Board Review Week of July 20th � GROWTH AND DEVELOPMENT

							Board Review Week of March 8, 2010


Infectious Diseases Part 2

1. Question 147
A worried mother brings her 4-year-old son to your office because his right eye has been red for 3
days. She assumed it was pink eye that he contracted at child care, but she now is concerned
because he has developed swelling in front of his right ear, and his eye has become redder. They
live in a wooded area and got a new kitten 6 weeks ago, but there is no history of the kitten
scratching the child. Physical examination reveals a well-appearing child who has obvious
conjunctival injection (Item Q147A) of the right eye but no discharge or pain. You palpate a 2x2-cm
tender, mobile preauricular lymph node (Item Q147B) and a 2x3-cm anterior cervical lymph node
on the right. The remainder of the physical examination findings are normal.




Of the following, the MOST likely pathogen causing this boy's symptoms is

    a)   Bartonella henselae
    b)   Francisella tularensis
    c)   Haemophilus influenzae
    d)   Pasteurella multocida
    e)   Staphylococcus aureus


2. Question 172
A 5-year-old boy develops fever, abdominal pain, diarrhea, and malaise 5 days after drinking fresh
cow's milk on a school field trip. His stool culture is positive for Campylobacter jejuni.

Of the following, the MOST appropriate treatment for this child is administration of

    a)   amoxicillin
    b)   azithromycin
    c)   cephalexin
    d)   clindamycin
    e)   metronidazole
3. Question 246
A 2-week-old girl presents to the clinic with a history of drainage from her right eye. Her mother
states that she noticed "the white part of her eye" turning red yesterday, but today the eye was
redder and swollen with some drainage. The infant was born at term via normal spontaneous
vaginal delivery without complications and is the mother's second child. The mother denies any
illness or sexually transmitted disease during her pregnancy, but states that she did smoke one
quarter pack of cigarettes per day. Physical examination reveals an afebrile, healthy-appearing
female whose only abnormality involves her right eye. The upper and lower eyelids are slightly
swollen, and her conjunctiva is erythematous, with a nonpurulent-appearing discharge. You suspect
she has neonatal conjunctivitis due to Chlamydia trachomatis.

Of the following, the MOST sensitive method for establishing the diagnosis is

    a)   conjunctival culture
    b)   detection of eosinophilia on a complete blood count
    c)   Giemsa staining of conjunctival scrapings
    d)   nucleic acid amplification test of conjunctival cells
    e)   serum immunoglobulin G testing for C trachomatis

4. Question 93
You are seeing a 5-year-old boy who has developed diplopia, dysphagia, dry mouth, diarrhea,
weakness in his arms, and shortness of breath over the past 18 hours. According to his records, he
received his diphtheria, tetanus, acellular pertussis (DTaP), poliovirus inactivated (IPV), measle-
mumps-rubella (MMR), and varicella booster immunizations about 1 month ago. He attended a class
picnic 3 weeks ago that was held in a state park. He has no history of unusual exposures or ill
contacts, and except for falling off his bike 5 days ago and scraping his arm, he has had no other
trauma. Physical examination reveals an awake and alert boy who complains of "seeing double" and
of pain with swallowing. His pupils are 3 mm bilaterally and sluggish, and his mucous membranes
are dry. He takes shallow breaths, but his lungs are clear, and his abdomen is mildly distended. His
left arm has a 4x4-cm abrasion that is mildly swollen, erythematous, and tender, with some
serosanguineous drainage. His left arm has 2/5 strength and decreased tone. He has 1+ reflexes in
the upper and lower extremities.

Of the following, the MOST likely cause of this patient's condition is

    a)   botulism
    b)   cerebral vascular accident
    c)   Guillain-Barré syndrome
    d)   tetanus
    e)   tick paralysis

5. Question 232
You are evaluating a 4-year-old girl who has had a temperature of 102°F (38.9°C), abdominal pain,
and pain on urination. On physical examination, the child appears apprehensive and has a
temperature of 101.8°F (38.8°C), mild abdominal pain in the suprapubic area, and an erythematous
urethral opening. Laboratory tests demonstrate a peripheral white blood cell count of 10x103/mcL
(10x109/L) with 55% polymorphonuclear leukocytes, 40% lymphocytes, and 5% monocytes.
Urinalysis is positive for blood and leukocyte esterase, and microscopic examination shows 5 to 10
red blood cells per high-power field (hpf) and 10 to 30 white blood cells/hpf. You send urine for
culture and start therapy with oral cefuroxime axetil. Two days later, her mother telephones to
report that the patient continues to be febrile and to complain of pain with urination. The urine
culture is growing gram-positive cocci in chains.

Of the following, the MOST likely pathogen is

    a)   Enterococcus faecalis
    b)   Escherichia coli
    c)   Pseudomonas aeruginosa
    d)   Streptococcus pneumoniae
    e)   Streptococcus pyogenes
6. Question 168
A 15-year-old young woman has had joint pain for the past 3 days. She developed fever, chills, and
fatigue 4 days ago, but the fever has resolved. In addition, she explains that her left elbow, right
knee, and right wrist are all painful, red, and swollen, and she has a rash on her hands and feet that
looks like pus-filled bumps. She is sexually active, with inconsistent condom use for contraception.
Physical examination reveals an afebrile young woman who has swelling, tenderness, and mild
erythema of the left elbow, right knee, and right wrist. She has a few pustules and vesicles on the
right palm and bilateral soles (Item Q168). The abdomen is not tender and is without masses.




Of the following, the MOST likely pathogen causing this patient's symptoms is

    a)   Chlamydia trachomatis
    b)   group A beta-hemolytic streptococci
    c)   Neisseria gonorrhoeae
    d)   parvovirus B19
    e)   Treponema pallidum

7. Question 108
The microbiology laboratory called your junior partner today to tell her that the blood culture from a
patient she admitted 2 days ago is growing Haemophilus influenzae type b. Because she has never
treated an infection caused by this organism, she wants to know what antimicrobial agent would be
best to use for her patient.

Of the following, the MOST appropriate antimicrobial agent to treat this infection is

    a)   ampicillin
    b)   cefotaxime
    c)   clindamyin
    d)   gentamicin
    e)   vancomycin

8. Question 2
A 15 year old boy presents with melena and anemia. Endoscopy demonstrates a nodular gastritis of
the antrum and an ulcer. Biopsies of the antrum demonstrate spiral-shaped organisms consistent
with Helicobacter pylori. You prescribe amoxicillin, clarithromycin and lansoprazole for 2 weeks. At
a follow-up visit, the family asks whether the treatment has been successful in eradicating the
organism.

Of the following, the PREFERRED noninvasive test to evaluate whether the pathogen has been
eradicated is

    a)   fecal Campylobacter-like organisms (CLO) test
    b)   fecal H pylori antigen
    c)   salivary H pylori antibody concentrations
    d)   serum H pylori immunoglobulin G serology
    e)   serum H pylori urease concentrations
9. Question 188
The nurse caring for a 5-day-old infant you have hospitalized calls your office to report that the
infant's blood culture is growing gram-positive rods. You admitted the infant to the hospital because
of a rectal temperature of 102.0°F (38.9°C) measured by his mother at home.

Of the following, the MOST likely pathogen is

    a)   Enterococcus sp
    b)   Escherichia coli
    c)   Listeria monocytogenes
    d)   Proteus mirabilis
    e)   Staphylococcus epidermidis

10. Question 209
Several weeks ago, a boy presented with fever, malaise, headache, and a skin lesion. The lesion
began as a red papule and slowly enlarged to form a large annular ring with a flat erythematous
border. Today he complains of recurrent joint pains that are particularly severe in his knees.

Of the following, the MOST likely diagnosis is

    a)   Epstein-Barr virus infection
    b)   Human parvovirus B19 infection
    c)   Lyme disease
    d)   Juvenile idiopathic arthritis
    e)   Rocky Mountain spotted fever

11. Question 121
A 16 year old boy presents with a very swollen, painful right knee. He is a soccer player, but there
is no history of recent injury. During the interview, you notice the boy has injected conjunctivae.

Of the following, further evaluation MOST likely will reveal

    a)   alopecia areata
    b)   Gottron papules
    c)   Kayser-Fleischer rings
    d)   Malar rash
    e)   Urethritis

12. Question 44
Upon entering your examination room, you find a father who is visibly upset. He has brought his 1
month old and 2 year old daughters to see you today because his wife was recently diagnosed with
tuberculosis. As you question him further, he tells you that his wife’s physician told him that his
wife’s chest radiograph was abnormal and she was “smear positive.” He hands you results from the
health department stating that he and his daughters all had negative skin tests and chest
radiographs. His wife is at the health department today to start medicines against tuberculosis, and
he wants to know if there is anything that should be done for the children.

Of the following, the MOST appropriate treatment is to

    a)   administer the Bacille Calmette-Guerin vaccine
    b)   being isoniazid therapy
    c)   provide reassurance
    d)   remove the children from the home for 3 months
    e)   repeat the skin test in 1 month

13. Question 131
A 15-year-old boy who has mild persistent asthma is brought to the emergency department
because of increased work of breathing of 1 day's duration. He reports a low-grade fever and
nonproductive cough for the past 4 days, but this morning he developed difficulty breathing and a
cough that produced a small amount of yellowish sputum. His respiratory rate is 24 breaths/min,
heart rate is 80 beats/min, and temperature is 99.0°F (37.3°C). He appears in no respiratory
distress, but his lung examination reveals bilateral rales and occasional wheezes. A chest radiograph
shows bilateral diffuse infiltrates with no effusions.

Of the following, the MOST likely etiologic agent causing his symptoms is

    a)   Haemophilus influenzae
    b)   Mycobacterium tuberculosis
    c)   Mycoplasma pneumoniae
    d)   Staphylococcus aureus
    e)   Streptococcus pneumoniae

14. Question 12
A 16-year-old girl presents to the clinic with a 6-day history of low-grade fever and cough. On
physical examination, she has a temperature of 100.6°F (38.1°C) and widespread crackles
throughout her lung fields. You believe she has a "walking pneumonia" caused by Mycoplasma
pneumoniae.

Of the following, the MOST accurate method used to establish the diagnosis is

    a)   polymerase chain reaction
    b)   serum cold agglutinins
    c)   serum Mycoplasma titers
    d)   sputum culture
    e)   sputum Gram stain

15. Question 125
You are evaluating a 7-year-old boy who has human immunodeficiency virus (HIV) infection and
failure to thrive. Over the last 2 months, he has had intermittent temperatures to 102.5°F (39.2°C),
anorexia, abdominal pain, diarrhea, and a 6-lb weight loss. His HIV infection has been poorly
controlled because of noncompliance with medications. His viral load is 150,000 copies, and his CD4
count is 40 cells/mm3. Physical examination shows a thin, small-for-age boy who is playing quietly.
He weighs 15.8 kg (<5th percentile). He has some oral thrush, cervical and inguinal adenopathy,
and mild diffuse abdominal tenderness to palpation.

Of the following, the MOST likely pathogen causing this patient's illness is

    a)   Cryptosporidium
    b)   Cytomegalovirus
    c)   Mycobacterium avium-intracellulare complex
    d)   Mycobacterium tuberculosis complex
    e)   Salmonella sp

16. Question 201
As you are examining a 2-year-old boy who is new to your practice, you note a swollen area on the
right side of his neck. You ask the mother about the swelling, and she starts to cry. She states that
this area has been swollen for 2 months despite courses of cephalexin, clindamycin, and
trimethoprim-sulfamethoxazole. Upon further questioning, you learn that the family recently moved
to "town" after living in a rural area for the past 10 years. She denies a history of animal or tick
exposure. Because her husband is highly allergic to cats, they won't even let their son pet one. The
boy is afebrile, and other than a 3 × 3 cm swelling in the submandibular region of the right neck,
results of the physical examination are normal. The swelling moves freely but is slightly tender to
palpation.

Of the following, the organism MOST likely to cause the swelling is

    a)   Bartonella henselae
    b)   Francisella tularensis
    c)   Mycobacterium avium-intracellulare
    d)   Staphylococcus aureus
    e)   Streptococcus pyogenes