DIRECTIONS: Each question below contains five suggested responses. Choose the one best response to each question.

270. A 25-year-old male with a history of recent unprotected sexual intercourse presents with a complaint of urethritis. Gram stain of a urethral smear shows intra-cellular gram-negative diplococci. All of the following actions are recommended EXCEPT

(A) administering a single oral dose of cefixime 400 mg

(B) administering a single oral dose of azithromycin 1 g

(C) obtaining a serologic test for syphilis

(D) advising the patient to obtain HIV testing

(E) administering a single oral dose of metronidazole 2 g

271. Which one of the following is NOT a recommended regimen for the treatment of N. gonorrhoeae urethritis or cervicitis?

(A) Ceftriaxone 125 mg intramuscularly, single dose

(B) Azithromycin 2 g orally, single dose

(C) Ciprofloxacin 500 mg orally, single dose

(D) Ofloxacin 400 mg orally, single dose

(E) Cefixime 400 mg orally, single dose

272. Which of the following characteristics or findings are suggestive of the secondary stage of syphilis?

(A) Painless chancre with indurated borders on the penis, vulva, or other areas of sexual contact

(B) Red papular rash on the trunk and flexor surfaces that spreads to the palms and soles

(C) Findings that develop about 21 days after initial infection

(D) Involvement of the cardiovascular and nervous systems

(E) Symptoms that develop years after initial infection

273. A 19-year-old female presents with painful pustular lesions on the vulva. She recalls having unprotected sexual intercourse approximately 10 days before with a male partner who had a single small lesion on the penis. She also reports dysuria that began when she noticed the lesions. All of the following statements are TRUE regarding the diagnosis EXCEPT

(A) although direct viral culture is more sensitive for detecting the organism, a smear of these lesions may show large intranuclear inclusions

(B) infection occurs by direct contact with mucosal surfaces or nonintact skin

(C) systemic symptoms including fever, headache, and myalgias are uncommon

(D) appropriate initial therapy consists of antiviral drugs including acyclovir, famciclovir, or valacyclovir

(E) recurrent outbreaks of these lesions occur in 60 to 90 percent of patients

274. A female patient reports a recent sexual contact with a partner who has just been treated for a suspected STD. During the examination, a urine test for pregnancy is found to be positive. Which of the following antibiotics is safe to prescribe before referring the patient to an obstetrician for prenatal care?

(A) Acyclovir

(B) Azithromycin

(C) Cefixime

(D) Metronidazole

(E) All of the above

275. The diagnosis of toxic shock syndrome requires a temperature above 38.9°C (102°F), a systolic blood pressure (BP) below 90 mm Hg, an orthostatic decrease of systolic BP by 15 mm Hg or syncope, a rash with subsequent desquamation, and involvement of at least three organ systems. Which of the following systems is NOT considered in the diagnosis?

(A) Hematologic: thrombocytopenia < 100,000 platelets/^L

(B) Renal: increase in BUN and creatinine two times normal level; pyuria without evidence of infection

(C) CNS: disorientation without focal neurologic signs

(D) Respiratory: respiratory rate > 28 breaths per minute, evidence of bilateral alveolar infiltrates on chest x-ray

(E) Gastrointestinal: vomiting, profuse diarrhea

276. All of the following statements regarding TSS and toxic shock-like syndrome (TSLS) are TRUE EXCEPT

(A) the majority of cases of TSS are associated with menstruation

(B) Staphylococcus aureus and Streptococcus pyogenes are the most common organisms isolated from patients with TSS and TSLS

(C) TSST-1, an exotoxin implicated in the production of many TSS symptoms, has been isolated from 20 percent of randomly tested S. aureus isolates

(D) up to 60 percent of patients relapse if they are not treated with p-lactamase-stable antimicrobial drugs

(E) residual neurologic deficits, including memory deficits, decreased concentration, and diffuse electroencephalographic abnormalities, are seen in 50 percent of TSS survivors

277. An HIV-positive patient presents to the ED complaining of shortness of breath and nonproductive cough. Chest x-ray shows diffuse interstitial infiltrates, and O2 saturation is 85 percent on room air. All of the following statements regarding this patient's probable diagnosis are TRUE EXCEPT

(A) Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection in AIDS patients

(B) pentamidine isothionate is an effective alternate therapy to TMP-SMX

(C) a normal chest x-ray rules out acute PCP infection

(D) 65 percent of patients relapse within 18 months

(E) oral steroid therapy should be started in patients with a PaO2 < 70 mm Hg, or an alveolar-arterial gradient > 35

278. CNS disease occurs in 75 to 90 percent of patients with AIDS. Which of the following is the MOST common cause of opportunistic infection of the CNS in AIDS patients?

(A) Cryptococcal meningitis

(B) Bacterial meningitis

(C) HSV encephalitis

(D) Toxoplasmosis

(E) AIDS dementia

279. Up to 5 percent of ED visits for AIDS patients are related to complications of pharmacologic therapy. Which of the following medications is LEAST likely to be responsible for a rash in an HIV patient?

(A) Acyclovir

(C) Clindamycin

(D) Ibuprofen

(E) Dapsone

280. All of the following statements regarding CMV retinitis are TRUE EXCEPT

(A) patients may present with photophobia, scotoma, eye redness, pain, or change in visual acuity

(B) treatment with ganciclovir (5 mg/kg) should be initiated

(C) patients may have funduscopic findings of CMV without ophthalmologic symptoms

(D) CMV retinitis occurs in 10 to 15 percent of AIDS patients

(E) funduscopic examination shows cottonwool spots


281. A patient who fell down a cliff while backpacking is brought to the ED after a prolonged rescue 8 h after falling. The patient sustained multiple lacerations and abrasions that are covered by dirt and grass. The patient is a 45-year-old U.S. native who cannot remember the last time she received tetanus prophylaxis. Which of the following represents the BEST management?

(A) Adult tetanus toxoid (Td) 0.5 mL intramuscularly

(B) Human tetanus immune globulin (TIG) 250 U intramuscularly

(C) Td 0.5 mL intramuscularly and TIG

250 U intramuscularly in the opposite extremity

(D) No prophylaxis is necessary because the patient is a U.S. native who received primary immunization as a child

(E) Td 0.5 mL intramuscularly and TIG 250 U intramuscularly, followed by additional doses of Td at 1 month and 6 months

282. Clostridium tetani is the organism responsible for causing tetanus. All of the following statements regarding tetanus are TRUE EXCEPT

(A) tetanospasmin, an exotoxin produced by C. tetani, is responsible for the clinical manifestations of tetanus

(B) tetanospasmin is released into the CNS after C. tetani crosses the blood-brain barrier

(C) clinical manifestations of tetanus include generalized muscular rigidity, violent muscular contractions, and instability of the autonomic nervous system

(D) the most common presenting complaint of patients with generalized tetanus is pain and stiffness in the masseter muscle

(E) tetanospasmin prevents the release of GABA and glycine from presynaptic nerve terminals

283. Which of the following animals is NOT a potential

carrier of rabies?











284. A colleague seeks your advice regarding travel immunizations. He is leaving in 2 weeks to be part of a medical missionary team in remote areas of Africa and Southeast Asia and plans to take malaria prophylaxis. Which of the following statements is LEAST correct regarding rabies prophylaxis in this case?

(A) Preexposure prophylaxis is recommended because the areas being visited are known to be endemic

(B) Prophylaxis with HDCV 1 mL intramuscularly should be administered in three doses at days 0, 7, and 21 or 28

(C) Active immunity to rabies persists for at least 2 years in most vaccine recipients

(D) There is no need to check rabies antibody titers after immunization has been completed

(E) If an exposure occurs, immediate treatment consists of cleaning wounds with soap, debriding devitalized tissue, copious irrigation with sterile saline or water, and avoidance of suturing

285. A 40-year-old male who immigrated 6 months previously to the United States from Guatemala presents to the ED with complaints of fever, chills, malaise, and abdominal pain. He reports having had similar symptoms just before immigrating and received treatment with an unknown medicine from a Guatemalan clinic. A Giemsa-stained blood smear confirms the presence of malarial parasites. Which of the following regimens is recommended in adults for the treatment of uncomplicated malaria caused by Plasmodium vivax?

(A) Quinine sulfate 650 mg orally three times a day for 5 to 7 days

(B) Quinine sulfate 650 mg orally three times a day for 5 to 7 days, plus doxycycline 100 mg orally two times a day for 7 days

(C) Chloroquine phosphate 1-g load, followed by 500 mg in 6 h, and then 500 mg/day for 2 days

(D) Quinidine gluconate 10 mg/kg intravenous load and then 0.02 mg/kg/min infusion for 48 h plus doxycycline 100 mg intravenously every 12 h for 48 h

(E) Chloroquine phosphate 1-g load, followed by 500 mg in 6 h, and then 500 mg/day for

2 days, plus primaquine phosphate 26.3-mg load per day for 14 days upon completion of chloroquine therapy

286. A frequent traveler reports previously taking chloro-quine for malaria prophylaxis while visiting India. The patient is now planning an extended trip to Sub-Saharan Africa and would like another supply of chloroquine. All of the following are TRUE regarding this patient's upcoming travel EXCEPT

(A) 300 mg chloroquine base orally every week is recommended, with continuation of prophylaxis for 4 weeks after the last exposure

(B) the patient should remain in well-screened areas between dusk and dawn, use mosquito nets, and wear long-sleeved clothing

(C) a pyrethrum-containing insect spray should be used in the evening and insect repellant containing DEET should be applied to exposed skin

(D) malaria can be contracted even if chemopro-phylaxis is taken and personal protection recommendations are followed

(E) the patient should receive prophylaxis for chloroquine-resistant P. falciparum with meflo-quine 228 mg base orally every week

287. Many cases of diarrhea are caused by consumption of contaminated food and water. Which of the following statements regarding food-borne illness is FALSE?

(A) Food-borne illness affects approximately 6 to 80 million Americans annually and causes 9,000 deaths each year

(B) The relative risk of food-borne infection with viruses, bacteria, or parasites ranges from 20 to 50 percent for all travelers depending on the geographic region visited

(C) Gastric pH, intestinal motility, and indigenous intestinal bacteria are physiologic mechanisms that can help prevent disease resulting from food-borne pathogens

(D) The most common pathogens causing food-borne illnesses are Salmonella, Campylobacter, Shigella, Escherichia coli O157, and the Norwalk viruses

(E) Viruses are the most common etiology of travelers' diarrhea

288. Which of the following laboratory studies or pieces of historical information is LEAST helpful when evaluating a patient for suspected bacterial diarrhea?

A 3- to 4-day history of food and water exposure

Information regarding frequent restaurant meals, consumption of raw foods and meats, overseas travel, exposure to day-care centers, and ingestion of stream or lake water Stool studies for fecal leukocytes Information regarding immunocompetence and recent use of antibiotics, antacids, H2 blockers, and proton pump inhibitors A history of other contacts who have developed similar symptoms

289. Which of the following organisms is the major cause of most travelers' diarrhea?

(B) Campylobacter

(C) Vibrio

(D) Giardia

(E) Shigella

290. A 37-year-old male arrives at the ED at 9:00 A.M. complaining of diarrhea that began at 5:00 a.m. The patient felt fine the night before after eating dinner at 8:00 p.m. at a local seafood restaurant. His dinner companion reportedly also developed copious diarrhea the same morning and is going to meet the patient at the ED. Which of the following organisms is MOST likely responsible for the food-borne illness?

(B) A Norwalk virus

(C) Enterotoxigenic E. coli

(D) Vibrio parahaemolyticus

(E) Campylobacter

291. Etiologic agents in tick-borne infections include bacterial, rickettsial, viral, and protozoal organisms. All of the following infections can be acquired from a tick bite EXCEPT

(A) Rocky Mountain spotted fever

(C) relapsing fever

(D) tularemia

(E) babesiosis

292. All of the following statements are TRUE regarding influenza EXCEPT

(A) influenza types A, B, and C may cause human infection

(B) migrating aquatic fowl are thought to be the natural animal reservoir for influenza type A

(C) antiviral therapy with amantidine and rimanti-dine is effective against influenza types A, B, and C

(D) annual influenza vaccination is recommended for healthcare workers

(E) influenza pneumonia carries a high mortality rate, and more than 90 percent of deaths occur in patients older than 70 years

293. Gas-forming soft tissue infections are life threatening and must be diagnosed early and treated aggressively. Which one of the following symptoms or findings is LEAST likely to be seen with these infections?

(A) Increasing symptoms over 7 to 10 days

(B) Pain out of proportion to physical findings

(C) Brawny edema with crepitance on palpation

(D) Bullae or malodorous serosanguinous discharge

(E) Low-grade fever, with tachycardia out of proportion to the fever

294. Which of the following patients is MOST likely to benefit from antibiotic therapy in addition to abscess incision and drainage?

(A) A previously healthy female with a Bartholin's gland abscess and no history suggesting a high risk for STD

(B) A healthy 25-year-old male with recurrence of a pilonidal abscess that first occurred 2 years previously

(C) A febrile 50-year-old female with NIDDM and recurrence of axillary hydradenitis suppurativa

(D) A 35-year-old male with a sebaceous gland cyst that has been present for 2 years and has now become infected

(E) An intravenous drug user without fever or tachycardia presenting with a 2-cm2 deltoid abscess that developed 7 days after "skin popping"

295. The CDC publishes a list of reportable communicable diseases that is updated and revised routinely. A 20-year-old patient is found to have a sexually transmitted disease. Which of the following is NOT included on the CDC list of reportable diseases?

(A) Chancroid

(B) Gonorrhea

(D) Syphilis

(E) Chlamydia

296. A patient presents to the ED with symptoms of Bell's palsy. Which of the following signs or symptoms are atypical and suggest a more worrisome diagnosis?

(A) Facial hemiparesis

(B) Taste disturbance

(C) Decreased blinking

(D) Sparing of the forehead muscles on the affected side

(E) Hearing increased on the affected side

297. All of the following statements are TRUE regarding CMV retinitis EXCEPT

(A) decreased vision or floaters in the visual field are typical complaints

(B) prompt treatment with gancyclovir or foscarnet can reverse visual deficits

(C) without treatment, CMV retinitis will progress to permanent blindness

(D) CMV retinitis occurs in more than 10 percent of AIDS patients

(E) in addition to retinitis, CMV can cause esophagitis, colitis, or adrenalitis

298. Universal precautions were recommended in 1987 by the CDC to protect healthcare workers from the potential hazards of exposure to blood and other body fluids. All of the following practices are part of the recommended universal precautions EXCEPT

(A) wear puncture-proof gloves when handling needles or sharp instruments with the potential for puncturing skin

(B) mask and eye protection are indicated if mucous membranes of the mouth, nose, and eyes may be exposed to drops of blood or other body fluids

(C) do not recap or bend needles

(D) use a bag-valve mask to prevent the need for mouth-to-mouth resuscitation

(E) healthcare workers with weeping dermatitis should avoid direct patient care until the condition resolves

299. The risk of tuberculosis (TB) among healthcare workers has increased, as has a resurgence of the disease. All of the following factors increase risk of TB transmission EXCEPT

(A) exposure to a highly contagious source case

(B) increased ventilatory rate of the healthcare worker

(C) increased air-exchange rate in the work environment

(D) working in an inner city environment

(E) increased duration of exposure to infected patients

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