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Board Review Week of July th GROWTH AND DEVELOPMENT by mikeholy

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									Board Review Week of March 1, 2010

Infectious Diseases Part 1

1. Question 189
A mother calls you to report that her 7-year-old son came home with a notice from school stating
that a child in his class was diagnosed with mumps. The mother does not know the immunization
status of the infected child but states that her son has received two measles-mumps-rubella (MMR)
vaccines and is up to date on all his other immunizations. Her son has been asymptomatic, with no
fever or other systemic complaints.

Of the following, the MOST appropriate action is to

    a)   administer a dose of mumps immune globulin to her son
    b)   confirm that her son has received two doses of MMR vaccine
    c)   keep her son home from school for 9 days to observe for the development of symptoms
    d)   treat her son with a course of ribavirin
    e)   vaccinate her son immediately with another dose of MMR to prevent infection from this
         exposure

2. Question 205
You are evaluating a 17-month-old previously healthy girl who presents with an 8-month history of
recurrent cellulitis and abscesses on her lower right abdomen. Eight months ago, she developed a
"pimple" on her abdomen that rapidly enlarged to the size of a golf ball and became very red, hard,
and tender over 2 days. The lesion spontaneously drained a purulent material and resolved. Over
the last 8 months, the girl has had nine similar episodes. She was seen on several occasions in an
urgent care center and each time was placed on a course of cephalexin, which resulted in no
improvement until the lesion drained spontaneously. The patient has no fever with the episodes.
Physical examination shows a 2x3-cm erythematous, indurated, very tender, fluctuant lesion on the
patient's right flank.

Of the following, the MOST likely organism causing this patient's recurrent infections is

    a)   methicillin-resistant Staphylococcus aureus
    b)   methicillin-sensitive Staphylococcus aureus
    c)   Staphylococcus epidermidis
    d)   Streptococcus pneumoniae
    e)   Streptococcus pyogenes

3. Question 30
A 4 month old female infant presents with a 1-day history of fever to 103 degrees F (39.5 C),
irritability alternating with periods of increased sleepiness, and decreased oral intake. Physical
examination reveals a febrile, very irritable infant who cries whenever she is moved. Her anterior
fontanelle is full, and she stiffens her body with attempts to move her neck passively. Laboratory
results show a peripheral white blood cell count of 26,000/mcL, with a differential count of 80%
monocytes and 4% eosinophils. Cerebrospinal fluid parameters include a glucose concentration of
10 mg/dL, protein concentration of 120 mg/dL and white blood cell count of 560/mcL with a
differential of 95% polymorphonuclear leukocytes and 5% monocytes. Gram stain is positive for
gram-positive diplococci.

In addition to vancomycin, which of the following antibiotics is MOST appropriate for the treatment
of this patient?

    a)   cefotaxime
    b)   cefuroxime
    c)   cephalexin
    d)   clarithromycin
    e)   clindamycin
4. Question 29
A 14-year-old girl presents for evaluation after 4 days of a temperature to 103.0°F (39.5°C),
nausea, abdominal cramping, and profuse bloody diarrhea. She reports that she has not traveled
anywhere, has no pets, and has had no ill contacts or unusual food exposures. One week ago, she
was diagnosed with a methicillin-sensitive Staphylococcus aureus chronic osteomyelitis of her distal
radius and has been receiving intravenous cefazolin therapy via a peripherally inserted central
catheter line. Physical examination reveals an uncomfortable teenager who complains of severe
abdominal pain and has a temperature of 102.8°F (39.4°C) and moist mucous membranes. Her
abdomen is diffusely tender, with voluntary guarding but no rebound tenderness on palpation.
Rectal examination demonstrates normal sphincter tone with no fissures or other lesions.
Laboratory findings include a peripheral white blood cell count of 15.0x103/mcL (15.0x109/L);
hemoglobin of 13.0 g//dL (130.0 g/L); platelet count of 300.0x103/mcL (300.0x109/L); and a
differential count of 65% neutrophils, 25% lymphocytes, and 10% monocytes. Her stool appears
watery and grossly bloody.

Of the following, the MOST appropriate treatment for this patient's condition is

    a)   ceftriaxone
    b)   clindamycin
    c)   metronidazole
    d)   trimethoprim-sulfamethoxazole
    e)   vancomycin


5. Question 110
You are evaluating a 2 year old boy in your office for recurrent cellulites of his right thigh. The
patient has had three episodes in the last 4 months. According to his mother, all the episodes start
with a “red bump” that progressively enlarges and, in most cases, drains spontaneously. He has
received two courses of cephalexin in the past, but there was no clinical improvement until the
abscess spontaneously drained. On one occasion, an incision and drainage procedure had to be
performed. Except for pain with walking, the patient has been afebrile and experienced no other
systemic symptoms. On physical examination, you note a 6x6 cm area of induration and erythema
on the lateral right thigh that is warm, firm, and tender to palpation. There is no active drainage
from the site.

Of the following, the MOST appropriate antibiotic for treatment of this patient is

    a)   amoxicillin
    b)   amoxicillin/clavulinic acid
    c)   clindaymycin
    d)   cefdinir
    e)   cephalexin


6. Question 12
A 15-year-old boy presents to the clinic because of a persistent cough. According to his mother, his
cough has been present for approximately 2 weeks, but it seems to be getting worse. He does not
cough all the time, but the coughing episodes tend to come in bursts. This morning she became
very worried because he passed out during a coughing spell. Physical examination reveals a
healthy-appearing male in no apparent distress. He is afebrile, and his vital signs are normal. He
has petechiae on his face but no other skin lesions. His lungs are clear.

Of the following, the MOST appropriate antimicrobial agent to prescribe for this patient is

    a)   azithromycin
    b)   clarithromycin
    c)   doxycycline
    d)   erythromycin
    e)   trimethoprim-sulfamethoxazole
7. Question 124
A 2 year old boy presents to the emergency department and requires intubation due to apnea.
Subsequent tests reveal a diagnosis of meningococcal meningitis. Because of the emergent nature
of the intubation, you were not able to put on a mask prior to performing this task. Therefore, you
will need to take prophylactic medications to prevent transmission of the organism to you.

Of the following, the MOST appropriate antimicrobial agent for prophylaxis is

    a)   azithromycin
    b)   cefdinir
    c)   doxycycline
    d)   penicillin
    e)   rifampin


8. Question 157
You are talking to a group of medical students about the antibiotic vancomycin and its associated
adverse effects. One of the students asks you to explain "red man syndrome."

Of the following, the MOST appropriate response is that "red man syndrome" is

    a)   a manifestation of a life-threatening anaphylactic reaction
    b)   a manifestation of the development of ototoxicity
    c)   related to cytokine release from cells
    d)   related to endotoxin release from cells
    e)   related to histamine release from cells


9. Question 60
You are seeing a young girl for a health supervision visit. Her older brother recently underwent a
bone marrow transplant, and you inquire about his health. The mother is tearful as she tells you it
has been difficult, explaining that he has had fever for about 10 days, his "counts are still down,"
and they are planning to start amphotericin B just in case he has a fungal infection. She is
concerned because she was told about potential adverse effects of the medication and how they
need to watch the "electrolytes in his blood" very closely. She doesn't know what "electrolytes" are,
but asks what parameter in his blood might be affected.

Of the following, the MOST clinically important parameter to monitor during the initiation of
amphotericin B therapy is

    a)   bicarbonate
    b)   creatinine
    c)   glucose
    d)   potassium
    e)   sodium


10. Question 125
You are speaking to a group of medical students about the clinical symptoms, physical examination
findings, and laboratory diagnosis of viral organisms that can cause acute encephalitis.

Of the following, the virus that can be identified MOST easily by culture techniques is

    a)   herpes simplex virus
    b)   Japanese encephalitis virus
    c)   LaCrosse encephalitis virus
    d)   St Louis encephalitis virus
    e)   West Nile virus
11. Question 77
You are evaluating a 2-year-girl who recently was adopted from Russia for a 4-day history of
temperature to 102.5°F (39.2°C), rash, coryza, malaise, conjunctivitis, and cough that have
worsened over the last 24 hours. She had nasal congestion and rhinorrhea for 5 days prior to
developing the fever, rash, and cough. The girl has been in the United States for 7 days. She was
adopted from a rural orphanage, where she was exposed to farm animals, but information regarding
her past medical history and immunizations is unavailable. Physical examination shows a tired-
appearing, irritable toddler who is clinging to her adopted mother. She has a temperature of
103.0°F (39.5°C), bilateral conjunctival injection, profuse clear rhinorrhea, an erythematous buccal
mucosa with scattered whitish specks (Item Q77A) on the left side, and an erythematous posterior
pharynx with no tonsillar exudates. There is a confluent erythematous maculopapular rash on her
face, trunk, and abdomen (Item Q77B), with scattered patches on her legs.




Of the following, the test MOST likely to confirm the diagnosis for this child is

    a)   blood culture
    b)   C-reactive protein measurement
    c)   Serology
    d)   throat culture
    e)   urine culture

12. Question 61
A medical student is working with you in your office for 1 month. During a lunch break, you begin
talking about a recent case of mumps you had seen. The medical student is surprised that you had
seen a case recently and asks you to describe the case.

Of the following, a true statement about the presentation of mumps is that

    a)   a rapidly rising, high spiking fever usually is present
    b)   bilateral parotid swelling occurs in most cases
    c)   maximum parotid swelling occurs at 7 days of illness
    d)   prodromal symptoms appear for 1 week prior to parotid swelling
    e)   purulent drainage from the Stensen's duct is typical


13. Question 237
A 10-year-old boy was bitten by a dog 2 days ago while visiting relatives in rural Mexico. He was
playing outside with his cousin when a stray dog suddenly ran up and bit him on the arm. After the
incident, the dog ran off and could not be found. His mother washed the wound with soap and
water, but no other medical attention was sought at that time. Physical examination today reveals a
moderately deep bite wound on the boy's right forearm that is erythematous, mildly indurated, and
tender, with seropurulent drainage. You prescribe appropriate antibiotic therapy.
Of the following, the MOST appropriate postexposure prophylaxis regimen for this patient is

    a)   rabies   immune globulin alone
    b)   rabies   immune globulin and rabies vaccine
    c)   rabies   immune globulin and tetanus vaccine
    d)   rabies   vaccine and tetanus vaccine
    e)   rabies   vaccine alone

14. Question 124
A 5-day-old infant who was found in a trash dumpster is brought to you for evaluation. Because you
have no history on the baby, you decide to send serology specimens to test for syphilis, human
immunodeficiency virus (HIV), hepatitis B, hepatitis C, and rubella. One week later, all of the test
results are negative, with the exception of the presence of antibodies to rubella and HIV.

Of the following, the MOST appropriate next step in the evaluation and treatment of this infant is to

    a)   begin zidovudine
    b)   begin zidovudine, lamivudine, and saquinavir
    c)   observe the infant
    d)   order an HIV DNA polymerase chain reaction test
    e)   repeat the HIV serology in 3 months

15. Question 142
Over the past week, you and your colleagues have seen a number of previously healthy children
younger than 2 years of age who present with fever, coryza, cough, vomiting, and diarrhea. Several
of the children have required hospitalization for respiratory distress and pneumonia. You suspect
that influenza virus infection is the cause of these illnesses.

Of the following, the MOST rapid test to confirm the diagnosis in these patients is

    a)   enzyme immunoassay antigen detection
    b)   immunoglobulin M (IgM) titers on acute sera
    c)   IgM titers on acute and convalescent sera
    d)   polymerase chain reaction
    e)   viral culture

16. Question 252
You are called by a nurse who has sustained a needle stick injury while drawing blood from a
patient's central line. The patient is a 14-year-old male who recently was diagnosed with acute
myelocytic leukemia. He has received several blood product transfusions for anemia and
thrombocytopenia. You obtain human immunodeficiency virus and hepatitis C serologies.

Of the following, the additional serologic test that MUST be obtained for the nurse is for

    a)   cytomegalovirus
    b)   hepatitis A
    c)   hepatitis B
    d)   measles
    e)   tetanus

								
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