IDS

Question 1

Which of the following does not increase susceptibility to Salmonella infection?

a. Increase stomach acidity
b. Inflammatory bowel disease
c. Age of less than 1 year old
d. Alteration of intestinal microbiome with antibiotics

Answer 1

The correct answer is: Increase stomach acidity

Question 2

Which of the following does not increase susceptibility to Salmonella infection?

a. Increase stomach acidity
b. Inflammatory bowel disease
c. Age of less than 1 year old
d. Alteration of intestinal microbiome with antibiotics

Answer 2

The correct answer is: Increase stomach acidity

Question 3

Which of the following is an indirect method recommended to confirm the diagnosis of typhoid fever?

a. Culture and isolation
b. Polymerase chain reaction
c. Antibody detection
d. Widal test

Answer 3

The correct answer is: Antibody detection

Question 4

A 30 year old male comes in for fever of three days duration. Leptospires were cultured in the blood. Antibody titers were negative. This patient is probably in which phase of the disease?

a. Incubation period
b. Leptospiremic phase
c. Immune phase
d. Convalescent phase

Answer 4

The correct answer is: Leptospiremic phase

Question 5

Based on Philippine Data in 2010, what is the most common clinical feature of leptospirosis after a flood?

a. Fever
b. Conjunctival suffusion
c. Abdominal pain
d. Calf tenderness

Answer 5

The correct answer is: Fever

Question 6

A 30 year old male consulted due to concerns about getting leptospirosis. He mentioned wading in flood water 1 day prior while going to work. On examination, he has an open lesion on his foot. What is recommended for this case?

a. Doxycycline 200 mg single dose within 24 to 72 hours from exposure
b. Doxycycline 200 mg once daily for 3-5 days to be started within 24 to 72 hours from exposure
c. Doxycycline 200 mg once weekly started within 24 to 72 hours from exposure
d. Doxycycline 200 mg once daily until with a negative Lepto-MAT result

Answer 6

The correct answer is: Doxycycline 200 mg once daily for 3-5 days to be started within 24 to 72 hours from exposure

Question 7

In the life cycle of schistosomiasis, what is the only stage that can be detected in humans (either in excreta or biopsy)?

a. Infective Cercariae
b. Metacercariae
c. Adult worms
d. Schistosome egg

Answer 7

The correct answer is: Schistosome egg

Question 8

40/M from Bicol consults due to abdominal enlargement. On PE, you noted hepatosplenomegaly and ascites. His HBT ultrasound showed “pipe-stem” fibrosis. Stool microscopy showed a large egg with a terminal spine. What is the appropriate drug to eradicate the parasite?

a. Praziquantel
b. Albendazole
c. Triclabendazole
d. Glucocoricoids

Answer 8

The correct answer is: Praziquantel

Question 9

A patient previously treated for PTB for only 3 weeks came in due to recurrence of cough, fever and weight loss. On work-up, GeneXpert revealed MTB Detected, RIF resistance negative. What is the regimen of choice? (TB CPG 2016 P88)

a. 2HRZE + 4HR
b. 2HRZES + 1HRZE + 6HR
c. 2HRZE + 10HR
d. 2HRZES + 1HRZE + 7HR

Answer 9

The correct answer is: 2HRZE + 4HR

Question 10

A 30/F presented with progressive low back pain and weight loss over several weeks. Her continued symptoms prompted consult with a private physician and initial work up done (MRI) showed anterior compression of the T11-T12 vertebrae and a paravertebral abscess. What is the treatment of choice for this patient? (TB CPG 2016 P93)

a. 2HRZE + 6HR
b. 2HRZES + 1HRZE + 6HR
c. 2HRZE + 10HR
d. 2HRZES + 1HRZE +7HR

Answer 10

The correct answer is: 2HRZE + 10HR

Question 11

A 30/F call center agent came in for work clearance. She has been having non-productive cough with weight loss for at the last 3 weeks. She initially consulted with their company physician and work up was done which revealed bilateral upper lobe infiltrates on chest X-ray. Sputum AFB x 2 was negative. She denies having any previous PTB treatment. She was already started on HRZE with noted improvement on cough. When will she be considered as non-infectious and can safely go back to work? (TB CPG 2016 P114)

a. 5 days
b. 14 days
c. 1 month
d. 2 months

Answer 11

The correct answer is: 5 days

Question 12

A 20/F ongoing treatment for TB consulted due to a petechial rash on her extremities. On work-up, Hgb 120, Hct 0.40 WBC 8, Plt 30. What is the most likely culprit? (TB CPG 2016 P124)

a. Isoniazid
b. Rifampicin
c. Pyrazinamide
d. Ethambutol

Answer 12

The correct answer is: Rifampicin

Question 13

Which of the following patients should undergo screening for latent TB? (TB CPG 2016 P162)

a. 20/F diagnosed with rheumatoid arthritis maintained on methotrexate and steroids
b. 65/F with hypertension and CKD St IV
c. 25/F pregnant patient on with FBS of 95 on her prenatal check-up
d. 50/M diabetic and smoker

Answer 13

The correct answer is: 50/M diabetic and smoker

Question 14

Which of the following measure is appropriate in prevention and control of the spread of TB in the general population? (TB CPG 2016 Chapter 6)

a. N95 masks should be worn by patients presumed to be infectious
b. Double layer of surgical masks provide additional protection for healthcare workers taking care of bacteriologically confirmed PTB patients
c. There is no need to screen household contacts of patients with cavitary disease
d. There is no need to treat latent TB in the general population

Answer 14

The correct answer is: There is no need to treat latent TB in the general population

Question 15

What is the most commonly involved site for extrapulmonary tuberculosis? (HPIM 20th ed. C173 P1243)

a. Pleura
b. Lymph nodes
c. Genitourinary tract
d. Central nervous system

Answer 15

The correct answer is: Lymph nodes

Question 16

Which among the following patients should be treated for latent tuberculosis? (HPIM 20th ed. C173 P1257 T173-5)

a. 50/F living with her son who has bacteriologically confirmed PTB, tuberculin reaction size 10mm
b. 30/F on pre-employment work up with tuberculin reaction size of 10mm, no other risk factors
c. 35/M IV drug user with tuberculin reaction size of 5mm
d. 28/M PLHIV patient, asymptomatic and TST was negative

Answer 16

The correct answer is: 50/F living with her son who has bacteriologically confirmed PTB, tuberculin reaction size 10mm

Question 17

What is the principal vector of the Dengue virus? (HPIM 20th ed C204 P1504)

a. Anopheles sp.
b. Aedes aegypti
c. Aedes albopictus
d. Culex sp.

Answer 17

The correct answer is: Aedes aegypti

Question 18

A 20/F consulted due to fever of 3 days duration with associated generalized body pain, headache and retroorbital pain. On PE, vital signs were stable, with note of generalized rash. Initial laboratory results showed increased hematocrit and decreased platelet count. What is the diagnosis for this patient? (Handbook for Clinical Management of Dengue P7)

a. Probable dengue
b. Laboratory confirmed dengue
c. Dengue with warning signs
d. Severe dengue

Answer 18

The correct answer is: Dengue with warning signs

Question 19

A 30/M consulted in the ER for fever 3 days duration with associated malaise and abdominal pain. A generalized rash appeared one day prior to consult. Considering dengue, which of the following tests will best confirm the diagnosis? (Handbook for Clinical Management of Dengue P15)

a. Dengue NS1 antigen
b. Single serum IgM detection
c. Single serum IgG detection
d. Paired sera for detection of seroconversion

Answer 19

The correct answer is: Dengue NS1 antigen

Question 20

A patient was being managed as a case of hypotensive shock from dengue. Initial resuscitation was done with 20ml/kg of crystalloid solution. However, the patient remained hypotensive despite the fluids. On rechecking of the patient’s CBC, the hematocrit decreased. What is the next step? (Handbook for Clinical Management of Dengue P24)

a. Continue hydration with plain saline solution
b. Initiate hydration with colloid solutions
c. Transfuse packed red blood cells
d. Start vasopressors

Answer 20

The correct answer is: Transfuse packed red blood cells

Question 21

A 30/M presented in the OPD for diarrhea for 2 days, associated with tenesmus and abdominal pain. He religiously took oral rehydration therapy but his symptoms persisted. What is the next appropriate step for this patient? (HPIM 20th ed. C128 P961)

a. Continue ORS and observe
b. Continue ORS and obtain stool sample to detect WBC
c. Continue ORS and obtain stool sample to detect parasites
d. Continue ORS and start antibiotic therapy

Answer 21

The correct answer is: Continue ORS and obtain stool sample to detect WBC

Question 22

A 30/M came in to the ER due to fever, diarrhea and abdominal pain. On PE, the patient had direct tenderness on the right lower quadrant. Stool exam showed fecal polymorphonuclear and mononuclear leukocytes. Given the patient’s presentation, what is the most likely causative organism? (HPIM 20th ed. C128 P959-961)

a. Yersinia enterocolitica
b. Shigella spp.
c. Salmonella typhi
d. Campylobacter jejuni

Answer 22

The correct answer is: Yersinia enterocolitica

Question 23

. A 30/M patient consulted in the OPD for abdominal pain and bloody diarrhea (4x for the past day). There was a recent travel history to Thailand where he tried out local delicacies. On his second day back, he complained of abdominal pain and). On evaluation, he is normotensive but slightly tachycardic. He has mild abdominal tenderness on palpation. Which of the following interventions is NOT appropriate? (HPIM 20th ed. C128 P963 T128-5)

a. Oral fluids
b. Saltine crackers
c. Loperamide
d. Azithromycin

Answer 23

The correct answer is: Loperamide

Question 24

Which of the following is correct regarding preventing traveler’s diarrhea? (HPIM 20th ed. C128 P964)

a. Bismuth may be taken as prophylaxis.
b. Salads and raw vegetables may be safely eaten.
c. When eating fruits, make sure to get the unpeeled ones.
d. Only bottled water is safe to drink.

Answer 24

The correct answer is: Bismuth may be taken as prophylaxis.

Question 25

A 30/F came into the ER due high spiking fever with associated abdominal pain of 1 week duration. She self-medicated with ciprofloxacin on the 4th day of her symptoms with no relief. A day prior to consult, the patient developed faint, salmon-colored blanching, maculopapular rash on the trunk and chest which prompted consult at the OPD. Which of the following specimens is the best option for culture studies to demonstrate the causative organism? (HPIM 20th ed. C160 P1176)

a. Bone marrow
b. Blood
c. Stool
d. Skin biopsy

Answer 25

The correct answer is: Bone marrow

Question 26

A 30/F pregnant patient recently came from a trip to her hometown in Mindanao. She presented in the ER with fever for 5 days associated with diarrhea, vomiting, and a rash which appeared in her truncal area. PE showed poor skin turgor. Initial labs showed a positive Typhidot test. Which of the following is appropriate treatment for the patient? (Typhoid CPG)

a. Azithromycin 500mg/tab 2 tabs q24 PO
b. Ciprofloxacin 500mg/tab 1 tab q12 POD
c. Ceftriaxone 2g IV q24
d. Ciprofloxacin 400 mg IV q12

Answer 26

The correct answer is: Ceftriaxone 2g IV q24

Question 27

. Which of the following is a known mode of transmission for leptospirosis? (HPIM 20th ed. C179 P1291)

a. Fomite
b. Feco-oral
c. Vertical transmission
d. Exposure to contaminated soil

Answer 27

The correct answer is: Exposure to contaminated soil

Question 28

Which of the following manifestations of leptospirosis is risk for mortality? (CPG for Leptospirosis 2010 P10)

a. Petechiae
b. Severe headache
c. Atrial fibrillation
d. Non-oliguric renal failure

Answer 28

The correct answer is: Atrial fibrillation

Question 29

A 50/M consulted in your clinic regarding prophylaxis for leptospirosis. He is planning to go on a 3-week hiking trip in a leptospirosis-endemic area with frequent exposure to rivers, swamps and lakes. Which is the most appropriate management for this patient? (CPG for Leptospirosis 2010 P36)

a. No pre-exposure prophylaxis is needed
b. Doxycycline 200mg once
c. Doxycycline 200mg daily for 3 days
d. Doxycycline 200mg once weekly, 1-2 days before exposure and continued until the end of the trip

Answer 29

The correct answer is: Doxycycline 200mg once weekly, 1-2 days before exposure and continued until the end of the trip

Question 30

A 60/M farmer came into the ER due to no urine output for 12 hours. 3 days before consult, he developed fever, abdominal pain and calf pain. Intake of paracetamol did not relieve symptoms. On arrival, vitals were 90/70, HR 120, RR 20, T 38.7 deg C. Initial labs showed CBC Hb 120, Hct 0.45 WBC 14 N 80 L 15 plt 150, Crea of 1.2 mg/dL, K 5.2 meq/L. Chest x-ray was normal. What is the next best step for this patient? (CPG for Leptospirosis 2010 P47)

a. Hydrate with pNSS 20cc/kg/hr
b. Start Norepinephrine
c. Give furosemide 40mg IV
d. Initiate dialysis

Answer 30

The correct answer is: Initiate dialysis

Question 31

A 40/M from Palawan consulted due to decrease in sensorium. He has been having spiking fever episodes every 2 days for the last week. Eventually, he was noted to have increased sleeping time and decreased responsiveness. On arrival at the ER, the patient had a generalized tonic-clonic seizure lasting 1 minute without regaining consciousness after. Which of the following species is the most likely culprit? (HPIM 20th ed. C219 P1578)

a. P. falciparum
b. P. malariae
c. P. ovale
d. P. vivax

Answer 31

The correct answer is: P. falciparum

Question 32

A 30/F pregnant patient is travelling to a region in Palawan endemic for malaria consulted your OPD for prophylaxis. Which of the following appropriate for this patient? (HPIM 20th ed. C219 P1588-9)

a. Primaquine
b. Mefloquine
c. Chloroquine
d. No drug available as prophylaxis for pregnant patients

Answer 32

The correct answer is: Mefloquine

Question 33

Which of the following is NOT part of the revised criteria for sepsis (SEPSIS-3)? (H20 C297 P2045)

a. Urine output of < 0.5cc/kg/hr
b. Requirement of a vasopressor to maintain a MAP ≥ 65mmHg
c. Lactate concentration ≥ 2mmol/L despite adequate fluid resuscitation
d. Life threatening dysfunction caused by a dysregulated host response to infection

Answer 33

The correct answer is: Urine output of < 0.5cc/kg/hr

Question 34

A 50/M diabetic came to the ER due to fever and cough of 1 week duration. On arrival, vitals were 90/60, HR 110, RR 24, T 38. He was slightly confused and PE showed crackles on the R lower lung field. Which of the following is NOT part of the initial management (within 3 hours) bundle for this patient? (H20 C297 P2049)

a. Early administration of appropriate broad-spectrum antibiotics
b. Collection of blood for culture before antibiotic administration within 1 hour
c. Measurement of serum lactate levels
d. IV fluids of 20ml/kg in the first 3 hours

Answer 34

The correct answer is: IV fluids of 20ml/kg in the first 3 hours

Question 35

What causes enlargement of the liver of patients with schistosomiasis? (HPIM 20th ed. C229 P1637)

a. Obstruction by live adult worms
b. Granuloma formation around the deposited eggs
c. Deposition of ova in the sinusoids
d. Cercarial invasion of liver parenchyma

Answer 35

The correct answer is: Granuloma formation around the deposited eggs

Question 36

A 20/M consulted at the ER due to fever and abdominal pain. He just came from a vacation in Central Visayas. PE showed fever, diffuse lymphadenopathy and hepatosplenomegaly. CBC showed high-level of peripheral eosinophilia. Kato-katz showed eggs which appeared rounded with a lateral spine. Which of the following is the appropriate treatment for this patient? (HPIM 20th ed. C229 P1639 T229-2)

a. Praziquantel 40 mg/kg PO in 2 divided doses for 1 day
b. Praziquantel 60 mg/kg PO in 3 divided doses for 1 day
c. Praziquantel 25 mg/kg PO TID for 2 consecutive days
d. Praziquantel 10 mg/kg PO as a single dose

Answer 36

The correct answer is: Praziquantel 60 mg/kg PO in 3 divided doses for 1 day

Question 37

A 60/M came in due to trismus. On history, the patient works as carpenter and sustained a deep cut on his hand 8 days ago due to a rusty nail. Since then, he developed muscle stiffness and difficulty swallowing, subsequently developing difficulty opening his mouth. On arrival, his BP was 150/80, HR 130 and RR 24. Which of the patient’s characteristics is a poor prognostic factor? (HPIM 20th ed. C147 P1104 T147-1)

a. Age
b. Incubation period
c. Blood pressure
d. Clinical presentation

Answer 37

The correct answer is: Blood pressure

Question 38

A 25/M came to the ER after sustaining multiple injuries from a vehicular crash. He cannot recall when he had his last vaccination for tetanus but he was sure he already had it. What is the appropriate treatment for this patient? (HPIM 20th ed. C147 P1105)

a. TIG only
b. Tetanus Toxoid only
c. TIG + Tetanus Toxoid
d. Cleaning the wound is enough since he is already immunized

Answer 38

The correct answer is: TIG + Tetanus Toxoid

Question 39

A 30/M recently bitten by a stray dog was brought into the ER because of change in behavior. On examination, he was febrile, tachycardic and agitated. He was hypersalivating and was exhibiting symptoms of aerophobia and hydrophobia. What diagnostic test can best clinch the diagnosis? (HPIM 20th ed. C203 P1487)

a. Nuchal biopsy
b. Corneal impression smear
c. Brain biopsy
d. Serum antibodies

Answer 39

The correct answer is: Nuchal biopsy

Question 40

A 25/F pregnant patient was recently bitten by a stray dog. They were unable to catch the dog. What would be the best treatment for the patient? (HPIM 20th ed. C203 P1489)

a. Observe the patient for development of symptoms
b. Rabies immunoglobulin (RIG) only
c. Rabies vaccine only
d. RIG and rabies vaccine

Answer 40

The correct answer is: RIG and rabies vaccine

Question 41

Which of the following is TRUE regarding SARS-CoV? (HPIM 20th ed. C194 P1379)

a. SARS-CoV typically presents with upper respiratory symptoms.
b. The route of entry is through the gastrointestinal tract.
c. Animal coronaviruses do not cross-infect humans.
d. Watery diarrhea may also be a presenting symptom

Answer 41

The correct answer is: Watery diarrhea may also be a presenting symptom

Question 42

Which of the following opportunistic illnesses is an AIDS defining illness in patients living with HIV (PLHIV)? (HPIM 20th ed. C197 P1394 T197-1)

a. Oral candidiasis
b. First episode of bacterial pneumonia
c. Herpes simplex of 1 week duration
d. Pulmonary tuberculosis

Answer 42

The correct answer is: Pulmonary tuberculosis

Question 43

Which of the following modes confers the highest risk of transmission of HIV? (HPIM 20th ed. C197 P1399 T197-3)

a. Needle-sharing during injection drug use
b. Insertive anal intercourse
c. Receptive heterosexual intercourse
d. Percutaneous needlestick injury

Answer 43

The correct answer is: Needle-sharing during injection drug use

Question 44

A 25/M with no known comorbids presented in the OPD due to fever of 3 days duration with lymphadenopathy, headache, lethargy and weight loss. He is sexually active with MSM and recently had a new partner. Given his clinical presentation, what is the best and least expensive screening test for this patient? (HPIM 20th ed. C197 P1426 T197-8)

a. p24 antigen capture assay
b. Western blot
c. Rapid HIV antibody test
d. HIV RNA detection by PCR

Answer 44

The correct answer is: p24 antigen capture assay

Question 45

Once a PLHIV patient’s CD4 count dips below 200, prophylaxis against which of the following organisms should be taken? (HPIM 20th ed. C197 P1431 T197-11)

a. Mycobacterium avium complex
b. Pneumocystis jirovecii
c. Toxoplasma gondii
d. Cytomegalovirus

Answer 45

The correct answer is: Pneumocystis jirovecii

Question 46

In a patient with TB meningitis who was recently diagnosed with HIV, when is the optimal time to initiate anti-retroviral treatment? (CPG on OIs in HIV 2016, P159)

a. 2 weeks
b. 4 weeks
c. 2 months
d. 3 months

Answer 46

The correct answer is: 4 weeks

Question 47

A 60/M presented with a 4-week history of unrelenting fever. He had already been seen by previous MDs and all obligatory investigations for fever of unknown origin (FUO) done were negative. Medications and all other external factors were already excluded. Funduscopy and cryoglobulin testing were also negative. FDG-PET done was also non-diagnostic. Based on the algorithm for the work-up of FUO, what is the next step? (HPIM 20th ed. C17 P119 F17-1)

a. Repeat history and physical examination
b. Chest and abdominal CT scan
c. Temporal artery biopsy
d. Trial of treatment with NSAIDs

Answer 47

The correct answer is: Repeat history and physical examination

Question 48

A 25/F presented with a 3 week history of fever with no other associated symptoms. After a thorough work-up, only the tuberculin skin test turned out to be positive. Empiric anti-Koch’s treatment was. After how many weeks of treatment should a new diagnosis be considered if the fever does not resolve? (HPIM 20th ed. C17 P122)

a. 4 weeks
b. 6 weeks
c. 8 weeks
d. 10 weeks

Answer 48

The correct answer is: 6 weeks

Question 49

The risk of developing TB disease after being infected depends largely on:

a. Innate immunologic and non-immunologic defenses
b. Probability of contact with a person who has infectious TB
c. Intimacy and duration of contact with a person with TB
d. Shared environment in which contact takes place

Answer 49

The risk of transmission and of subsequent acquisition of M. tuberculosis infection is determined mainly by exogenous factors:
• Probability of contact with a person who has an infectious form of TB
• Intimacy and duration of that contact
• Degree of infectiousness of the case
• Shared environment in which the contact takes place

The risk of developing disease after being infected depends largely on endogenous factors:
• Individual’s innate immunologic and nonimmunologic defenses
• Level at which the individual’s cell-mediated immunity is functioning.

The correct answer is: Innate immunologic and non-immunologic defenses

Question 50

Who among the following is the LEAST LIKELY to be considered a “Presumptive TB” case?

a. 30 year old nurse with cough of 7 days duration
b. 22 year old male with cough of 20 days who has been caring for his girlfriend with active TB
c. An 18 year old, asymptomatic male with chest X ray findings of bilateral apical infiltrates
d. A 90 year old female with cough and hemoptysis of 2 weeks duration

Answer 50

The correct answer is: 30 year old nurse with cough of 7 days duration

Question 51

What is the primary diagnostic test for diagnosing Tuberculosis?

a. Chest radiograph
b. Direct sputum smear microscopy
c. Sputum TB culture
d. Rapid diagnostic tests (i.e. Xpert MTB/Rif)

Answer 51

The correct answer is: Direct sputum smear microscopy

Question 52

What is FALSE regarding DSSM interpretation and use of sputum TB culture (based on the PhilCAT 2016)?

a. At least 2 out of 3 sputum smear positive should be present to be considered smear positive
b. TB culture is requested in the diagnostic work-up of TB cases
c. Culture positive for M. tuberculosis is considered bacteriologically confirmed PTB, even in the absence of CXR findings
d. Long turnaround time of results limit the routine use of TB culture

Answer 52

The correct answer is: At least 2 out of 3 sputum smear positive should be present to be considered smear positive

Question 53

A 25 year old male sought consult for cough. His chest radiograph had no radiologic findings consistent with active TB. He only has one sputum specimen positive for AFB. This patient is classified as:

a. PTB, Bacteriologically confirmed, Smear positive
b. PTB, Clinically diagnosed, Smear positive
c. PTB, Bacteriologically confirmed, Smear negative
d. PTB, Clinically diagnosed, Smear negative

Answer 53

The correct answer is: PTB, Bacteriologically confirmed, Smear positive

Question 54

Which of the following statements is FALSE regarding the role of a chest radiograph in PTB diagnosis?
a. Patient with CXR findings suggestive of PTB even without symptoms is a Presumptive TB
b. A single CXR film cannot accurately confirm active PTB
c. Bilateral apical infiltrates on CXR is considered specific for active TB
d. A good quality CXR film is needed to initially guide clinician in identifying presumptive PTB for further bacteriologic confirmation
Feedback

Answer 54

CHEST X-RAY FOR PTB DIAGNOSIS
Patient with CXR findings suggestive of PTB with or without symptoms is a Presumptive TB

A single CXR film cannot accurately confirm active PTB by this modality alone

No radiologic findings considered specific for active TB. Clinical correlation, together with bacteriologic confirmation, is required to assess activity BEFORE initiation of treatment

A good quality CXR film is needed to initially guide clinician in identifying presumptive PTB for further bacteriologic confirmation

CXR can be done in parallel or sequential to DSSM
The correct answer is: Bilateral apical infiltrates on CXR is considered specific for active TB

Question 55

Which of the following is true regarding the etiologic agent for Tuberculosis?

a. Rod-shaped, non-spore-forming, thin aerobic bacterium
b. Often gram positive on gram staining
c. Acid fastness is due mainly to the organisms’ low content of mycolic acids
d. Its cell wall has low permeability, increasing effectiveness of most anti-tuberculosis agents

Answer 55

M. TUBERCULOSIS
Rod-shaped, non-spore-forming, thin aerobic bacterium

Often neutral on Gram’s staining

Once stained, the bacilli cannot be decolorized by acid alcohol à this characteristic justifies their classification as acid-fast bacilli

Acid fastness: due mainly to the organisms’ high content of mycolic acids, long-chain cross-linked fatty acids, and other cell-wall lipids.

In the mycobacterial cell wall, lipids (e.g., mycolic acids) are linked to underlying arabinogalactan and peptidoglycan
• This structure results in very low permeability of the cell wall, thus reducing the effectiveness of most antibiotics

The correct answer is: Rod-shaped, non-spore-forming, thin aerobic bacterium

Question 56

Who among the following patients with tuberculosis is considered a “Relapse” case?

a. Patient previously treated for TB, declared cured, and is now diagnosed with a new episode of TB
b. Patient previously treated for TB and declared treatment failed at the end of the most recent course of treatment
c. Patient previously treated for TB and was lost to follow-up at the end of the most recent course of treatment
d. Patient has previously been treated for TB but outcome after their most recent course of treatment is unknown

Answer 56

The correct answer is: Patient previously treated for TB, declared cured, and is now diagnosed with a new episode of TB

Question 57

A 30 year old male with pleural effusion comes in for dyspnea. Thoracentesis was done. Which of the following findings in pleural fluid would support a diagnosis or tuberculosis?

a. Protein concentration less than 50% of that in serum
b. Normal to low glucose concentration
c. pH of ~7.80
d. Neutrophil predominance in later stages

Answer 57

PLEURAL EFFUSION IN TB
Straw-colored (sometimes hemorrhagic)

Exudative with:
• Protein concentration >50% of that in serum (usually ~4–6 g/dL)
• Normal to low glucose concentration
• pH of ~7.3 (occasionally <7.2)
• Detectable white blood cells (usually 500–6000/ μL)

Neutrophils may predominate in the early stage

Lymphocyte predominance is the typical finding later

AFBs are rarely seen on direct smear

Cultures often may be falsely negative for M. tuberculosis

Positive cultures are more common among postprimary cases

Pleural concentration of adenosine deaminase:
• May be a useful screening test
• TB may be excluded if the value is very low

The correct answer is: Normal to low glucose concentration

Question 58

For the diagnostic evaluation of PTB, which of the following is recommended, based on the PTB guidelines?

a. Three specimens should be obtained for DSSM, 1 day apart
b. Two consecutive specimens collected 1 hour apart should be obtained
c. At least 2 mL of sputum is required for DSSM
d. The conventional ZN microscopy is preferred over the light-emitting diode (LED) microscopy

Answer 58

The correct answer is: Two consecutive specimens collected 1 hour apart should be obtained

Question 59

A 30 year old male comes in with cough and back pain. Two of his AFB smears were negative. His chest radiograph was suggestive of PTB. Based on the NTP Manual for TB diagnosis among smear-negative presumptive TB adults, what is the next step?

a. Request for Xpert MTB/Rif
b. Commit to a diagnosis of clinically diagnosed TB
c. Consider another diagnosis
d. Request for two more AFB smears

Answer 59

The correct answer is: Request for Xpert MTB/Rif

Question 60

What is the mechanism of action of Isoniazid?

a. Inhibits mycolic acid synthesis
b. Inhibits transcription by interfering with DNA-dependent RNA polymerase
c. Targets essential membrane transport in fatty acid synthesis
d. Inhibits translation during protein synthesis

Answer 60

The correct answer is: Inhibits mycolic acid synthesis

Question 61

Which of the following is FALSE regarding the management of drug-induced hepatotoxicity? (based on PhilCAT 2016 CPG)

a. Routine liver function monitoring not needed among asymptomatic patients.
b. Serum ALT should be requested for monitoring of patients with baseline risk factors for hepatotoxicity
c. All medications should be stopped immediately when serum ALT>3x ULN in the presence of symptoms
d. When ALT becomes <2x ULN, step-wise reintroduction may be started with Isoniazid, followed by Rifampicin

Answer 61

DRUG INDUCED HEPATOTOXICITY
Routine liver function monitoring NOT needed among asymptomatic patients

Serum ALT (SGPT) should only be requested for:
(1) individuals who exhibit symptoms of hepatotoxicity such as jaundice, anorexia, nausea, vomiting, or abdominal pain
(2) monitoring of patients with baseline risk factors for hepatotoxicity or abnormal baseline LFTs (2-4 weeks after the start of anti-TB medications)
All medications should be stopped immediately and evaluated when serum ALT is:
• >3x ULN in the presence of symptoms, or
• >5x ULN in the absence of symptoms

After ALT becomes <2x ULN with symptom resolution, step-wise reintroduction of potentially hepatotoxic anti-TB drugs may be started with Rifampicin (with or without Ethambutol), followed by INH after 3 to 7 days, subsequently rechecking transaminases.

Pyrazinamide should be permanently discontinued in patients with prolonged or severe hepatotoxicity

The correct answer is: When ALT becomes <2x ULN, step-wise reintroduction may be started with Isoniazid, followed by Rifampicin

Question 62

26/M who previously completed treated for PTB 2 years ago consults for chronic cough and hemoptysis. Sputum AFB shows acid fast bacilli. Xpert MTB/Rif shows rifampicin-sensitivity. What is the appropriate treatment regimen?

a. 2 HRZE/10 HR
b. 2 HRZES/1 HRZE/5 HRE
c. 2 HRZES/1 HRZE/9 HRE
d. 3 HRZES/1 HRZE/6 HRE

Answer 62

The correct answer is: 2 HRZES/1 HRZE/5 HRE

Question 63

A 40 year old male was diagnosed with PTB and CNS TB. What regimen should be given?

a. 2 HRZE / 4 HR
b. 2 HRZE / 10 HR
c. 2 HRZES / 1 HRZE / 5 HRE
d. 2 HRZES / 1 HRZE / 9 HRE

Answer 63

The correct answer is: 2 HRZE / 10 HR

Question 64

A 40/M consults for cough of 3 weeks duration and back pain. Sputum AFB is positive. She is started on HRZE. On the 2nd month of treatment, DSSM is still positive. What is the next step in management?

a. Extend intensive phase for 1 more month
b. Extend intensive phase for 2 more months
c. Proceed to continuation phase and repeat DSSM at the 3rd month
d. Proceed to continuation phase and repeat DSSM at the 5th month

Answer 64

The correct answer is: Proceed to continuation phase and repeat DSSM at the 3rd month

Question 65

35/M consults for chronic cough and hemoptysis. Sputum AFB is positive. He recalls taking medicines in the health center 5 years ago but was only compliant for 2 months and was lost to follow-up. What is the next step in management?

a. Refer to TBDC
b. Send for Xpert MTB/Rif
c. Send for Sputum TB culture
d. Start intensive phase of TB treatment

Answer 65

INDICATIONS FOR DST

• Retreatment cases
• Treatment failure
• Contacts of known drug-resistant TB cases
*DST should not be routinely performed among new cases of PTB

The correct answer is: Send for Xpert MTB/Rif

Question 66

A 25 year old male was started on HRZE. After 1 week of therapy, he experienced gastrointestinal intolerance and some muscle pains. Which of the following should be done?

a. Manage reactions with symptomatic therapy
b. Immediately stop the medications
c. Referral to a specialist is warranted
d. Interrupt treatment for 1 month, then resume when side effects resolve

Answer 66

Minor adverse reactions can be managed with symptomatic therapy. First-line drugs should not be stopped without adequate justification.
For major adverse reactions, all drugs must be discontinued. Switching to single drug formulations may be needed. Referral to a specialist is warranted

The correct answer is: Manage reactions with symptomatic therapy

Question 67

What is the most common presentation of extrapulmonary TB in both HIV-seronegative and HIV-infected patients?

a. Pleuritis / pleural effusion
b. Meningitis
c. Pericarditis
d. Lymphadenitis

Answer 67

LYMPH NODE TB (TUBERCULOUS LYMPHADENITIS)
Most common presentation of extrapulmonary TB in both HIV-seronegative individuals and HIV-infected patients

Presents as painless swelling of the lymph nodes, most commonly at posterior cervical and supra- clavicular sites (a condition historically referred to as scrofula).

Associated pulmonary disease is present in <50% of cases

Systemic symptoms are uncommon except in HIV- infected patients

The diagnosis is established by fine-needle aspiration biopsy (with a yield of up to 80%) or surgical excision biopsy
The correct answer is: Lymphadenitis

Question 68

The cut-off for a positive Tuberculin Reaction Size is related both to the probability that the reaction represents true infection and to the likelihood that the individual will develop TB. What is the cut-off for HIV infected persons?

a. More than or equal to 5 mm
b. More than or equal to 10 mm
c. More than or equal to 15 mm
d. More than or equal to 20 mm

Answer 68

TUBERCULIN REACTION SIZE
Positive reactions area of induration ≥5 mm in diameter:
• Persons with HIV infection
• Recent close contacts of infectious cases
• Organ transplant recipients
• Previously untreated persons whose chest radiograph shows fibrotic lesions consistent with old TB
• Persons receiving drugs that suppress the immune system

10-mm cutoff is used to define positive reactions in most other at-risk persons.
•Positive reactions area of induration ≥5 mm in diameter:
•Persons with HIV infection
•Recent close contacts of infectious cases
•Organ transplant recipients
•Previously untreated persons whose chest radiograph shows fibrotic lesions consistent with old TB
•Persons receiving drugs that suppress the immune system
•10-mm cutoff is used to define positive reactions in most other at-risk persons.

The correct answer is: More than or equal to 5 mm

Question 69

Which of the following is true regarding tuberculous empyema?

a. Very common complication of pulmonary TB
b. Pleural fluid contains a large number of neutrophils
c. Acid fast smears are often negative
d. Result of the rupture of a cavity, with spillage into the pleural space

Answer 69

TB EMPYEMA
Less common complication of pulmonary TB

Result of the rupture of a cavity, with spillage of a large number of organisms into the pleural space

May create a bronchopleural fistula with evident air in the pleural space

CXR shows hydropneumothorax with an air-fluid level

Pleural fluid:
• Purulent and thick and contains large numbers of lymphocytes
• Acid-fast smears and mycobacterial cultures are often positive
Surgical drainage is usually required as an adjunct to chemotherapy

The correct answer is: Result of the rupture of a cavity, with spillage into the pleural space

Question 70

Which of the following is TRUE regarding genitourinary TB?

a. Culture-negative pyuria in acidic urine should raise the suspicion of TB
b. More common in males
c. In males, genital TB preferentially affects the prostate
d. Responds poorly to chemotherapy

Answer 70

GENITOURINARY TB
Local symptoms predominate

Up to 75% of patients have abnormalities on CXR suggesting previous or concomitant pulmonary disease.

Urinalysis:
• Abnormal results in 90% of cases, revealing pyuria and hematuria
• Documentation of culture-negative pyuria in acidic urine should raise the suspicion of TB
Culture of three morning urine specimens yields a definitive diagnosis in nearly 90% of cases.

Genital TB preferentially affects the epididymis, producing a slightly tender mass that may drain externally through a fistulous tract

Responds well to chemotherapy

The correct answer is: Culture-negative pyuria in acidic urine should raise the suspicion of TB

Question 71

What is the most common site of skeletal TB?

a. Knee
b. Spine
c. Elbow
d. Hip

Answer 71

SKELETAL TB
In bone and joint disease, pathogenesis is related to reactivation of hematogenous foci or to spread from adjacent paravertebral lymph nodes

Weight-bearing joints are most commonly affected:
• Spine in 40% of cases
• Hips in 13%
• Knees in 10%
Upper thoracic spine is the most common site of spinal TB in children

Lower thoracic and upper lumbar vertebrae are usually affected in adults

Skeletal TB responds to chemotherapy

Severe cases may require surgery

The correct answer is: Spine

Question 72

True regarding Pericardial TB (Tuberculous Pericarditis)

a. Pericardial TB is benign, even without treatment
b. Effusion is transudative in nature
c. High count of lymphocytes and monocytes are documented in fluid
d. Direct smear examination is commonly positive

Answer 72

TB PERICARDITIS
Due either to direct extension from adjacent mediastinal or hilar lymph nodes or to hematogenous spread, pericardial TB has often been a disease of the elderly in countries with low TB prevalence.

The onset may be subacute, although an acute presentation, with dyspnea, fever, dull retrosternal pain, and a pericardial friction rub, is possible.

The effusion is exudative in nature, with a high count of lymphocytes and monocytes. Hemorrhagic effusion is common.

Direct smear examination is very rarely positive.

Without treatment, pericardial TB is usually fatal

The correct answer is: High count of lymphocytes and monocytes are documented in fluid

Question 73

The use of corticosteroids as adjunctive therapy in extrapulmonary TB is recommended only for patients with TB meningitis and ______?

a. Pott’s disease
b. Genitourinary TB
c. Milliary TB
d. TB pericarditis

Answer 73

The correct answer is: TB pericarditis

Question 74

What is the definition of MULTI-RESISTANT TB (MDR-TB)?

a. Resistance to more than one first-line anti-TB drug, other than both Isoniazid and Rifampicin
b. Resistance to at least both Isoniazid and Rifampicin
c. Resistance to INH and Rifampicin + resistance to any fluoroquinolone
d. Resistance to the 3 second-line drugs

Answer 74

The correct answer is: Resistance to at least both Isoniazid and Rifampicin

Question 75

Which of the following statements is FALSE regarding antiretroviral therapy in patients with HIV and Tuberculosis?

a. Antiretroviral therapy should be initiated after the second week of TB treatment regardless of CD4 count.
b. For patients with TB meningitis, antiretroviral therapy should be initiated before the intensive phase of TB treatment.
c. Efavirenz is the preferred NNRTI for HIV patients on TB treatment.
d. Avoid the use of nevirapine because of drug-drug interactions.

Answer 75

The correct answer is: For patients with TB meningitis, antiretroviral therapy should be initiated before the intensive phase of TB treatment.

Question 76

A 26 year old female comes in for fever for 7 days with headache, abdominal pain, and episodes of confusion. Which of the following features would NOT warrant admission for this patient:

a. Blood pressure of 100/60 with a heart rate of 110 bpm
b. Amenorrhea for 3 months
c. Unavailability of a caregiver to give medicines
d. Long distance travel from her house to the hospital

Answer 76

The correct answer is: Blood pressure of 100/60 with a heart rate of 110 bpm

Question 77

What is the most prominent symptom of typhoid fever?

a. Prolonged fever
b. Abdominal pain
c. Calf tenderness
d. Rose spots

Answer 77

SALMONELLA TYPHI
Incubation period averages 10–14 days but ranges from 5 to 21 days, depending on the inoculum size and the host’s health and immune status

Most prominent symptom = prolonged fever (38.8°–40.5°C; 101.8°– 104.9°F), which can continue for up to 4 weeks if untreated.

Early physical findings of enteric fever include:
• Rash (“rose spots”; 30%): make up a faint, salmon-colored, blanching, maculopapular rash located primarily on the trunk and chest
• Hepatosplenomegaly (3–6%)
• Epistaxis
• Relative bradycardia at the peak of high fever (<50%)

The correct answer is: Prolonged fever

Question 78

Which of the following does not increase susceptibility to Salmonella infection?

a. Increase stomach acidity
b. Inflammatory bowel disease
c. Age of less than 1 year old
d. Alteration of intestinal microbiome with antibiotics

Answer 78

PATHOPHYSIOLOGY OF TYPHOID
All Salmonella infections begin with ingestion of organisms, most commonly in contaminated food or water

Infectious dose ranges from 200 colony-forming units (CFU) to 106 CFU

Ingested dose is an important determinant of incubation period and disease severity

The following increase susceptibility to Salmonella infection:
• Conditions that decrease either stomach acidity (an age of <1 year, acid suppression therapy, or achlorhydric disease)
• Conditions that decrease intestinal integrity (inflammatory bowel disease, cytotoxic chemotherapy, prior gastrointestinal surgery, or alteration of the intestinal microbiome by antibiotic administration)

The correct answer is: Increase stomach acidity

Question 79

True regarding the etiologic agent if Typhoid Fever

a. Gram negative, spore forming, facultatively anaerobic bacilli
b. Produces acid on glucose fermentation
c. Does not reduce nitrates
d. Produces cytochrome oxidase

Answer 79

SALMONELLA
Gram-negative, non-spore-forming, facultatively anaerobic bacilli

The initial identification of salmonellae in the clinical microbiology laboratory is based on growth characteristics:
• Produce acid on glucose fermentation
• Reduce nitrates
• Do not produce cytochrome oxidase
All salmonellae except Salmonella Gallinarum-Pullorum are motile by means of peritrichous flagella, and all but S. Typhi produce gas (H2S) on sugar fermentation

The correct answer is: Produces acid on glucose fermentation

Question 80

Which of the following is an indirect method recommended to confirm the diagnosis of typhoid fever?

a. Culture and isolation
b. Polymerase chain reaction
c. Antibody detection
d. Widal test

Answer 80

The correct answer is: Antibody detection

Question 81

A 40 year old male comes in for prolonged fever, headache, persistent abdominal pain, spontaneous GI bleeding, and dehydration. The work up is for suspect typhoid fever. Which antibiotic regimen is appropriate to start this case with for?

a. Amoxicillin 500 mg/cap 2 caps Q6 x 14 days
b. Chloramphenicol 500 mg 2 caps Q6 x 14 days
c. Ceftriaxone 2-3 g IV Q24 hours x 14 days
d. Vancomycin 1g Q12 IV 14 days

Answer 81

The correct answer is: Ceftriaxone 2-3 g IV Q24 hours x 14 days

Question 82

Which of the following antibiotics is a first line treatment for typhoid fever among pregnant patients?

a. Ampicillin
b. Azithromycin
c. Ciprofloxacin
d. Cefixime

Answer 82

The correct answer is: Ampicillin

Question 83

When do gastrointestinal complications most commonly occur in typhoid fever?

a. Incubation period
b. First week of illness
c. Second to third week of illness
d. Third to fourth week of illness

Answer 83

GASTROINTESTINAL COMPLICATIONS
Gastrointestinal bleeding (10–20%) and intestinal perforation (1–3%) most commonly occur in the third and fourth weeks of illness

Result from hyperplasia, ulceration, and necrosis of the ileocecal Peyer’s patches at the initial site of Salmonella infiltration

The correct answer is: Third to fourth week of illness

Question 84

What are the most effective class of agents for the treatment of drug-susceptible typhoid fever?

a. Macrolides
b. Cephalosporins
c. Fluoroquinolones
d. Penicillin

Answer 84

ANTIBIOTIC THERAPY OF TYPHOID
Prompt administration of appropriate antibiotic therapy prevents severe complications of enteric fever and results in a case–fatality rate of <1%

The initial choice of antibiotics depends on the susceptibility of the S. Typhi and S. Paratyphi strains in the area of residence or travel

For treatment of drug-susceptible typhoid fever:
• Fluoroquinolones are the most effective class of agents
• Cure rates of ~98% and relapse and fecal carriage rates of <2%
• Experience is most extensive with ciprofloxacin

The correct answer is: Fluoroquinolones

Question 85

A 48/M chef consults due to incidental finding of chronic Salmonella carriage along with cholelithiasis. What would be the appropriate treatment for this patient?

a. No treatment is required since this is a self-limiting condition
b. Start Ciprofloxacin 500mg BID x 28 days
c. Admit for Ceftriaxone treatment x 10-14 days
d. Refer to Surgery for surgical management

Answer 85

MANAGEMENT OF CHRONIC CARRIERS
Can be treated for 4–6 weeks with an appropriate oral antibiotic

Treatment with oral amoxicillin, TMP-SMX, ciprofloxacin, or norfloxacin is ~80% effective in eradicating chronic carriage of susceptible organisms.

In cases of anatomic abnormality (e.g., biliary or kidney stones), eradication often requires both antibiotic therapy and surgical correction.

The correct answer is: Refer to Surgery for surgical management

Question 86

Who among the following is suspected to have multi-drug resistant typhoid fever (MDRTF)?

a. Pregnant patient who is still febrile after 3-5 days of therapy with a first line agent
b. Failure to respond after 5-7 days treatment with a first line antibiotic
c. Household contact with a documented case or during an epidemic of MDRTF
d. Clinical deterioration or development of complications during conventional antibiotic treatment using first-line drugs

Answer 86

The correct answer is: Pregnant patient who is still febrile after 3-5 days of therapy with a first line agent

Question 87

Which of the following is TRUE regarding the history and/or clinical manifestations that should alert a health practitioner to suspect leptospirosis?

a. Chronic fever of 2 weeks duration
b. Ingestion of contaminated water
c. Polyuria
d. Contact with a patient with leptospirosis

Answer 87

The correct answer is: Ingestion of contaminated water

Question 88

Which of the following is not a component of the Weil’s syndrome?

a. Jaundice
b. Renal dysfunction
c. Hemorrhagic diathesis
d. Meningitis

Answer 88

HPIM 20th Ed, Page 1290
MANIFESTATIONS OF LEPTOSPIROSIS
Mild form: nonspecific symptoms such as fever, headache, and myalgia

Severe leptospirosis: jaundice, renal dysfunction, and hemorrhagic diathesis (often referred to as Weil’s syndrome)

With or without jaundice, severe pulmonary hemorrhage is increasingly recognized as an important presentation of severe disease

Triad Weil’s syndrome
• Hemorrhage
• Jaundice
• Acute kidney injury

The correct answer is: Meningitis

Question 89

What is FALSE regarding the pathogenesis of leptospirosis?

a. Transmission occurs through cuts, abraded skin, or mucous mem- branes
b. During the initial incubation period, leptospires cannot be isolated from the bloodstream
c. During the leptospiremic phase, the organisms proliferate, cross tissue barriers, and disseminate hematogenously to all organs
d. During the immune phase, the appearance of antibodies coincides with the disappearance of leptospires from the blood.

Answer 89

PATHOGENESIS OF LEPTOSPIROSIS
Transmission occurs through cuts, abraded skin, or mucous mem- branes, especially the conjunctival and oral mucosa

After entry, the organisms proliferate, cross tissue barriers, and disseminate hematogenously to all organs (leptospiremic phase)
• During this initial incubation period, leptospires can be isolated from the bloodstream
During the immune phase, the appearance of antibodies coincides with the disappearance of leptospires from the blood

However, the bacteria persist in various organs, including liver, lung, kidney, heart, and brain.

The correct answer is: During the initial incubation period, leptospires cannot be isolated from the bloodstream

Question 90

A 30 year old male comes in for fever of three days duration. Leptospires were cultured in the blood. Antibody titers were negative. This patient is probably in which phase of the disease?

a. Incubation period
b. Leptospiremic phase
c. Immune phase
d. Convalescent phase

Answer 90

HPIM 20th Ed, Page 1290
BIPHASIC COURSE OF LEPTOSPIROSIS
Acute leptospiremic phase:
• Characterized by fever of 3–10 days’ duration
• Organism can be cultured from blood and detected by PCR
Immune phase
• Resolution of symptoms may coincide with the appearance of antibodies
• Leptospires can be cultured from the urine

The correct answer is: Leptospiremic phase

Question 91

Based on Philippine Data in 2010, what is the most common clinical feature of leptospirosis after a flood?

a. Fever
b. Conjunctival suffusion
c. Abdominal pain
d. Calf tenderness

Answer 91

The correct answer is: Fever

Question 92

. Which of the following statements is FALSE regarding the clinical manifestations of leptospirosis?

a. Bleeding and multiorgan failure are clinical hallmarks of leptospirosis
b. Majority of cases are thought to be severe, presenting as the Weil’s syndrome
c. The natural course of mild leptospirosis usually involves spontaneous resolution within 7–10 days
d. Acute kidney injury is common in severe disease, presenting after several days of illness

Answer 92

COURSE OF LEPTOSPIROSIS
Majority of cases are thought to be relatively mild, presenting as the sudden onset of a febrile illness.

Most patients are asymptomatic or only mildly ill and do not seek medical attention.

The natural course of mild leptospirosis usually involves spontaneous resolution within 7–10 days,

Severe disease is often rapidly progressive

Acute kidney injury is common in severe disease:
• Presents after several days of illness
• Can be either nonoliguric or oliguric
• Typical electrolyte abnormalities include hypokalemia and hyponatremia

The correct answer is: Majority of cases are thought to be severe, presenting as the Weil’s syndrome

Question 93

Among patients with leptospirosis, which of the following clinical features of leptospirosis is associated with increased risk for mortality?

a. High grade fever
b. Hemoptysis
c. Abdominal pain
d. Conjunctival suffusion

Answer 93

HIGH RISK FEATURES OF LEPTOSPIROSIS
Clinical features associated with increased risk for mortality include:
• Altered mental status
• Respiratory insufficiency (rales, infiltrates)
• Hemoptysis
• Oliguric hyperkalemic acute renal failure
• Cardiac involvement (myocarditis, complete or incomplete heart block, AF)

The correct answer is: Hemoptysis

Question 94

Which of the following tests for leptospirosis is classified as a DIRECT Detection Method?

a. Polymerase chain reaction
b. Microagglutination test (MAT)
c. IgM Rapid Diagnostic Test
d. Leptospira Antigen-Antibody Agglutination Test

Answer 94

The correct answer is: Polymerase chain reaction

Question 95

According to the local Philippine guidelines, which of the following is the gold standard for the diagnosis of leptospirosis?

a. Polymerase chain reaction (PCR)
b. Microagglutination test (LeptoMAT)
c. Culture and isolation
d. Leptospirosis IgM, IgG

Answer 95

A definitive diagnosis of leptospirosis is based on:
• isolation of the organism from the patient
• on a positive result in the polymerase chain reaction (PCR)
• or on seroconversion or a rise in antibody titer. Preferably, a fourfold or greater rise in titer is detected between acute- and convalescent-phase serum specimens.

The correct answer is: Culture and isolation

Question 96

Which of the following laboratory findings are markers of severe leptospirosis?

a. Platelet count of 105,000 cells/cu mm
b. Serum creatinine of 2.5 mg/dL
c. Serum potassium of 4.8 mmol/L
d. ECG showing sinus tachycardia

Answer 96

The correct answer is: Serum potassium of 4.8 mmol/L

Question 97

A 30 year old male with a history of wading in contaminated water comes in for fever, calf pain, and hemoptysis. What antibiotic is appropriate?

a. Oral doxycycline
b. Penicillin-G
c. Ceftriaxone
d. Azithromycin

Answer 97

The correct answer is: Penicillin-G

Question 98

A 30 year old male consulted due to concerns about getting leptospirosis. He mentioned wading in flood water 1 day prior while going to work. On examination, he has an open lesion on his foot. What is recommended for this case?
a. Doxycycline 200 mg single dose within 24 to 72 hours from exposure
b. Doxycycline 200 mg once daily for 3-5 days to be started within 24 to 72 hours from exposure
c. Doxycycline 200 mg once weekly started within 24 to 72 hours from exposure
d. Doxycycline 200 mg once daily until with a negative Lepto-MAT result
Feedback

Answer 98

The correct answer is: Doxycycline 200 mg once daily for 3-5 days to be started within 24 to 72 hours from exposure

Question 99

Your 25/F roommate had to wade in flood waters to get home. Her last known menstrual period was 4 months prior. After reading the 2010 CPG on Leptospirosis, what post-exposure prophylaxis will you prescribe?

a. Penicillin 1.5M units IM, 1 dose
b. Doxycycline 200mg cap, 1 dose
c. Azithromycin 250mg tab, 1 dose
d. No prophylaxis, as it can harm the possible fetus in utero

Answer 99

The correct answer is: Azithromycin 250mg tab, 1 dose

Question 100

Who among the following patients with Leptospirosis should undergo acute renal replacement therapy or dialysis?

a. 30 year old male with hemoptysis and ARDS
b. 20 year old, asymptomatic patient with creatinine of 2.7 mg/dL
c. 45 year old male with a potassium of 5.2 meq/L and a urine output of 70 mL/hour
d. 34 year old with a pH of 7.30 on ABG

Answer 100

The correct answer is: 30 year old male with hemoptysis and ARDS

Question 101

Among the following blood flukes, which of the following causes “urogenital” schistosomiasis?

a. Schistosoma mansoni
b. Schistosoma japonicum
c. Schistosoma mekongi
d. Schistosoma haematobium

Answer 101

The correct answer is: Schistosoma haematobium

Question 102

Which of the following blood flukes is present in the Philippines?

a. Schistosoma mansoni
b. Schistosoma japonicum
c. Shistosoma guineensis
d. Schistosoma mekongi

Answer 102

The correct answer is: Schistosoma japonicum

Question 103

How is schistosoma infection contracted in humans?

a. Ingestion of mature eggs
b. Inhalation of larval stage
c. Bloodborne passed by vector mosquito
d. Penetration of cercariae into intact skin

Answer 103

PATHOPHYSIOLOGY OF SCHISTOSOMIASIS
Contracted through contact with freshwater bodies harboring infected intermediate-host snails

Cercariae
• Infective larval stage released from the snail
• Penetrates intact human skin within a few minutes after attaching to the skin.

After penetration, the cercariae transform to schistosomula, which then enter a small vein or lymphatic vessel, circulate in the bloodstream through the lung capillaries, and are pumped via the heart to all parts of the body to reach the portal vein

There, the worms mature into adult males or females, pair, and migrate to their final location in the mesenteric or pelvic venous plexus.

The correct answer is: Penetration of cercariae into intact skin

Question 104

In the life cycle of schistosomiasis, what is the only stage that can be detected in humans (either in excreta or biopsy)?

a. Infective Cercariae
b. Metacercariae
c. Adult worms
d. Schistosome egg

Answer 104

The schistosome egg is the only stage of the parasites’ life cycle that can be detected in humans, either in excreta or in tissue biopsies

The eggs are large and can easily be distinguished morpho- logically from other helminth eggs.

The correct answer is: Schistosome egg

Question 105

Which of the following is TRUE regarding Katayama Fever

a. It is also known as Cercarial Dermatitis or “Swimmer’s Itch”)
b. Onset usually occurs years after exposure to the parasite
c. Most do not recover spontaneously and would warrant treatment
d. It is rare in people chronically exposed to the infection

Answer 105

Cercarial Dermatitis (“Swimmer’s Itch”)
• Cercarial penetration of the skin may result in a maculopapular rash called cercarial dermatitis or “swimmer’s itch
Acute Schistosomiasis (Katayama Fever)
• Symptomatic acute schistosomiasis
• Usually seen in travelers who have contracted the infection for the first time
• Onset occurs between 2 weeks and 3 months after exposure to the parasite
• Symptoms may appear suddenly and include fever, myalgia, general malaise and fatigue, headache, nonproductive cough, and intestinal symptoms such as abdominal tenderness or pain
Many patients recover spontaneously from acute schistosomiasis after 2–10 weeks

Katayama fever is rare in people chronically exposed to infection in areas endemic for S. mansoni or S. haematobium.

The correct answer is: It is rare in people chronically exposed to the infection

Question 106

40/M from Bicol consults due to abdominal enlargement. On PE, you noted hepatosplenomegaly and ascites. His HBT ultrasound showed “pipe-stem” fibrosis. Stool microscopy showed a large egg with a terminal spine. What is the appropriate drug to eradicate the parasite?

a. Praziquantel
b. Albendazole
c. Triclabendazole
d. Glucocoricoids

Answer 106

The correct answer is: Praziquantel

Question 107

Which of the following is TRUE regarding hepatosplenic schistosomiasis?

a. Caused by schistosome eggs trapped in the portal vein
b. Early inflammatory hepatosplenic schistosomiasis is the main entity seen in older adults
c. Patients with severe hepatosplenic disease and portal hypertension may develop esophageal varices
d. Hepatic encephalopathy is the most severe complication of hepatosplenic schistosomiasis

Answer 107

HEPATOSPLENIC SCHISTOSOMIASIS
Caused by schistosome eggs trapped in liver tissue
Occurs in S. mansoni and S. japonicum infections

Early inflammatory hepatosplenic schistosomiasis is the main entity seen in children and adolescents.

Late hepatosplenic schistosomiasis with periportal or Symmers fibrosis:
• May develop in young and middle-aged adults with long- standing, high-level exposure to infection.
• Ascites, attributable both to portal hypertension and to hypoalbuminemia, may be seen, especially in S. japonicum infection.
Patients with severe hepatosplenic disease and portal hypertension may develop esophageal varices detectable by endoscopy or ultrasound
• Experience repeated bouts of hematemesis, melena, or both
• Hematemesis is the most severe complication of hepatosplenic schistosomiasis, and death may result from massive loss of blood

The correct answer is: Patients with severe hepatosplenic disease and portal hypertension may develop esophageal varices

Question 108

This blood fluke is now classified as a human carcinogen

a. Schistosoma mansoni
b. Schistosoma japonicum
c. Schistosoma hematobium
d. Schistosoma mekongi

Answer 108

The correct answer is: Schistosoma hematobium

Question 109

For urogenital schistosomiasis, what is the characteristic sign in the active stage?

a. Painless, terminal hematuria
b. Abdominal (hypogastric) mass
c. Dysuria and pyuria
d. Fever and abdominal pain

Answer 109

S. haematobium has been classified by the International Agency for Research on Cancer (IARC) as definitely carcinogenic to humans (i.e., a group 1 carcinogen)
• Chronic S. haematobium infection is associated with squamous cell carcinoma of the urinary bladder
The signs and symptoms of S. haematobium infection relate to the worms’ predilection for the veins of the urogenital tract.

A characteristic sign in the active stage is painless, terminal hematuria

As the infection progresses, the inflammatory component decreases and fibrosis becomes more prominent.

Cystoscopy reveals “sandy patches” composed of large numbers of calcified eggs surrounded by fibrous tissue and an atrophic mucosal surface.

The correct answer is: Painless, terminal hematuria

Question 110

Which of the following statements is TRUE regarding the pathophysiology of Tetanus?

a. Tetanus is diagnosed on clinical grounds
b. C. tetani is an anaerobic, gram-negative, spore-forming rod whose spores are highly resilient
c. Deep lacerations to the limbs are the most common infection sites in adults.
d. Tetanus is still common in the developed world

Answer 110

TETANUS
Diagnosed on clinical grounds

The CDC defines probable tetanus as “an acute illness with muscle spasms or hypertonia in the absence of a more likely diagnosis.”

C. tetani
• Anaerobic, gram-positive, spore-forming rod
• Spores are highly resilient and can survive readily in the environment throughout the world
• Spores resist boiling and many disinfectants
Superficial abrasions to the limbs are the most common infection sites in adults

Deeper infections (e.g., attributable to open fracture, abortion, or drug injection) are associated with more severe disease and worse outcomes

Tetanus is a rare disease in the developed world.

The correct answer is: Tetanus is diagnosed on clinical grounds

Question 111

Which of the following is TRUE regarding the diagnosis of Tetanus?

a. If symptom are mild, treatment may be delayed while laboratory tests are conducted to confirm the diagnosis
b. Culture of C. tetani from a wound provides supportive evidence
c. PCR for detection of tetanus toxin as a 99% sensitivity for tetanus
d. Serum anti-tetanus immunoglobulin G may be measured in a sample taken after the administration of antitoxin or immunoglobulin

Answer 111

DIAGNOSIS OF TETANUS
Treatment should not be delayed while laboratory tests are conducted

Culture of C. tetani from a wound provides supportive evidence

Serum anti-tetanus immunoglobulin G also may be measured in a sample taken before the administration of antitoxin or immunoglobulin

Polymerase chain reaction also has been used for detection of tetanus toxin, but its sensitivity is unknown

The correct answer is: Culture of C. tetani from a wound provides supportive evidence

Question 112

What is the preferred antibiotic for tetanus?

a. Metronidazole
b. Clindamycin
c. Penicillin
d. Vancomycin

Answer 112

The most common initial symptoms are trismus (lockjaw), muscle pain and stiffness, back pain, and difficulty swallowing.

The diagnosis of tetanus is based on clinical findings

Metronidazole (400 mg rectally or 500 mg IV every 6 h for 7 days) is preferred for antibiotic therapy

An alternative is penicillin (100,000–200,000 IU/kg per day), although this drug theoretically may exacerbate spasms and in one study was associated with increased mortality.

The correct answer is: Metronidazole

Question 113

40/M construction worker is brought to the ER for a 12-hour history of trismus. He has no comorbidities. On PE, you notice several healing abrasions on his forearm which he said he obtained from a fall on his motorbike. After cleaning the wound and starting him on Metronidazole, what should be given as part of treatment for this patient?

a. Tetanus immune globulin
b. Equine antitoxin
c. Propofol infusion
d. IV magnesium sulfate

Answer 113

MANAGEMENT OF TETANUS
Identify the entry wound, clean and debride any necrotic material.

Metronidazole (400 mg rectally or 500 mg IV every 6 h for 7 days) is the preferred antibiotic.
• Penicillin is an alternative but may exacerbate spasms
Use sedatives or magnesium IV, and cardiovascularly inert, non-depolarizing neuromuscular blockers.

Secure airway early and do tracheostomy for patients with severe tetanus

Administer 3000-5000 IU of human tetanus IG (TIG) IM and around the wound.
• Human TIG is the preparation of choice

Give full primary course of immunization (tetanus toxin is poorly immunogenic and the immune response following natural infection is inadequate)

Equine-derived antitoxin is available widely and is used in low-income countries at a dosage of 10,000–20,000 U administered IM as a single dose or as divided doses after testing for hypersensitivity.

The correct answer is: Tetanus immune globulin

Question 114

What is the WHO recommendation for the vaccination of pregnant women in order to prevent maternal and neonatal tetanus?

a. 2 doses of tetanus toxoid at least 4 weeks apart
b. 3 doses of tetanus toxoid at least 4 weeks apart
c. 1 dose of tetanus toxoid during pregnancy then another after delivery
d. Tetanus vaccination is contraindicated during pregnancy

Answer 114

PREVENTION OF MATERNAL AND NEONATAL TETANUS
WHO recommendation: two doses of tetanus toxoid at least 4 weeks apart to previously unimmunized pregnant women

In high-risk areas, a more intensive approach has been successful:
• all women of childbearing age receiving a primary course along with education on safe delivery and postnatal practices

The correct answer is: 2 doses of tetanus toxoid at least 4 weeks apart

Question 115

A 60 year old male comes in with trismus, muscle pain and stiffness, and back pain. He recalled that 5 days prior to consult, he sustained a deep laceration on his leg after falling from a jeepney. His SBP was 130 mmHg and his baseline heart rate was 120 bpm. In the case above, which is considered a factor associated with a poor prognosis?

a. Age of 60 years old
b. Incubation period of 5 days
c. Systolic BP of 130 mmHg
d. Heart rate of 120 bpm

Answer 115

Rapid development of tetanus is associated with more severe disease and poorer outcome; it is important to note time of onset and length of incubation period.

The correct answer is: Incubation period of 5 days

Question 116

Which of the following statements is TRUE regarding the pathophysiology of rabies?

a. Rabies is a rapidly progressive, chronic infectious disease of the central nervous system (CNS)
b. Rabies is a zoonotic infection
c. Rabies virus spreads centripetally from the spinal cord or brain stem towards the peripheral nerves
d. Hematogenous spread of rabies virus as been well documented

Answer 116

PATHOPHYSIOLOGY OF RABIES
Rapidly progressive, acute infectious disease of the central nervous system (CNS) in humans and animals that is caused by infection with rabies virus.
Rabies has encephalitic and paralytic forms that progress to death.

Rabies is a zoonotic infection that occurs in a variety of mammals throughout the world

Incubation period of rabies (defined as the interval between expo- sure and the onset of clinical disease) is usually 20–90 days

Rabies virus spreads centripetally along peripheral nerves toward the spinal cord or brainstem via retrograde fast axonal transport

Rabies virus replicates in acinar cells of the salivary glands and is secreted in the saliva of rabid animals that serve as vectors of the disease

There is no well-documented evidence for hematogenous spread of rabies virus.

The correct answer is: Rabies is a zoonotic infection

Question 117

What is the most characteristic pathologic finding in rabies?

a. Babes nodules
b. Roth spots
c. Amyloid plaques
d. Negri bodies

Answer 117

PATHOLOGY OF RABIES
Mild inflammatory changes in the CNS in rabies, with mononuclear inflammatory infiltration in the leptomeninges, perivascular regions, and parenchyma, including microglial nodules called Babes nodules

Negri bodies are eosinophilic cytoplasmic inclusions in brain neurons that are composed of rabies virus proteins and viral RNA.

The correct answer is: Negri bodies

Question 118

Which of the following is true regarding encephalitic rabies?

a. Encephalitic rabies is less common than paralytic rabies
b. Muscle weakness predominates
c. Hyperexcitability, hydrophobia, and aerophobia are usually lacking
d. Brainstem dysfunction progresses rapidly and coma is the rule

Answer 118

Two acute neurologic forms of rabies are seen in humans: the encephalitic (furious) form in 80% and the para- lytic form in 20%.

Encephalitic Rabies
• Episodes of hyperexcitability are typically followed by periods of complete lucidity that become shorter as the disease progresses
• Rabies encephalitis is distinguished by early brainstem involvement, which results in the classic features of hydrophobia (involuntary, painful contraction of the diaphragm and accessory respiratory, laryngeal, and pharyngeal muscles in response to swallowing liquids) and aerophobia (the same features caused by stimulation from a draft of air)
Paralytic rabies (20%)
• Muscle weakness predominates
• Cardinal features of encephalitic rabies (hyperexcitability, hydrophobia, and aerophobia) are lacking

The correct answer is: Brainstem dysfunction progresses rapidly and coma is the rule

Question 119

Which of the following is true regarding the management of rabies?

a. There is no effective therapy for rabies
b. Preexposure prophylaxis is important to prevent the disease after an animal bite
c. Most patients with rabies die within months of the onset of illness
d. After a dog bite, healthy dogs may be observed for 30 days. Postexposure prophylaxis is not necessary if the animal remains healthy.

Answer 119

MANAGEMENT OF RABIES
There is no established treatment for rabies.

Since there is no effective therapy for rabies, it is extremely important to prevent the disease after an animal exposure (i.e. postexposure prophylaxis)

Healthy dogs, cats, or ferrets may be confined and observed for 10 days

PEP is not necessary if the animal remains healthy

If the animal develops signs of rabies during the observation period, it should be euthanized immediately; the head should be transported to the laboratory under refrigeration, rabies virus should be sought by DFA testing, and viral isolation should be attempted by cell culture and/or mouse inoculation.

The correct answer is: There is no effective therapy for rabies

Question 120

Which of the following is FALSE regarding the diagnosis of RABIES?

a. Diagnosis should be considered in patients presenting with acute atypical encephalitis or acute flaccid paralysis
b. Hydrophobia may be absent sometimes
c. Once rabies is suspected, rabies-specific laboratory tests should be performed to confirm the diagnosis
d. Negative antemortem rabies-specific laboratory tests usually exclude a diagnosis of rabies

Answer 120

DIAGNOSIS OF RABIES
Diagnosis should be considered in patients presenting with acute atypical encephalitis or acute flaccid paralysis, including those in whom Guillain-Barré syndrome is suspected

Lack of hydrophobia is not unusual in rabies

Once rabies is suspected, rabies-specific lab- oratory tests should be performed to confirm the diagnosis

Diagnostically useful specimens include:
•	Serum
•	CSF
•	Fresh saliva
•	Skin biopsy samples from the neck, and brain tissue (rarely obtained before death)

Negative antemortem rabies-specific laboratory tests never exclude a diagnosis of rabies, and tests may need to be repeated after an interval for diagnostic confirmation.

The correct answer is: Negative antemortem rabies-specific laboratory tests usually exclude a diagnosis of rabies

Question 121

32/F consults at the ER after being bitten by a stray dog. She has a laceration wound on her leg. Last known menstrual period was 2 months prior to consult. Wound care was administered at a local clinic and she was given tetanus prophylaxis and antibiotics. She has no prior rabies immunization. Which of the following should she receive?

a. Rabies IG 20 IU/kg at the site of the bite + Rabies vaccine on Day 0, 3, 7, 14.
b. Rabies IG 30 IU/kg at the site of the bite + Rabies vaccine on Day 0, 3, 7, 14, 21.
c. Rabies IG 20 IU/kg at the site of the bite + Rabies vaccine on Day 0, 3, 7, 14, 28.
d. Rabies vaccine on Day 0, 3, 7, 14, 28 only as the patient is possibly pregnant

Answer 121

All previously unvaccinated persons should be passively immunized with rabies immune globulin (RIG).
• If RIG is not immediately available, it should be administered no later than 7 days after the first vaccine dose.
• After day 7, endogenous antibodies are being produced, and passive immunization may actually be counterproductive.
If anatomically feasible, the entire dose of RIG (20 IU/kg) should be infiltrated at the site of the bite; otherwise, any RIG remaining after infiltration of the bite site should be administered IM at a distant site
Four 1-mL doses of rabies vaccine should be given IM in the deltoid area. (The anterolateral aspect of the thigh also is acceptable in children.)
• Gluteal injections, which may not always reach muscle, should not be given and have been associated with rare vaccine failures.
Ideally, the first dose should be given as soon as possible after exposure; failing that, it should be given without further delay.

The three additional doses should be given on days 3, 7, and 14; a fifth dose on day 28 is no longer recommended.

Pregnancy is not a contraindication for immunization.

The correct answer is: Rabies IG 20 IU/kg at the site of the bite + Rabies vaccine on Day 0, 3, 7, 14.

Question 122

. According to the DOH Guidelines (2012) for rabies, feeding an animal with possible rabies is considered as:

a. Category I Exposure
b. Category II Exposure
c. Category III Exposure
d. Category IV Exposure

Answer 122

The correct answer is: Category I Exposure

Question 123

A 40 year old male sustained a minor abrasion without bleeding after playing with a stray dog. Which of the following is NOT true regarding the management of this patient? (Note: the animal is no longer available for observation)

a. Alcohol may be applied on injured site
b. Vaccine should be started immediately until day 28
c. RIG should be started immediately
d. Anti-tetanus immunization should be administered

Answer 123

The correct answer is: RIG should be started immediately

Question 124

Which is the following is NOT TRUE regarding local wound care for rabies?

a. If soap is not available, wound should be extensively washed with water
b. Povidone iodine may be applied
c. Suture the wound as soon as possible to avoid rabies infection
d. Do not apply any ointment or cream to the bite wound

Answer 124

The correct answer is: Suture the wound as soon as possible to avoid rabies infection

Question 125

Who among the following patients with an animal bite require antibiotic treatment?

a. A 30 year old female with an open wound licked by a stray cat
b. An 18 year old male who was feeding a possibly infected dog
c. A 20 year old pregnant patient who sustained a minor abrasion after playing with their household dog
d. A 25 year old nurse caring for a patient with rabies

Answer 125

The correct answer is: A 30 year old female with an open wound licked by a stray cat

Question 126

Which of the following best describes the critical phase of Dengue

a. Earliest manifestation is leukopenia
b. Typically lasts for 7 days
c. Rapid decline in platelet count precedes plasma leakage
d. Coincides with the reabsorption of extravascular fluid and increased risk of acute pulmonary edema

Answer 126

A. Earliest manifestation is leukopenia – starts in the febrile phase and progressively decreases during the critical phase together with thrombocytopenia and hemoconcentration
B. Typically lasts for 7 days- typically lasts for 24-48 hrs
C. Rapid decline in platelet count precedes plasma leakage
D. Coincides with the reabsorption of extravascular fluid and increased risk of acute pulmonary edema- corresponds to recovery phase
Febrile Phase
• High-grade fever
• Lasts 2-7 days
• Facial flushing, skin erythema, generalized body ache, myalgia, arthralgia, retro-orbital eye pain, photophobia, rubeliform exanthema and headache
• Sore throat, injected pharynx, and conjunctival injection
• Anorexia, nausea and vomiting
• Earliest abnormality in CBC is decreasing WBC count
• Positive tourniquet test suggestive of Dengue
• Mild hemorrhagic manifestations (bleeding gums/nose, prolonged heavy menses)
Critical Phase
• Defervescence
• Onset of warning signs with capillary permeability
• Increasing hematocrit (hemoconcentration) due to plasma leakage
o Ascites and pleural effusion may occur after rigorous IV fluid therapy
• Rapidly declining platelet count
• Shock due to critical volume of plasma lost through leakage
Recovery Phase
• Gradual reabsorption of extravascular compartment fluid takes place in the following 48−72 hours
• General well- being improves, appetite returns, gastrointestinal symptoms abate, haemodynamic status stabilizes, and diuresis ensues.
• “isles of white in the sea of red”
• CBC picture
o Hematocrit stabilizes or may be lower due to reabsorbed fluid
o Rise in WBC to normal
o Platelet count normalizes albeit much later than normalization of WBC

The correct answer is: Rapid decline in platelet count precedes plasma leakage

Question 127

TRUE of the clinical course of dengue

a. Peak of fever coincides with peak of viremia
b. Decreasing platelet count typically occurs during peak of fever
c. Decreasing platelet count and hematocrit coincides with appearance of antibodies
d. Increasing hematocrit reflects dehydration from insensible losses from fever

Answer 127

The correct answer is: Peak of fever coincides with peak of viremia

Question 128

25/F presenting with fever for 3 days associated with myalgia, sore throat and epigastric pain. She has no co-morbidities. She is awake and oriented, normotensive but tachycardic, has tender upper abdominal area with palpable liver edge and hyperactive bowel sounds. She has full and equal pulses and CRT of less than 2 seconds. Positive tourniquet test was also noted. Initial lab test done showed hemoglobin of 12.5 g/dL, hematocrit of 30, WBC count of 2.8 x 109 /L and adequate platelet count. The patient tested positive for Dengue NS1. Based on the WHO Clinical guidelines on the management of Dengue, what is her diagnosis?

a. Probable Dengue Infection
b. Dengue with warning signs
c. Past Dengue Infection
d. Severe Dengue with signs of compensated shock

Answer 128

The correct answer is: Dengue with warning signs

Question 129

What is the best management for the patient in question #3?

a. Check for seroconversion to confirm dengue infection
b. Admit to hospital regular room, start intravenous fluid therapy at 10ml/kg/hr, monitor CBC every 6-12 hours
c. Request for paired serum IgM and IgG for confirm dengue infection
d. Admit to hospital regular room and administer Paracetamol for fever with advise to increase oral fluid intake as tolerated

Answer 129

The correct answer is: Admit to hospital regular room and administer Paracetamol for fever with advise to increase oral fluid intake as tolerated

Question 130

The patient was referred to you again because of cold extremities. She is awake, coherent and oriented. Her BP is 90/75 mmHg, HR 120, RR 22 and temperature of 37C. Repeat CBC showed hemoglobin of 12.0 g/dL, hematocrit of 50, WBC count of 1.8 x 109 /L and platelet count of 65 x 109 /L. What is the best management for this patient?

a. Start IV therapy with isotonic saline at 20ml/kg/hr and obtain hematocrit after 1 hour of infusion
b. Start IV therapy with lactated ringer’s solution at 10ml/kg/hr then decrease to 5-7ml/kg/hr once hematocrit normalizes or decreases
c. Start IV therapy with isotonic saline at 3ml/kg/hr then decrease to 1-2ml/kg/hr after an hour if hematocrit decreases
d. Start IV therapy with lactated ringer’s solution at 2ml/kg/hr and obtain hematocrit after 4 hours of IV therapy

Answer 130

LABORATORY DIAGNOSIS OF DENGUE

A diagnosis of dengue infection is confirmed by the detection of the virus, the viral genome or NS1 Ag, or seroconversion of IgM or IgG (from negative to positive IgM/IgG or four-fold increase in the specific antibody titre) in paired sera (see Table 5).
A positive IgM serology or a haemagglutinin inhibition test (HIA) antibody titre of 1280 or higher (or comparable figures by ELISA in a single specimen), are all diagnostic criteria of a probable dengue infection. Both probable and confirmed dengue cases should be notified to health authorities (1–4, 9, 30).

Antigen detection tests such as Dengue NS1 are best done during Days 1-5 of fever to confirm acute dengue infection

Serologic tests are done after day 5 of fever and during the critical and convalescent phase to detect recent Dengue infection. Paired sera taken from acute phase (Days 1-5) and from days 15-21 with evidence of serologic conversion can also be used to confirm dengue infection, albeit, with very long waiting time (until the convalescent phase)

The correct answer is: Start IV therapy with lactated ringer’s solution at 10ml/kg/hr then decrease to 5-7ml/kg/hr once hematocrit normalizes or decreases

Question 131

35/M presenting at the ER with fever and chills for 5 days associated with generalized weakness and dizziness. He also noted occasional gum bleeding during brushing of teeth and melena. He has no co-morbidities. BP was noted to be 80/60, tachycardic and with cold clammy extremities. Positive tourniquet test was noted. Initial lab test done showed hemoglobin of 14.5 g/dL, hematocrit of 60, WBC count of 3.5 x 109 /L and platelet count of 50 x 109 /L. Dengue NS1, IgM and IgG were all positive. What would be the best management for this patient?

a. Start IV therapy with 0.9 NaCl at 10 ml/kg/hr for 1-2 hours
b. Start IV therapy with 0.9 NaCl at 20ml/kg/hr for 30 minutes then reassess BP and hematocrit
c. Start IV therapy with 0.9 NaCl at 5-7ml/kg/hr for 1-2 hours and prepare platelet concentrate for transfusion
d. Start IV therapy with 0.9 NaCl at 7-10 ml/kg/hr for 1 hour

Answer 131

The correct answer is: Start IV therapy with 0.9 NaCl at 20ml/kg/hr for 30 minutes then reassess BP and hematocrit

Question 132

After an hour, patient is still hypotensive at 80/60 but hematocrit decreased to 40. What is the next best management for this patient?

a. Start dopamine therapy at 2.5mcg/kg/min
b. Decrease IVF rate to 5-10ml/kg/hr due to excessive intravenous fluid
c. Check if there’s overt bleeding and maintain IV at 20ml/kg/hr.
d. Give another IV fluid bolus of 10ml/kg/hr

Answer 132

The correct answer is: Check if there’s overt bleeding and maintain IV at 20ml/kg/hr.

Question 133

50/M was referred for new-onset fever and desaturation. He was admitted a week ago due to a vehicular accident. He was intubated since admission due to depressed sensorium (GCS 5). Chest x-ray showed infiltrates in right mid to lower lung fields, tram-tracking and blunted costophrenic angle on the right. What would be the best management for this patient?

a. Obtain bronchoalveolar lavage and start Piperacillin-Tazobactam 4.5g IV q6
b. Obtain blood culture from 2 sites and start Levofloxacin 750mg IV q24
c. Obtain tracheal aspirate for culture and sensitivity and start Vancomycin at 15mg/kg IV q8 + Piperacillin-Tazobactam at 4.5g IV q6 + Gentamicin 5mg/kg IV q 24
d. Obtain tracheal aspirate for culture and sensitivity and start Vancomycin at 15mg/kg IV q8 + Piperacillin-Tazobactam at 4.5g IV q6 + Levofloxacin 750mg IV q24

Answer 133

The correct answer is: Obtain tracheal aspirate for culture and sensitivity and start Vancomycin at 15mg/kg IV q8 + Piperacillin-Tazobactam at 4.5g IV q6 + Levofloxacin 750mg IV q24

Question 134

The risk factors for MDR organisms are the following, EXCEPT,

a. Seven or more days of hospitalization prior to occurrence of VAP
b. Prior IV antibiotic within 90 days
c. Acute renal replacement therapy prior to VAP
d. Septic shock at the time of VAP

Answer 134

The correct answer is: Seven or more days of hospitalization prior to occurrence of VAP

Question 135

The following antibiotics can be used against Psudomonas aeruginosa, EXCEPT

a. Ciprofloxacin
b. Piperacillin-tazobactam
c. Ertapenem
d. Cefepime

Answer 135

The correct answer is: Ertapenem

Question 136

A newly-wed couple consulted in the clinic for possible prevention and prophylaxis for malaria since they’ll go to South Africa for their honeymoon. The wife, who suffered from Major Depressive Disorder before, would like to experience the safari, hence their decision to go to Africa. Which of the following measures would you advise the couple?

a. Apply insect repellant everytime they would go on tours during the day
b. Start Mefloquine 250mg PO once a week, 2 weeks before their departure to be continued for 4 weeks after their arrival here in the Philippines
c. Start Doxycycline 100mg PO daily 2 days before their departure to be continued for 4 weeks after their arrival here in the Philippines
d. Start Hydoxychloroquine 200mg 2 days before their departure be continued for 4 weeks after their arrival here in the Philippines

Answer 136

A. Apply insect repellant everytime they would go on tours during the day- Anopheles bites from dusk to dawn
B. Start Mefloquine 250mg PO once a week, 2 weeks before their departure to be continued for 4 weeks after their arrival here in the Philippines- not recommended for those with psychiatric disorders
C. Start Doxycycline 100mg PO daily 2 days before their departure to be continued for 4 weeks after their arrival here in the Philippines
D. Start Hydoxychloroquine 200mg 2 days before their departure be continued for 4 weeks after their arrival here in the Philippines- dose and timing is not correct; not advisable in areas where there is chloroquine-resistant P. falciparum

The correct answer is: Start Doxycycline 100mg PO daily 2 days before their departure to be continued for 4 weeks after their arrival here in the Philippines

Question 137

Etiologic agent of quartan malarial nephropathy

a. Plasmodium vivax
b. Plasmodium falciparum
c. Plasmodium ovale
d. Plasmodium malariae

Answer 137

The correct answer is: Plasmodium malariae

Question 138

This parasite is responsible for almost all deaths and neurologic complications from malaria

a. Plasmodium vivax
b. Plasmodium falciparum
c. Plasmodium ovale
d. Plasmodium malariae

Answer 138

The correct answer is: Plasmodium falciparum

Question 139

45/M presented with high-grade fever and chills which started 3 days ago. This was associated with mild tolerable headache and myalgia. He was diagnosed with malaria 1 year ago after traveling to Brazil and was treated with artemether-lumefantrine. However, this time, he denied any travel to malaria-endemic area. Peripheral blood smear showed ring form trophozoites and schuffner’s dots and no signs of oval or enlarged RBCs:

Which of the following is TRUE regarding the etiologic agent of this disease?

a. Cause of the malignant tertian fever
b. Capable of producing hypnozoites that remain dormant in the liver
c. Prefers older RBCs
d. Infected erythrocytes are enlarged and oval in shape with characteristic schuffner’s dots

Answer 139

Patient has relapse of malaria and it is usually caused by P. vivax or P. ovale but the smear showed ring form trophozoites and schuffner’s dots and no signs of oval or enlarged RBCs –> P.vivax

A. Cause of the malignant tertian fever- P. vivax causes benign tertian fever whereas falciparum causes malignant (severe) tertian fever
B. Capable of producing hypnozoites that remain dormant in the liver- dormant parasite can live for 2 weeks up to a year in the liver
C. Prefers older RBCs – prefers young RBCs and reticulocytes
D. Infected erythrocytes are enlarged and oval in shape with characteristic schuffner’s dots- characteristic of P.ovale

The correct answer is: Capable of producing hypnozoites that remain dormant in the liver

Question 140

What is the best management for this patient?

a. Primaquine for 14 days
b. Artemether-lumefantrine for 3 days
c. Artemether-lumefantrine + doxycyline for 3 days
d. Doxycycline 100mg PO once a day for 2 weeks

Answer 140

The correct answer is: Primaquine for 14 days

Question 141

TRUE of malaria transmission
a. Stable transmission usually occurs in hypoendemic areas
b. Anopheles mosquito must survive for more than 7 days for it to be able to transmit sporozoites
c. Lower temperatures are more favorable for sporogony and therefore transmission
d. High altitude areas are favorable breeding grounds of Anopheles mosquito
Feedback

Answer 141

A. Stable transmission usually occurs in hypoendemic areas- stable transmission occurs in hyper and holoendemic areas; unstable transmission occurs in hypoendemic areas
B. Anopheles mosquito must survive for more than 7 days for it to be able to transmit sporozoites- Mosquito longevity is an important determinant of transmission; sporogony lasts for 7-8 days therefore a mosquito must stay alive for more than 7 days to transmit the sporozoites
C. Lower temperatures are more favorable for sporogony and therefore transmission- Sporogony (sporozoite development) is not completed in cooler temperatures such as < 21C with P.falciparum and < 16% with P. vivax
D. Transmission is usually high in high altitude areas- high altitudes have cooler temperatures and therefore not favorable for sporogony

The correct answer is: Anopheles mosquito must survive for more than 7 days for it to be able to transmit sporozoites

Question 142

Which of the following best describes the pathogenesis of falciparum malaria

a. Infected erythrocytes form rosettes and have reduced deformability compromising their passage through capillaries and venules
b. Characteristic paroxysm of fever, chills and rigors corresponding to rupture of schizonts and release of pro-inflammatory cytokines occurs every 72 hours
c. P. falciparum infects younger RBC’s and reticulocytes
d. Infection with P.falciparum, due to its severity, can result to lifelong immunity against this parasite.

Answer 142

A.Infected erythrocytes form rosettes and have reduced deformability compromising their passage through capillaries and venules
Rosette formation, agglutination, cytoadherence are central to the pathogenesis of falciparum malaria
B. Characteristic paroxysm of fever, chills and rigors corresponding to rupture of schizonts and release of pro-inflammatory cytokines occurs every 72 hours
P. Falciparum exhibits tertian periodicity (every 48 hrs)
C. P. falciparum infects younger RBC’s and reticulocytes
Infects RBCs of all ages
D. Infection with P.falciparum, due to its severity, can result to lifelong immunity against this parasite.
The complexity of the immune response in malaria, the sophistication of the parasites’ evasion mechanisms, and the lack of a good in vitro correlate with clinical immunity have all slowed progress toward an effective vaccine.

The correct answer is: Infected erythrocytes form rosettes and have reduced deformability compromising their passage through capillaries and venules

Question 143

The following complications of falciparum malaria are commonly seen in adults, EXCEPT

a. Jaundice
b. Renal Failure
c. Pulmonary Edema
d. Anemia

Answer 143

The correct answer is: Anemia

Question 144

Which of the following laboratory findings indicate poor prognosis in malaria?

a. WBC < 12,000
b. Random blood glucose of < 50 mg/dL
c. Presence of more mature forms of P. falciparum in the blood smear
d. Severe Anemia

Answer 144

The correct answer is: Presence of more mature forms of P. falciparum in the blood smear

Question 145

A patient who was hospitalized for 3 days for severe malaria, suddenly developed sepsis with positive growth on blood cultures from 2 sites. Which among the following agent is the most likely cause of this patient’s sepsis?

a. E. coli
b. Acinetobacter baumanii
c. MRSA
d. Salmonella

Answer 145

The correct answer is: Salmonella

Question 146

Which of the following best describes the etiologic agent of SARS epidemic in 2002

a. It is unique among all viral pneumonias in that it lacks upper respiratory symptoms
b. Transmission is through contact with infected camels
c. It belongs to the family Adenoviridae
d. It originated from Wuhan, China

Answer 146

The correct answer is: It is unique among all viral pneumonias in that it lacks upper respiratory symptoms

Question 147

Flu season is coming but Barangay Malusog has limited supply of quadrivalent flu vaccines for its constituents. The rural health officer decided to allocate the vaccines to high-risk individuals. Who among the following resident/s will be able to receive the vaccine?

a. 7/F elementary school student
b. 43/M with TB bronchiectasis
c. 38/F planning to get pregnant but is allergic to eggs
d. 48/F with BMI of 32

Answer 147

The correct answer is: 43/M with TB bronchiectasis

Question 148

The following is true regarding the etiologic agent of the Flu Pandemic in 1918, EXCEPT?

a. Belongs to Influenza group A with hemagglutinin subtype 1 and neuraminidase subtype 1
b. Virus is of avian origin with eventual human-human transmission
c. Spread is through small- and large-droplets from coughing or sneezing
d. Underwent antigenic drift enabling it to cause a pandemic

Answer 148

A. Belongs to Influenza group A with hemagglutinin subtype 1 and neuraminidase subtype 1
B. Enveloped virus with segmented single-stranded, negative-sense RNA that allows gene reassortment
C. Spread is through small- and large-droplets from coughing or sneezing
D. Underwent antigenic drift enabling it to cause a pandemic- antigenic shift causes pandemics

The correct answer is: Underwent antigenic drift enabling it to cause a pandemic

Question 149

Transmission through airborne droplet nuclei has been demonstrated in which of the following viruses

a. Influenza AH5N1
b. Human Parainfluenza Virus
c. Measles Virus
d. Respiratory Syncytial Virus

Answer 149

The correct answer is: Measles Virus

Question 150

19/F, nursing student, came in due to high-grade fever for 2 days associated with runny nose, occasional dry cough and excessive tearing. Generalized maculopapular rash were noted sparing the palms and soles as well as multiple white spots in her buccal mucosa. What is the most likely diagnosis?

a. Rubeola
b. Rubella
c. Varicella
d. Pertussis

Answer 150

The correct answer is: Rubeola

Question 151

. 24/M, medical intern, came in for rashes which appeared a day before. He experienced low-grade fever 2 days ago followed by the appearance of rashes. Generalized maculopapular, vesicular lesions on an erythematous base were found. What is the most likely etiologic agent?

a. Measles virus
b. Rubella
c. Varicella zoster virus
d. Dengue

Answer 151

The correct answer is: Varicella zoster virus

Question 152

Which of the following patients has SEPSIS based on the 2020 Philippine CPG for Sepsis and Septic Shock in Adults?

a. 50/F with diabetes and non-healing would on the right foot, irritable due to pain, Temp of 37.5C, BP 140/80, HR 110 and RR 22
b. 55/M with TB bronchiectasis presenting with 2 day history of increased sputum production, dyspnea, fever of 38C, BP 100/70, HR 120, RR 26, O2 saturation of 90% on room air
c. 60/M with hypertension presenting with chest pain and dyspnea. BP 80/60, HR 120 irregular, RR 26, Temp 38C and O2 saturation of 92% on room air
d. 65/F with right breast mass and fever of 38C, BP 110/80, HR 95, RR 24

Answer 152

The correct answer is: 55/M with TB bronchiectasis presenting with 2 day history of increased sputum production, dyspnea, fever of 38C, BP 100/70, HR 120, RR 26, O2 saturation of 90% on room air

Question 153

The following are SOFA variables, EXCEPT

a. RR ≥ 20
b. Altered mental status
c. Systolic BP of ≤ 100mmHg
d. Serum Creatinine ≥ 1.2 mg/dL

Answer 153

The correct answer is: RR ≥ 20

Question 154

Most common source of sepsis:

a. Soft tissue infection
b. Pulmonary Infection
c. Urinary tract infection
d. Intraabdominal Infection

Answer 154

The correct answer is: Pulmonary Infection

Question 155

Which of the following is TRUE regarding the pathogenesis of sepsis

a. Most common pathogen associate molecular pattern (PAMP) that initiates the inflammatory response is the lipid A moiety of the LPS
b. Sepsis induces enhanced coagulation that effectively isolate the microorganism and prevent organ dysfunction
c. Whether the patient will have hyperimmune or immunosuppressed phenotype is largely dependent on the initial host response to inflammation
d. Excessive and unopposed nitric oxide release promotes vasoconstriction worsening tissue hypoxia and organ dysfunction

Answer 155

The correct answer is: Most common pathogen associate molecular pattern (PAMP) that initiates the inflammatory response is the lipid A moiety of the LPS

Question 156

55/M was admitted for difficulty of breathing for 5 days. He developed fever and productive cough 1 week ago which eventually progressed to difficulty in breathing. He is hypertensive and diabetic. He presented at the ER confused and irritable with BP 80/50, HR 120, RR 30, Temp 38C, wt 70kg and O2 saturation of 88% on room air. He was immediately hooked to O2 support at 10 LPM which improved his oxygen saturation to 94%. Bilateral crackles were noted from mid-base, heart rate is regular without murmurs, no edema, CRT is 4 sec and pulses were thready. What is the next best step in the management of this patient

a. Inform anes on duty and prepare for endotracheal intubation
b. Get baseline serum lactate levels
c. Start fluid resuscitation with PNSS at 10ml/kg
d. Get ABG and compute for PaO2/FiO2

Answer 156

The correct answer is: Get baseline serum lactate levels

Question 157

Chest X-ray showed bilateral infiltrates suggestive of pneumonia. The following best describe antibiotic therapy for this patient, EXCEPT

a. Antibiotic must be started within an hour of sepsis recognition
b. Start Cetfriaxone 2g IV + Azithromycin 500mg/tab PO OD
c. Empiric coverage for MRSA for patients in septic shock
d. Start Piperacillin + Tazobactam 4.5g IV + Azithromycin 500mg OD

Answer 157

The correct answer is: Start Cetfriaxone 2g IV + Azithromycin 500mg/tab PO OD

Question 158

Patient is unresponsive to fluid resuscitation and BP remains at 90/50. What would be the next best management for this patient?

a. Start Norepinephrine
b. Give another 10ml/kg fluid bolus
c. Insert arterial catheter
d. Do Passive Leg Raising

Answer 158

The correct answer is: Do Passive Leg Raising

Question 159

True of the organisms causing sepsis, EXCEPT

a. Most common gram-positve isolate is Streptococcus pneumonia
b. Most common gram-negative isolate is E.coli
c. Blood cultures are positive in 50% of the time among septic patients
d. Incidence of sepsis is higher in males than in females

Answer 159

The correct answer is: Blood cultures are positive in 50% of the time among septic patients

Question 160

Which of the following best describes supportive measures in Septic Shock

a. Hydrocortisone must be initiated at a dose of 300mg/day via continuous IV drip in patients on dual vasopressors
b. Insulin must be initiated following two consecutive capillary blood glucose readings of more than 180mg/dL
c. PRBC transfusion considered in all patients with hemoglobin less than <70 g/dL
d. Continuous IV sedation must be maintained for all patients while they are on mechanical ventilator

Answer 160

The correct answer is: Insulin must be initiated following two consecutive capillary blood glucose readings of more than 180mg/dL

Question 161

Which of the following patients has Advanced HIV or stage 3 HIV?

a. 25/F with recurrent acute suppurative tonsillopharyngitis
b. 28/M with aphthous ulcers lasting for 2 weeks
c. 5/F with invasive cervical cancer
d. 30/M with primary adrenal insufficiency from TB adrenalitis

Answer 161

A. 25/F with recurrent acute suppurative tonsillopharyngitis –only for patients < 6 years old
B. 28/M with aphthous ulcers lasting for 2 weeks- must be more than 1 month duration
C. 5/F with invasive cervical cancer- only for patients > 6 years old
D. 30/M with primary adrenal insufficiency from TB adrenalitis

The correct answer is: 30/M with primary adrenal insufficiency from TB adrenalitis

Question 162

Which of the following patients is classified as HIV stage 0

a. 30/M recently diagnosed with HIV with CD4+ T cell count of 1000 cells/uL
b. 28/F with negative HIV ELISA test after 3 months of initial diagnosis of HIV
c. 38/M with CD4+ T cell count of 800 cells/uL
d. 30/F with CD4+ T cell count of 350 cells/uL

Answer 162

The correct answer is: 28/F with negative HIV ELISA test after 3 months of initial diagnosis of HIV

Question 163

Which of the following sexual activities has the lowest risk of HIV transmission

a. Sharing of sex toys
b. Oral sex
c. Heterosexual intercourse
d. Homosexual intercourse

Answer 163

The correct answer is: Sharing of sex toys

Question 164

Treatment of the following STI’s help prevent HIV transmission, EXCEPT

a. Gonorrhea
b. Trichomoniasis
c. Syphilis
d. Herpes Simplex ulcer

Answer 164

The correct answer is: Herpes Simplex ulcer

Question 165

Which among the following blood products is NOT associated with transmission of HIV

a. FFP
b. PRBC
c. Hep B Ig
d. Platelet concentrate

Answer 165

The correct answer is: Hep B Ig

Question 166

30/M nurse-on-duty (NOD) accidentally pricked himself with the needle used during IV insertion in a patient admitted due to PCP. The NOD is worried he might get HIV. What would be the best advise for this patient?

a. Pin-prick transmission is low at 0.23% so no need to worry
b. Advise HIV ELISA after 2 weeks to check for antibodies to HIV
c. He can start post-exposure prophylaxis with antiretroviral drugs
d. Instruct him to attend another hospital infection control lecture to prevent another incident

Answer 166

The correct is: He can start post-exposure prophylaxis with antiretroviral drugs

Question 167

He underwent HIV ELISA test which turned out to be positive. What would be the next step in his management?

a. Repeat the test
b. Do western blot for HIV-1
c. Wait for 3-6 months before repeating HIV EIA
d. Start antiretroviral therapy since he already has exposure and tested positive for antibodies to HIV

Answer 167

The correct answer is: Repeat the test

Question 168

Which of the following are direct mechanisms of CD4+ T cell dysfunction in HIV

a. Inhibition of lymphopoiesis
b. Syncytia formation
c. Autoimmunity
d. Induction of apoptosis

Answer 168

The correct answer is: Syncytia formation

Question 169

20/F victim of domestic violence was referred for HIV testing. Her initial HIV ELISA test done 2 weeks ago turned out to be positive, however, in the clinic, her test turned out to be negative. She is currently 12 weeks pregnant, allegedly from the sexual assault done to her. What is the next step in the management of this patient?

a. Western blot must be done to confirm diagnosis of HIV
b. The test is false-positive since it’s done during her pregnancy
c. Repeat the test using fourth-generation EIA
d. Re-test after 3-6 months

Answer 169

The correct answer is: Re-test after 3-6 months

Question 170

The average length of time from initial infection to clinical manifestation of AIDS in an untreated patient

a. 10 years
b. 7 years
c. 5 years
d. 1.5 years

Answer 170

The correct answer is: 10 years

Question 171

The average length of time from initial infection to clinical manifestation of AIDS in an untreated patient

a. 10 years
b. 7 years
c. 5 years
d. 1.5 years

Answer 171

The correct answer is: 10 years

Question 172

Which statement is TRUE regarding non-AIDS illnesses in patients with HIV

a. Most common CV disease is HIV-associated cardiomyopthy
b. Anemia is the most common hematologic abnormality and is commonly caused by Tenofovir
c. Proteinuria is the hallmark of HIV-associated nephropathy (HIVAN)
d. Most common thyroid abnormality is subclinical hyperthyroidism

Answer 172

A. Most common CV disease is HIV-associated cardiomyopthy- coronary artery disease
B. Anemia is the most common hematologic abnormality and is commonly caused by Tenofovir – Zidovudine blocks maturation of RBC –> most common finding is increased MCV
C. Proteinuria is the hallmark of HIV-associated nephropathy (HIVAN)- edema and hypertension is rare. HIVAN typically occurs at CD4+ T cell count of less than 200
D. Most common thyroid abnormality is subclinical hyperthyroidism- subclinical hypothyroidism

The correct answer is: Proteinuria is the hallmark of HIV-associated nephropathy (HIVAN)

Question 173

30/M with HIV is being given cART. On follow-up, he was noted to have elevated triglycerides and impaired glucose tolerance test. Which among his medications are likely to be the cause of these abnormalities?

a. Zidovudine
b. Abacavir
c. Lamivudine
d. Efavirenz

Answer 173

The correct answer is: Zidovudine

Question 174

TRUE of Immune Reconstitution Inflammatory Syndrome (IRIS)

a. Common in patients starting cART with CD4+ T cell count < 200
b. Underlying mechanism appears to be similar to Type II hypersensitivity reaction with improvement in immune function
c. Common in patients with underlying, untreated tuberculosis
d. Glucocorticoids must be started early upon recognition of IRIS

Answer 174

The correct answer is: Common in patients with underlying, untreated tuberculosis

Question 175

Which of the following describes the mechanisms of enteric pathogens in infectious diarrhea. EXCEPT
a. Cholera toxin produces secretory diarrhea
b. Yersinia enterocolitica produces cytotoxin responsible for fever and abdominal pain
c. Shigella produces cytotoxin that destroys intestinal mucosal cells causing dysentery
d. Bacillus cereus produces a neurotoxin that induces vomiting
Feedback

Answer 175

The correct answer is: Yersinia enterocolitica produces cytotoxin responsible for fever and abdominal pain

Question 176

30/F came in due to sudden onset vomiting and watery diarrhea. She denies fever, headache, sore throat, cough or colds. She is previously well without co-morbids. She remembered that last meal she had 6 hours ago were spaghetti and sandwich from a party attended by her mother last night. What is the most likely etiologic agent?

a. Vibrio cholerae
b. Staphyloccous aureus
c. Enterotoxigenic E. coli
d. Rotavirus

Answer 176

The correct answer is: Staphyloccous aureus

Question 177

28/M came in due to profuse, watery diarrhea of 1 day duration. This is associated with vomiting and crampy abdominal pain which was relieved with defecation. Prior to consultation, he already had 8 episodes of watery diarrhea apporximately amounting to 1 “tabo”. He denied fever, melena or hematochezia. He’s not on any medications. He was previously well without co-morbidities. According to his wife, he attended a party 2 nights ago in a seafood restaurant in Parañaque. What would be the likely cause of his diarrhea?

a. Vibrio cholerae
b. Staphyloccous aureus
c. Enterotoxigenic E. coli
d. Rotavirus

Answer 177

The correct answer is: Vibrio cholerae

Question 178

34/F, executive consultant, consulted due to bloody stools. 1 week prior, she experienced low-grade fever, occasional crampy abdominal pain followed by soft-stools and feeling of incomplete defecation. Symptoms persisted until 2 days ago, she noticed soft stools admixed with bloody, mucopurulent stools. She has no co-morbidities and no medications being taken. She denies changes in diet or activity although she recently traveled to India for 2 days for a business meeting. The following are appropriate management for this patient, EXCEPT

a. Obtain fecalysis
b. Advised to increase fluid intake
c. Start Ciprofloxacin 500mg PO q12 for 5 days
d. Start loperamide

Answer 178

A. Obtain fecalysis – work-up is needed if patient presents with fever T>38.5C, bloody diarrhea, severe symptoms, more than 4 hrs duration and with recent antibiotic use
B. Advised to increase fluid intake – fluid and electrolyte replacement are cornerstone in the management of acute diarrhea
C. Start Ciprofloxacin 500mg PO q12 for 5 days- febrile dysentery can be empirically treated with Ciprofloxacin
D. Start loperamide- avoided in febrile dysentery since it can prolong or exacerbate the symptoms

The correct answer is: Start loperamide

Question 179

Stool analysis showed numerous RBCs and PMNs. No parasite or ova seen. The most likely etiologic agent is

a. Giardia lamblia
b. Entameba histolytica
c. Shigella dysenteriae
d. Enteropathogenic E.coli

Answer 179

The correct answer is: Shigella dysenteriae

Question 180

Which of the following is TRUE regarding complications of acute infectious diarrhea

a. Guillain-Barré syndrome usually after Bacillus cereus toxic infection
b. Hemolytic-Uremic Syndrome can occur after infection with enteropathogenic E.coli
c. Reactive arthritis occuring after Shigellosis
d. Chronic diarrhea with malabsorption after cholera

Answer 180

The correct answer is: Reactive arthritis occuring after Shigellosis

Question 181

Most common manifestation of amebic infection

a. Asymptomatic cyst passage
b. Dysentery
c. Liver abscess
d. Amebic Colitis

Answer 181

The correct answer is: Asymptomatic cyst passage

Question 182

The following is included in the new definition of FUO, EXCEPT

a. Fever of at > 38.3C on at least two occasions
b. Duration of > 3 weeks
c. Lymphoma
d. Uncertain diagnosis 1 week of inpatient evaluation

Answer 182

The correct answer is: Uncertain diagnosis 1 week of inpatient evaluation

Question 183

Most common neoplasm associated with Fever of Unknown Origin

a. Multiple Myeloma
b. Lymphoma
c. Acute Myelogenous Leukemia
d. Malignant Histiocytosis

Answer 183

The correct answer is: Lymphoma

Question 184

Most common infection associated with Fever of Unknown Origin

a. Whipple’s Disease
b. HIV
c. Tuberculosis
d. Legionella

Answer 184

The correct answer is: Tuberculosis

Question 185

Which of the following BEST describes the work-up for FUO

a. Chest xray has relatively low sensitivity hence, it is not advisable to include this as part of the extensive work-up of FUO
b. Abdominal CT is preferred over Abdominal sonography
c. Multiple blood cultures and at least one urine culture must be done on all patients
d. Antibiotic and glucocorticoids must be stopped prior to doing diagnostic tests

Answer 185

A. Chest xray has relatively low sensitivity hence, it is not advisable to include this as part of the extensive work-up of FUO- simple and low-cost and remains obligatory in all patients
B. Abdominal CT is preferred over Abdominal sonography- ultrasound is preferable in the initial obligatory work-up
C. Multiple blood cultures and at least one urine culture must be done on all patients- Performing more than three blood cultures or more than one urine culture is useless in patients with FUO in the absence of PDCs (e.g., a high level of clinical suspicion of endocarditis).
D. Antibiotic and glucocorticoids must be stopped prior to doing diagnostic tests

The correct answer is: Antibiotic and glucocorticoids must be stopped prior to doing diagnostic tests

Question 186

38/F, businesswoman, came in due to weight loss. She had a 3-month history of on and off fever with the highest Temp noted to be 38.5C. Fever is usually noted in the afternoon or evening and would resolve spontaneously in the morning. It doesn’t interfere with her activities except in few episodes when she would experience headache and myalgia which resolve after intake of paracetamol. No consults were done since she just attributed this to over work and stress in selling. 1 month prior to consult, she noticed weight loss and easy fatigability. Her children who noticed her dramatic weight loss urged her to consult a doctor. She denies any intake of medications or herbal medicine. Systemic PE is unremarkable save for bitemporal wasting. The following tests are warranted, EXCEPT

a. CBC with platelet count and differential count
b. Chest Xray PA upright
c. ESR and CRP
d. TSH

Answer 186

A. CBC with platelet count and differential count
B. Chest Xray PA upright
C. ESR and CRP
D. TSH – not included in the initial obligatory test for FUO; only symptom that can be attributed to thyroid dysfunction is weight loss- no tremors, palpitations, diarrhea typical of hyperthyroidism

The correct answer is: TSH

Question 187

Chest Xray of the patient showed the following result. What would be the best management for her case?

a. Start HRZE
b. Get sputum AFB x 2
c. Get bronchoalveolar lavage specimen
d. Perform Tuberculin Skin Test (TST)

Answer 187

A. Start HRZE
B. Get sputum AFB x 2 – sputum samples in miliary TB are oftentimes negative
C. Get bronchoalveolar lavage specimen- need to test resistance to TB meds
D. Perform Tuberculin Skin Test (TST)- usually negative in miliary TB

The correct answer is: Get bronchoalveolar lavage specimen

Question 188

32/M came in due to dysuria of 3 days duration. Dysuria is further described as burning sensation everytime he urinates with note of milky non-foul smelling discharge after urinating. He denies fever and hypogastric pain. On PE, there’s a note of purulent discharge per urethra. Gram stain of the discharge showed 4 PMNS per HPF and intracellular diplococci. The following are appropriate management for the patient, EXCEPT

a. Start Ceftriaxone 250mg IM + Azithromycin 1g PO as single dose
b. Treat the sexual partner with Ceftriaxone 250mg IM and azithromycin 1g PO single dose
c. Promote condom use if not desirous of pregnancy
d. Treat the partner only after appropriate tests are done

Answer 188

The correct answer is: Treat the partner only after appropriate tests are done

Question 189

28/F came in due to abnormal vaginal discharge described as profuse and whitish noted her panty. She denies fever, dysuria or hypogastric pain. No inguinal nodes or ulcers noted. Examination of vaginal discharge showed a pH of 5 and intense fishy odor when mixed with KOH. What is the best management for this patient?

a. Start Metronidazole 2g PO as single dose
b. Start Metronidazole 500mg BID PO for 7 days
c. Start Fluconazole 150mg PO single dose
d. Give Metronidazole 500mg BID PO for 7 days and treat the sexual partner too

Answer 189

The correct answer is: Start Metronidazole 500mg BID PO for 7 days

Question 190

30/F came in due to intense vulvar itching of 1 week duration. She also has dysuria described as pain in the vulvar area after urinating. Examination revealed an erythematous vulva and whitish, curd-like vaginal discharge, non-foul smelling. Further examination of the vaginal discharge showed pH 3.5 and pseudohyphae on KOH mount. The following is TRUE regarding her condition, EXCEPT

a. Candida albicans is the most common cause of vulvovaginal candidiasis
b. Single dose of Fluconazole 150mg PO is widely acceptable due to its efficacy and ease of administration
c. Microscopic examination is less sensitive than culture therefore culture is needed prior to therapy
d. Treatment of sexual partner is not routinely indicated

Answer 190

The correct answer is: Microscopic examination is less sensitive than culture therefore culture is needed prior to therapy

Question 191

35/M presented with a painless, non-tender indurated ulcer in the penile shaft associated with bilateral inguinal adenopathy. He had unprotected sex with a commercial sex worker 2 weeks ago. His rapid serologic test for syphilis done a week ago was allegedly negative. Which of the following is TRUE regarding his case?

a. Therapy should be withheld after appropriate specimen is collected for microscopy
b. Negative RPR rules out the diagnosis of Primary Syphilis and repeat testing is not warranted for this patient
c. Likely etiologic agent for this case is Hemophilus ducreyi
d. HIV testing and counseling must be done for all patients with genital ulcer

Answer 191

A. Therapy should be withheld after appropriate specimen is collected for microscopy- presumptive therapy must be initiated based on the patient’s risk profile even in the absence of diagnostic tests
B. Negative RPR rules out the diagnosis of Primary Syphilis and repeat testing is not warranted for this patient- 30% of syphilitic chancre is associated with negative serologic test
C. Likely etiologic agent for this case is HSV-2- see table 131-7. based on the clinical features and characteristic of the ulcer, the likely agent is still T. pallidum
D. HIV testing and counseling must be done for all patients with genital ulcer

The correct answer is: HIV testing and counseling must be done for all patients with genital ulcer

Question 192

40/M with extremely painful genital ulcer with irregular, ragged border that bleed easily on manipulation. This is associated with right inguinal node 2 x 2 cm in diameter, tender and with fluctuant border. The most likely agent causing this disease is

a. Klebsiella granulomatis
b. Chlamydia trachomatis
c. HSV-2
d. Hemophilus ducreyi

Answer 192

The correct answer is: Hemophilus ducreyi

Question 193

Which of the following can be given to the patient/

a. Ciprofloxacin 500mg PO BID x 3 days
b. Ceftriaxone 250mg IM single dose
c. Benzathine penicillin 2.4M units IM single dose
d. Acyclovir 400mg PO TID x 5 days

Answer 193

The correct answer is: Ceftriaxone 250mg IM single dose

Question 194

Which of the following viruses causes viral hemorrhagic fever

a. Reovirus
b. Retrovirus
c. Filovirus
d. Flavivirus

Answer 194

A. Reovirus- tick-borne (Colorado Tick Fever), viral encephalitis
B. Retrovirus- HIV
C. Filovirus- Ebola virus
D. Flavivirus- Dengue, Yellow Fever

The correct answer is: Flavivirus

Question 195

Which of the following is TRUE regarding risk factors for Severe Dengue

a. Males are more often affected
b. Severity of Dengue drops after the age of 12
c. Malnutrition is a risk factor
d. Previous infection with Dengue type 4 with subsequent re-infection with Dengue type 2

Answer 195

A. Males are more often affected – females are more often affected
B. Severity of Dengue drops after the age of 12
C. Malnutrition is a risk factor- malnutrition is protective
D. Previous infection with Dengue type 4 with subsequent re-infection with Dengue type 2
Dengue type 1 –> type 2 is more severe

The correct answer is: Severity of Dengue drops after the age of 12

Question 196

Which of the following is TRUE regarding risk factors for Severe Dengue

a. Males are more often affected
b. Severity of Dengue drops after the age of 12
c. Malnutrition is a risk factor
d. Previous infection with Dengue type 4 with subsequent re-infection with Dengue type 2

Answer 196

A. Males are more often affected – females are more often affected
B. Severity of Dengue drops after the age of 12
C. Malnutrition is a risk factor- malnutrition is protective
D. Previous infection with Dengue type 4 with subsequent re-infection with Dengue type 2
Dengue type 1 –> type 2 is more severe

The correct answer is: Severity of Dengue drops after the age of 12

Question 197

The following diseases are brought about by the bite of infected Aedes aegypti, EXCEPT:

a. West Nile Virus
b. Chikungunya
c. Yellow Fever
d. Dengue

Answer 197

A.West Nile Virus- Culex mosquito
B.Chikungunya
C.Yellow Fever
D.Dengue

The correct answer is: West Nile Virus- Culex mosquito

Question 198

30/F, vendor in the market, previously infected with Dengue asks for advise on how to prevent re-infection. What would be the best prevention for her case?

a. Put on mosquito net at night
b. Apply OFF Lotion during the day when she’s at work
c. Buy mosquito-eating larva
d. Buy air-conditioner and always close the doors and windows to prevent entry of mosquitoes

Answer 198

The correct answer is: Apply OFF Lotion during the day when she’s at work

Question 199

What laboratory parameter best describes the CRITICAL phase of Dengue

a. Low WBC count
b. Elevated hematocrit
c. Low platelet count
d. Bradycardia on ECG

Answer 199

The correct answer is: Elevated hematocrit

Question 200

30/M, OFW, came in to your clinic for vaccination. He will be destined in the middle east. The following are the recommended vaccine, EXCEPT

a. Hep A and Hep B
b. Quadrivalent Flu vaccine
c. MMR
d. Yellow Fever

Answer 200

The correct answer is: Yellow Fever

Question 201

The following are routine immunization regardless of travel, EXCEPT

a. Hep A and Hep B
b. Quadrivalent Flu vaccine
c. MMR
d. Polio Vaccine

Answer 201

The correct answer is: Hep A and Hep B

Question 202

Which of the following is true of Pericardial TB?

a. It is an important cause of constrictive tamponade
b. Effusion is transudative in nature
c. High count of lymphocytes and monocytes are documented in fluid
d. Direct smear examination is commonly positive

Answer 202

The correct answer is: High count of lymphocytes and monocytes are documented in fluid

Question 203

What is the definition of MULTI-RESISTANT TB (MDR-TB)?

a. Resistance to more than one first-line anti-TB drug, other than both Isoniazid and Rifampicin
b. Resistance to at least both Isoniazid and Rifampicin
c. Resistance to INH and Rifampicin + resistance to any fluoroquinolone
d. Resistance to all of the 3 second -line drugs

Answer 203

The correct answer is: Resistance to at least both Isoniazid and Rifampicin

Question 204

Which of the following statements is FALSE regarding antiretroviral therapy in patients with HIV and Tuberculosis?

a. Antiretroviral therapy should be initiated after the second week of TB treatment regardless of CD4 count.
b. For patients with TB meningitis, antiretroviral therapy should be initiated before the intensive phase of TB treatment.
c. Efavirenz is the preferred NNRTI for HIV patients on TB treatment.
d. Avoid the use of nevirapine because of drug-drug interactions.

Answer 204

The correct answer is: For patients with TB meningitis, antiretroviral therapy should be initiated before the intensive phase of TB treatment.

Question 205

A 20/F on-going HRZE treatment for PTB consulted due to a petechial rash on her extremities. Tests show Hgb 120, Hct 0.40 WBC 8, Plt 30. What is the most likely cause of this clinical presentation?

a. Isoniazid
b. Rifampicin
c. Pyrazinamide
d. Ethambutol

Answer 205

The correct answer is: Rifampicin

Question 206

Which of the following patients should undergo screening for latent TB according to the TB Clinical Practice Guidelines of 2016?

a. 20/F diagnosed with rheumatoid arthritis maintained on methotrexate and steroids
b. 65/F with hypertension and CKD St IV
c. 25/F pregnant patient with FBS of 95 mg/dL on her prenatal check-up
d. 50/M diabetic and smoker

Answer 206

The correct answer is: 50/M diabetic and smoker

Question 207

Which of the following measure is appropriate in prevention and control of the spread of TB in the general population according to the TB Clinical Practice Guidelines of 2016?

a. N95 masks should be worn by patients presumed to be infectious
b. Double layer of surgical masks provide additional protection for healthcare workers taking care of bacteriologically confirmed PTB patients
c. There is no need to screen household contacts of patients with cavitary disease
d. There is no need to treat latent TB in the general population

Answer 207

The correct answer is: There is no need to treat latent TB in the general population

Question 208

What is the most common site for extrapulmonary tuberculosis?

a. Pleura
b. Lymph nodes
c. Genitourinary tract
d. Central nervous system

Answer 208

The correct answer is: Lymph nodes

Question 209

What is the principal vector of the Chikungunya virus?

a. Anopheles sp.
b. Aedes aegypti
c. Aedes albopictus
d. Culex sp

Answer 209

The correct answer is: Aedes aegypti

Question 210

A 20/F consulted due to fever of 3 days duration with associated generalized body pain, headache and retroorbital pain. On PE, vital signs were stable, with note of generalized rash. Initial laboratory results showed increased hematocrit and decreased platelet count. According to the Handbook for the Clinical Management of Dengue, what is the diagnosis for this patient?

a. Probable dengue
b. Laboratory confirmed dengue
c. Dengue with warning signs
d. Severe dengue

Answer 210

The correct answer is: Dengue with warning signs

Question 211

A patient was being managed as a case of hypotensive shock from dengue. Initial resuscitation was done with 20ml/kg of crystalloid solution. However, the patient remained hypotensive. Repeat CBC showed the hematocrit decreased. What is the next step?

a. Continue hydration with plain saline solution
b. Initiate hydration with colloid solutions
c. Transfuse packed red blood cells
d. Start vasopressors

Answer 211

The correct answer is: Transfuse packed red blood cells

Question 212

. A 30/M presented in the OPD for diarrhea for 2 days, associated with tenesmus and abdominal pain. He had oral rehydration therapy but his symptoms persisted. Maintaining ORS, what is the next appropriate step for this patient? (HPIM 20th ed. C128 P961)

a. Observe
b. Routine fecalysis
c. Stool culture
d. Antibiotic therapy

Answer 212

The correct answer is: Routine fecalysis

Question 213

A 30/M came in to the ER due to fever, diarrhea and abdominal pain. On PE, the patient had direct tenderness on the right lower quadrant. Stool examination showed fecal polymorphonuclear and mononuclear leukocytes. Given the patient’s presentation, what is the most likely causative organism?

a. Yersinia enterocolitica
b. Shigella spp.
c. Salmonella typhi
d. Campylobacter jejuni

Answer 213

The correct answer is: Yersinia enterocolitica

Question 214

Which of the following is correct in preventing traveler’s diarrhea?

a. Bismuth may be taken as prophylaxis.
b. Salads, raw vegetables from recommended restaurants can be safe.
c. Ampicillin can be started by the patient on the first symptoms and diarrhea
d. Only bottled water is safe to drink.

Answer 214

The correct answer is: Ampicillin can be started by the patient on the first symptoms and diarrhea

Question 215

A 30/F came to the ER due high spiking fever with associated abdominal pain of 1 week duration. She self-medicated with ciprofloxacin on the 4th day of her symptoms with no relief. A day prior to consult, the patient developed faint, salmon-colored blanching, maculopapular rash on the trunk and chest which prompted consult. Which of the following specimens would give 90% sensitivity?

a. Bone marrow
b. Blood
c. Stool
d. A+B+C

Answer 215

The correct answer is: A+B+C

Question 216

A 30/F pregnant patient recently came from a trip to her hometown in Mindanao. She presented in the ER with fever for 5 days associated with diarrhea, vomiting, and a rash which appeared in the trunk. PE showed poor skin turgor. Initial labs showed a positive Typhidot test. According to the Philippine Typhoid Clinical Practice Guidelines, which of the following is appropriate treatment for the patient?

a. Azithromycin 500mg/tab 2 tabs q24 PO
b. Ciprofloxacin 500mg/tab 1 tab q12 POD
c. Ceftriaxone 2g IV q24
d. Ciprofloxacin 400 mg IV q12

Answer 216

The correct answer is: Ceftriaxone 2g IV q24

Question 217

Which of the following is a known mode of transmission for leptospirosis?

a. Fomite
b. Fecal-oral
c. Vertical transmission
d. Exposure to contaminated soil

Answer 217

The correct answer is: Exposure to contaminated soil

Question 218

A 50/M consulted in your clinic regarding prophylaxis for leptospirosis. He is planning to go on a 3-week hiking trip in a leptospirosis-endemic area. According to the 2010 CPG for leptospirosis, which is the most appropriate management for this patient?

a. Precaution and proper clothing and foot wear
b. Doxycycline 200mg single dose
c. Doxycycline 200mg daily for 3 days
d. Doxycycline 200mg once weekly, 1-2 days before exposure and continued until the end of the trip

Answer 218

The correct answer is: Precaution and proper clothing and foot wear

Question 219

A 60/M farmer came to the ER due to no urine output for 12 hours. 3 days before consult, he developed fever, abdominal pain and calf pain. Intake of paracetamol did not relieve symptoms. On arrival, vitals were 90/70 mmHg, HR 120/min, RR 20/min, T 38.7ºC. CBC Hb 120, Hct 0.45 WBC 14 N 80 L 15 plt 150, Crea of 1.2 mg/dL, K 5.2 meq/L. Chest x-ray was normal. According to the 2010 CPG for leptospirosis, what is the next best step for this patient?

a. Hydrate with pNSS 20cc/kg/hr
b. Start Norepinephrine
c. Give furosemide 40mg IV
d. Initiate dialysis

Answer 219

The correct answer is: Initiate dialysis

Question 220

A 40/M from Palawan consulted due to decrease in sensorium. He has been having spiking fever episodes every 2 days for the last week. Eventually, he was noted to have increased sleeping time and decreased responsiveness. On arrival at the ER, the patient had a generalized tonic-clonic seizure lasting 1 minute without regaining consciousness. Which of the following species of malaria is the most likely culprit? (HPIM 20th ed. C219 P1578)

a. P. falciparum
b. P. malariae
c. P. ovale
d. P. vivax

Answer 220

The correct answer is: P. falciparum

Question 221

A 30/F pregnant patient who is travelling to a region in Palawan endemic for malaria consulted your OPD for prophylaxis. Which of the following appropriate for this patient?

a. Primaquine
b. Mefloquine
c. Chloroquine
d. No drug available as prophylaxis for pregnant patients

Answer 221

The correct answer is: Mefloquine

Question 222

Which of the following is NOT part of the revised criteria for sepsis (SEPSIS-3)? (H20 C297 P2045)

a. Urine output of < 0.5cc/kg/hr
b. Requirement of a vasopressor to maintain a MAP ≥ 65mmHg
c. Lactate concentration ≥ 2mmol/L despite adequate fluid resuscitation
d. Life threatening dysfunction caused by a dysregulated host response to infection

Answer 222

The correct answer is: Urine output of < 0.5cc/kg/hr

Question 223

A 50/M diabetic came to the ER due to fever and cough of 1 week duration. On arrival, vitals were 90/60, HR 110, RR 24, T 38. He was slightly confused and PE showed crackles on the R lower lung field. Which of the following is NOT part of the initial management (within 3 hours) bundle for this patient?

a. Early administration of appropriate broad-spectrum antibiotics
b. Collection of blood for culture before antibiotic administration within 1 hour
c. Measurement of serum lactate levels
d. IV fluids of 20ml/kg in the first 3 hours

Answer 223

The correct answer is: IV fluids of 20ml/kg in the first 3 hours

Question 224

A 20/M consulted at the ER due to fever and abdominal pain. He just came from a vacation in Central Visayas. PE showed fever, diffuse lymphadenopathy and hepatosplenomegaly. CBC showed high-level of peripheral eosinophilia. Kato-katz showed eggs which appeared rounded with a lateral spine. Which of the following is the appropriate dose of praziquantel for this patient?

a. 40 mg/kg PO in 2 divided doses for 1 day
b. 60 mg/kg PO in 3 divided doses for 1 day
c. 25 mg/kg PO TID for 2 consecutive days
d. 10 mg/kg PO as a single dose

Answer 224

The correct answer is: 60 mg/kg PO in 3 divided doses for 1 day

Question 225

A 60/M came in due to trismus. On history, the patient works as carpenter and sustained a deep cut on his hand 8 days ago from a rusty nail. On arrival, his BP was 150/80, HR 100 and RR 24. Which of the patient’s characteristics is a poor prognostic factor?

a. Age
b. Incubation period
c. Systolic hypertension
d. Clinical findings

Answer 225

The correct answer is: Systolic hypertension

Question 226

A 25/M came to the ER after sustaining multiple injuries from a vehicular crash. He cannot recall when he had his last vaccination for tetanus but he was sure he already had it. What is the appropriate treatment for this patient?

a. TIG only
b. Tetanus Toxoid only
c. TIG + Tetanus Toxoid
d. Cleaning the wound is enough since he is already immunized

Answer 226

The correct answer is: TIG + Tetanus Toxoid

Question 227

A 25/F pregnant patient was recently bitten by a stray dog. They were unable to catch the dog. What would be the best treatment for the patient? (HPIM 20th ed. C203 P1489)

a. Observe the patient for development of symptoms
b. Rabies immunoglobulin (RIG) only
c. Rabies vaccine only
d. RIG and rabies vaccine

Answer 227

The correct answer is: RIG and rabies vaccine

Question 228

Which of the following statements is TRUE regarding the pathophysiology of rabies?

a. Rabies is a rapidly progressive, chronic infectious disease of the central nervous system (CNS)
b. Rabies is a zoonotic infection
c. Rabies virus spreads centripetally from the spinal cord or brain stem towards the peripheral nerves
d. Hematogenous spread of rabies virus as been well documented

Answer 228

The correct answer is: Rabies is a zoonotic infection

Question 229

Which of the following opportunistic illnesses is an AIDS defining illness in patients living with HIV?

a. Oral candidiasis
b. First episode of bacterial pneumonia
c. Herpes simplex of 1 week duration
d. Pulmonary tuberculosis

Answer 229

The correct answer is: Oral candidiasis

Question 230

Which of the following modes confers the highest risk of transmission of HIV?

a. Needle-sharing during injection drug use
b. Insertive anal intercourse
c. Receptive heterosexual intercourse
d. Percutaneous needlestick injury

Answer 230

The correct answer is: Needle-sharing during injection drug use

Question 231

Which of the following statements is FALSE regarding antiretroviral therapy in patients with HIV and Tuberculosis?

a. Antiretroviral therapy should be initiated after the second week of TB treatment regardless of CD4 count.
b. For patients with TB meningitis, antiretroviral therapy should be initiated before the intensive phase of TB treatment.
c. Efavirenz is the preferred NNRTI for HIV patients on TB treatment.
d. Avoid the use of nevirapine because of drug-drug interactions.

Answer 231

The correct answer is: For patients with TB meningitis, antiretroviral therapy should be initiated before the intensive phase of TB treatment.

Question 232

A 60/M presented with a 4-week history of persistent fever. Obligatory investigations for cause of fever were negative. Medications and all other external factors were already excluded. Fundoscopy and cryoglobulin testing were also negative. FDG-PET done was also non-diagnostic. Based on the algorithm for the work-up of FUO, what is the next step? (HPIM 20th ed. C17 P119 F17-1)

a. Repeat history and physical examination
b. Chest and abdominal CT scan
c. Temporal artery biopsy
d. Trial of treatment with NSAIDs

Answer 232

The correct answer is: Chest and abdominal CT scan

Question 233

What is the most characteristic pathologic finding in rabies?

a. Babes nodules
b. Roth spots
c. Amyloid plaques
d. Negri bodies

Answer 233

The correct answer is: Negri bodies

Question 234

Which of the following is true regarding encephalitic rabies?

a. Encephalitic rabies is less common than paralytic rabies
b. Muscle weakness predominates
c. Hyperexcitability, hydrophobia, and aerophobia are usually lacking
d. Brainstem dysfunction progresses rapidly and coma is the rule

Answer 234

The correct answer is: Brainstem dysfunction progresses rapidly and coma is the rule

Question 235

Which of the following best describes the pathogenesis of falciparum malaria?

a. Infected erythrocytes form rosettes and have reduced deformability compromising their passage through capillaries and venules
b. Characteristic paroxysm of fever, chills and rigors corresponding to rupture of schizonts and release of pro-inflammatory cytokines occurs every 72 hours
c. P. falciparum infects younger RBC’s and reticulocytes
d. Infection with P.falciparum, due to its severity, can result to lifelong immunity against this parasite.

Answer 235

The correct answer is: Infected erythrocytes form rosettes and have reduced deformability compromising their passage through capillaries and venules

Question 236

The following complications of falciparum malaria are commonly seen in adults, EXCEPT:

a. Jaundice
b. Renal Failure
c. Pulmonary Edema
d. Anemia

Answer 236

The correct answer is: Anemia

Question 237

Which of the following laboratory findings indicate poor prognosis in malaria?

a. WBC < 12,000
b. Random blood glucose of < 50 mg/dL
c. Presence of more mature forms of P. falciparum in the blood smear
d. Severe Anemia

Answer 237

The correct answer is: Presence of more mature forms of P. falciparum in the blood smear

Question 238

Transmission through airborne droplet nuclei has been demonstrated in which of the following viruses?

a. Influenza AH5N1
b. Human Parainfluenza Virus
c. Measles Virus
d. Respiratory Syncytial Virus

Answer 238

The correct answer is: Measles Virus

Question 239

24/M, medical intern, came in for rashes which appeared a day before. He experienced low-grade fever 2 days ago followed by the appearance of rashes. Generalized maculopapular, vesicular lesions on an erythematous base were found. What is the most likely etiologic agent?

a. Measles virus
b. Rubella
c. Varicella zoster virus
d. Dengue

Answer 239

The correct answer is: Varicella zoster virus

Question 240

Most common source of sepsis:

a. Soft tissue infection
b. Pulmonary Infection
c. Urinary tract infection
d. Intraabdominal Infection

Answer 240

The correct answer is: Pulmonary Infection

Question 241

Which of the following is TRUE regarding the pathogenesis of sepsis

a. Most common pathogen associate molecular pattern (PAMP) that initiates the inflammatory response is the lipid A moiety of the LPS
b. Sepsis induces enhanced coagulation that effectively isolate the microorganism and prevent organ dysfunction
c. Whether the patient will have hyperimmune or immunosuppressed phenotype is largely dependent on the initial host response to inflammation
d. Excessive and unopposed nitric oxide release promotes vasoconstriction worsening tissue hypoxia and organ dysfunction

Answer 241

The correct answer is: Most common pathogen associate molecular pattern (PAMP) that initiates the inflammatory response is the lipid A moiety of the LPS

Question 242

Chest X-ray showed bilateral infiltrates suggestive of pneumonia. The following best describe antibiotic therapy for this patient, EXCEPT

a. Antibiotic must be started within an hour of sepsis recognition
b. Start Cetfriaxone 2g IV + Azithromycin 500mg/tab PO OD
c. Empiric coverage for MRSA for patients in septic shock
d. Start Piperacillin + Tazobactam 4.5g IV + Azithromycin 500mg OD

Answer 242

The correct answer is: Start Cetfriaxone 2g IV + Azithromycin 500mg/tab PO OD

Question 243

Which of the following patients haS Advanced HIV or stage 3 HIV?

a. 25/F with recurrent acute suppurative tonsillopharyngitis
b. 28/M with aphthous ulcers lasting for 2 weeks
c. 5/F with invasive cervical cancer
d. 30/M with primary adrenal insufficiency from TB adrenalitis

Answer 243

The correct answer is: 30/M with primary adrenal insufficiency from TB adrenalitis

Question 244

Which of the following patients is classified as HIV stage 0

a. 30/M recently diagnosed with HIV with CD4+ T cell count of 1000 cells/uL
b. 28/F with negative HIV ELISA test after 3 months of initial diagnosis of HIV
c. 38/M with CD4+ T cell count of 800 cells/uL
d. 30/F with CD4+ T cell count of 350 cells/uL

Answer 244

The correct answer is: 28/F with negative HIV ELISA test after 3 months of initial diagnosis of HIV

Question 245

Treatment of the following STI’s help prevent HIV transmission, EXCEPT

a. Gonorrhea
b. Trichomoniasis
c. Syphilis
d. Herpes Simplex ulcer

Answer 245

The correct answer is: Herpes Simplex ulcer

Question 246

30/M nurse-on-duty (NOD) accidentally pricked himself with the needle used during IV insertion in a patient admitted due to PCP. The NOD is worried he might get HIV. What would be the best advise for this patient?

a. Pin-prick transmission is low at 0.23% so no need to worry
b. Advise HIV ELISA after 2 weeks to check for antibodies to HIV
c. He can start post-exposure prophylaxis with antiretroviral drugs
d. Instruct him to attend another hospital infection control lecture to prevent another incident

Answer 246

The correct answer is: He can start post-exposure prophylaxis with antiretroviral drugs

Question 247

Which of the following are direct mechanisms of CD4+ T cell dysfunction in HIV

a. Inhibition of lymphopoiesis
b. Syncytia formation
c. Autoimmunity
d. Induction of apoptosis

Answer 247

The correct answer is: Syncytia formation

Question 248

Which statement is TRUE regarding non-AIDS illnesses in patients with HIV

a. Most common CV disease is HIV-associated cardiomyopthy
b. Anemia is the most common hematologic abnormality and is commonly caused by Tenofovir
c. Proteinuria is the hallmark of HIV-associated nephropathy (HIVAN)
d. Most common thyroid abnormality is subclinical hyperthyroidism

Answer 248

The correct answer is: Proteinuria is the hallmark of HIV-associated nephropathy (HIVAN)

Question 249

30/M with HIV is being given cART. On follow-up, he was noted to have elevated triglycerides and impaired glucose tolerance test. Which among his medications are likely to be the cause of these abnormalities?

a. Zidovudine
b. Abacavir
c. Lamivudine
d. Efavirenz

Answer 249

The correct answer is: Zidovudine