Rash Bash
Brain Pain
Lunging for Answers
GIrms
Heartsick
100
A 23-year-old man presents to the emergency department for new-onset rash over 12 hours. He reports having a sore throat, malaise, and a mild cough for two days. He visited an urgent care yesterday and was given an antibiotic for which he cannot remember the name. Today he developed a rash over his entire body. He is afebrile with normal vital signs. On examination, he has bilateral tonsillar swelling with diffuse exudates and erythema. He has bilateral cervical lymphadenopathy. His airway is open and tonsillar swelling is symmetric. He has a diffuse morbilliform rash to his torso and extremities. What is the most likely diagnosis to explain the rash in this patient?
A. Allergic reaction to the antibiotic
B. Infectious mononucleosis
C. Measles
D. Scarlet fever
B. Infectious mononucleosis
100
37-year-old man with a history of human immunodeficiency virus with a previous CD4+ count of 90 cells/µL presents to the emergency department feeling poorly with a mild headache, neck pain with stiffness and nausea. He has not been compliant with his medications. Physical examination shows vital signs of HR 97, BP 133/70, RR 16, T 99.0℉. The patient has noticeable meningismus. Head CT performed is unremarkable. Lumbar puncture is performed during the workup. Opening pressure is 40 cm H2O and results show WBC 75 cells/µL with 20% PMNs, glucose 24 mg/dL, protein 290 mg/dL and negative gram stain. What further cerebrospinal fluid analysis should be performed to confirm the most likely diagnosis in this patient?
A. Acid-fast bacilli test
B. Herpes simplex virus PCR
C. India ink stain
D. Venereal Disease Research Laboratory test
C. India ink stain
100
A 4-year-old girl presents to the emergency department with respiratory distress and persistent high fevers. She was diagnosed with influenza by her primary care provider three days ago, but suddenly worsened today. On exam, she is ill-appearing with a temperature of 40.2°C, a heart rate of 180 bpm, a respiratory rate of 45 breaths per minute, and pulse oximetry of 88% on room air. She has moderate subcostal and intercostal retractions and has loud focal crackles over her right lower lobe while the rest of her lung fields are clear. While choosing her antimicrobial therapy, which of the following organisms must be considered?
A. Bordetella pertussis
B. Chlamydia trachomatis
C. Mycoplasma pneumoniae
D. Staphylococcus aureus
D. Staphylococcus aureus
100
Which of the following laboratory results signifies acute hepatitis B?
A. HBsAg +, anti-HBc IgG +, HBeAg -, HBV DNA +
B. HBsAg +, anti-HBc IgM +, HBeAg +, HBV DNA +
C. HBsAg -, anti-HBs +, HBeAg -, HBV DNA -
D. HBsAg -, anti-HBs -, HBeAg -, HBV DNA -
B. HBsAg +, anti-HBc IgM +, HBeAg +, HBV DNA +
100
A 32-year-old woman presents with progressive fatigue, shortness of breath, and chest discomfort that has worsened over the last 2 days. She had a mild upper respiratory infection last week but otherwise reports no significant past medical history. She does not take any medications and reports no illicit drug use. On examination, she has a T 37.9°C, HR 132 bpm, RR 16/min, and oxygen saturation 98% on room air. Lungs are clear to auscultation. Chest radiograph demonstrates mild cardiomegaly without infiltrates. Electrocardiogram shows sinus tachycardia with nonspecific ST segment and T wave changes. Troponin is 0.25 ng/mL. What is the likely cause of her symptoms?
A. Acute coronary artery thrombosis
B. Community-acquired pneumonia
C. Myocarditis
D. Pericarditis
D. Pulmonary embolism
C. Myocarditis
200
A 14-year-old boy with no past medical history presents with new-onset rash and “bumps under my skin.” The patient first noticed a blotchy red rash on his trunk that “went away except for the outer edge.” He presented because the rings have spread and coalesced, as shown above. The rash is not pruritic, but he notices that being outside in the summer heat worsens the rash. Also noted on exam are painless, firm nodules over the knees and elbows. He denies any tenderness or history of trauma to those areas. What test would be most likely to confirm his diagnosis?
A. Antistreptolysin O titer
B. KOH prep
C. Lymph node biopsy
D. Throat culture
A. Antistreptolysin O titer
200
A 24-year-old man who emigrated from Mexico 5 years ago presents to the ED via EMS after he had a seizure at home. His spouse noticed tonic-clonic activity that lasted about one minute. The patient has no past medical history. Vital signs are BP 138/89, HR 105, T 37.7°C, RR 18, and pulse oximetry 100% on room air. He is somnolent but responds to verbal command and is moving all four extremities purposefully. A CT scan is obtained and seen above. Which of the following is the most likely diagnosis?
A. Herpes encephalitis
B. Meningioma
C. Neurocysticercosis
D. Toxoplasmosis
C. Neurocysticercosis
Bonus: what is the correct treatment?
A. Albendazole and praziquantel
200
A 10-month-old term previously healthy boy presents to the emergency department in February in respiratory distress. He has had nasal congestion and cough worsening over the last two days along with fevers to 100.6°F. On exam he is alert but obviously tachypneic, with nasal flaring, and subcostal and intercostal retractions. He has diffuse crackles throughout his lungs with moderate wheezing. Which of the following is the most appropriate next step?
A. Nasal suctioning
B. Nebulized albuterol
C. Nebulized hypertonic saline
D. Oral prednisone
A. Nasal suctioning
200
A 21-year-old man with a history of human immunodeficiency virus (HIV) not on highly active antiretroviral therapy presents complaining of bloody stools. He states that his symptoms began one week ago consisting of lower abdominal pain with defecation, tenesmus, hematochezia, and rectal discharge. The inguinal lymph nodes are swollen and tender bilaterally. Anoscopy shows friable mucosa with vesicular lesions. What treatment is most appropriate for this patient?
A. Acyclovir
B. Amoxicillin and clavulanic acid
C. Ceftriaxone and doxycycline
D. Erythromycin
A. Acyclovir
200
Which of the following is the most common complication in patients with endocarditis?
A. Congestive heart failure
B. Meningitis
C. Pulmonary infarction
D. Seizure
A. Congestive heart failure
300
Your community is currently suffering from a bioterrorist incident. Affected patients are presenting to the emergency department with high fevers followed one to two days later by a maculopapular rash with lesions in the same stage of development. What is the most likely causative biological warfare agent?
A. Bacillus anthracis
B. Francisella tularensis
C. Variola major
D. Yersinia pestis
C. Variola major
300
A 32-year-old man with unknown medical history presents to the emergency department in status epilepticus after reporting a headache to his boyfriend. He is intubated immediately upon arrival and started on antiepileptic therapy. Above is the result of the computed tomography scan of his head. What is the most appropriate next step in management?
A. Albendazole and praziquantel
B. Amphotericin B and flucytosine
C. Pyrimethamine and sulfadiazine
D. Vancomycin and ceftriaxone
C. Pyrimethamine and sulfadiazine
300
A 19-year-old woman with cystic fibrosis presents with fever and a productive cough. She is tachycardic and tachypneic on presentation. She has not been hospitalized in over a year. The patient’s X-ray is shown above. What management is indicated?
A. Ciprofloxacin and admission
B. Piperacillin/tazobactam, vancomycin, levofloxacin, and admission
C. Vancomycin, piperacillin/tazobactam, tobramycin, and admission
D. Piperacillin/tazobactam, steroids, and admission
C. Vancomycin, piperacillin/tazobactam, tobramycin, and admission
300
A 57-year-old alcoholic man presents to the ED with fever and abdominal pain. His vital signs are T 102°F, HR 110 beats/minute, RR 18 breaths/minute, BP 100/70 mm Hg, and oxygen saturation 95% on room air. His abdomen is distended and diffusely tender. He has spider angiomata and scleral icterus. Which of the following organisms is most likely responsible for his condition?
A. Campylobacter jejuni
B. Clostridium difficile
C. Klebsiella pneumoniae
D. Streptococcus pyogenes
E. Staphylococcus aureus
C. Klebsiella pneumoniae
300
A 23-year-old woman presents to the ED complaining of severe chest pain. She is pale and diaphoretic. Her vital signs are T 103.2F, HR 124 beats/minute, RR 22 breaths/minute, BP 93/57 mm Hg, and oxygen saturation 96% on room air. She has painful nodules on her fingertips and multiple track marks on her arms. Bedside cardiac ultrasound reveals hyperdynamic activity, no pericardial effusion, and an oscillating right ventricular mass. Blood cultures are most likely to grow which of the following (and on which valve)?
1. Aortic
2. Mitral
3. Bicuspid
4. Tricuspid
A. Gram-negative diplococci
B. Gram-negative rods
C. Gram-positive cocci in clusters
D. Gram-positive cocci in pairs
4. Tricuspid and C. Gram-positive cocci in clusters
400
Which description below is most consistent with the exanthem associated with rubella?
A. Erythematous malar rash that starts on the face and spreads caudally into a reticular rash on the trunk and extremities
B. Erythematous, blanching maculopapular rash that begins on the face and spreads caudally with associated white lesions on the buccal mucosa
C. Maculopapular, blanching exanthem that starts on the trunk and neck and spreads to the face and extremities with an associated resolved fever
D. Pinpoint, pink, maculopapular rash that starts on the face and spreads caudally to the trunk and extremities with associated fevers
D. Pinpoint, pink, maculopapular rash that starts on the face and spreads caudally to the trunk and extremities with associated fevers
400
A 17-year-old boy from New Jersey presents with a 1-day history of facial droop. He also complains of a headache. The cutaneous image above represents a rash the patient described having 3 weeks prior to arrival whereas the facial image above represents the current physical examination findings. In addition, you note mild nuchal rigidity. A non-contrast head CT is performed and is normal. Which of the following is the next best step for this patient?
A. Acyclovir and corticosteroids
B. Lumbar puncture
C. MRI brain
D. Serological testing for Lyme disease
B. Lumbar puncture
400
An 18-month-old boy is brought in by his parents for shortness of breath. The parents woke to him coughing a low-pitched cough. They also noted other noises when he was breathing in that resolved upon walking outside. The patient is frequently coughing but has no abnormal sounds on auscultation of the neck or lungs. What is the most appropriate treatment?
A. Albuterol
B. Dexamethasone
C. Racemic epinephrine
D. Ribavarin
B. Dexamethasone
400
A 27-year-old man presents for evaluation of fever. His temperature is 102.8°F. His heart rate is 88/min. Which of the following infections causes these characteristic vital signs?
A. Acinetobacter
B. Haemophilus influenzae
C. Salmonella typhi
D. Streptococcus pneumoniae
C. Salmonella typhi
400
Which of the following medications, used in the treatment of pericarditis, is associated with a higher incidence of recurrent pericarditis?
A. Aspirin
B. Colchicine
C. Ibuprofen
D. Prednisone
D. Prednisone
500
A 30-year-old woman presents to the ED after being sexually assaulted four months ago. She is concerned she may have a sexually transmitted disease. On physical exam, she is noted to have a diffuse macular rash and moist broad-based papular lesions on her external genitalia. Which of the following tests is most likely to confirm the diagnosis?
A. Endocervical culture
B. Fluorescent treponemal antibody absorption
C. Rapid plasma reagin
D. Tissue biopsy
B. Fluorescent treponemal antibody absorption
500
A 14-year-old boy presents with headache, fever, and altered mental status. He was recently seen and evaluated for sinusitis one week ago but was not given antibiotic treatment at that time. A CT scan of the head is performed. What management is indicated?
A. Ceftriaxone, metronidazole, and admit
B. Ceftriaxone, metronidazole, and neurosurgery consultation
C. Ceftriaxone, vancomycin, and neurosurgery consultation
D. Pyramethamine, sulfadiazine, and neurosurgery consultation
B. Ceftriaxone, metronidazole, and neurosurgery consultation
Bonus question: How does this infection usually begin, and what bugs are responsible?
500
A 4-year-old boy presents with his mom for a cough. He is a previously healthy, fully immunized boy with a recent diagnosis of croup several days ago. At the initial visit, he was treated with nebulized epinephrine and oral dexamethasone and subsequently discharged home. Mom states he continued to improve up until yesterday when he started developing higher fevers and noisy breathing, particularly at night. When the patient woke this morning, she noticed he had increased work of breathing and worsening of his “noisy breathing.” Vital signs are remarkable for a temperature of 102.2°F (39°C), HR of 140 bpm, RR of 45/min, BP of 90/50 mm Hg, and pulse oximetry of 93%. Exam is remarkable for a toxic-appearing young boy that is sitting upright but tolerating his secretions. Inspiratory stridor is noted on exam at rest with intercostal and suprasternal retractions. What is the most likely pathogen causing the patient's presentation?
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Staphylococcus aureus
D. Streptococcus pneumoniae
C. Staphylococcus aureus
500
A 33-year-old man with a past medical history of HIV and a CD4 count of 40 presents to the emergency department with generalized weakness. He stopped taking all of his medications last month due to financial issues. He states he has experienced fever, night sweats, abdominal pain, and profuse diarrhea for the past week. His temperature is 102°F (38.9°C), blood pressure is 127/68 mm Hg, pulse is 110 bpm, respiratory rate is 24/min, and oxygen saturation is 95% on room air. Laboratory values are notable for a hemoglobin of 9.0 g/dL and an elevated lactate dehydrogenase and alkaline phosphatase. Physical exam reveals diffuse lymphadenopathy. A CT scan of the abdomen demonstrates mesenteric and abdominal lymph node enlargement. Which of the following is the best treatment for this patient?
A. Azithromycin and ceftriaxone
B. Azithromycin and clarithromycin
C. Azithromycin and ethambutol
D. Azithromycin, rifabutin, and ethambutol
C. Azithromycin and ethambutol
500
A 9-year-old girl with a history of pharyngitis is brought to the ED by her mother with fever and diffuse joint pains. An ECG is notable for a first-degree AV block. On exam, she has erythematous ring-like lesions with central clearing on her trunk. Her left knee joint is swollen and tender. Which of the following is the most likely diagnosis?
A. Acute rheumatic fever
B. Juvenile rheumatoid arthritis
C. Lyme disease
D. Septic arthritis
A. Acute rheumatic fever