reveals inflammation of the nasal mucosa, purulent rhinorrhea, and mild left maxillary sinus tenderness to percussion.
Which one of the following would be the most appropriate pharmacotherapy? (check one)
Amoxicillin/clavulanate (Augmentin)
Levofloxacin (Levaquin)
Loratadine (Claritin)
Mometasone (Nasonex)

Answer 43

Mometasone (Nasonex)

This patient presents with symptoms of acute rhinosinusitis. In the first 3–4 days, viral and bacterial rhinosinusitis are indistinguishable. Guidelines from the American Academy of Otolaryngology—Head and Neck Surgery suggest that antibiotics should not be routinely prescribed for acute mild to moderate sinusitis unless symptoms persist for 7 days or worsen after initial improvement. Watchful waiting without antibiotic treatment is appropriate when follow-up is accessible (SOR A). In this scenario antibiotic therapy is not indicated.

Amoxicillin with or without clavulanate is appropriate for symptoms lasting 7 or more days without improvement and is the first-line antibiotic treatment for acute bacterial rhinosinusitis (SOR A). Due to the risk of adverse effects and no benefit over β-lactams, respiratory fluoroquinolones are not considered first-line antibiotic therapy. Symptomatic treatment is recommended within the first 10 days of the onset of symptoms and may be continued if antibiotics are started. Intranasal corticosteroid use has a modest therapeutic benefit for patients with acute rhinosinusitis. Decongestants and antihistamines have not been proven effective for the treatment of acute rhinosinusitis.

Question 44

In addition to group B Streptococcus (GBS), which one of the following is the most common cause of neonatal sepsis? (check one)
Escherichia coli
Group A Streptococcus
Listeria monocytogenes
Staphylococcus aureus
Streptococcus pneumoniae

Answer 44

Escherichia coli

Newborns with sepsis may have focal signs of infection such as pneumonia or respiratory distress syndrome, but they also may have nonfocal signs and symptoms. In the newborn period the two most common causes of neonatal sepsis are group B Streptococcus and Escherichia coli. Listeria monocytogenes was once a more common cause but it is now uncommon. Streptococcal pneumonia is an uncommon cause of sepsis in neonates. Staphylococcus aureus and group A Streptococcus are not as common but should be considered in newborns with cellulitis.

Question 45

You are evaluating a 64-year-old female in the emergency department for pyelonephritis. Her past medical history is negative and she has previously been in good health. The patient appears acutely ill but is oriented. On examination her weight is 100 kg (220 lb), her temperature is 38.9°C (102.0°F), her pulse rate is 110 beats/min, her respiratory rate is 24/min, her blood pressure is 136/72 mm Hg, and her oxygen saturation is 94% on room air. Initial laboratory findings include a venous lactate level of 4.0 mmol/L (N 0.6–1.7).

You decide to start normal saline intravenously. Which one of the following would be the most appropriate initial rate? (check one)
100 mL/hr
150 mL/hr
200 mL/hr
3000 mL over 30 minutes
3000 mL over 3 hours

Answer 45

3000 mL over 3 hours

The Surviving Sepsis Campaign recommends that patients with elevated serum lactate or hypotension receive isotonic intravenous fluids such as normal saline or lactated Ringer’s solution at an initial rate of 30 mL/kg in the first 3 hours using small boluses of approximately 500 mL. A serum lactate value >36 g/dL (4 mmol/L) is correlated with increased severity of illness and poorer outcomes even if hypotension is not yet present. Patients who are hypotensive or whose serum lactate level is >36 g/dL require intravenous fluids or colloid to expand their circulating volume and effectively restore perfusion pressure. The administration of 30 mL/kg of fluid is recommended as a fluid challenge, which should be started as early as possible in the course of septic shock.

Question 46

According to the American Academy of Pediatrics guidelines, when school personnel suspect that a child has head lice, which one of the following is the most appropriate management strategy? (check one)
The child should be sent home until treated, and a notice should be sent to the parents of the child’s classmates that a case of lice has occurred at the school
The child should be sent home and may return to school after an over-the-counter treatment has been started
The child should be sent home and may return to school once treatment has been completed and the child is free of all nits and lice
The child should be sent home and may return to school once treatment has been completed and the child is free of all nits and lice
The child should remain in class and should not be treated unless there is a clear diagnosis and live lice are seen

Answer 46

The child should remain in class and should not be treated unless there is a clear diagnosis and live lice are seen

Head lice is a relatively common infestation in school-aged children and adolescents, but it is often unnecessarily feared and affected children are stigmatized. Since transmission rates are relatively low in the classroom setting and treatments can be expensive and difficult, children suspected of having head lice should remain in class and should not be treated unless there is a clear diagnosis. Nits are louse eggs and do not necessarily represent an active, infectious case of head lice. Children’s privacy should be respected appropriately, and in most cases there is no need to notify an entire class or school of the presence of a case of lice.

Question 47

A 68-year-old male with type 2 diabetes with peripheral neuropathy presents for routine follow-up. On examination of his feet, you note that the majority of his toenails are thickened and discolored. The great toenails lift easily from the nailbeds. A clipping from one nail is sent for KOH evaluation with positive results.

Of the following, which one is the most effective treatment for this condition (check one)
Topical efinaconazole 10% (Jublia) daily for 48 weeks
Topical tea tree oil daily until the nails grow out
Oral fluconazole (Diflucan) once weekly until the nails grow out
Oral terbinafine daily for 12 weeks
Fractional carbon dioxide laser therapy

Answer 47

Oral terbinafine daily for 12 weeks

More than 10% of U.S. adults have onychomycosis, and age over 60 is an important risk factor. Patients with suspected onychomycosis should undergo testing to confirm the infection, preferably with a KOH preparation. The American Academy of Dermatology’s recommendations in the Choosing Wisely initiative support testing before treatment. The most efficacious therapy for onychomycosis of any severity is an oral antifungal. Terbinafine is the most effective oral antifungal and should be first-line therapy for most patients (SOR B). Oral fluconazole and itraconazole are also beneficial but exhibit lower cure rates than terbinafine. Oral antifungals are contraindicated in patients with chronic liver disease; transaminase levels should be checked before starting therapy.

Topical antifungals are appropriate for mild onychomycosis but are not as effective as the oral forms. Efinaconazole is the most effective of the topical antifungals but is quite expensive. Tea tree oil and other topical treatments such as Vicks VapoRub, oregano, and vitamin E have shown antifungal activity, but larger studies are needed to validate their effectiveness. Laser therapy for onychomycosis is approved by the FDA but there is a dearth of evidence as to its effectiveness.

Question 48

A 10-year-old male has an 8-mm induration 2 days after a tuberculin skin test. He shares a bedroom with his 18-year-old brother who was recently diagnosed with tuberculosis. There are no other historical or physical examination findings to suggest active tuberculosis infection and a chest radiograph is normal.

Which one of the following would be most appropriate at this point? (check one)
Monitoring with annual tuberculin skin testing
Observation and repeat tuberculin skin testing in 3 weeks
Isoniazid daily for 9 months
Pyrethrins 0.33%/pipernyl butoxide 4% (RID)
Once-weekly isoniazid and rifampin for 3 months

Answer 48

Isoniazid daily for 9 months

This patient’s close contact with a person known to be infected with tuberculosis (TB) places him at risk for infection, so screening for TB is indicated. For this patient, testing with either a tuberculin skin test or an interferon-gamma release assay is appropriate. Based on CDC guidelines an induration 5 mm at 48–72 hours following an intradermal injection of tuberculin is a positive test in individuals who have been in recent contact with a person with infectious TB, those with radiographic evidence of prior TB, HIV-infected persons, and immunosuppressed patients. For other individuals at increased risk for TB, the threshold for a positive test is an induration 10 mm at 48–72 hours. For those with no known risks for TB infection, the induration must exceed 15 mm in size to be considered positive. Once positive, there is no indication for additional skin tests.

A positive screening test along with a review of systems, a physical examination, and a chest radiograph that do not show evidence of active infection confirms the diagnosis of latent TB. For children age 2–11 years, treatment with isoniazid, 10–20 mg/kg daily or 20–40 mg/kg twice weekly for 9 months, is the preferred and most efficacious treatment regimen. The shorter 6-month treatment course is considered an acceptable option for adults, but it is not recommended for children. The use of rifampin alone or in combination with isoniazid is also an acceptable option for adults but not for children under the age of 12.

Question 49

A 17-year-old seasonal farm worker presents with a 7-day history of left-sided facial weakness that he first noted upon awakening. He has no facial pain. Approximately 2 weeks prior to the onset of this problem he removed a tick from the left side of his neck, but he is uncertain how long it had been present. The redness at the site resolved spontaneously and he had no additional symptoms until the onset of facial weakness. He has not had any rash, fever, swollen glands, or neck stiffness.

On examination he has weakness of the muscles on the left side of his face, including the forehead, and he can only partially close his left eye. The remainder of the physical examination is normal, including the absence of rashes and lymphadenopathy.

In addition to corticosteroids, which one of the following would be indicated at this time? (check one)
Amoxicillin as a single dose
Ceftriaxone (Rocephin) for 7 days
Doxycycline for 14 days
Trimethoprim/sulfamethoxazole (Bactrim) for 10 days
No antibiotics

Answer 49

Doxycycline for 14 days

Early systemic Lyme disease may manifest with facial nerve palsy, and treatment should include corticosteroids. The evidence for efficacy of antivirals for facial nerve palsy is lacking, especially beyond 3–4 days after onset. But in this case, specific treatment to eradicate the Lyme disease is also indicated, in order to prevent later, more severe systemic complications.

For facial nerve palsy, treatment with doxycycline or amoxicillin for 14 days is effective. Patients with more severe neurologic manifestations of Lyme disease, such as altered mental status, meningoencephalitis, or other cranial nerve palsies, require longer courses of antibiotics, usually intravenously.

A single-dose treatment with doxycycline or amoxicillin is recommended as prophylaxis in asymptomatic patients after a known tick bite. This is only recommended for tick attachment longer than 36 hours, or of unknown duration.

Question 50

A 20-year-old male college student comes to your office to ask what he can do to prevent meningitis. His roommate was just hospitalized with invasive meningococcal disease. The patient has no symptoms at this time, a physical examination is normal, and he received meningococcal vaccine at the recommended times. He lives in a campus dormitory that houses 22 students.

Which one of the following would be most appropriate? (check one)
Reassure him that as long as he did not have direct contact with respiratory secretions he is at low risk of infection and does not need prophylaxis
Reassure him that because of his immunization status he is at low risk of infection and does not need prophylaxis
Tell him there is no preventive treatment so he should monitor his symptoms very closely and return immediately if he develops a fever, headache, or stiff neck
Treat him and the rest of the students in the dormitory with a single dose of ciprofloxacin (Cipro)

Answer 50

Treat him and the rest of the students in the dormitory with a single dose of ciprofloxacin (Cipro)

Postexposure prophylaxis after exposure to invasive meningococcal disease is indicated for any close contact regardless of immunization status. Close contacts include those exposed in households, dormitories, or day care centers, and those who have direct contact with oral secretions. There are several options for prophylaxis, including ciprofloxacin, 500 mg orally one time; azithromycin, 500 mg orally one time; ceftriaxone, 250 mg intramuscularly one time; or rifampin, 600 mg orally twice daily for 2 days. Treatment should begin as soon as possible after exposure but no later than 14 days. While rifampin can be used for postexposure prophylaxis, a one-time dose is not adequate. This patient is at risk of infection due to his close contact with the source patient. Postexposure prophylaxis is indicated even for vaccinated patients.

Question 51

A registered nurse at the local hospital calls to notify you of a newborn admission. She reports that the neonate was born at 40 weeks gestation to a G2P2002 via vaginal delivery. The mother was noted to be group B Streptococcus positive, and delivery was complicated by a maternal fever of 38.3°C (101.0°F) and suspected intra-amniotic infection for which the mother received 6 hours of broad-spectrum antibiotics. Her membranes ruptured 6 hours before delivery. The nurse notes that the infant has normal vital signs and appears healthy.

Which one of the following would be recommended for the newborn to reduce antibiotic administration in this case? (check one)
Categorical risk factor assessment
Use of the neonatal early-onset sepsis calculator
A C-reactive protein level
A CBC and differential
Blood cultures

Answer 51

Use of the neonatal early-onset sepsis calculator

Neonatal early-onset sepsis (EOS) has an incidence of 0.5 per 1000 live births according to the CDC, and group B Streptococcus (GBS) remains the most common cause. Risk factors for neonatal EOS include maternal GBS, prolonged rupture of membranes, intrauterine inflammation or infection, and the combination of inflammation and infection, commonly known as maternal chorioamnionitis, or triple I. Updated guidelines from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists replaced traditional guidelines on prevention of neonatal EOS from the CDC.

Current guidelines recommend either categorical risk factor assessment, use of the neonatal EOS calculator, or enhanced observation. However, categorical risk factor assessment, similar to 2002 and 2010 CDC guidelines, would result in blood cultures and administration of antibiotics to any newborn where there was a maternal intrapartum fever.

The other two approaches, particularly use of the neonatal EOS calculator, have been demonstrated to decrease antibiotic administration. This calculator uses a multivariate approach to determining neonatal EOS risk, combining information from both the delivery and postpartum assessment of the newborn. Enhanced observation utilizes frequent clinical assessment and is thought to similarly reduce antibiotic administration. The AAP guidelines suggest C-reactive protein levels and CBCs have poor predictive value in identifying neonatal EOS and should not be used to guide management. Blood cultures are frequently obtained with co-administration of antibiotics and there is no data to suggest that blood cultures alone would reduce antibiotic administration.

Question 52

A 34-year-old female presents to your office after she was bitten on the hand by a neighbor’s cat. The patient has no allergies and has been in good health. You decide to treat the patient with a prophylactic antibiotic.

Which one of the following would be the antibiotic of choice? (check one)
Amoxicillin/clavulanate (Augmentin)
Azithromycin (Zithromax)
Cephalexin (Keflex)
Clindamycin (Cleocin)
Metronidazole (Flagyl)

Answer 52

Amoxicillin/clavulanate (Augmentin)

Prophylactic antibiotics should be given for all closed-fist injuries unless the skin has not been penetrated,
and for puncture wounds caused by cat bites. The antibiotic should have both aerobic and anaerobic
activity and include Pasteurella coverage for animal bites and Eikenella coverage for human bites.
Suggested regimens include amoxicillin/clavulanate. If the patient is allergic to penicillin, clindamycin plus
levofloxacin or moxifloxacin, which has anaerobic coverage, can be used. Azithromycin, cephalexin, and
metronidazole are not first-line antibiotics following a cat bite.

Question 53

A 48-year-old female is treated appropriately for MRSA bacteremia. An echocardiogram is negative for endocarditis. There are no indwelling devices such as prosthetic heart valves or vascular grafts.

Assuming that the patient improves with an excellent response to antibiotics, which one of the following is recommended? (check one)
No repeat blood cultures
Repeat blood cultures when the antibiotic course is completed
Repeat blood cultures when the patient’s temperature is ≤37.5°C (99.5°F)
Repeat blood cultures 2–4 days after the initial set and as needed thereafter
Repeat blood cultures 2 weeks after the antibiotic course is completed

Answer 53

Repeat blood cultures 2–4 days after the initial set and as needed thereafter

This patient’s MRSA bacteremia is considered uncomplicated due to the effectiveness of the antibiotic therapy and the lack of endocarditis or implanted prostheses such as heart valves. Therefore, the Infectious Diseases Society of America recommends that follow-up cultures of blood samples be obtained 2–4 days after the initial cultures and as needed thereafter to document clearance of bacteremia (SOR A; Quality of Evidence II).

Question 54

A 22-year-old gravida 1 para 0 with a history of homelessness and recent intravenous drug use presents for prenatal care. Mantoux tuberculin testing is performed and produces 20 mm of induration. She had a negative tuberculin test 1 year ago. A chest radiograph is normal. You decide to treat her with isoniazid for latent tuberculosis infection.

Which one of the following should also be given to prevent the development of peripheral neuropathy? (check one)
Folate
Vitamin B6
Vitamin D
Duloxetine (Cymbalta)
Gabapentin (Neurontin)

Answer 54

Vitamin B6

Most pregnant women with a positive tuberculin skin test are asymptomatic and have no evidence of active tuberculosis, and therefore have latent tuberculosis infection. The risk of reactivation of tuberculosis and progression to active disease is the highest in the first 2 years of conversion. In women with a known conversion to a positive PPD in the last 2 years, treatment with isoniazid (INH), 300 mg daily, is recommended starting after the first trimester. Treatment should last 6–9 months. Pregnant women are at an increased risk for peripheral neuropathy when treated with INH. Vitamin B6 supplementation decreases the risk of developing peripheral neuropathy with the use of INH.

Question 55

A 30-year-old male presents to your office with a 10-day history of rhinorrhea, nasal congestion, cough, and headache. He initially had a low-grade fever that resolved, but over the past 2 days all of his symptoms have gotten worse. His past medical history is unremarkable and he does not smoke. On examination there is a purulent secretion noted from the right nasal cavity and tenderness over the right maxillary sinus region.

The most appropriate treatment is (check one)
amoxicillin/clavulanate (Augmentin)
azithromycin (Zithromax)
cefuroxime (Ceftin)
levofloxacin (Levaquin)
trimethoprim/sulfamethoxazole (Bactrim)

Answer 55

amoxicillin/clavulanate (Augmentin)

In the first 3 to 4 days of illness, viral rhinosinusitis cannot be distinguished from early acute bacterial rhinosinusitis. If the patient seems to be improving and then symptoms start to worsen on days 5–10 of the illness (double sickening), acute bacterial rhinosinusitis should be suspected. The color of the nasal discharge should not be used as the sole indication for antibiotic therapy. One study showed that unilateral predominance with purulent rhinorrhea had an overall reliability of 85% for diagnosing sinusitis. After 10 days of upper respiratory symptoms, the probability of acute bacterial rhinosinusitis is 60%.

Antibiotic therapy should be considered if the patient does not improve after 7–10 days from the onset of symptoms or if the symptoms worsen at any time. According to most guidelines, the first-line antibiotic for treatment of adults with sinusitis is amoxicillin/clavulanate. Respiratory fluoroquinolones are not recommended as first-line medications, as they offer no additional benefits and have significant side effects. Second and third-generation cephalosporins, trimethoprim/sulfamethoxazole, and macrolide antibiotics are no longer recommended for initial therapy. This is due to high rates of resistance in Streptococcus pneumoniae and Haemophilus influenzae .

Question 56

You see a 38-year-old male 11 days after his cat bit him on the thumb. He went to an urgent care clinic and was given a ceftriaxone (Rocephin) injection and 10 days of oral amoxicillin/clavulanate (Augmentin). He says the redness and pain in his thumb and hand have improved some, but the thumb remains very painful. He received a tetanus booster recently. His cat is well.

His vital signs are normal and examination of the thumb reveals a swollen, erythematous, tender, warm interphalangeal joint with decreased range of motion. There are healing 2-mm dorsal skin wounds over the joint.

Which one of the following would you recommend at this point? (check one)
Continued amoxicillin/clavulanate
Azithromycin (Zithromax)
Clindamycin (Cleocin)
Rabies vaccine and continued amoxicillin/clavulanate
Consultation for surgery

Answer 56

Consultation for surgery

This patient’s cat is well more than 10 days after the bite, so rabies vaccine is not necessary. Azithromycin is indicated for cat scratch disease, but the presentation does not suggest this. Severe infections may require incision, drainage, and intravenous antibiotics. A surgery consultation is recommended to evaluate for tendon sheath or joint infection.

Question 57

Which one of the following is true regarding direct observational therapy (DOT) in the treatment of active tuberculosis? (check one)
It guarantees patient compliance with the prescribed regimen
It is recommended only in the office or clinic setting
It decreases drug-resistant tuberculosis
Patients require less monitoring for signs of treatment failure

Answer 57

It decreases drug-resistant tuberculosis

In the treatment of active tuberculosis, direct observational therapy (DOT) involves providing the antituberculosis drugs directly to patients and watching them swallow the medication. It is the preferred care management strategy for all patients with tuberculosis. The use of DOT does not guarantee the ingestion of all doses of every medication, as patients may miss appointments, may not actually swallow the pills, or may regurgitate the medication, sometimes deliberately. Due to these limitations, the use of DOT does not remove the need to monitor patients for signs of treatment failure. DOT is effective in a wide variety of settings, including in the community with health nurses. It even shows benefit when the observation makes use of telehealth settings or mobile phones.

Among the important benefits of DOT are that it has been shown to decrease both the acquisition and transmission of drug-resistant tuberculosis and to increase treatment success in HIV-positive patients.

Question 58

A 32-year-old female presents with a 4-month history of nasal drainage, congestion, and loss of her sense of smell. She reports having a cold about 4 months ago that never resolved. On examination the nasal turbinates are swollen and you note mucopurulent drainage on the right.

Which one of the following is the most likely cause of her symptoms? (check one)
Chronic rhinosinusitis
Granulomatosis with polyangiitis (Wegener’s granulomatosis)
Nasal polyposis
Sarcoidosis
Seasonal allergic rhinitis

Answer 58

Chronic rhinosinusitis

The American Academy of Otolaryngology defines chronic rhinosinusitis as the presence of two of four
cardinal symptoms, which include nasal drainage, nasal obstruction, facial pain or pressure, and hyposmia
or anosmia, along with objective signs on examination or radiographic studies. This patient has three
cardinal symptoms of chronic rhinosinusitis and objective evidence on the physical examination. No nasal
polyps were seen on the examination. Granulomatosis with polyangiitis and sarcoidosis can both present
similarly but are uncommon causes of chronic rhinosinusitis. Allergic rhinitis can be associated with
chronic rhinosinusitis but would also present with allergic symptoms.

Question 59

The father of a healthy 14-year-old male calls you about a recent mumps outbreak in your community. The child never received the MMR vaccine because the parents declined the immunization despite extensive counseling about the topic.

You advise the father that (check one)
mumps typically starts with a cough, coryza, and conjunctivitis
mumps causes a pruritic rash with fluid-filled blisters
mumps can cause orchitis, possibly resulting in decreased fertility
Koplik spots or whitish papules in the mouth are pathognomonic for mumps
the MMR vaccine is not recommended for patients in this age range

Answer 59

mumps can cause orchitis, possibly resulting in decreased fertility

Prodromal symptoms of mumps include myalgia, fatigue, loss of appetite, fever, and headache. Parotitis
is the most common manifestation. Infertility, meningitis, and encephalitis are serious complications of
orchitis. Measles is characterized by cough, coryza, conjunctivitis, and Koplik spots. Varicella is
characterized by a pruritic rash with fluid-filled blisters. MMR vaccine is indicated for this child.

Question 60

A 45-year-old male presents for follow-up of a recent positive HIV test. He has not had any symptoms. An initial laboratory evaluation is significant for the following:
HIV viral load …………………………… 124,000 copies/mL
CD4 lymphocyte count ……………….. 289 cells/μL
Hepatitis C antibody …………………. negative
Anti-HBs ………………………………………… positive
Anti-HBc …………………………………………. positive
HBsAg …………………………………………….. negative

Renal function is normal. He has an upcoming appointment with the comprehensive HIV clinic to initiate antiretroviral therapy.

Which one of the following would be appropriate to recommend today? (check one)
Prophylactic emtricitabine/tenofovir (Truvada
Prophylactic sulfamethoxazole/trimethoprim (Bactrim)
Hepatitis B vaccine
Herpes zoster vaccine (Shingrix)
Meningococcal B (MenB) vaccine

Answer 60

Herpes zoster vaccine (Shingrix)

The CDC’s Advisory Committee on Immunization Practices updated its recommendations in 2022 to include a two-dose series of recombinant zoster vaccine for all adults age 19 and older with HIV. Vaccination against meningococcal bacteria A, C, W, and Y (MenACWY) is also recommended, and meningococcal B (MenB) vaccination is only recommended based on the presence of other risk factors, including asplenia, complement deficiency, treatment with complement inhibitors, or risk due to outbreaks. Prophylactic emtricitabine/tenofovir is approved for pre- and postexposure prophylaxis of HIV, but would not be used alone in the care of patients with established HIV. Pneumocystis jirovecii prophylaxis, most commonly with sulfamethoxazole/trimethoprim, is recommended in patients with CD4 lymphocyte counts <200 cells/μL. Hepatitis B vaccine is recommended but would not be necessary for patients such as this one with natural immunity or confirmed immunity from vaccination.

Question 61

A 49-year-old male presents to the urgent care center with a fever, cough, and pleuritic chest pain. His medical history is unremarkable with no cardiac risk factors. The patient’s vital signs include a temperature of 39.0°C (102.2°F), a heart rate of 120 beats/min, a respiratory rate of 24/min, a blood pressure of 90/58 mm Hg, and an oxygen saturation of 95% on room air. The patient is awake and able to follow commands.

An examination reveals warm skin with a capillary refill time of 2–3 seconds. The patient has normal heart sounds with a rapid peripheral pulse and no evidence of jugular vein distention. A chest radiograph is suggestive of pneumonia.

Which one of the following would be the most appropriate next step in treatment? (check one)
Administering a 1-L bolus of half-normal saline
Administering epinephrine by auto-injector
Administering a minimum of 30 mL/kg of lactated Ringer’s solution within the first 3 hours
Starting a dobutamine drip at 2 μg/kg/min
Starting a norepinephrine drip at 0.05 μg/kg/min

Answer 61

Administering a minimum of 30 mL/kg of lactated Ringer’s solution within the first 3 hours

This patient has an acute febrile illness and meets criteria for systemic inflammatory response syndrome (SIRS) and decompensated shock. Shock is a medical emergency requiring urgent treatment to prevent death or other complications. The four types of shock are differentiated based on clinical signs. Correct treatment hinges on accurate determination of the type of shock. This patient demonstrates high-output shock typical of septic shock. Initial treatment of septic shock begins with fluid resuscitation using isotonic crystalloid by an intravenous or intraosseous route. Recent guidelines recommend a minimum of 30 mL/kg of isotonic crystalloid, with a preference for lactated Ringer’s solution over normal saline. Hypotonic solutions, such as half-normal saline, should never be administered as a bolus. There is no indication for epinephrine or dobutamine in this patient. Norepinephrine can be indicated for septic shock that has not responded to fluid resuscitation.

Question 62

During an outbreak of head lice at a local school the principal asks you for advice to send home to the parents. In addition to treatment with topical permethrin (Nix), which one of the following would you recommend? (check one)
Using a hairbrush to remove any lice or eggs
Applying petroleum jelly to the hair and scalp
Using a conditioner or a combined shampoo and conditioner when applying treatment
Washing clothing and bedding in hot water and drying with hot air
Treating household pets such as cats and dogs

Answer 62

Washing clothing and bedding in hot water and drying with hot air

The appropriate recommendation for head lice is to wash any recently used bedding and clothing with hot
water or expose them for 5 minutes to a temperature >130°F to kill lice and eggs. Items that cannot be
washed or dried in this manner or dry-cleaned should be sealed in a plastic bag for 2 weeks. Additional
or alternative treatments include topical ivermectin, benzoyl alcohol, malathion, and spinosad. Other
recommended measures include removal of any visible nits (eggs) with a nit comb, not a brush. Topical
petroleum jelly is not an effective treatment. Conditioners can interfere with the action of permethrin,
decreasing its effectiveness. Human head lice are specific to humans, so pets are not affected.

Question 63

A 28-year-old white female comes to your office at 37 weeks gestation with a 24-hour history of painful vesicles on the vulva. She does not have a past history of similar lesions. You make a presumptive diagnosis of genital herpes.

Of the following, the most sensitive and specific test is (check one)
exfoliative cytology (Tzanck test)
a polymerase chain reaction (PCR) test
an enzyme-linked immunosorbent assay (ELISA)
HSV serology (IgG/IgM)

Answer 63

a polymerase chain reaction (PCR) test

When genital herpes occurs during pregnancy, the best method of diagnosis is either a tissue culture or a
polymerase chain reaction (PCR) test, which is more sensitive. Enzyme-linked immunosorbent assays are
sensitive, but not as sensitive or specific as PCR.

Question 64

Which one of the following groups has the highest prevalence of syphilis? (check one)
Baby boomers
Incarcerated females
Men who have sex with men
Rural men 20–29 years of age
Individuals with a history of illicit intravenous drug use

Answer 64

Men who have sex with men

Factors associated with increased prevalence rates for syphilis in the United States include a history of
incarceration or commercial sex work, living in the southern or western United States, residing in a major
metropolitan area, African-American ethnicity, and being a male younger than 29 years of age. The risk
for syphilis infection is highest among men who have sex with men and among persons who are
HIV-positive.
The U.S. Preventive Services Task Force (USPSTF) recommends that asymptomatic, nonpregnant adults
and adolescents who are at increased risk be screened for syphilis infection (A recommendation). The
USPSTF also recommends that local community and socioeconomic factors be considered when identifying
patients at increased risk for infection who should be screened.