4-16-07

Front 1

A young man comes to the emergency department complaining of a headache and stiff neck. The pain began a few hours ago and has become progressively worse. The patient is acting confused, is shielding his eyes, is complaining that the light is too bright, and has a temperature of 39°C (102.2°F). Kernig’s and Brudzinski’s signs are positive. Which of the following sequences of actions is most appropriate?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Computed tomography (CT) scan, intravenous (IV) antibiotics, lumbar puncture
B. CT scan, lumbar puncture, IV antibiotics
C. IV antibiotics, CT scan, lumbar puncture
D. IV antibiotics, lumbar puncture, CT scan
E. Lumbar puncture, CT scan, IV antibiotics

Back 1

Option C (Intravenous [IV] antibiotics, computed tomography [CT] scan, lumbar puncture) is correct. This patient most likely has meningitis, which can be a medical emergency. IV antibiotics (ceftriaxone and vancomycin to cover penicillin-resistant pneumococcus) should be administered immediately. A CT scan needs to be obtained before lumbar puncture in anyone whose human immunodeficiency virus status is unknown so that a mass lesion can be ruled out. Lumbar puncture should reveal organisms up to 12 hours after antibiotics.

Front 2

The clinical presentation—sore throat, lymphadenopathy, and fever that resolves 1 to 2 weeks after onset - is classic for

Back 2

infectious mononucleosis.

Front 3

This is a common gram-negative organism that complicates human bite wounds.
A. Bartonella henselae
B. Eikenella corrodens
C. Erysipelothrix rhusiopathiae
D. Pasteurella multocida
E. Streptobacillus moniliformis

Back 3

B. Eikenella corrodens

Front 4

It usually occurs in farmers after bites from infected swine. A cellulitis picture predominates.
A. Bartonella henselae
B. Eikenella corrodens
C. Erysipelothrix rhusiopathiae
D. Pasteurella multocida
E. Streptobacillus moniliformis

Back 4

C. Erysipelothrix rhusiopathiae

Front 5

This is the cause of rat bite fever, which produces irregularly relapsing fever, dry cough, and extreme malaise. Mortality is high with this condition and treatment is with intravenous (IV) penicillin.
A. Bartonella henselae
B. Eikenella corrodens
C. Erysipelothrix rhusiopathiae
D. Pasteurella multocida
E. Streptobacillus moniliformis

Back 5

E. Streptobacillus moniliformis

Front 6

typically causes two conditions in patients with HIV: retinitis and colitis. This usually occurs after the CD4 count is below 50.
A. Cryptococcus neoformans
B. Cryptosporidium parvum
C. Cytomegalovirus (CMV)
D. Pneumocystis carinii
E. Toxoplasma gondii

Back 6

C. Cytomegalovirus (CMV)

Front 7

A 24-year-old woman visits you in the hospital outpatient clinic requesting an HIV test. She has just learned that a frequent sexual partner has been diagnosed with Kaposi's sarcoma. Currently, she has no complaints. She has a history of genital herpes. The last reactivation episode was 1 year ago. She takes no medications. On exam, vital signs are normal and there are no abnormal physical findings. An HIV immunoassay is positive as well as a confirmatory HIV western blot. CD4 count is 659 and HIV-1 PCR RNA viral load is 90,000. You recommend that the patient begin a pharmacological regimen consisting of a protease inhibitor and two nucleoside analogues. What should be prescribed if you wish to add another class of drug to attempt to reduce the patient's viral load?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Enfuvirtide
B. Ganciclovir
C. Indinavir
D. Lamivudine
E. Zidovudine

Back 7

Option A (Enfuvirtide) is correct. Enfuvirtide is in a fusion inhibitor, a class of anti-HIV drugs those blocks HIV from entering the immune cells by inhibiting gp41 protein. This interferes with structural rearrangements required for virus-cell fusion. When enfuvirtide was added to antiretroviral optimized regimens in clinical trials patients were twice as likely to achieve undetectable HIV-1 plasma levels.

Front 8

fusion inhibitor, a class of anti-HIV drugs those blocks HIV from entering the immune cells by inhibiting gp41 protein.
A. Enfuvirtide
B. Ganciclovir
C. Indinavir
D. Lamivudine
E. Zidovudine

Back 8

A. Enfuvirtide

Front 9

cyclic nucleoside analog of 2’-deoxyguanosine guanine
A. Enfuvirtide
B. Ganciclovir
C. Indinavir
D. Lamivudine
E. Zidovudine

Back 9

B. Ganciclovir

Front 10

prevents formation of HIV precursor proteins required for viral replication and cell infection.
A. Enfuvirtide
B. Ganciclovir
C. Indinavir
D. Lamivudine
E. Zidovudine

Back 10

C. Indinavir

protease inhibitor

Front 11

thymidine analog that inhibits viral replication by blocking reverse transcriptase.
A. Enfuvirtide
B. Ganciclovir
C. Indinavir
D. Lamivudine
E. Zidovudine

Back 11

D. Lamivudine
AND
E. Zidovudine

Front 12

A 51-year-old man presents to the emergency department with weakness of the facial muscles occurring over the last 3 hours. Three months ago, he noticed a rash on his leg that had a red border and normal appearing skin in the center. He is an avid outdoorsman and hunter. On examination, there is bilateral inability to close the eyes, elevate the brow, or frown. What is the most appropriate next step in the management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Doxycycline
B. Electromyography EMG of facial nerve
C. Enzyme-linked immunosorbent assay (ELISA)
D. Observation
E. Oral corticosteroids

Back 12

Option C (Enzyme-linked immunosorbent assay [ELISA]) is correct. This patient presents with bilateral facial nerve palsy and a history of a rash. The fact that he is an avid outdoorsman should raise the suspicion that he had been bitten by a tick and the rash was erythema migrans. Bilateral facial nerve palsy is suggestive of secondary Lyme disease, and an appropriate screening test would be ELISA for Borrelia burgdorferi. Western blot is needed to confirm the results of the ELISA. A cerebrospinal fluid analysis should also be performed to detect subclinical meningitis.


Option A (Doxycycline) is incorrect. This is the treatment for uncomplicated primary Lyme disease. Secondary Lyme disease typically requires intravenous ceftriaxone.

Option B (Electromyography of facial nerve) is incorrect. Electromyography is useful to determine whether the nerve remains intact. It would not lead to the correct diagnosis in this case.

Option D (Observation) is incorrect. Observation is incorrect, as antibiotic therapy in patients with secondary Lyme disease has been demonstrated to speed recovery.

Option E (Oral corticosteroids) is incorrect. Corticosteroids have been studied but have not been demonstrated to have any efficacy in treating the complications of Lyme disease.

Front 13

Secondary Lyme disease typically requires intravenous :

Back 13

ceftriaxone

Front 14

A 39-year-old man has a 1-week history of fever, chills, and night sweats. He is a regular user of intravenous (IV) heroin and last used 3 hours ago. Physical examination reveals grouped petechiae over the extremities, as well as pink, 5-mm macules on the palms and soles. A soft pansystolic murmur is heard best over the lower left parasternal region and increases with respiration. Echocardiography reveals a valvular vegetation. What is the most appropriate immediate pharmacotherapy?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Ceftriaxone
B. Penicillin
C. Vancomycin
D. Vancomycin and gentamicin
E. Vancomycin, gentamicin, and rifampin

Back 14

Option D (Vancomycin and gentamicin) is correct. This patient has infective endocarditis and is also an intravenous drug user. Because of the IV drug use, the most likely cause is Staphylococcus aureus. It also places him at higher risk of having Methicillin-resistant S. aureus, and thus empiric coverage should account for this. Once blood cultures are returned, specific antibiotic therapy can be achieved, but empiric therapy is important in patients who have infective endocarditis and are significantly symptomatic.

Option A (Ceftriaxone) is incorrect. Ceftriaxone therapy is useful in individuals who have infective endocarditis of a prosthetic valve caused by an enterococcal organism.

Option B (Penicillin) is incorrect. Monotherapy with vancomycin is recommended in patients who have confirmed Streptococcus viridans infective endocarditis.

Option C (Vancomycin) is incorrect. Monotherapy with vancomycin is recommended in patients who have confirmed Streptococcus viridans infective endocarditis and are penicillin allergic.

Option E (Vancomycin, gentamicin, and rifampin) is incorrect. This is appropriate empiric therapy in individuals with prosthetic valves, as the are at increased risk for gram-negative organisms.

Front 15

This is appropriate empiric therapy in individuals with prosthetic valves and infective endocarditis
A. Ceftriaxone
B. Penicillin
C. Vancomycin
D. Vancomycin and gentamicin
E. Vancomycin, gentamicin, and rifampin

Back 15

Option E (Vancomycin, gentamicin, and rifampin) is incorrect. This is appropriate empiric therapy in individuals with prosthetic valves, as the are at increased risk for gram-negative organisms.

Front 16

recommended in patients who have confirmed Streptococcus viridans infective endocarditis and are penicillin allergic.
A. Ceftriaxone
B. Penicillin
C. Vancomycin
D. Vancomycin and gentamicin
E. Vancomycin, gentamicin, and rifampin

Back 16

Option C (Vancomycin) is incorrect. Monotherapy with vancomycin is recommended in patients who have confirmed Streptococcus viridans infective endocarditis and are penicillin allergic.

Front 17

recommended in patients who have confirmed Streptococcus viridans infective endocarditis.
A. Ceftriaxone
B. Penicillin
C. Vancomycin
D. Vancomycin and gentamicin
E. Vancomycin, gentamicin, and rifampin

Back 17

Option B (Penicillin) is incorrect. Monotherapy with vancomycin is recommended in patients who have confirmed Streptococcus viridans infective endocarditis.

Front 18

useful in individuals who have infective endocarditis of a prosthetic valve caused by an enterococcal organism.
A. Ceftriaxone
B. Penicillin
C. Vancomycin
D. Vancomycin and gentamicin

Back 18

Option A (Ceftriaxone) is incorrect. Ceftriaxone therapy is useful in individuals who have infective endocarditis of a prosthetic valve caused by an enterococcal organism.

Front 19

A 19-year-old man presents to his physician with a 3-day history of severe diarrhea and fever. He was previously well until he suddenly developed a dark-colored diarrhea that resulted in 10 to 15 bowel motions a day. He has experienced fevers to 38.5°C (101.3°F), as well as associated nausea and vomiting. His vital signs are blood pressure, 120/80 mm Hg; pulse, 77 beats/minute; temperature, 38.4°C (101.1°F); and respirations, 12 breaths/minute. Physical examination is unremarkable. Fecal occult blood test and Löffler alkaline methylene blue stain are both positive. What is the most likely cause of this patient's symptoms?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Campylobacter jejuni
B. Enterohemorrhagic Escherichia coli
C. Shigella dysenteriae
D. Staphylococcus aureus
E. Yersinia enterocolitica

Back 19

Option A (Campylobacter jejuni) is correct. This patient has an acute onset febrile diarrhea with positive fecal blood and leukocytes. No other information is provided except that he was previously in good health. Consequently, the most common cause of febrile diarrheal illnesses in the United States is Campylobacter jejuni, accounting for approximately one third of all cases.

Front 20

the most common cause of febrile diarrheal illnesses in the United States

Back 20

Campylobacter jejuni, accounting for approximately one third of all cases.

Front 21

commonly spread by undercooked hamburger meat, but can also be transmitted by swimming water. It produces a hemolytic-uremic syndrome in up to 10% of patients and more frequently in pediatric patients.

Back 21

Enterohemorrhagic Escherichia coli

Front 22

renowned for producing a preformed heat-stable exotoxin causing vomiting and diarrhea. It is associated with custards and potato salads.

Back 22

Staphylococcus aureus

Front 23

can cause a diarrheal illness but is better known for its ability to produce symptoms that mimic acute appendicitis or Crohn disease.

Back 23

Yersinia enterocolitica

Front 24

A 55-year-old male with a history of alcohol abuse presents to the emergency room with fever and abdominal pain. His symptoms began 2 days ago and have progressively grown worse. His past medical history is significant for Hepatitis C and alcoholic cirrhosis. He has had multiple therapeutic paracenteses secondary to ascites accumulation. On exam he has a tender abdomen and is slightly diaphoretic. Vital signs show temperature 38.6°C (101.4°F), heart rate 111 beats/min, and blood pressure 110/69. Labs are sent and paracentesis is done. The peritoneal fluid neutrophil count returns at 345/mm3. What preferred treatment for this condition?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Ampicillin
B. Cefotaxime
C. Cephalexin
D. Ciprofloxacin
E. Sulfamethoxazole (Bactrim DS)

Back 24

Option B (Cefotaxime) is correct. This patient has spontaneous bacterial peritonitis--SBP. Cefotaxime or another third-generation cephalosporin is standard coverage for SBP. This will cover both gut flora and skin flora that can lead to infection.

Option A (Ampicillin) is incorrect. Although ampicillin can be used in combination with gentamicin for spontaneous bacterial peritonitis (SBP), it alone is not sufficient coverage.

Option C (Cephalexin) is incorrect. Cephalexin (Keflex) does not cover a broad enough spectrum to cover the gut flora that may lead to SBP.

Option D (Ciprofloxacin) is incorrect. Ciprofloxacin is not broad enough to cover both the gut flora such as Escherichia coli and Staphylococcus/Streptococcus that can cause the infection.

Option E (Sulfamethoxazole (Bactrim DS)) is incorrect. Sulfamethoxazole (Bactrim DS) can be used as prophylactic therapy for those patients who have frequent SBP but does not play a role in acute therapy.

Front 25

standard coverage for SBP. This will cover both gut flora and skin flora that can lead to infection.
A. Ampicillin
B. Cefotaxime
C. Cephalexin
D. Ciprofloxacin
E. Sulfamethoxazole (Bactrim DS)

Back 25

Cefotaxime or another third-generation cephalosporin

Front 26

an be used as prophylactic therapy for those patients who have frequent SBP but does not play a role in acute therapy.
A. Ampicillin
B. Cefotaxime
C. Cephalexin
D. Ciprofloxacin
E. Sulfamethoxazole (Bactrim DS)

Back 26

Option E (Sulfamethoxazole (Bactrim DS)) is incorrect. Sulfamethoxazole (Bactrim DS) can be used as prophylactic therapy for those patients who have frequent SBP but does not play a role in acute therapy.

Front 27

The presence of progressive dyspnea on exertion, fever, and nonproductive cough along with bilateral infiltrates with or without pnuemothorax are classic signs for

Back 27

Pneumocystis carinii pneumonia (PCP).

Front 28

can cause symptoms very similar to PCP, but acute infection usually shows hilar or mediastinal lymphadenopathy and pneumonitis in the lower lung fields. Chronic infections lack adenopathy but usually show calcified fibronodular apical infiltrates and/or emphysematous changes.

Back 28

H. capsulatum

Front 29

present with low-grade fevers, dyspnea on exertion, and nonproductive cough, but this form does not cause pneumothorax.
A. Coccidiodes immitis
B. Histoplasma capsulatum
C. Mycoplasma
D. Parainfluenza virus
E. Pneumocystis carinii

Back 29

Option C (Mycoplasma) is incorrect. Patients with Mycoplasma pneumonia also present with low-grade fevers, dyspnea on exertion, and nonproductive cough, but this form does not cause pneumothorax.

Front 30

t is typically described a multiple 2- to 6-mm skin-colored firm, smooth, umbilicated papules.

Back 30

Molluscum contagiosum

Front 31

An 18-year-old female patient is evaluated for painless genital lesions. There are eight discrete, dome-shaped papules spread over the vulvar area. The papules are smooth, skin colored, and waxy. Each has a central umbilicus filled with a semisolid white material. Microscopic examination of the Giemsa-stained white material is diagnostic. Successful treatment of this condition should include which of the following?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Acyclovir
B. Erythromycin or dicloxacillin
C. Methotrexate
D. Trichloroacetic acid
E. Zinc oxide

Back 31

Option D (Trichloroacetic acid) is correct. Successful treatment usually requires freezing the lesion, removing the central core of the papule, or applying trichloroacetic acid.

Option A (Acyclovir) is incorrect. Acyclovir is used in the management of certain viral diseases, such as herpes. The causal organism of molluscum contagiosum is a poxvirus, which does not respond to acyclovir treatment.

Option B (Erythromycin or dicloxacillin) is incorrect. Oral antibiotics (e.g., erythromycin or dicloxacillin) could be used to treat skin conditions such as impetigo, but would have no effect on viral lesions.

Option C (Methotrexate) is incorrect. Methotrexate may be appropriate for certain immune-related skin conditions, such as bullous pemphigoid, but it is not appropriate for viral conditions.

Option E (Zinc oxide) is incorrect. Zinc oxide is used in symptomatic treatment of chemical dermatitis. It has no effect on a viral lesion.

Front 32

caused by an infected clot, usually within the jugular venous system, which can shower infected thrombi through the lungs. it can be seen after streptococcus pharyngitis.

Back 32

Lemierre syndrome

Front 33

is an infection of the submandibular and sublingual spaces of the mouth. It can lead to rapid compromise of the airway as the tongue and mouth swell. Infection of the second or third mandibular molar usually precedes this infection.

Back 33

Ludwig angina

Front 34

can be seen after streptococcus pharyngitis because the infection tracts through the facial planes of the neck.
A. Lemierre syndrome
B. Ludwig angina
C. Parapharyngeal abscess
D. Splenic rupture
E. Toxic megacolon

Back 34

C. Parapharyngeal abscess

Front 35

can cause nearly identical presentation and findings as AIDS-related neurotoxoplasmosis. It is acquired by consuming undercooked pork from a contaminated animal.

Back 35

Taenia solium, Neurocysticercosis

Front 36

usually causes disease in AIDS patients with CD4 counts less than 50. It usually manifests as hepatitis, retinitis, and esophagitis.

Back 36

Cytomegalovirus

Front 37

usually presents as a granulomatous lung disease or involving the bone marrow.
A. Blastomyces dermatitidis
B. Cytomegalovirus
C. Mycobacterium kansasii
D. Taenia solium
E. Toxoplasma gondii

Back 37

A. Blastomyces dermatitidis

Front 38

contraindicated in pregnancy and cannot be given despite it being the drug of choice for chlamydia.

Back 38

Doxycycline

Front 39

This patient is infected with Chlamydia trachomatis and is also pregnant. As such, she requires treatment with

Back 39

erythromycin, because doxycycline and tetracycline are contraindicated in pregnancy.

Front 40

It is time for vaccinations for 10 healthy, active, and vocal 2-month-old patients, all awaiting you in the clinic playroom this morning. Charts indicate they have received the immunizations recommended before 2 months of age. Assuming their histories and physicals do not indicate otherwise, they all should receive which of the following vaccines today?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. DTaP, MMR, OPV, Hep B, HIB
B. IPV, DTaP, HIB, Hep B
C. MMR, IPV, DT, HIB
D. MMR, IPV, Hep B
E. OPV, DTaP, Hep B

Back 40

Option B (IPV, DTaP, HIB, Hep B) is correct. The current recommended vaccine schedule includes the first hepatitis B vaccine at birth. At 2 months the second Hep B vaccine is given along with the IPV, DTaP, and HIB.

Option A (DTaP, MMR, OPV, Hep B, HIB) is incorrect. MMR is not given before 12 months. The OPV, which is a live vaccine with the possible side effect of causing vaccine-associated paralytic polio, is no longer preferred for young infants.

Option C (MMR, IPV, DT, HIB) is incorrect. This selection leaves out the second hepatitis B vaccine that should be given. MMR is not given before 12 months. The DT vaccine without pertussis is used for infants with certain types of neurologic disorders who may be at higher risk for seizures after pertussis vaccine. All other healthy infants who have not had an adverse reaction to a pertussis vaccine should receive DTaP.

Option D (MMR, IPV, Hep B) is incorrect. MMR is not given before 12 months. DtaP should be given, as should HIB.

Option E (OPV, DTaP, Hep B) is incorrect. The OPV, which is a live vaccine with the possible side effect of causing vaccine-associated paralytic polio, is no longer preferred for young infants. The IPV, which is inactivated, is now recommended for at least the first two doses. HIB should also be given at this time.

Front 41

the first stage is termed the intestinal stage and causes abdominal pain, nausea, and vomiting. After a week, the muscle stage occurs and result in the typical features. There are splinter hemorrhages, retinal hemorrhages, muscle pain, and severe muscular weakness. Eosinophilia is observed but may be a late finding.

Back 41

trichinellosis. Trichinella spiralis is commonly acquired from undercooked pork.

Front 42

A 24-year-old woman visits the emergency room (ER) with complaints of severe fatigue and shortness of breath. She was well until 2 days ago when there was abrupt onset of a high fever, headache, and muscle aches. Today she has developed a severe cough and increasing fatigue and shortness of breath. Further questioning reveals the woman returned 4 days ago from a rural region of Vietnam where she attended the funeral of her 30-year-old brother, who died unexpectedly following a brief unexplained illness. The brother's condition began with symptoms similar to those of the patient. Vital signs are temperature: 39.9°C (103.9°F), blood pressure (BP): 135/85, heart rate (HR): 105 beats/min, and respiratory rate (RR): 24 breaths/min. Pulse oximetry shows 75% O2 saturation. Physical exam reveals an acutely ill–appearing woman in respiratory distress with a regular rhythm tachycardia, inspiratory rib retractions, and fine crackles throughout both lung fields. What pharmacotherapeutic agent should be included in your empiric treatment of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Amantadine
B. Heparin
C. Interferon A
D. Prednisone
E. Zanamivir

Back 42

Option E (Zanamivir) is correct. The clinical scenario indicates a significant probability of infection from a highly virulent airborne infectious agent. Of the medications listed, zanamivir is an approved antiviral treatment that is effective in decreasing mortality and morbidity in influenza A, a likely cause of the patient's acute disease. Although avian influenza A viruses usually do not normally infect humans, more than 100 confirmed cases of human infection with avian influenza viruses have been reported since 1997. So far, the strain with the highest incidence and virulence, the H5N1 strain, has not developed resistance to zanamivir. This vignette is a possible scenario where the dreaded mutation of H5N1 allowing efficient, aerosolized, person-to-person transmission has occurred.

Option A (Amantadine) is incorrect. The strain of avian influenza with the highest incidence and virulence, the H5N1 strain, has developed resistance to amantadine. This vignette is a possible scenario where the dreaded mutation of H5N1 allowing efficient, aerosolized, person-to-person transmission has occurred.

Option B (Heparin) is incorrect. There is little reason to believe the patient has suffered a pulmonary embolism. Although in general it should be part of the differential diagnosis of acute respiratory distress, in this scenario a good argument can be made that the risks of treatment outweigh the potential benefits.

Option C (Interferon A) is incorrect. There is no indication for empiric treatment with interferon A in a patient with acute respiratory distress.

Option D (Prednisone) is incorrect. Corticosteroid treatment of adult respiratory distress syndrome is highly controversial. It is not a recommended initial empiric treatment option in a patient with a likely viral respiratory infection and respiratory distress.

Front 43

A 74-year-old man has developed a progressively worsening dry cough over the last 5 days. This has been accompanied by abdominal pain, diarrhea, headache, malaise, chills, and fevers to 40.5°C (104.9°F). His previous medical history is notable for type II diabetes mellitus. On examination, there are extensive rales on chest auscultation. Abdominal examination is normal. A urinary antigen test is positive and confirms the presence of a gram-negative bacillus infection. What is the most likely form of transmission of this patient's condition?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Aerosolization
B. Fecal-oral
C. Hematogenous
D. Person to person
E. Sexual

Back 43

Option A (Aerosolization) is correct. This patient likely has Legionnaires disease, caused by Legionella pneumophila, a gram-negative, obligate aerobic bacillus. Diagnosis is often made by urinary antigen testing. The major reservoir for Legionella is water, where the bacterium can infect and replicate within amoebae. Transmission is via aerosolization.

Option B (Fecal-oral) is incorrect. Hepatitis A and E are well known conditions that are transmitted fecal-orally. Legionella is not transmitted in this fashion.

Option C (Hematogenous) is incorrect. A wide variety of microorganisms are spread via hematogenous routes. However, Legionella is not one of them.

Option D (Person to person) is incorrect. Person-to-person transmission does not occur with Legionella, an important point in determining the epidemiology of Legionnaires disease outbreaks.

Option E (Sexual) is incorrect. Sexual transmission does not occur with Legionnaires disease.

Front 44

A 25-year-old man has developed a burning, painful sensation when he urinates. He has experienced these symptoms for the previous 2 days. He denies any nocturia, urethral discharge, testicular pain, fevers, or change in bowel habits. He has been otherwise well, takes no medications, and has no known allergies. He is a university student, drinks 20 to 40 g of ethanol weekly, does not smoke, and is currently sexually active with three partners in the last 12 months. Milking of the urethra reveals a mucopurulent discharge. Urethral Gram stain reveals gram-negative intracellular diplococci. A nucleic acid amplification test confirms the Gram stain findings. Appropriate antibiotic therapy is instituted. The man returns to the clinic 1 week after his initial visit and has no complaints. What is the most appropriate next step in the management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Anal culture
B. Antibiotic susceptibility testing of isolated organism
C. No further management required
D. Repeated urethral Gram stain in 2 weeks
E. Repeated urethral Gram stain now

Back 44

Option C (No further management required) is correct. This patient has gonorrhea, which often presents with dysuria and mucopurulent urethral discharge. A test of cure following therapy with cefixime or ceftriaxone is not required in male patients who are asymptomatic. Screening for syphilis and human immunodeficiency virus, as well as screening and treatment of partners would also be appropriate management.

Option A (Anal culture) is incorrect. Anal culture for Neisseria gonorrhoeae is common followup practice for females because there may be anal carriage and reinfection.

Option B (Antibiotic susceptibility testing of isolated organism) is incorrect. This patient is asymptomatic. If he were continuing to experience symptoms, antibiotic resistance should be considered and susceptibility testing indicated.

Option D (Repeated urethral Gram stain in 2 weeks) is incorrect. A test of cure is not required in asymptomatic males. Further, a test of cure, which would be indicated in pregnant females, would best be achieved with nucleic acid amplification techniques.

Option E (Repeated urethral Gram stain now) is incorrect. A test of cure is not required in males with uncomplicated gonococcal urethritis.

Front 45

presents with sudden onset of high fever and severe headaches followed by lesions on the wrists and ankles. Characteristically, these lesions then spread to the palms, soles and trunk.

Back 45

RMSF

Front 46

A 39-year-old man presents to the emergency department because of the sudden onset of severe headaches and high fever. He is admitted for observation and on the second day, develops 2- to 5-mm, blanchable macules over the wrists and ankles. While in hospital, the rash spreads to his palms and soles, and changes in appearance to become deep red papules. He admits to returning from Tennessee last week where he went camping and was bitten by a tick. What is the most likely vector for this patient's condition?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Anopheles spp
B. Borrelia burgdorferi
C. Dermacentor variabilis
D. Ixodes dammini
E. Rickettsia rickettsii

Back 46

Option C (Dermacentor variabilis) is correct. The dog tick Dermacentor variabilis is the vector for Rickettsia rickettsii, which causes this patient's condition, Rocky Mountain spotted fever (RMSF), which presents with sudden onset of high fever and severe headaches followed by lesions on the wrists and ankles. Characteristically, these lesions then spread to the palms, soles and trunk.

Option A (Anopheles species) is incorrect. This is the mosquito vector for malaria.

Option B (Borrelia burgdorferi) is incorrect. This is the etiologic agent for Lyme disease, which presents with flulike symptoms and erythema migrans (an expanding erythematous patch with central clearing).

Option D (Ixodes dammini) is incorrect. Also known as the deer tick, this is the vector for Borrelia burgdorferi, which causes Lyme disease.

Option E (Rickettsia rickettsii) is incorrect. This is the etiologic agent of this patient's condition, RMSF. A vector is defined as an organism that spreads a particular virulent agent.

Front 47

the mosquito vector for malaria.
A. Anopheles spp
B. Borrelia burgdorferi
C. Dermacentor variabilis
D. Ixodes dammini
E. Rickettsia rickettsii

Back 47

Option A (Anopheles species) is incorrect. This is the mosquito vector for malaria.

Front 48

A 37-year-old man presents to the emergency department, because of worsening pain in his left leg. He first noticed the pain 10 days ago over the pretibial area and localized redness and swelling have developed since. Additionally, he admits to fatigue and headaches, but denies fevers, night sweats or anorexia. He has been previously well. He admits to intravenous (IV) drug use with heroin on a regular basis and last self-administered 2 hours ago. His vital signs are blood pressure (BP), 120/80 mm Hg, pulse, 74 beats per minute; temperature, 37.2°C (98.9°F); respiration rate, 18 breaths per minute. The left pretibial area is swollen, erythematous, and tender to touch, particularly on the tibia. What is the most appropriate next step in the management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Bone biopsy
B. IV nafcillin
C. Magnetic resonance imaging (MRI)
D. Technetium 99m bone scan
E. X-ray

Back 48

Option E (X-ray) is correct. This patient is an IV drug user and has bone pain with overlying erythema. This is suggestive of osteomyelitis. The first step in evaluation is to obtain an X-ray of the area. Classic radiologic findings are lytic lesions, scalloping, and osteopenia. Periosteal elevation can also be seen. X-ray, however, can take 10 to 14 days to reveal signs of osteomyelitis and thus, is not very sensitive or specific.

Option A (Bone biopsy) is incorrect. This is the gold standard for diagnosis, but it is invasive. In this particular instance, the anatomy may allow for a relatively easy biopsy. Nevertheless, this should not be done prior to an X-ray.

Option B (IV nafcillin) is incorrect. This is appropriate empiric therapy for suspected osteomyelitis, but therapy would be inappropriate prior to obtaining a blood culture or diagnosis.

Option C (Magnetic resonance imaging [MRI]) is incorrect. MRI is considered the imaging modality of choice, because it can identify the location and extent of osteomyelitis. Owing to the expense and possible difficulty obtaining an MRI quickly, X-ray is performed almost always prior. If the X-ray is negative, MRI is often the next step, particularly in the diabetic foot.

Option D (Technetium 99m bone scan) is incorrect. A bone scan is very useful in detecting early osteomyelitis. An X-ray is almost always obtained prior because of cost.

Front 49

A 37-year-old man presents to the physician because of recent exposure to a patient with tuberculosis (TB). He presently has no symptoms. He works as a prison guard in the state penitentiary and spent an 8-hour shift in close contact with a prisoner diagnosed several days later with active pulmonary TB. Purified protein derivative (PPD) is placed on his skin and the test observed 54 hours later. There is 11 mm of induration at the site. What is the most appropriate next step in the management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Isoniazid
B. Isoniazid and rifampin
C. No further management required
D. Rifampin
E. Rifampin and pyrazinamide

Back 49

Option A (Isoniazid) is correct. This patient has a positive PPD test, because he is a close contact of a confirmed case of active TB.

Option B (Isoniazid and rifampin) is incorrect. This is alternative therapy for patients in whom there is a concern for treatment compliance. The question does not provide any such clues.

Option C (No further management required) is incorrect. Previously, contacts older than the age of 35 years who are low risk (i.e., anyone without possible exposure to TB and no symptoms) were not treated with isoniazid therapy because of the risk of hepatitis. However, current guidelines do not recommend it.

Option D (Rifampin) is incorrect. Rifampin can be used in patients who are exposed to TB that has been shown to be resistant to isoniazid.

Option E (Rifampin and pyrazinamide) is incorrect. This was alternative therapy for treatment of latent TB. However, recent studies have demonstrated unacceptably high rates of liver toxicity and this regime is not recommended.

Front 50

A 42-year-old female presents to the emergency room after slamming her hand in a door. She complains of severe right hand pain. She denies any other injury. Vital signs are within normal limits. Examination reveals swelling over the dorsum of her right hand. Her skin is intact. She has normal capillary refill and normal sensation distal to the injury. An x-ray shows a fracture of at the distal ends of her fourth and fifth metacarpals. Orthopedic surgery followup is secured and the patient is placed in what type of splint?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Cockup wrist splint
B. Posterior splint
C. Sugar tong
D. Thumb spica
E. Ulnar gutter

Back 50

Option E (Ulnar gutter) is correct. An ulnar gutter splint encompasses the fourth and fifth digits as well as the wrist and stops two thirds of the way up the forearm. The wrist and hand are molded into a safe position that is described as the form the hand takes when holding a can of soda (with the wrist flexed and fingers flexed). This is a good choice for metacarpal fractures.

Option A (Cockup wrist splint) is incorrect. A cockup wrist splint can be used in wrist sprains. It consists of a splint with Velcro fasteners. The cock up portion places the wrist in flexion. It does not isolate the metacarpals.

Option B (Posterior splint) is incorrect. A posterior splint can be used in ankle sprains or fractures. A lower extremity sugar tong with a foot plate is, however, a better choice for ankle fractures. The sugar tong is made by wrapping a long piece of plaster around the heel and extending up both the medial and lateral aspect of the leg. The foot plate is an extra support that is added from the heel to the toes. A posterior splint is just that, a piece of plaster that runs from the leg to the toes along the posterior aspect of the leg. When splinted the foot should be placed in mild dorsiflexion.

Option C (Sugar tong) is incorrect. A sugar tong splint of the arm is useful in wrist fractures. It extends from the distal metacarpals to around the elbow. The elbow is bent at 90 degrees and the wrist is flexed. This splint prevents movement at both the wrist and elbow joints.

Option D (Thumb spica) is incorrect. A thumb spica splint wraps around the thumb and up the wrist to the midforearm. It can be used in thumb injuries or in scaphoid fractures.

Front 51

splint encompasses the fourth and fifth digits as well as the wrist and stops two thirds of the way up the forearm. The wrist and hand are molded into a safe position that is described as the form the hand takes when holding a can of soda (with the wrist flexed and fingers flexed). This is a good choice for metacarpal fractures.
A. Cockup wrist splint
B. Posterior splint
C. Sugar tong
D. Thumb spica
E. Ulnar gutter

Back 51

E. Ulnar gutter

Front 52

can be used in wrist sprains. It consists of a splint with Velcro fasteners. places the wrist in flexion.
A. Cockup wrist splint
B. Posterior splint
C. Sugar tong
D. Thumb spica
E. Ulnar gutter

Back 52

A. Cockup wrist splint

Front 53

useful in wrist fractures. It extends from the distal metacarpals to around the elbow. The elbow is bent at 90 degrees and the wrist is flexed. This splint prevents movement at both the wrist and elbow joints.
A. Cockup wrist splint
B. Posterior splint
C. Sugar tong
D. Thumb spica
E. Ulnar gutter

Back 53

C. Sugar tong

Front 54

wraps around the thumb and up the wrist to the midforearm. It can be used in thumb injuries or in scaphoid fractures.
A. Cockup wrist splint
B. Posterior splint
C. Sugar tong
D. Thumb spica
E. Ulnar gutter

Back 54

D. Thumb spica

Front 55

A 21-year-old male presents to the emergency room after an altercation with a “friend” during which he punched the other man in the mouth. He has no significant medical history and is on no medications. On exam he has a puncture wound and two longitudinal lacerations on the dorsum of his hand. X-rays of the hand are negative. He is given a tetanus shot. Prior to discharge what prophylactic antibiotics should be prescribed?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Amoxicillin (Augmentin)
B. Cephalexin (Keflex)
C. Metronidazole
D. Penicillin
E. Trimethoprim (Bactrim)

Back 55

Option A (Amoxicillin (Augmentin)) is correct. It covers the bacteria that are most likely to cause infection after a human bite. Amoxicillin (Augmentin) is first-line therapy as an outpatient. In the penicillin-allergic patient, treatment can consist of ciprofloxacin or clindamycin.

Option B (Cephalexin (Keflex)) is incorrect. Although cephalexin (Keflex) is commonly used for simple cellulitis, the polymicrobial nature of a human bite contains too many bacteria that are not covered by a first-generation cephalosporin.

Option C (Metronidazole) is incorrect. Metronidazole does not sufficiently cover the gram-positives that are most likely to cause infection in a human bite. Possible sources of infection included groups D and A streptococcus and group A staphylococcus. Bacteroides and Peptostreptococcus also cause infections after human bites. All human bite recipients must have their wounds cleaned and, if the skin has been broken, treated prophylactically with antibiotics.

Option D (Penicillin) is incorrect. Penicillin alone is not broad enough to cover the polymicrobial infection that can be caused by a human bite.

Option E (Trimethoprim (Bactrim)) is incorrect. Trimethoprim (Bactrim) would not cover the anaerobes in the human mouth. It can be used on combination with clindamycin for penicillin allergic patients.

Front 56

(Amoxicillin (Augmentin)) is correct. It covers the bacteria that are most likely to cause infection after a human bite. Amoxicillin (Augmentin) is first-line therapy as an outpatient. In the penicillin-allergic patient, treatment can consist of

Back 56

ciprofloxacin or clindamycin.

Front 57

A 35-year-old man presents to the emergency department with an 8-day history of fever, cough, and chest pain on deep inspiration or cough. He has also experienced fatigue and anorexia during this period. He was previously well and does not take any regular medications. Physical examination reveals rales over the left posterior lung field. Chest X-ray (CXR) shows left-sided hilar adenopathy, along with left lower lobe calcified infiltrates and a small left-side pleural effusion. Auramine-rhodamine staining of a sputum smear reveals yellow orange fluorescence. What is the most likely diagnosis?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Coccidioidomycosis
B. Mycobacterial pneumonia
C. Pneumococcal pneumonia
D. Pneumocystis carinii pneumonia
E. Tuberculosis (TB)

Back 57

Explanation
Option E (Tuberculosis [TB]) is correct. This patient has primary TB. Primary TB presents most frequently with prolonged fever, cough, variable sputum production, anorexia, and malaise. Night sweats and hemoptysis are more common in reactivation TB. The CXR in primary TB is asymmetric hilar adenopathy and lower lobe infiltrates. Apical involvement is more common in reactivated postprimary TB and there is an absence of lymphadenopathy. Acid-fast bacilli are most commonly tested using the auramine-rhodamine fluorescence testing. The Ziehl-Nielsen testing method is less frequently used.

Option A (Coccidioidomycosis) is incorrect. Coccidioidomycosis is caused by inhalation of Coccidioides immitis, a fungus endemic to the southwest United States southwest. Most infections are asymptomatic but when symptomatic can progress to respiratory failure. Diagnosis is based on culture.

Option B (Mycobacterial pneumonia) is incorrect. Mycobacterial pneumonia presents with prolonged malaise, fatigue, dry cough, and headache. Sputum analysis rarely yields diagnostic results. Diagnosis is often made by specific serologic antibody titers.

Option C (Pneumococcal pneumonia) is incorrect. Pneumococcal pneumonia is the most common form of community-acquired pneumonia. Organisms are lancet-shaped gram-positive cocci.

Option D (Pneumocystis carinii pneumonia) is incorrect. Pneumocystis carinii pneumonia is most common in patients who have human immunodeficiency virus or are immunosuppressed. Bronchoalveolar lavage is a common method for diagnosis, as well as direct fluorescent antibody testing.

Front 58

A 30–year-old man has come to the office with acute ankle swelling that began 48 hours ago. He has had this type of arthritis flare twice before and was given antibiotics for it. He is sexually active and usually uses a condom. He is in severe pain and wants to feel better. His friend gave him some ibuprofen (Motrin) and codeine, which helped alleviate the pain a little. Physical examination reveals a swollen, erythematous left ankle and right knee. He has two lesions on his hands (see figure). What laboratory test would help diagnose this man's condition?
Lbs100f1

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Ankle aspiration
B. Antinuclear antibody
C. Chlamydia smear of the urethra
D. Complement levels
E. Sedimentation rate

Back 58

Option D (Complement levels) is correct. This patient is showing signs of GC arthritis. Testing complement levels is important here because people with recurrent gonococcal (GC) infections, especially disseminated infections, have terminal complement deficiencies.

Option A (Ankle aspiration) is incorrect. Early in GC arthritis, the effusions are negative for organisms, so the best action is to culture the lesions. A joint aspiration would not be entirely incorrect, but it would not be that productive at this stage, especially with the other clues that this is a GC infection.

Option B (Antinuclear antibody) is incorrect. This will not help determine the diagnosis and may be falsely positive because he is infected. Antinuclear antibodies should be avoided in acute arthritis when there are no other clues of connective tissue disease because they will often be false positive.

Option C (Chlamydia smear of the urethra) is incorrect. Although Chlamydia accompanies gonococcal (GC) infection frequently, it does not cause this type of arthritis. This patient has the classic lesions of GC arthritis and should be cultured and treated for that. He may need Chlamydia treatment as well. Chlamydia is more commonly associated with reactive spondyloarthritis.

Option E (Sedimentation rate) is incorrect. The sedimentation rate will be elevated, but it is not diagnostic and will not help in treatment or diagnosis. Because the patient has inflammation clinically, there is no reason to test it serologically in this case. A C-reactive protein would not help, either.

Front 59

A 21-year-old man presents to the university health clinic, because of a penile discharge for the last 3 days. He states that this has been accompanied by an increase in frequency of urination, as well as painful urination. He has a previous history of appendicitis at age 7 years and has been well since. Physical examination reveals a white mucopurulent urethral discharge. A Gram stain of the discharge reveals eight polymorphonuclear leukocytes per high-power field and no bacteria. What is the most appropriate next step in the management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Ceftriaxone
B. Ceftriaxone and doxycycline
C. Ciprofloxacin
D. Doxycycline
E. Trimethoprim-sulfamethoxazole

Back 59

Option D (Doxycycline) is correct. This patient has nongonococcal urethritis, most likely caused by Chlamydia trachomatis. Urethritis is defined as a mucopurulent discharge, greater than 5 white blood cells (WBCs) per high-power field (hpf), positive leukocyte esterase on first void-urine or more than 10 WBCs per hpf in first-void urine. The most appropriate first step when gonococci are not identified is to institute appropriate antibacterial therapy. This is either with doxycycline or azithromycin. Because Gram stains are not 100% sensitive or specific, nucleic amplification for gonorrhea should be undertaken.

Option A (Ceftriaxone) is incorrect. Gonorrhea is caused by Neisseria gonorrhoeae and can be identified on Gram stain as gram-negative intracellular diplococci. Treatment is with ceftriaxone.

Option B (Ceftriaxone and doxycycline) is incorrect. This is initial therapy for individuals diagnosed with gonorrhea using a gram stain. Chlamydia cannot be identified by Gram stain and, as such, treatment should be instituted for both gonorrhea and chlamydia.

Option C (Ciprofloxacin) is incorrect. Ciprofloxacin is alternative therapy for gonorrhea.

Option E (Trimethoprim-sulfamethoxazole) is incorrect. Trimethoprim-sulfamethoxazole is appropriate therapy for a urinary tract infection, which would be rare in a man of this age.

Front 60

A 21-year-old female presents to her primary care provider with a 1-week history of vaginal pruritus. During this period, she has noticed an increase in vaginal discharge and describes it as having a yellow-green color to it. She is current sexually active with one partner and uses a combination oral contraceptive pill (OCP). She has had three previous sexual partners and denies any previous sexually transmitted diseases (STDs). Her previous medical history is unremarkable, and she denies any other symptoms. Physical examination reveals a mucopurulent cervical discharge that appears yellow-green when compared against a sheet of white paper. A Gram stain of vaginal material demonstrates Gram-negative extracellular diplococci. What is the most appropriate next step in management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Culture on Thayer-Martin medium
B. Empirical ceftriaxone and doxycycline therapy for her alone
C. Empirical ceftriaxone and doxycycline therapy for her and her sexual partner
D. Empirical ceftriaxone therapy for her alone
E. Empirical ceftriaxone therapy for her and her sexual partner
F. Venereal Disease Research Laboratory (VDRL) titers

Back 60

Option A (Culture on Thayer-Martin medium) is correct. This patient may have gonorrhea, but demonstrating extracellular gram-negative diplococci can be a part of the normal vaginal flora. Neisseria gonorrhea exists intracellularly. It is important to note that for cases of sexual abuse or assault, the only legally defensible demonstration of gonorrhea is culture.

Option B (Empirical ceftriaxone and doxycycline therapy for her alone) is incorrect. This is the correct pharmacotherapy for her, but her partner should be treated as well.

Option C (Empirical ceftriaxone and doxycycline therapy for her and her sexual partner) is incorrect. Once there is a diagnosis, this is the most appropriate next step in the management of this patient. Of course, an examination and investigation of her partner is desired, but in some circumstances treatment is possible without physician contact.

Option D (Empirical ceftriaxone therapy for her alone) is incorrect. This is the correct drug for Neisseria gonorrhea, but not the correct regimen for two reasons. First, once gonorrhea is diagnosed, chlamydia should be empirically treated, because both conditions frequently coexist, and it is much more difficult to detect chlamydia. Second, her partner should be treated or else she risks reinfection.

Option E (Empirical ceftriaxone therapy for her and her sexual partner) is incorrect. Her partner does require treatment, a principle called “epidemiologic treatment,” but a diagnosis has not been made yet.

Option F (Venereal Disease Research Laboratory [VDRL] titers) is incorrect. Venereal Disease Research Laboratory (VDRL) is a nonspecific test for investigation of syphilis. This patient does not have the painless ulcer (chancre) associated with syphilis, nor does she have any other signs or symptoms consistent with syphilis.

Front 61

A 7-year-old girl is brought to the emergency room by her mother for “side pain.” The girl had been in her normal state of health until the night before, when she began to cry and complain of pain in her left side. Acetominophen did not help the pain, and the girl vomited three times during the night. At 4:00 am, her temperature was 38.8°C (102°F). No diarrhea, hematuria, or polyuria were reported. Her past medical history includes frequent “tummy aches,” croup at age 2 years, and a urinary tract infection at age 4 years. For the past 2 years, the girl has had episodes of nocturnal enuresis after having been toilet trained at age 3 years. On physical exam, you note a well-nourished girl at the 75th percentile for height and the 95th percentile for weight. The child appears ill and uncomfortable, curled with her knees in front of her on the stretcher. She has diffuse abdominal tenderness and left costovertebral angle tenderness. Vital signs were: T = 39.2°C (102.6°F), HR = 128 beats per minute, RR = 16 breaths per minute, BP = 122/73 mm Hg. The remainder of exam was within normal limits. A urine dipstick shows trace amounts of protein and “large” blood, a pH of 7.3; “moderate” leukocyte esterase and nitrates and was negative for glucose. A microscopic examination showed RBC casts and many polymorphonuclear neutrophils along with motile bacteria. The girl is admitted to the hospital. In addition to radiologic studies to evaluate for renal stones and ureter integrity, which of the following should be evaluated to prevent secondary complications of this girl’s condition?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. An evaluation of the girl’s family situation
B. Liver function tests
C. Platelet counts
D. Quantitation of serum fibrin split products
E. Serum ammonia levels

Back 61

Option E (Serum ammonia levels) is correct. This girl has a urinary tract infection (UTI) caused by Proteus mirabilis, a motile organism that commonly causes UTIs and renal stones and is unique among urinary tract pathogens in its splitting of urea to form NH4 and CO2. This raises the pH of the urine, making it a more hospitable environment for pathogens. Sometimes, infection with Proteus causes hyperammonemia and central nervous system manifestations. Assessing this patient’s serum ammonia levels would alert the physician to possible impending complications.

Option A (An evaluation of the girl’s family situation) is incorrect. There is no reason to believe that this girl’s urinary tract infection is related to abuse of any kind. Gonorrheal or chlamydial infection, however, would be an indication to contact Child Protective Services.

Option B (Liver function tests) is incorrect. There is no reason to believe that this girl has liver problems. Although Proteus infections cause elevated ammonia levels, this is not a product of impeded liver function, but rather is caused by the bacterium’s urea-splitting abilities, which releases NH4 as an endproduct.

Option C (Platelet counts) is incorrect. A platelet count would be a good idea if this girl were suspected of having thrombotic, thrombocytopenic purpura (TTP), which often has renal manifestations, or ideopathic, thrombocytopenic purpura. However, the absence of purpura or symptoms of thrombocytopenia (e.g., easy bruising) make these unlikely. There is a better explanation for the girl’s hematuria given the other findings.

Option D (Quantitation of serum fibrin split products) is incorrect. Elevated levels of D-dimer and fibrin split products would be seen with disseminated, intravascular coagulation, which would manifest itself with signs of bleeding, shock, and organ infarction. TTP (as mentioned in rationale C) would also lead to consumption of fibrin, but is not high on the differential in this case.

Front 62

A 25-year-old woman presents to the emergency department with her husband, who says that over the past two days, she has developed neck stiffness, headache, and fever and has grown increasingly sensitive to light. On physical examination, the patient’s hips and knees flex when she flexes her neck. Temperature is 38.9° C (102° F), and there is some papilledema. The rest of the physical examination is normal. Her HIV status is not known. Which of the following is the most appropriate procedure for further evaluation of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Blood culture → start antibiotics → CT → LP
B. Blood culture → start antibiotics → LP → CT
C. LP → HIV test → start antibiotics
D. LP → start antibiotics → blood culture
E. Start antibiotics → blood culture → CT → LP

Back 62

Option A (Blood culture → start antibiotics → CT → LP) is correct. This is the ideal sequence in the evaluation/management of meningitis.

Option B (Blood culture → start antibiotics → LP → CT) is incorrect. It is recommended to obtain a CT scan before the LP.

Option C (LP → HIV test → start antibiotics) is incorrect. HIV testing is not part of a routine meningitis evaluation.

Option D (LP → start antibiotics → blood culture) is incorrect. It is recommended to obtain a CT scan before the LP, and it is not recommended to start antibiotics until blood cultures are obtained.

Option E (Start antibiotics → blood culture → CT → LP) is incorrect. It is not recommended to start antibiotics until blood cultures are obtained.