4-18-07

Front 1

This is the causative agent of Q fever

Back 1

Coxiella brunetti

Front 2

The most common cause of a rash with pneumonia is

Back 2

Mycoplasma pneumoniae

Front 3

A 27-year-old man presents to the emergency room because of a painful lesion on his penis. He states the lesion has been present for the last 3 days and has significantly changed in appearance during this time. Initially, it was a small, flesh-colored, covered lesion. On examination, there is a single, well-defined ulcer. The lesion is covered with a grey necrotic exudate that is easily removed with a swab. The lesion is pictured after application of a swab. There is also extremely painful, unilateral, inguinal lymphadenopathy. What is the most likely cause of these findings?
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Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Calymmatobacterium granulomatis
B. Chlamydia trachomatis, L1 serotype
C. Haemophilus ducreyi
D. Sarcoptes scabiei
E. Treponema pallidum

Back 3

Option C (Haemophilus ducreyi) is correct. This patient has chancroid, a condition of painful genital ulceration combined with very tender regional lymphadenopathy. Chancroid is caused by H. ducreyi and is uncommon in the United States. However, it is quite common in Africa and Southeast Asia. The inguinal lymph nodes can become liquified and form buboes.

Option A (Calymmatobacterium granulomatis) is incorrect. This is the cause of granuloma inguinale, which presents as a painless nodule that evolves to become a beefy-red, raised, granulomatous ulcer.

Option B (Chlamydia trachomatis, L1 serotype) is incorrect. The L1–L3 serotypes of C. trachomatis are responsible for lymphogranuloma venereum, which presents with a brief genital ulcer that rarely causes patients to seek treatment. Secondary inflammation following the ulcer causes painful, unilateral inguinal lymphadenopathy (which also form buboes), as well as structures of the rectum.

Option D (Sarcoptes scabiei) is incorrect. This is the cause of scabies, an extremely pruritic condition that presents with papulonodular, erythematous lesions. The lesions are characteristically more pruritic at night or when the body temperature is elevated.

Option E (Treponema pallidum) is incorrect. This is the cause of syphilis, which presents as a painless 1- to 2-cm ulcer with erythematous borders and a nonexudative base. There may be associated inguinal lymphadenopathy that is also nontender.

Front 4

presents as a painless nodule that evolves to become a beefy-red, raised, granulomatous ulcer.
A. Calymmatobacterium granulomatis
B. Chlamydia trachomatis, L1 serotype
C. Haemophilus ducreyi
D. Sarcoptes scabiei
E. Treponema pallidum

Back 4

Option A (Calymmatobacterium granulomatis) is incorrect. This is the cause of granuloma inguinale, which presents as a painless nodule that evolves to become a beefy-red, raised, granulomatous ulcer.

Front 5

responsible for lymphogranuloma venereum, which presents with a brief genital ulcer that rarely causes patients to seek treatment. Secondary inflammation following the ulcer causes painful, unilateral inguinal lymphadenopathy (which also form buboes), as well as structures of the rectum.
A. Calymmatobacterium granulomatis
B. Chlamydia trachomatis, L1 serotype
C. Haemophilus ducreyi
D. Sarcoptes scabiei
E. Treponema pallidum

Back 5

Option B (Chlamydia trachomatis, L1 serotype) is incorrect. The L1–L3 serotypes of C. trachomatis are responsible for lymphogranuloma venereum, which presents with a brief genital ulcer that rarely causes patients to seek treatment. Secondary inflammation following the ulcer causes painful, unilateral inguinal lymphadenopathy (which also form buboes), as well as structures of the rectum.

Front 6

an extremely pruritic condition that presents with papulonodular, erythematous lesions. The lesions are characteristically more pruritic at night or when the body temperature is elevated.
A. Calymmatobacterium granulomatis
B. Chlamydia trachomatis, L1 serotype
C. Haemophilus ducreyi
D. Sarcoptes scabiei
E. Treponema pallidum

Back 6

Option D (Sarcoptes scabiei) is incorrect. This is the cause of scabies, an extremely pruritic condition that presents with papulonodular, erythematous lesions. The lesions are characteristically more pruritic at night or when the body temperature is elevated.

Front 7

presents as a painless 1- to 2-cm ulcer with erythematous borders and a nonexudative base. There may be associated inguinal lymphadenopathy that is also nontender.
A. Calymmatobacterium granulomatis
B. Chlamydia trachomatis, L1 serotype
C. Haemophilus ducreyi
D. Sarcoptes scabiei
E. Treponema pallidum

Back 7

Option E (Treponema pallidum) is incorrect. This is the cause of syphilis, which presents as a painless 1- to 2-cm ulcer with erythematous borders and a nonexudative base. There may be associated inguinal lymphadenopathy that is also nontender.

Front 8

cutaneous anthrax.
A. Acyclovir
B. Doxycycline
C. Fluconazole
D. Oral corticosteroids
E. Trimethoprim-sulfamethoxazole

Back 8

Option B (Doxycycline) is correct. The described lesion is characteristic of cutaneous anthrax. The most common form of anthrax is cutaneous and is usually found in animal farmers exposed to the spores. Untreated, mortality can be as high as 30%. Doxycycline is the preferred first-line antibiotic, although penicillin is also active against Bacillus anthracis. There is a concern about inducible beta-lactamase.

Front 9

A 39-year-old woman presents to the emergency room with a 2-week history of increasing fatigue and jaundice. She has also noticed that her urine has become dark-colored like tea during this period. She currently works as a hospital cleaner and reluctantly admits to an unreported needlestick injury from a patient with known hepatitis B about 3 weeks prior. On examination, there is hepatomegaly with hepatic punch tenderness. What laboratory investigation would be most appropriate in the diagnosis of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Anti-HBc IgM
B. Anti-HBe IgM
C. Anti-HBs IgM
D. HBV DNA
E. HBV RNA

Back 9

Option A (Anti-HBc IgM) is correct. Anti-hepatitis B core immunoglobuin M (anti-HBc IgM): This antibody appears just prior to the onset of symptoms and is used along with the detection of hepatitis B surface antigen (HBsAg) as the primary method of diagnosing acute hepatitis B.

Option B (Anti-HBe IgM) is incorrect. Antibody to hepatitis B e antigen (HBeAg) indicates either recovery or chronic hepatitis B vaccine (HBV) infection with low infectivity.

Option C (Anti-HBs IgM) is incorrect. Antibody to surface antigen indicates recovery or immunization.

Option D (HBV DNA) is incorrect. Hepatitis B vaccine (HBV) deoxyribonucleic acid (DNA) is useful as a prognostic indicator in patients diagnosed with HBV. It is not useful diagnostic test because HBV DNA is often undetectable after symptoms have developed. Patients who remain HBV DNA–positive 6 weeks after symptom onset have a high likelihood of developing chronic hepatitis B.

Option E (HBV RNA) is incorrect. Hepatitis B is a deoxyribonucleic acid (DNA) virus and thus, ribonucleic acid (RNA) would not be useful as a diagnostic method.

Front 10

A 47-year-old woman presents to the emergency room following the sudden onset of abdominal pain, fever, and diarrhea. The diarrhea is described as watery and has been constant since onset. The patient denies any blood or mucous in the bowl. She had a similar episode 2 weeks ago following an extended course of antibiotics for a persistent urinary tract infection. At that time, her stool tested positive for Clostridium difficile toxin, and she was administered metronidazole. Her diarrhea symptoms resolved promptly after treatment. On examination, her vital signs are within normal limits, and her abdomen is diffusely tender to superficial palpation. Stool enzyme immunoassay confirms presence of C. difficile toxin. What is the most appropriate next step in the management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Colonoscopy
B. Intravenous vancomycin
C. Oral loperamide
D. Oral metronidazole
E. Oral vancomycin

Back 10

Option D (Oral metronidazole) is correct. The enzyme immunoassay confirms that this patient has again developed C. difficile associated pseudomembranous colitis. The first-line therapy is metronidazole. Recurrence after complete resolution is not considered treatment failure. Consequently, metronidazole is indicated again as therapy.

Option A (Colonoscopy) is incorrect. The diagnosis of pseudomembranous colitis has been made using enzyme immunoassay. Consequently, there is no need for colonoscopy.

Option B (Intravenous [IV] vancomycin) is incorrect. Vancomycin is typically given intravenously. However, in cases of C. difficile, vancomycin must be given orally to be effective against the bacteria in the lumen of the gut. Systemic absorption is not required and thus, IV administration is incorrect.

Option C (Oral loperamide) is incorrect. This is an antimotility/antidiarrheal agent. In cases of pseudomembranous colitis, antidiarrheals are contraindicated.

Option E (Oral vancomycin) is incorrect. Oral vancomycin is second-line therapy for C. difficile. Its use as a primary agent is limited for fear of developing vancomycin-resistant enterococci (VRE).

Front 11

Legionella Treatment is with

Back 11

levofloxacin

Front 12

A 31-year-old female presents to her primary care provider complaining of vaginal discharge for the past 2 days. She has also noticed that it is somewhat malodorous and is concerned because she recently began a new sexual relationship 2 weeks ago. Speculum examination demonstrates a thin, gray, homogenous discharge containing bubbles. The discharge is adherent to the walls of the vagina. The labia, vulva, and cervix are not erythematous. Examination with phenaphthazine (Nitrazine) paper demonstrates a pH > 4.5. What finding would be most likely to be detected on a wet mount slide?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Abundant lactobacilli
B. Coccobacilli surrounding vaginal epithelial cells
C. Motile pear-shaped organisms
D. Numerous polymorphonuclear (PMN) leukocytes
E. Pseudohyphae

Back 12

Option B (Coccobacilli surrounding vaginal epithelial cells) is correct. This patient has bacterial vaginosis (BV) and we would expect “clue cells” on wet prep. Clue cells are vaginal epithelial cells, which have become coated in coccobacilli named Gardnerella vaginalis. Presence of clue cells is diagnostic of BV, and treatment is with metronidazole. It is not a sexually transmitted disease (STD) and therefore, male partners do not require treatment.

Option A (Abundant lactobacilli) is incorrect. Abundant lactobacilli would be seen in a normal vaginal discharge. Bacterial vaginosis (BV) is thought to be the result of an abnormal vaginal ecosystem where the natural lactobacilli are significantly reduced.

Option C (Motile pear-shaped organisms) is incorrect. Motile pear-shaped organisms would be expected in a patient presenting with vulvar erythema and a profuse yellow-green discharge consistent with Trichomonas. Trichomonas vaginalis is a protozoal parasite that typically resides in the seminal fluid of males. It is also treated with metronidazole, but the partner should also be treated.

Option D (Numerous polymorphonuclear [PMN] leukocytes) is incorrect. Bacterial vaginosis (BV) is associated with few polymorphonuclear (PMN) leukocytes and that finding is thought to underscore why the discharge in BV is thin and gray rather than purulent.

Option E (Pseudohyphae) is incorrect. Pseudohyphae are a sign of Candida vaginitis but cannot be demonstrated on wet prep. A potassium hydroxide (KOH) test would reveal pseudohyphae. In the present case, the KOH prep would likely demonstrate the “whiff test,” referring to the amine odor produced when KOH is applied to the bacterial vaginosis discharge.

Front 13

A 56-year-old male with a fever of 102.3° F (38.8° C) comes into the emergency room with a change in mental status. His urine shows gram + cocci. What is the next step in management?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Echocardiogram
B. Kidney ultrasound
C. Obtain blood cultures, urine, and sputum cultures
D. Repeat urinalysis
E. Start antibiotic therapy

Back 13

Option C (Obtain blood cultures, urine, and sputum cultures) is correct. The patient should be fully cultured before antibiotics are begun.

Option A (Echocardiogram) is incorrect. If a heart murmur is heard or there is question of endocarditis, then an echo may be part of the evaluation after full cultures are taken.

Option B (Kidney ultrasound) is incorrect. This may be helpful later in finding the source of the infection.

Option D (Repeat urinalysis) is incorrect. This is unnecessary.

Option E (Start antibiotic therapy) is incorrect. Antibiotics should be initiated only after all cultures are gathered.

Front 14

The resident on call is called at 2 a.m. to evaluate a postsurgical patient who has spiked a fever. The patient is a 66-year-old man who underwent artificial hip replacement surgery 3 days ago. He has had no problems since his surgery. Now he complains of headache and sore throat. He seems confused and is ill-appearing. His temperature is 104°F, and blood pressure is 100/65 mm Hg. He is vomiting and has profuse watery diarrhea. A generalized sunburn-like rash is present and he has a pronounced conjunctivitis with no discharge. There are no focal neurologic signs or nuchal rigidity. Lungs are clear, and the abdomen is soft, nontender, and without rebound. There is a noticeable serous drainage from the surgical wound site. Laboratory tests show elevated white blood cell count and increased prothrombin time, partial thromboplastin time, blood urea nitrogen, and serum creatinine. A diagnostic workup is most likely to isolate which of the following organisms?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Bacteroides fragilis
B. Legionella pneumophila
C. Neisseria meningitidis
D. Staphylococcus aureus
E. Streptococcus pneumoniae

Back 14

Option D (Staphylococcus aureus) is correct. This patient is showing sgins of toxic shock syndrome (TSS). TSS is a constellation of signs and symptoms resulting from the toxins of S. aureus. It can be the result of a postoperative wound infection even in the absence of a bacteremia.

Option A (Bacteroides fragilis) is incorrect. These bacteria do not etiologically fit the clinical picture presented. The possibility of perforated bowel is unlikely without peritonitis in this time frame.

Option B (Legionella pneumophila) is incorrect. Legionella pneumonia or sepsis is less likely in this scenario and does not fit the clinical findings as well as TSS.

Option C (Neisseria meningitidis) is incorrect. The most likely site of infection is the surgical wound given the clinical picture of septic/toxic shock. Physical examination showed no nuchal rigidity.

Option E (Streptococcus pneumoniae) is incorrect. The clinical picture is more consistent with TSS. Chest examination did not suggest pneumonia.

Front 15

A 19-year-old man presents to the emergency department after being bitten by his neighbor's dog. He was playing with the animal by tapping on the dog's nose when the dog bit him on the forearm. The man has received all age-appropriate vaccines, but has never been immunized for rabies. The owner of the dog states that the dog has been well and has never bitten anyone previously. He is unsure if the dog has been vaccinated for rabies. Physical examination reveals a 1-cm-deep, clean puncture wound over the forearm. Distal sensation and circulation are intact. In addition to wound care, what is the most appropriate next step in management?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Immediately administer rabies immune globulin
B. Immediately administer rabies immune globulin and rabies vaccine
C. Immediately administer rabies vaccine
D. Immediately euthanize dog and perform brain biopsy for signs of rabies
E. Immediately quarantine dog and observe for 10 days for signs of rabies

Back 15

Option E (Immediately quarantine dog and observe for 10 days for signs of rabies) is correct. Postexposure prophylaxis for rabies is a medial urgency, not medical emergency, because rabies virus takes 30 to 45 days to infect. In dogs and other animals, the signs of rabies take up 10 days to appear. Consequently, the most appropriate management if the animal is observable is to quarantine the dog and observe for signs of rabies. Should signs appear, the dog should be immediately euthanized and have its brain examined for pathologic signs of rabies. A notable exception to observation is if there is a bite to the face—the incubation period is shorter (often 10 days) and thus, immediate prophylaxis is indicated.

Option A (Immediately administer rabies immune globulin) is incorrect. Rabies immune globulin alone is never indicated in postexposure prophylaxis.

Option B (Immediately administer rabies immune globulin and rabies vaccine) is incorrect. In patients who have not been previously vaccinated, this is appropriate postexposure prophylaxis. Prophylaxis is indicated at any time where a bite comes from a mammal suspected of having rabies. Bites from wild animals, particularly raccoons, skunks, bats, and foxes, are considered to be rabies-positive unless otherwise proven.

Option C (Immediately administer rabies vaccine) is incorrect. This is appropriate postexposure prophylaxis in patients who have been previously immunized.

Option D (Immediately euthanize dog and perform brain biopsy for signs of rabies) is incorrect. This would be appropriate if the animal were suspected of having rabies, despite the dog's vaccination history being unknown.

Front 16

A 70-year-old man presents with a scaly, well-demarcated, erythematous patch of alopecia over the scalp. The lesion has been present for 3 months and initially began only as a scaly patch. Since that time, he has progressively lost all the hair located in the patch. Examination of the patch under ultraviolet is carried out. What is the most likely cause of these findings?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Autoimmune reaction
B. Microsporum species
C. Pityrosporum ovale
D. Reactive alopecia
E. Trichophyton tonsurans

Back 16

Option B (Microsporum species) is correct. This patient has tinea capitis. Tinea capitis is caused by two organisms, Trichophyton and Microsporum. Microsporum fluoresces under ultraviolet light, whereas Trichophyton does not. Because this lesion shows fluorescence, Microsporum is the cause.

Option A (Autoimmune reaction) is incorrect. An autoimmune reaction is the proposed mechanism for alopecia areata. The diagnosis of alopecia areata can be made by the finding of exclamation point hairs. There is no fluorescence under ultraviolet (UV) light.

Option C (Pityrosporum ovale) is incorrect. This is the cause of pityriasis (tinea) versicolor. The condition presents as areas of the body that will not tan after exposure to sun.

Option D (Reactive alopecia) is incorrect. A reactive alopecia is the mechanism of telogen effluvium where there is diffuse hair loss.

Option E (Trichophyton tonsurans) is incorrect. This is the most common cause of tinea capitis and is thought to account for approximately 90% of cases. However, it does not fluoresce under UV light.

Front 17

the most common cause of tinea capitis
A. Autoimmune reaction
B. Microsporum species
C. Pityrosporum ovale
D. Reactive alopecia
E. Trichophyton tonsurans

Back 17

Option E (Trichophyton tonsurans) is incorrect. This is the most common cause of tinea capitis and is thought to account for approximately 90% of cases. However, it does not fluoresce under UV light.

Front 18

fluoresces under ultraviolet light and causes tinea capitis

Microsporum species
Trichophyton tonsurans

Back 18

Option B (Microsporum species) is correct. This patient has tinea capitis. Tinea capitis is caused by two organisms, Trichophyton and Microsporum. Microsporum fluoresces under ultraviolet light, whereas Trichophyton does not. Because this lesion shows fluorescence, Microsporum is the cause.

Front 19

This is the cause of tinea versicolor.
A. Autoimmune reaction
B. Microsporum species
C. Pityrosporum ovale
D. Reactive alopecia
E. Trichophyton tonsurans

Back 19

Option C (Pityrosporum ovale) is incorrect. This is the cause of pityriasis (tinea) versicolor. The condition presents as areas of the body that will not tan after exposure to sun.

Front 20

A 29-year-old man presents to a community health clinic with a week-long history of painful swallowing. The pain is located retrosternally and occasionally radiates into the oropharynx. He denies weight loss, hematemesis, or change in stool color. He has a known history of human immunodeficiency virus (HIV) infection and his last CD4 count was 48 cells/mm3. A barium swallow is performed and demonstrates multiple large, deep linear ulcers. Endoscopy is performed with brushings and biopsy. Histopathology reveals a paucity of cells with enlarged and smudged nuclei that are intensely eosinophilic. What is the most likely cause of this patient's symptoms?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Candida albicans
B. Cytomegalovirus (CMV)
C. Eosinophilic esophagitis
D. Gastroesophageal reflux disease (GERD)
E. Herpes simplex virus (HSV)

Back 20

Option B (Cytomegalovirus [CMV]) is correct. This patient has AIDS and is presenting with odynophagia resulting from esophagitis. CMV is the most common cause of ulcerative esophagitis and diagnostic findings on barium swallow and endoscopy are as described in the question.

Option A (Candida albicans) is incorrect. Candida is the most common cause of esophagitis in patients with acquired immune deficiency syndrome (AIDS). It often presents with oral thrush. Barium swallow reveals shaggy mucosa, whereas biopsy shows the pseudohyphae on periodic acid-Schiff stain.

Option C (Eosinophilic esophagitis) is incorrect. This is a rare cause of esophagitis and is usually the result of atopy. Biopsy reveals very high numbers of eosinophils.

Option D (Gastroesophageal reflux disease [GERD]) is incorrect. Gastroesophageal reflux disease (GERD) is the most common cause of esophagitis overall and causes reflux esophagitis. Erythema and edema with a friable mucosa are typically seen on endoscopy.

Option E (Herpes simplex virus [HSV]) is incorrect. Herpes simplex virus is another common cause of esophagitis in patients with AIDS. Barium swallow reveals multiple shallow ulcers, often in volcanic shapes.

Front 21

is the most common cause of ulcerative esophagitis

Back 21

Cytomegalovirus

Front 22

Cause of esophagitis in which Barium swallow reveals shaggy mucosa
A. Candida albicans
B. Cytomegalovirus (CMV)
C. Eosinophilic esophagitis
D. Gastroesophageal reflux disease (GERD)
E. Herpes simplex virus (HSV)

Back 22

Candida

Front 23

Erythema and edema with a friable mucosa are typically seen on endoscopy.
A. Candida albicans
B. Cytomegalovirus (CMV)
C. Eosinophilic esophagitis
D. Gastroesophageal reflux disease (GERD)
E. Herpes simplex virus (HSV)

Back 23

Option D (Gastroesophageal reflux disease [GERD]) is incorrect. Gastroesophageal reflux disease (GERD) is the most common cause of esophagitis overall and causes reflux esophagitis. Erythema and edema with a friable mucosa are typically seen on endoscopy.

Front 24

Barium swallow reveals multiple shallow ulcers, often in volcanic shapes.
A. Candida albicans
B. Cytomegalovirus (CMV)
C. Eosinophilic esophagitis
D. Gastroesophageal reflux disease (GERD)
E. Herpes simplex virus (HSV)

Back 24

E. Herpes simplex virus (HSV)

Front 25

Vaccination against hepatitis B is genetically engineered ...

Back 25

Option D (Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody negative) is correct. Vaccination against hepatitis B is genetically engineered hepatitis B surface antigen (HBsAg). Consequently, the only positive finding on serology is antibody to hepatitis B surface antigen.

Front 26

Vaccination against hepatitis B
A. Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody negative
B. Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody positive
C. Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody positive
D. Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody negative
E. Hepatitis B surface-antigen positive, surface-antibody negative, and core-antibody positive

Back 26

Option D (Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody negative) is correct. Vaccination against hepatitis B is genetically engineered hepatitis B surface antigen (HBsAg). Consequently, the only positive finding on serology is antibody to hepatitis B surface antigen.

Front 27

the “window” period
A. Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody negative
B. Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody positive
C. Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody positive
D. Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody negative
E. Hepatitis B surface-antigen positive, surface-antibody negative, and core-antibody positive

Back 27

Option B (Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody positive) is incorrect. This is the “window” period and the use of immunoglobulin (Ig)M anti–hepatitis B core antigen (HBcAg) is used to make the diagnosis of acute hepatitis B virus (HBV) infection.

Front 28

there was once an infection with hepatitis B, but the patient is now recovered and is immune.
A. Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody negative
B. Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody positive
C. Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody positive
D. Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody negative
E. Hepatitis B surface-antigen positive, surface-antibody negative, and core-antibody positive

Back 28

Option C (Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody positive) is incorrect. The presence of core-antibody positive and surface-antigen negative combined with a positive surface antibody indicate that there was once an infection with hepatitis B, but the patient is now recovered and is immune.

Front 29

acute hepatitis infection.
A. Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody negative
B. Hepatitis B surface-antigen negative, surface-antibody negative, and core-antibody positive
C. Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody positive
D. Hepatitis B surface-antigen negative, surface-antibody positive, and core-antibody negative
E. Hepatitis B surface-antigen positive, surface-antibody negative, and core-antibody positive

Back 29

Option E (Hepatitis B surface-antigen positive, surface-antibody negative, and core-antibody positive) is incorrect. This is the pattern seen with acute hepatitis infection.

Front 30

A 2-day course of rifampin, 600 mg taken orally (PO) twice daily (BID), is recommended for all the household members and medical personnel who have had contact with a patient diagnosed with meningococcal meningitis. For pregnant or lactating women and for children younger than 2 years of age...?

Back 30

intramuscular (IM) ceftriaxone or ciprofloxacin is preferred.

Front 31

A 62-year-old woman is referred to the physician from the dentist, because she is scheduled to undergo professional teeth cleaning. Two years ago, she developed a case of Streptococcus viridans-associated infective endocarditis (IE). She was appropriately treated and has not had any complaints since. At present, she takes no regular medications and has a severe penicillin allergy. What is the most appropriate management to prevent recurrent IE in this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Amoxicillin
B. Clindamycin
C. Gentamicin
D. No further management required
E. Vancomycin and gentamicin

Back 31

Option B (Clindamycin) is correct. This patient is at high risk for developing IE. She also has a severe allergy to penicillin. Consequently, the most appropriate prophylaxis is with clindamycin. Azithromycin or clarithromycin would also be acceptable.

Option A (Amoxicillin) is incorrect. This patient has a severe penicillin allergy. Amoxicillin is cross-allergic with penicillin.

Option C (Gentamicin) is incorrect. Gentamicin therapy is not used alone in the prophylaxis of IE.

Option D (No further management required) is incorrect. This patient requires prophylaxis. A list of conditions that do not require prophylaxis is in the High Yield Hit.

Option E (Vancomycin and gentamicin) is incorrect. This would be appropriate antibiotic therapy in patients who have a penicillin allergy, are at high risk for developing IE and are undergoing a gastrointestinal or genitourinary procedure. For procedures above the diaphragm, clindamycin is sufficient.

Front 32

An oral surgeon visits his physician for an excruciatingly painful vesicular lesion that has developed over the last 3 days on his right index finger. Based only on this evidence, which of the following is most likely the cause of this condition?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Foreign body
B. Herpes simplex virus
C. Human papillomavirus
D. Staphylococcus aureus
E. Streptococcus viridans

Back 32

Option B (Herpes simplex virus) is correct. Dentists are prone infection of the finger with herpes simplex from contamination from patients’ mouths. The condition is referred to as herpetic whitlow. It is a vesicular lesion that is reportedly extraordinarily painful.

Option A (Foreign body) is incorrect. A foreign body usually does not produce a vesicular lesion. Granulomatous lesions are more consistent with this diagnosis.

Option C (Human papillomavirus) is incorrect. The common wart is indeed more common than herpetic whitlow, but it is usually not painful or vesicular.

Option D (Staphylococcus aureus) is incorrect. This is unlikely to cause an excruciatingly painful vesicular lesion. Dentists are prone to infection of the finger with herpes simplex from contamination from patients’ mouths.

Option E (Streptococcus viridans) is incorrect. This is unlikely to cause an excruciatingly painful vesicular lesion. Dentists are prone to infection of the finger with herpes simplex from contamination from patients’ mouths.

Front 33

A 26-year-old man arrives in the emergency room (ER) complaining of an injured right hand. The injury occurred the previous evening when the patient punched an acquaintance in the mouth following a spirited discussion at a local tavern. On exam, vital signs are normal. The right hand shows mild generalized swelling without warmth or redness. There is pain with clenching of the fist but no limitation to range of motion. A 1 inch laceration is located between the first and second metacarpal-phalangeal joint expansions. No drainage is apparent from the laceration. A hand and wrist X-ray series shows soft tissue swelling with no sign of bone dislocation, fracture or other abnormalities. What antibiotic(s) would provide adequate initial prophylactic coverage in this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Cefoxitin
B. Cephalexin
C. Clindamycin
D. Oxacillin and dicloxacillin
E. Penicillin G

Back 33

Option A (Cefoxitin) is correct. The infectious organisms associated with human bite, clenched-fist injury are S. aureus, streptococci, E. corrodens, gram-negative bacilli, and anaerobes. Adequate antibacterial coverage is parenteral first-generation cephalosporin or antistaphylococcal penicillin and penicillin G or β-lactamase inhibitor, such as ampicillin-sulbactam or amoxicillin-clavulanate potassium, or a second-generation cephalosporin, such as cefoxitin. This choice provides only two antistaphylococcal penicillins.

Option B (Cephalexin) is incorrect. The infectious organisms associated with human bite, clenched-fist injury are Staphylococcus aureus, streptococci, E. corrodens, gram-negative bacilli, and anaerobes. Adequate antibacterial coverage is parenteral first-generation cephalosporin or antistaphylococcal penicillin and penicillin G or β-lactamase inhibitor, such as ampicillin-sulbactam or amoxicillin-clavulanate potassium, or a second-generation cephalosporin, such as cefoxitin. Cephalexin is a first-generation cephalosporin.

Option C (Clindamycin) is incorrect. E. corrodens, one of the primary organisms of concern in human bite clenched fist injuries, is resistant to clindamycin.

Option D (Oxacillin and dicloxacillin) is incorrect. The infectious organisms associated with human bite, clenched-fist injury are Staphylococcus aureus, streptococci, E. corrodens, gram-negative bacilli, and anaerobes. Adequate antibacterial coverage is parenteral first-generation cephalosporin or antistaphylococcal penicillin and penicillin G or β-lactamase inhibitor, such as ampicillin-sulbactam or amoxicillin-clavulanate potassium, or a second-generation cephalosporin, such as cefoxitin. This choice provides only two antistaphylococcal penicillins.

Option E (Penicillin G) is incorrect. The infectious organisms associated with human bite, clenched-fist injury are Staphylococcus aureus, streptococci, Eikenella corrodens, gram-negative bacilli, and anaerobes. Adequate antibacterial coverage is parenteral first-generation cephalosporin or antistaphylococcal penicillin and penicillin G or β-lactamase inhibitor, such as ampicillin-sulbactam or amoxicillin-clavulanate potassium, or a second-generation cephalosporin, such as cefoxitin.

Front 34

A 63-year-old man is referred to the physician by the dentist, because he is to undergo a dental pulpectomy. Three years ago, he underwent mitral valve replacement with a mechanical valve. Since that time, he has been asymptomatic and otherwise well. What is the most appropriate therapy to prevent disability associated with this procedure?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Amoxicillin
B. Ampicillin and gentamicin
C. Antibiotic prophylaxis not required
D. Clindamycin
E. Gentamicin

Back 34

Option A (Amoxicillin) is correct. This patient is considered a high risk for developing infective endocarditis (IE), as he has a prosthetic heart valve. Dental procedures are associated with significant bacteremia, and it is necessary to employ antibiotics to reduce the risk of developing IE from this bacteremia. Dental procedures, as well as oral, respiratory, and esophageal procedures are covered with amoxicillin 1 hour prior to the procedure.

Option B (Ampicillin and gentamicin) is incorrect. This is an appropriate regime for high-risk individuals who are undergoing genitourinary or gastrointestinal procedures.

Option C (Antibiotic prophylaxis not required) is incorrect. This patient is at high risk and requires prophylaxis. See the High Yield Hit for a complete detail of which conditions do not require prophylaxis.

Option D (Clindamycin) is incorrect. Clindamycin can be used in patients who are at risk for developing IE, are undergoing dental, oral, respiratory, or esophageal procedures and are allergic to penicillin.

Option E (Gentamicin) is incorrect. Gentamicin alone is not used as prophylaxis against IE, because of its poor gram-positive coverage.

Front 35

Three years ago, he underwent mitral valve replacement with a mechanical valve. Since that time, he has been asymptomatic and otherwise well. This is an appropriate regime for high-risk individuals who are undergoing genitourinary or gastrointestinal procedures.
A. Amoxicillin
B. Ampicillin and gentamicin
C. Antibiotic prophylaxis not required
D. Clindamycin
E. Gentamicin

Back 35

Option B (Ampicillin and gentamicin) is incorrect. This is an appropriate regime for high-risk individuals who are undergoing genitourinary or gastrointestinal procedures.

Front 36

can be used in patients who are at risk for developing IE, are undergoing dental, oral, respiratory, or esophageal procedures and are allergic to penicillin.
A. Amoxicillin
B. Ampicillin and gentamicin
C. Antibiotic prophylaxis not required
D. Clindamycin
E. Gentamicin

Back 36

Option D (Clindamycin) is incorrect. Clindamycin can be used in patients who are at risk for developing IE, are undergoing dental, oral, respiratory, or esophageal procedures and are allergic to penicillin.

Front 37

Gentamicin alone is not used as prophylaxis against IE, because of ...

Back 37

Gentamicin alone is not used as prophylaxis against IE, because of its poor gram-positive coverage.

Front 38

A 22-year-old male is referred to his doctor from the local penitentiary. He complains of a red, painful “boil” on his right upper thigh. He states the doctor at the prison started him on antibiotics (cephalexin (Keflex)) for this infection and “lanced” the lesion several days ago. Despite the treatment the infected area has gotten worse. Vital signs show heart rate 80 beats/min, blood pressure 130/67 mm Hg, and temperature of 36.6°C (97.8°F). On close examination of the patient's upper thigh there is a 3 cm area of warm red skin surrounding a 5 mm scab. There is no streaking or redness extending up or down the leg. After doing a repeat incision and drainage on the wound and packing it with iodoform gauze, what is the appropriate antibiotic therapy?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Amoxicillin (Augmentin)
B. Ampicillin
C. Ceftriaxone
D. Doxycycline
E. Intravenous vancomycin

Back 38

Option D (Doxycycline) is correct. Doxycycline alone or in combination with rifampin or trimethoprim (Bactrim) can be used as outpatient treatment for MRSA. The multidrug-resistant infection is becoming more and more common especially in the incarcerated population. The patient above is non-toxic and otherwise well appearing and therefore outpatient treatment would be the first line of therapy. Local incision and drainage of the abscess and wound care are also important.

Option A (Amoxicillin (Augmentin)) is incorrect. Although amoxicillin (Augmentin) is a well-used oral antibiotic, it does not cover methicillin-resistant Staphylococcus aureus (MRSA) infections.

Option B (Ampicillin) is incorrect. Ampicillin is often given to neonates to cover listeria and to children for group A streptococcus, but it does not cover MRSA.

Option C (Ceftriaxone) is incorrect. Although ceftriaxone is a broad coverage tertiary cephalosporin, it does not cover MRSA.

Option E (Intravenous vancomycin) is incorrect. Intravenous vancomycin would be sufficient to treat MRSA, but as outpatient treatment intravenous antibiotics are difficult to administer. First-line therapy in a non-toxic patient can begin with the antibiotics noted previously.

Front 39

A 23-year-old female presents to the university health clinic after noticing a significant and malodorous vaginal discharge. She has been otherwise well and denies any associated symptoms. At present she is sexually active with one male partner and has had three lifetime sexual partners. Her previous medical history is notable for an appendectomy at the age of 14. She denies any previous sexually transmitted diseases (STDs). Speculum examination reveals a distinct odor, a nonerythematous cervix, and a gray, thin discharge that surrounds the vaginal vault. Wet preparation demonstrates clumps of coccobacilli that appear to be surrounding vaginal epithelial cells. There is an absence of lactobacilli. What is the most appropriate next step in the management of this patient?

Answer Choices Correct AnswerCorrect answer Your AnswerYour answer
A. Clotrimazole suppository
B. Metronidazole for her sexual partner
C. Povidone-iodine
D. Topical clindamycin
E. Topical treatment with yogurt

Back 39

Option D (Topical clindamycin) is correct. This patient has bacterial vaginosis as demonstrated by the wet prep. Both topical and oral treatment with clindamycin or metronidazole produce similar rates of cure. Use of topical clindamycin can be useful in college-age patients as oral metronidazole is associated with a disulfiram-like reaction when alcohol is ingested.

Option A (Clotrimazole suppository) is incorrect. Clotrimazole therapy would be appropriate if this patient had pseudohyphae on a wet-mount-KOH preparation indicative of Candida vaginitis.

Option B (Metronidazole for her sexual partner) is incorrect. Bacterial vaginosis is not a sexually transmitted disease (STD), therefore, partners do not require therapy. In multiple-treatment resistant bacterial vaginosis, therapy of the sexual partner can be attempted.

Option C (Povidone-iodine) is incorrect. This therapy is one of the original therapies for bacterial vaginosis, but has been completely replaced by modern therapy.

Option E (Topical treatment with yogurt) is incorrect. Attempting to restore the vaginal ecosystem is the theoretical basis behind yogurt therapy. However, studies have failed to demonstrate a significant cure rate with this therapy.