Management 1
A 45-year-old man presented with a 2-week history of substernal chest pain. He described it as burning and associated with swallowing solids and liquids. He had not had any vomiting, diarrhea, or blood in his stools. He was known to have HIV and intermittently took his ART and prophylaxis treatments.
On oral examination there were white mucosal plaque lesions that easily scraped off but no ulcerations.
Lab: CD4 65 cells/μL, HIV-1 RNA viral load 22,150 copies/mL
What is the most appropriate treatment?
A. Acyclovir
B. Fluconazole
C. Ganciclovir
D. Nystatin
E. Pantoprazole
A 57-year-old man presented with a lump on the right side of his neck. He had been feeling well with no systemic symptoms. He had well-controlled diabetes (HbA1C of 6%) and no drug allergies.
On PE, the lump was nontender and easily moveable. It was not red or hot. He underwent a biopsy to evaluate for malignancy.
GS: inflammatory cells and gram-positive branching rods seen, negative AFB and modified AFB stains.
What is the most appropriate treatment?
A. Clindamycin
B. Doxycycline
C. Penicillin
D. Trimethoprim–sulfamethoxazole (TMP–SMX)
E. Surgical resection
A 43-year-old woman presented with a 9-month history of arthralgia and swelling of wrists and small joints of her hands bilaterally. Her symptoms had not resolved despite regular use of NSAIDs. She was otherwise fit and well and worked as a systems analyst for a large multinational company. She associated the start of her symptoms with a business trip to Brazil during which time she had a brief febrile illness with myalgia, a mild rash, and skin peeling from the palms of her hands.
What is the most likely infective cause?
A. Chikungunya virus
B. Parvovirus B19
C. HIV
D. Rubella virus
E. Zika virus
A 31-y-o-M presented with fever, productive cough, lethargy, weakness, and malaise. He was known to have HIV but was not taking ART. He lived in Missouri. His respiratory status and mental status deteriorated, and he was transferred to the ICU.
Lab: HIV viral load 174,000 copies/mL, CD4 count 1 cell/μL
CXR: LLL pneumonia
BAL: Positive WBCs, routine bacterial, fungal, and AFB cultures negative
BAL: PCR for adenovirus, CMV, and HSV negative
Pneumocystis DFA on BAL and induced sputum negative
Respiratory viral panel negative
Legionella urine antigen negative
Serum and CSF cryptococcal antigen negative
Histoplasma urine antigen, and serum antibody negative
Antibodies for Blastomyces, Coccidioides, and West Nile virus negative
What is the most appropriate additional test to request?
A. Anaerobic culture on BAL
B. Chlamydophila psittaci PCR on BAL
C. Legionella culture on BAL
D. M. pneumoniae serology
E. West Nile virus antibody on CSF
A 43-year-old woman traveled to West Africa for a year-long research project. A few weeks into her trip she began to notice strange dreams followed by a paranoid feeling of people following her.
What prophylactic agent is most likely to be responsible?
A. Atovaquone/proguanil
B. Chloroquine
C. Doxycycline
D. Mefloquine
E. Primaquine
A 60-o-W presented two weeks earlier with cough and fevers she was diagnosed with pulmonary histoplasmosis.
At this follow-up visit, the patient reported an improvement in the cough and resolution of fevers. She was currently on: Itraconazole 10 mg/mL oral solution – 20 mL by mouth twice daily (started 2 weeks ago), Hydrochlorothiazide 25 mg once daily, Aspirin 81 mg once daily, Metformin 500 mg twice daily, Atorvastatin 10 mg once daily, Omeprazole 20 mg once daily. She denied any missed doses of medications and reported taking the itraconazole solution on an empty stomach.
Lab: Serum itraconazole 0.8 μg/mL, Serum hydroxyitraconazole 1.5 μg/mL
Creatinine 1 mg/dL, ALT 15 U/L
What is the most appropriate action?
A. Change to itraconazole capsules 200 mg by mouth twice daily
B. Change to posaconazole DR tabs 100 mg – take 3 tablets by mouth once daily
C. Continue itraconazole oral solution 200 mg by mouth twice daily
D. Educate the patient to take the itraconazole solution with food and repeat itraconazole serum concentration in 2 weeks
E. Increase itraconazole oral solution to 400 mg by mouth twice daily
A 36-y-o-M presented unwell with a 2-week history of fever and new-onset intense myalgia. He also initially had abdominal pain, diarrhea, and vomiting. He was usually well and did not take any regular medications. He was a nonsmoker and did not take any recreational drugs. He had arrived in the US 3 weeks earlier from rural Mexico. For his farewell party his friends in Mexico prepared for him smoked boar meat.
On examination, his temperature was 38.5°C, his heart rate was 110 beats/minute, his respiratory rate was 26 breaths/minute, and his oxygen saturations were 93% on room air. He had periorbital edema and conjunctivitis, bibasilar crackles, and peripheral edema.
Lab: CPK 512 U/L, EKG: flat T waves in I, AVL, V5, and V6
Cardiac MR: gadolinium enhancement in the lateral and inferolateral epicardial areas
What is the most likely diagnosis?
A. Brucellosis
B. Enterovirus myocarditis
C. Influenza myocarditis
D. Lateral wall myocardial infarct
E. Trichinellosis
A 22-year-old woman was admitted to the ICU with suspected bacterial meningitis and was placed on empirical therapy with ceftriaxone and vancomycin. CSF culture grew Neisseria meningitidis on day 2. The patient had been on antibiotics for 48 hours.
What are the most appropriate infection prevention precautions?
A. Airborne precautions in a negative-pressure side room
B. Continue standard precautions
C. Airborne precautions
D. Contact precautions
E. Droplet precautions
A 19-year-old woman presented with vaginal discharge and odor for one week. She was sexually active with one regular male partner. She reported inconsistent condom use.
Pelvic examination: no external skin lesions. A thin, white to gray vaginal discharge was present. There was no cervical discharge or cervical motion tenderness.
Lab: Vaginal fluid pH was 5.5, and a fishy odor was noted on addition of potassium hydroxide solution. On wet prep of the specimen, epithelial cell borders were obscured by bacteria.
Urine NAAT for gonorrhea, chlamydia, and trichomoniasis were sent.
What is the most appropriate treatment?
A. Ceftriaxone 250 mg IM plus azithromycin 1g stat
B. Doxycycline 100 mg BID for 7 days
C. Fluconazole 150 mg oral stat
D. Secnidazole 2 grams oral stat
E. Metronidazole 2 grams oral stat
A 59-year-old man was seen with a recurrence of fevers and chills. He was on day 7 of a 2-week course of doxycycline (100 mg BID) for presumed Lyme disease. He was a deer hunter from Nantucket, who had first presented with a 5-day history of a circular rash on his back, associated with fevers and chills. The rash had cleared, and his systemic symptoms had settled on starting doxycycline.
Lab: WBC: 4.5, Hgb 12.5, plt 130K, LDH: 350
What is the most appropriate treatment?
A. Atovaquone and azithromycin PO for 7 days
B. Ceftriaxone IV followed by doxycycline PO to complete 21 days
C. Ceftriaxone IV for 21 days
D. Clindamycin and chloroquine PO for 7 days
E. Doxycycline PO for 21 days
A 49-year-old man planned to travel to India for 10 days in Delhi. He was healthy, did not take any medications, and reported he received all his vaccines as a child. His last Tdap was 3 years prior, and he received annual influenza vaccination. He worked in sales.
In addition to typhoid and hepatitis A, what vaccination should be recommended to this patient?
A. Hepatitis B
B. Japanese encephalitis
C. MMR
D. No additional vaccinations needed
E. Rabies
A 22-y-o-M presented with fever, abdominal pain, nausea, vomiting, headache, and profound generalized weakness. He had no significant medical history. He denied alcohol drinking or drug use. He had returned from a 2-week trip to India. He reported a lot of flooding in the local village where he stayed. He also had a lot of mosquito bites and had eaten different local delicacies bought from the streets. Two of his roommates had become sick with fever and vomiting prior to his return. He had not taken any pretravel advice.
On examination, his temperature was 40.1°C, blood pressure 110/80 mmHg, heart rate 115 beats/minute, and respiratory rate 24 breaths/minute. He had icteric sclerae and muscle tenderness in his lower back and bilateral calves.
Lab: WBC 12 ×109/L, Platelets 145,000/μL, Hemoglobin 10 g/dL AST 180 U/L, ALT 190 U/L, Alkaline phosphatase 160 U/L, Total bilirubin 15 mg/dL (predominantly conjugated)
US of the abdomen showed normal gallbladder and liver.
What is the most likely route of acquisition of his illness?
A. Floodwater exposure
B. Food consumption
C. Mosquito bite
D. Sexual transmission
E. Sick contact
A 74-y-o-W presented with headache and fever for 4 days. She had type 2 DM and hypertension, controlled with metformin and amlodipine. There was no recent travel. She lived at home with her partner. She previously had an anaphylaxis reaction to penicillin. Her partner reported that she had been unsteady on her feet for the last 2 days.
On examination she was drowsy, with a reduced conscious level (GCS 14/15). Her temperature was 38.2°C, and her heart rate was 98 beats/minute. She had neck stiffness and was photophobic. She had nystagmus on left lateral gaze and a slight facial droop on the right. Peripheral nervous system examination was grossly intact, but difficult to assess formally as the patient was unable to follow commands.
What is the best choice for therapy?
A. Ampicillin+Ceftriaxone+Vancomycin
B. Chloramphenicol+Ceftriaxone
C. Linezolid+Ceftriaxone
D. Meropenem+Vancomycin
E. Vancomycin+ Ceftriaxone
Which of the following is the most appropriate vaccination course for pneumococcus for a healthy 65-year-old person, who doesn’t know if he has ever been vaccinated?
A 52-y-o-W presented with a 3-day history of worsening headache. She had no past medical history of note and worked as an air hostess. Recent flights had been to New York, Los Angeles, and Paris. She was married with one teenage son and had not had any new sexual partners. She did not have any oral or genital ulceration on specific questioning. She had had similar illnesses on at least two other occasions.
On examination she was photophobic with mild neck stiffness. She was alert and cognitively intact.
Lab: WBC: 7.1 ×109/L, CSF WBC 342 ×106/L; 99% lymphocytes, CSF protein 1012 mg/L, CSF/plasma glucose 2.6/5.2 mmol/L, CSF GS: no organisms seen
What is the most likely causative organism?
A. Borrelia burgdorferi
B. Cytomegalovirus
C. Enterovirus
D. HSV-2
E. Neisseria meningitidis
A 32-year-old woman, works as a nurse in a childcare center where a child was diagnosed with acute Hep A. She is born and brought up in the US and had no recent travel. She was asymptomatic. She was usually well and was not taking any regular medications.
What is the most appropriate action?
A. Give HAV-containing immunoglobulin
B. Give single-dose HAV vaccination
C. Reassurance only
D. Screen for underlying immunodeficiency or liver disorders
E. Test HAV IgG and IgG
A 29-y-o-W presented with lower abdominal pain and bleeding between menstrual periods. She also reported intermittent fevers to 101°F. She had appendicitis age 13 years and had no known drug allergies. She had had unprotected vaginal intercourse with two casual male partners in the past 3 months.
On examination, her temperature was 101.2°F (38.4°C), blood pressure 124/82 mmHg, pulse 80/minute, and respiratory rate of 14 breaths/minute, SaO2 98% on room air.
A mucopurulent discharge was visible over the cervix, there was cervical motion and adnexal tenderness, and the cervix os bled easily upon application of pressure.
NAAT studies were sent for gonorrhea, chlamydia, and trichomoniasis.
What is the most appropriate empiric treatment?
A. Azithromycin 1 gram orally for one dose
B. Ceftriaxone 250 mg IM for one dose
C. Ceftriaxone 500 mg IM stat plus doxycycline 100 mg BID
D. Metronidazole 2 gram orally for one dose
E. Metronidazole 500 mg orally BID for 7 days
A 21-year-old man was admitted to a detoxification center because of injection drug use with heroin. He complained of malaise but did not have fever or cough.
PE unremarkable
A tuberculin skin test was administered and read at 48 hours. The indurated area was 8 mm in diameter, and the erythema was 15 mm in diameter.
HIV was negative.
What is the most appropriate management?
A. Chest radiography
B. Isoniazid
C. Isoniazid, rifampin, pyrazinamide, and ethambutol
D. Reassurance only
E. Repeat tuberculin skin testing in 2 weeks
An 18-year-old man presented with a 3-day history of fever, diffuse abdominal pain, and chest pain. His past medical history included exploratory laparotomy 2 years ago, and he was on no medications. These symptoms have occurred several times over a course of several years. He returned from Turkey 6 weeks previously where he visited relatives. He had a pet cat.
On examination, his temperature was 38.6°C. There were signs of peritonitis with rebound tenderness and guarding on abdominal examination. There were discrete erythematous plaques over his shins bilaterally.
What is the most likely diagnosis?
What is the most likely diagnosis?
A. Acute yersiniosis
B. Bartonella henselae infection
C. Familial Mediterranean fever
D. Malaria
E. Typhoid fever
A 45-y-o-M with a 4-week history of daily fevers up to 38.2°C (100.9°F). The patient reported feeling otherwise fine except for some fatigue and denied any unintentional weight loss. An exhaustive history-taking and physical and a thorough baseline work-up was performed, all of which is unrevealing.
Labs included a CBC, CMP, CXR, BCs, urinalysis and urine culture, and HIV testing, which were not revealing.
What is the most appropriate action?
A. Bone marrow aspirate
B. Glucocorticoid therapy
C. Start empiric treatment for bacterial pneumonia
D. Wait and observe the patient
E. Whole body FDG/PET-CT