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ID Board Review Questions

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ID Board Review Questions Emily Landon Mawdsley, MD 5/3/10 ID Board Review Questions Emily Landon Mawdsley, MD 5/3/10 A 25-year-old woman who is 28 weeks pregnant has ... – PowerPoint PPT presentation

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Title: ID Board Review Questions


1
ID Board Review Questions
  • Emily Landon Mawdsley, MD
  • 5/3/10

2
A 25-year-old woman who is 28 weeks pregnant has
a positive urine culture detected during a
routine prenatal visit. She has not had fever,
urinary frequency, or dysuria and is not taking
any medications other than prenatal vitamins. She
has never had a urinary tract infection before
and has no medical problems. On physical
examination, vital signs, including temperature,
are normal. There is no costovertebral angle
tenderness. The urine culture shows greater than
105 colony-forming units/mL of Escherichia coli
that are sensitive to nitrofurantoin and
ciprofloxacin but resistant to cefazolin,
trimethoprim-sulfamethoxazole, and
ampicillin. Which of the following is the most
appropriate treatment? A) Ampicillin B)
Ciprofloxacin C) Nitrofurantoin D)
Trimethoprim E) Observation
3
A 25-year-old woman who is 28 weeks pregnant has
a positive urine culture detected during a
routine prenatal visit. She has not had fever,
urinary frequency, or dysuria and is not taking
any medications other than prenatal vitamins. She
has never had a urinary tract infection before
and has no medical problems. On physical
examination, vital signs, including temperature,
are normal. There is no costovertebral angle
tenderness. The urine culture shows greater than
105 colony-forming units/mL of Escherichia coli
that are sensitive to nitrofurantoin and
ciprofloxacin but resistant to cefazolin,
trimethoprim-sulfamethoxazole, and
ampicillin. Which of the following is the most
appropriate treatment? A) Ampicillin B)
Ciprofloxacin C) Nitrofurantoin D)
Trimethoprim E) Observation
4
A 57-year-old man is evaluated for a 2-day
history of fever, severe myalgia, and a frontal
headache. He denies cough, diarrhea, abdominal
pain, or urinary tract symptoms. He returned 1
week ago from a vacation in Puerto Rico. He slept
in a well-screened room under mosquito
netting. On physical examination, the patient is
moderately ill appearing. Temperature is 39.2 C
(102.6 F), blood pressure is 108/75 mm Hg, pulse
rate is 96/min, and respiration rate is 18/min.
There is a maculopapular rash on his trunk. The
remainder of the examination is
normal. Laboratory studies Hemoglobin 14.8 g/dL
(148 g/L), Leukocyte count 3700/µL (3.7 109/L),
Platelet count 99,000/µL (99 109/L), Creatinine
1.1 mg/dL (97.2 µmol/L), Alanine aminotransferase
84 U/L, Aspartate aminotransferase 92 U/L,
INR1.1, Activated partial thromboplastin time 27
s, Urinalysis Normal Which of the following is
the most likely diagnosis? A) Chikungunya B)
Dengue C) Influenza D) Malaria E) Typhoid fever
5
A 57-year-old man is evaluated for a 2-day
history of fever, severe myalgia, and a frontal
headache. He denies cough, diarrhea, abdominal
pain, or urinary tract symptoms. He returned 1
week ago from a vacation in Puerto Rico. He slept
in a well-screened room under mosquito
netting. On physical examination, the patient is
moderately ill appearing. Temperature is 39.2 C
(102.6 F), blood pressure is 108/75 mm Hg, pulse
rate is 96/min, and respiration rate is 18/min.
There is a maculopapular rash on his trunk. The
remainder of the examination is
normal. Laboratory studies Hemoglobin 14.8 g/dL
(148 g/L), Leukocyte count 3700/µL (3.7 109/L),
Platelet count 99,000/µL (99 109/L), Creatinine
1.1 mg/dL (97.2 µmol/L), Alanine aminotransferase
84 U/L, Aspartate aminotransferase 92 U/L,
INR1.1, Activated partial thromboplastin time 27
s, Urinalysis Normal Which of the following is
the most likely diagnosis? A) Chikungunya B)
Dengue C) Influenza D) Malaria E) Typhoid fever
6
A 70-year-old man is evaluated in the emergency
department with the acute onset of fever, rigors,
and productive cough. The patient has a history
of diabetes mellitus and chronic obstructive
pulmonary disease treated with glyburide,
metformin, albuterol, and tiotropium and a severe
penicillin allergy that leads to anaphylaxis. On
physical examination, the patient appears
confused. The temperature is 40.0 oC (104.0 oF),
blood pressure is 90/60 mm Hg, pulse rate is
120/min, and respiration rate is 34/min.
Pulmonary examination reveals diffuse rhonchi in
both lung fields. Laboratory studies Leukocyte
count 3000/µL (3 109/L) with 50 band forms,
Platelet count 80,000/µL (80 109/L), Blood urea
nitrogen 40 mg/dL (14.3 mmol/L), Creatinine 2.1
mg/dL (185.6 µmol/L) A chest radiograph reveals
right lower lobe and left lingular infiltrates.
The patient is admitted to the intensive care
unit. Which of the following empiric
antimicrobial regimens should be initiated? A)
Azithromycin plus cefotaxime B) Levofloxacin plus
aztreonam C) Trimethoprim-sulfamethoxazole D)
Vancomycin plus gentamicin
7
A 70-year-old man is evaluated in the emergency
department with the acute onset of fever, rigors,
and productive cough. The patient has a history
of diabetes mellitus and chronic obstructive
pulmonary disease treated with glyburide,
metformin, albuterol, and tiotropium and a severe
penicillin allergy that leads to anaphylaxis. On
physical examination, the patient appears
confused. The temperature is 40.0 oC (104.0 oF),
blood pressure is 90/60 mm Hg, pulse rate is
120/min, and respiration rate is 34/min.
Pulmonary examination reveals diffuse rhonchi in
both lung fields. Laboratory studies Leukocyte
count 3000/µL (3 109/L) with 50 band forms,
Platelet count 80,000/µL (80 109/L), Blood urea
nitrogen 40 mg/dL (14.3 mmol/L), Creatinine 2.1
mg/dL (185.6 µmol/L) A chest radiograph reveals
right lower lobe and left lingular infiltrates.
The patient is admitted to the intensive care
unit. Which of the following empiric
antimicrobial regimens should be initiated? A)
Azithromycin plus cefotaxime B) Levofloxacin plus
aztreonam C) Trimethoprim-sulfamethoxazole D)
Vancomycin plus gentamicin
8
A 35-year-old man is evaluated in the emergency
department for a 1-month history of chronic cough
productive of blood-tinged sputum. He admits to
frequent encounters with commercial sex-workers
while visiting Russia, India, and Thailand. On
physical examination, temperature is 38.8 C
(100.9 F), blood pressure is 90/50 mm Hg, pulse
rate is 95/min, and respiration rate is 30/min.
Thrush is noted on oral examination. Crackles are
heard over the upper lung fields. Bilateral
upper lobe cavitary lesions are present on a
chest radiograph. Acid-fast bacillus is found on
the direct sputum smear. Which of the following
is the best treatment option? A) Ciprofloxacin,
pyrazinamide, ethambutol, ethionamide, and
cycloserine B) Isoniazid C) Isoniazid and
rifampin D) Isoniazid, rifampin, pyrazinamide,
and ethambutol
9
A 35-year-old man is evaluated in the emergency
department for a 1-month history of chronic cough
productive of blood-tinged sputum. He admits to
frequent encounters with commercial sex-workers
while visiting Russia, India, and Thailand. On
physical examination, temperature is 38.8 C
(100.9 F), blood pressure is 90/50 mm Hg, pulse
rate is 95/min, and respiration rate is 30/min.
Thrush is noted on oral examination. Crackles are
heard over the upper lung fields. Bilateral
upper lobe cavitary lesions are present on a
chest radiograph. Acid-fast bacillus is found on
the direct sputum smear. Which of the following
is the best treatment option? A) Ciprofloxacin,
pyrazinamide, ethambutol, ethionamide, and
cycloserine B) Isoniazid C) Isoniazid and
rifampin D) Isoniazid, rifampin, pyrazinamide,
and ethambutol
10
A 25-year-old man is brought to the emergency
department because of a 1-day history of fever
and progressive delirium. On physical
examination, temperature is 38.5 C (101.3 F),
blood pressure is 86/58 mm Hg, pulse rate is
122/min, and respiration rate is 34/min. The
patient is oriented only to person. On pulmonary
examination, he demonstrates increased work of
breathing. There is no lymphadenitis. Abdominal
examination is normal. The leukocyte count is
32,000/µL (32 109/L). A chest radiograph shows
bilateral diffuse alveolar infiltrates. An
initial blood smear shows small gram-negative
coccobacilli, and special stains show bacteria
that look like safety pins. Infection with which
of the following organisms is most likely? A
Francisella tularensis B Salmonella enterica C
Staphylococcus aureus D Streptococcus
pneumoniae E Yersinia pestis
11
A 25-year-old man is brought to the emergency
department because of a 1-day history of fever
and progressive delirium. On physical
examination, temperature is 38.5 C (101.3 F),
blood pressure is 86/58 mm Hg, pulse rate is
122/min, and respiration rate is 34/min. The
patient is oriented only to person. On pulmonary
examination, he demonstrates increased work of
breathing. There is no lymphadenitis. Abdominal
examination is normal. The leukocyte count is
32,000/µL (32 109/L). A chest radiograph shows
bilateral diffuse alveolar infiltrates. An
initial blood smear shows small gram-negative
coccobacilli, and special stains show bacteria
that look like safety pins. Infection with which
of the following organisms is most likely? A
Francisella tularensis B Salmonella enterica C
Staphylococcus aureus D Streptococcus
pneumoniae E Yersinia pestis
12
A 70-year-old man is evaluated in January for a
2-day history of fever and cough productive of
yellow sputum. He was well until 10 days ago when
he developed headache, myalgia, and coryza. He
seemed to be improving by day 8 of his illness,
but he then developed his current symptoms.
Medical history is significant for hypertension
and chronic obstructive pulmonary disease treated
with hydrochlorothiazide, albuterol, and
tiotropium. On physical examination, temperature
is 38.9 oC (102.0 oF), blood pressure is 110/70
mm Hg, pulse rate is 100/min, and respiration
rate is 22/min. Pulmonary examination reveals
crackles at the left lung base. Laboratory
studies indicate a leukocyte count of 15,000/µL
(15 109/L) with 20 band forms. Chest
radiograph reveals a left lower lobe
infiltrate. Which of the following empiric
antimicrobial regimens should be initiated? A)
Azithromycin plus ceftriaxone B) Clindamycin plus
levofloxacin C) Piperacillin-tazobactam D)
Vancomycin plus levofloxacin
13
A 70-year-old man is evaluated in January for a
2-day history of fever and cough productive of
yellow sputum. He was well until 10 days ago when
he developed headache, myalgia, and coryza. He
seemed to be improving by day 8 of his illness,
but he then developed his current symptoms.
Medical history is significant for hypertension
and chronic obstructive pulmonary disease treated
with hydrochlorothiazide, albuterol, and
tiotropium. On physical examination, temperature
is 38.9 oC (102.0 oF), blood pressure is 110/70
mm Hg, pulse rate is 100/min, and respiration
rate is 22/min. Pulmonary examination reveals
crackles at the left lung base. Laboratory
studies indicate a leukocyte count of 15,000/µL
(15 109/L) with 20 band forms. Chest
radiograph reveals a left lower lobe
infiltrate. Which of the following empiric
antimicrobial regimens should be initiated? A)
Azithromycin plus ceftriaxone B) Clindamycin plus
levofloxacin C) Piperacillin-tazobactam D)
Vancomycin plus levofloxacin
14
A 19-year-old male college student has a 2-day
history of a urethral discharge and a burning
sensation on urination. He has had three female
sexual partners in the past month. Physical
examination discloses a scant mucoid discharge
from the urethral orifice. No rashes or other
lesions are seen. Gram stain of the urethral
secretions shows greater than 12
polymorphonuclear cells/hpf. No intra- or
extracellular organisms are seen. Which of the
following is the most appropriate treatment? A)
Acyclovir orally B) Azithromycin orally C)
Benzathine penicillin G, intramuscularly D)
Cefixime orally E) Metronidazole orally
15
A 19-year-old male college student has a 2-day
history of a urethral discharge and a burning
sensation on urination. He has had three female
sexual partners in the past month. Physical
examination discloses a scant mucoid discharge
from the urethral orifice. No rashes or other
lesions are seen. Gram stain of the urethral
secretions shows greater than 12
polymorphonuclear cells/hpf. No intra- or
extracellular organisms are seen. Which of the
following is the most appropriate treatment? A)
Acyclovir orally B) Azithromycin orally C)
Benzathine penicillin G, intramuscularly D)
Cefixime orally E) Metronidazole orally
16
A 25-year-old man is evaluated for a 2-week
history of left-sided facial pain. Medical
history is unremarkable. A diagnosis of sinusitis
is established, and the patient receives therapy
with azithromycin, which partially resolves his
pain. One week after initiation of therapy, he is
admitted to the emergency department with
headache and a tonic-clonic seizure. On physical
examination, temperature is normal, and he is
drowsy. There are no focal neurologic deficits.
Laboratory studies are normal. An MRI shows a
3.5-cm ring-enhancing lesion in the left
frontoparietal region. Aspiration of the lesion
reveals purulent material. Empiric therapy with
vancomycin, metronidazole, and ceftriaxone is
initiated. Culture of the aspirate grows only
Escherichia coli. Which of the following is the
most appropriate treatment? A) Change
antimicrobial therapy to imipenem B) Change
antimicrobial therapy to levofloxacin C) Continue
ceftriaxone only D) Continue metronidazole and
ceftriaxone only E) Continue vancomycin,
metronidazole, and ceftriaxone
17
A 25-year-old man is evaluated for a 2-week
history of left-sided facial pain. Medical
history is unremarkable. A diagnosis of sinusitis
is established, and the patient receives therapy
with azithromycin, which partially resolves his
pain. One week after initiation of therapy, he is
admitted to the emergency department with
headache and a tonic-clonic seizure. On physical
examination, temperature is normal, and he is
drowsy. There are no focal neurologic deficits.
Laboratory studies are normal. An MRI shows a
3.5-cm ring-enhancing lesion in the left
frontoparietal region. Aspiration of the lesion
reveals purulent material. Empiric therapy with
vancomycin, metronidazole, and ceftriaxone is
initiated. Culture of the aspirate grows only
Escherichia coli. Which of the following is the
most appropriate treatment? A) Change
antimicrobial therapy to imipenem B) Change
antimicrobial therapy to levofloxacin C) Continue
ceftriaxone only D) Continue metronidazole and
ceftriaxone only E) Continue vancomycin,
metronidazole, and ceftriaxone
18
A 35-year-old male customs inspector is brought
to the emergency department because of a 2-day
history of fever, shortness of breath, and chest
pain. He has had no recent known contact with ill
persons. On physical examination, the patient is
diaphoretic and appears acutely ill. He is
oriented only to person. Temperature is 38.0 C
(100.4 F), blood pressure is 88/60 mm Hg, pulse
rate is 110/min, and respiration rate is 28/min.
Coarse bronchial breath sounds are heard. The
leukocyte count is 15,000/µL (15 109/L). A
chest radiograph shows a widened mediastinum and
bilateral pleural effusions. A buffy coat Gram
stain of a peripheral blood smear shows box
carshaped gram-positive bacilli. Which of the
following is the most appropriate treatment? A)
Ciprofloxacin, rifampin, and vancomycin B)
Erythromycin, clindamycin, and rifampin C)
Erythromycin, vancomycin, and rifampin D)
Penicillin, rifampin, and vancomycin
19
A 35-year-old male customs inspector is brought
to the emergency department because of a 2-day
history of fever, shortness of breath, and chest
pain. He has had no recent known contact with ill
persons. On physical examination, the patient is
diaphoretic and appears acutely ill. He is
oriented only to person. Temperature is 38.0 C
(100.4 F), blood pressure is 88/60 mm Hg, pulse
rate is 110/min, and respiration rate is 28/min.
Coarse bronchial breath sounds are heard. The
leukocyte count is 15,000/µL (15 109/L). A
chest radiograph shows a widened mediastinum and
bilateral pleural effusions. A buffy coat Gram
stain of a peripheral blood smear shows box
carshaped gram-positive bacilli. Which of the
following is the most appropriate treatment? A)
Ciprofloxacin, rifampin, and vancomycin B)
Erythromycin, clindamycin, and rifampin C)
Erythromycin, vancomycin, and rifampin D)
Penicillin, rifampin, and vancomycin
20
A 27-year-old previously healthy woman is
diagnosed with community-acquired pneumonia for
which she receives ceftriaxone therapy. Medical
history is otherwise noncontributory. Routine
and mycobacterial sputum cultures are performed.
The patient recovers uneventfully over the
subsequent 2 weeks, and a follow-up chest
radiograph shows improvement. The routine sputum
cultures reveal only normal flora however, after
3 weeks, the mycobacterial culture grows two
colonies of Mycobacterium avium complex. Which
of the following is the most appropriate next
step in management? A) Initiate clarithromycin,
rifampin, and ethambutol B) Initiate isoniazid C)
Initiate isoniazid, rifampin, pyrazinamide, and
ethambutol D) No further treatment
21
A 27-year-old previously healthy woman is
diagnosed with community-acquired pneumonia for
which she receives ceftriaxone therapy. Medical
history is otherwise noncontributory. Routine
and mycobacterial sputum cultures are performed.
The patient recovers uneventfully over the
subsequent 2 weeks, and a follow-up chest
radiograph shows improvement. The routine sputum
cultures reveal only normal flora however, after
3 weeks, the mycobacterial culture grows two
colonies of Mycobacterium avium complex. Which
of the following is the most appropriate next
step in management? A) Initiate clarithromycin,
rifampin, and ethambutol B) Initiate isoniazid C)
Initiate isoniazid, rifampin, pyrazinamide, and
ethambutol D) No further treatment
22
A 42-year-old woman is evaluated for a
postoperative wound infection. Eight weeks ago,
the patient underwent bilateral augmentation
mammoplasty. Six weeks after surgery, she
developed violaceous draining nodules at the
surgical closure site of the right breast. After
7 days of dicloxacillin, the wound had enlarged.
Wound cultures grew normal skin flora. The
patient was hospitalized, and intravenous
vancomycin plus cefepime was added but without
clinical benefit. A second set of wound cultures
grew a few colonies of Candida albicans. Medical
history is otherwise unremarkable. On physical
examination, temperature is 38.0 C (100.4 F),
blood pressure is 105/75 mm Hg, pulse rate is
84/min, and respiration rate is 16/min. Her left
breast surgical scar is well healed, and the
right breast surgical wound is partially opened
and packed along the medial half. The lateral
half of the wound is erythematous, with two sinus
tracts draining purulent material. Which of the
following is the most likely causative agent for
her wound infection? A) Fluconazole-resistant
Candida albicans B) Methicillin-resistant
Staphylococcus aureus C) Mycobacterium
abscessus D) Mycobacterium tuberculosis E)
Nocardia asteroides
23
A 42-year-old woman is evaluated for a
postoperative wound infection. Eight weeks ago,
the patient underwent bilateral augmentation
mammoplasty. Six weeks after surgery, she
developed violaceous draining nodules at the
surgical closure site of the right breast. After
7 days of dicloxacillin, the wound had enlarged.
Wound cultures grew normal skin flora. The
patient was hospitalized, and intravenous
vancomycin plus cefepime was added but without
clinical benefit. A second set of wound cultures
grew a few colonies of Candida albicans. Medical
history is otherwise unremarkable. On physical
examination, temperature is 38.0 C (100.4 F),
blood pressure is 105/75 mm Hg, pulse rate is
84/min, and respiration rate is 16/min. Her left
breast surgical scar is well healed, and the
right breast surgical wound is partially opened
and packed along the medial half. The lateral
half of the wound is erythematous, with two sinus
tracts draining purulent material. Which of the
following is the most likely causative agent for
her wound infection? A) Fluconazole-resistant
Candida albicans B) Methicillin-resistant
Staphylococcus aureus C) Mycobacterium
abscessus D) Mycobacterium tuberculosis E)
Nocardia asteroides
24
A 20-year-old male college student is evaluated
for a 3-day history of intermittent fever and
rigors as well as vomiting, diarrhea, and severe
headache. Two weeks ago, he returned from a
20-day African safari in Kenya and Tanzania. He
sought no medical advice about immunizations or
other prophylaxis prior to the trip. On physical
examination, the patient is not ill appearing.
Temperature is 39.0 C (102.2 F), blood pressure
is 105/70 mm Hg, pulse rate is 100/min, and
respiration rate is 22/min. The remainder of the
examination is normal. Laboratory studies
Hemoglobin 14.5 g/dL (145 g/L), Leukocyte count
3700/µL (3.7 109/L), Platelet count 95,000/µL
(95 109/L), Glucose 85 mg/dL (4.7 mmol/L) A
malaria smear shows greater than 5 parasitemia
with only ring forms present. Which of the
following is the most appropriate treatment? A)
Chloroquine B) Pyrimethamine-sulfadoxine C)
Quinine and doxycycline D) Quinine and
doxycycline followed by primaquine
25
A 20-year-old male college student is evaluated
for a 3-day history of intermittent fever and
rigors as well as vomiting, diarrhea, and severe
headache. Two weeks ago, he returned from a
20-day African safari in Kenya and Tanzania. He
sought no medical advice about immunizations or
other prophylaxis prior to the trip. On physical
examination, the patient is not ill appearing.
Temperature is 39.0 C (102.2 F), blood pressure
is 105/70 mm Hg, pulse rate is 100/min, and
respiration rate is 22/min. The remainder of the
examination is normal. Laboratory studies
Hemoglobin 14.5 g/dL (145 g/L), Leukocyte count
3700/µL (3.7 109/L), Platelet count 95,000/µL
(95 109/L), Glucose 85 mg/dL (4.7 mmol/L) A
malaria smear shows greater than 5 parasitemia
with only ring forms present. Which of the
following is the most appropriate treatment? A)
Chloroquine B) Pyrimethamine-sulfadoxine C)
Quinine and doxycycline D) Quinine and
doxycycline followed by primaquine
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