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1 | |
A 21-year-old woman with relapsed acute lymphoblastic leukemia is treated with a five-drug induction regimen (cyclophosphamide, daunorubicin, vincristine, prednisone, and L-asparaginase). On the sixth day after the initiation of this therapy the patient develops a fever and is started on intravenous ceftazidime. The patient defervesces but develops another fever 5 days later and is started on amphotericin B. Ten days later the patient, still on oral steroids, remains febrile, neutropenic, and thrombocytopenic and is noted to have shortness of breath. Chest x-rays show a densely consolidated pulmonary infiltrate in the left lung zone. A sputum culture demonstrates normal oral flora and several colonies of Aspergillus. The most appropriate conclusion to draw is that |
| | A) | the patient most likely has invasive pulmonary aspergilliosis |
| | B) | the Aspergillus is a contaminant; the patient most likely has bacterial pneumonia |
| | C) | biopsy is not required for a definitive diagnosis |
| | D) | the patient most likely has viral pneumonitis |
| | E) | the patient is colonized with Aspergillus, but the most likely etiology of the infiltrate is drug toxicity |
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2 | |
A 28-year-old Egyptian farmer presents with left flank pain. Ultrasonography reveals enlargement of the left ureter and hydronephrosis of the left kidney. Cystoscopy reveals a mass extending from the left ureter into the bladder. Parasitic ova (150 by 50 mm) are noted in the urine and in a biopsy of the ureteral mass. Which of the following statements is correct? |
| | A) | Renal failure is likely in the absence of treatment. |
| | B) | The lesion is not reversible by chemotherapy. |
| | C) | In the absence of treatment, the patient has an increased risk for transitional cell carcinoma of the bladder. |
| | D) | The patient is suffering from schistosomiasis. |
| | E) | The organism causing this problem is spread by fecal-oral contact. |
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3 | |
A 45-year-old man reports to his internist because of fatigue. He gives a history of being treated successfully for testicular cancer 10 years earlier. The physical examination is unremarkable. Routine blood tests reveal a normal complete blood count, normal creatinine, normal -fetoprotein, and normal -human chorionic gonadotropin, but his hepatic transaminases are each three times the upper limit of normal. Knowing that the patient had received blood transfusional therapy while receiving cancer chemotherapy, the physician orders serologic studies for hepatitis viruses, which reveals evidence of having had a prior infection with hepatitis C virus (HCV). The next most appropriate diagnostic or therapeutic strategy would be to |
| | A) | send serum to detect HCV RNA by polymerase chain reaction (PCR) analysis |
| | B) | refer for liver biopsy |
| | C) | begin interferon (IFN) therapy |
| | D) | repeat the serologic test for hepatitis C virus |
| | E) | order tomographic scanning of the abdomen and pelvis |
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4 | |
Which of the following patients would be most likely to harbor a Helicobacter pylori infection in the stomach? |
| | A) | A 60-year-old middle-income American |
| | B) | A 25-year-old American in a low-income group |
| | C) | A 60-year-old Pakistani |
| | D) | A 25-year-old Zairian |
| | E) | A 70-year-old Dane |
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5 | |
A 55-year-old woman from Oregon presents with diplopia 24 h after eating home-canned fruit. Within a few hours of presentation she is also noted to have dysphonia and arm weakness. Other symptoms include nausea, vomiting, dizziness, blurred vision, and dry mouth. The patient is afebrile, alert, and oriented. Which of the following is LEAST important in managing this patient's illness? |
| | A) | Intravenous penicillin |
| | B) | Spirometric monitoring |
| | C) | Antitoxin therapy |
| | D) | Laxatives |
| | E) | Enema |
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6 | |
Which of the following is associated with a low risk for the development of pneumonia in a hospitalized patient? |
| | A) | Administration of omeprazole |
| | B) | Administration of ranitidine |
| | C) | Administration of sucralfate |
| | D) | Use of an endotracheal tube |
| | E) | Narcotic administration |
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7 | |
A 35-year-old patient undergoing initial therapy for acute myeloid leukemia has tolerated the chemotherapy well. However, 6 days after the initiation of chemotherapy and ~10 days after the insertion of an indwelling transthoracic intravenous device (Hickman catheter), he develops a fever. Examination is negative except for erythema and tenderness at the insertion site and along the subcutaneous tunnel. Blood cultures and chest x-ray are negative. The most appropriate course of action at this point is to |
| | A) | remove the line and insert a new one over a guidewire |
| | B) | begin intravenous vancomycin |
| | C) | begin intravenous vancomycin and gentamicin |
| | D) | remove the line |
| | E) | begin intravenous vancomycin, gentamicin, and amphotericin B |
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8 | |
A 70-year-old man with a history of heavy smoking and moderately severe chronic obstructive pulmonary disease (COPD) has been feeling poorly. He reports cough, chills, pleuritic chest pain, and low-grade fever. Chest x- ray reveals a small dense infiltrate in the right lower lobe. Gram's stain of the patient's sputum reveals numerous gram-negative cocci, many of which occur in pairs. The most appropriate therapy would be |
| | A) | no antimicrobial therapy is required |
| | B) | tetracycline |
| | C) | ciprofloxacin |
| | D) | trimethoprim/sulfamethoxazole (TMP/SMZ) |
| | E) | penicillin/clavulanic acid |
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9 | |
Which of the following statements concerning the use of protease inhibitors to treat individuals infected with HIV is correct? |
| | A) | Initial treatment of HIV-infected patients should include a reverse transcriptase inhibitor, with protease inhibitors being administered after progressive disease |
| | B) | Inhibition of the human protease has significant clinical consequences |
| | C) | These drugs are metabolized by cytochrome P450 enzymes |
| | D) | Gastrointestinal side effects are rare |
| | E) | These agents work chiefly by stabilizing, rather than decreasing, the viral load |
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10 | |
A 25-year-old intravenous drug abuser with fever has blood cultures obtained, and 24 h later a report from the microbiology laboratory indicates the presence of gram-positive cocci in clusters. The identification of the organism and sensitivities are pending. The most appropriate antibiotic choice would be |
| | A) | penicillin |
| | B) | nafcillin |
| | C) | vancomycin |
| | D) | TMP/SMZ |
| | E) | ciprofloxacin |
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11 | |
Four months after having undergone a sibling-donor renal allograft, a 38-year-old man is has done well and has had no evidence of graft rejection or major problems stemming from his chronic immunosuppressive therapy (cyclosporine and prednisone). He now develops a fever to 39°C (102°F), headache, and a stiff neck. MRI of the brain with gadolinium enhancement reveals no abnormalities. The most likely cause of the patient's current clinical problem is infection with |
| | A) | Listeria monocytogenes |
| | B) | Mycobacterium tuberculosis |
| | C) | Toxoplasma gondi |
| | D) | H. influenzae |
| | E) | Epstein-Barr virus (EBV) |
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12 | |
A 12-year-old girl presents with painful epitrochlear lymphadenopathy associated with low-grade fever and malaise. The patient has a cat and also gave a history of a papillary lesion in the left forearm about 1 week or 10 days ago. The most likely etiologic agent in this situation is |
| | A) | Bartonella henselae |
| | B) | Staphylococcus aureus |
| | C) | Epstein-Barr virus |
| | D) | Sporothrix schenkii |
| | E) | Yersinia pestis |
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13 | |
Which of the following statements concerning catheter-associated urinary tract infection is correct? |
| | A) | Most catheter-associated infections are symptomatic. |
| | B) | Topical periurethral antibiotics should be applied. |
| | C) | Routine antimicrobial prophylaxis is indicated. |
| | D) | The majority of patients catheterized for longer than 2 weeks develop bacteriuria. |
| | E) | Skin organisms such as Staphylococcus and Streptococcus are the most common cause of infections. |
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14 | |
What are the clinical consequences of Bacillus anthracis endospores coming in contact with an abrasion on the arm of a rancher? |
| | A) | The endospores germinate in the skin, gain access to the blood, and cause death due to massive sepsis. |
| | B) | The endospores germinate in the skin, gain access to the lymphatic system, and cause significant axillary lymphadenopathy. |
| | C) | The endospores germinate in the skin, gain access to the blood, and cause fatal pneumonia. |
| | D) | (D) The endospores are engulfed by dermal macrophages and are transported by them to the blood, at which point they germinate; the ensuing bacterial proliferation causes death due to massive sepsis. |
| | E) | The lesion that forms undergoes central necrosis and surrounding edema. |
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15 | |
A 23-year-old previously healthy female letter carrier works in a suburb in which the presence of rabid foxes and skunks has been documented. She is bitten by a bat, which then flies away. Initial examination reveals a clean break in the skin in the right upper forearm. She has no history of receiving treatment for rabies and is unsure about vaccination against tetanus. The physician should |
| | A) | clean the wound with a 20% soap solution |
| | B) | clean the wound with a 20% soap solution and administer tetanus toxoid |
| | C) | clean the wound with a 20% soap solution, administer tetanus toxoid, and administer human rabies immune globulin intramuscularly |
| | D) | clean the wound with a 20% soap solution, administer tetanus toxoid, administer human rabies immune globulin intramuscularly, and administer human diploid cell vaccine |
| | E) | clean the wound with a 20% soap solution and administer human diploid cell vaccine |
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16 | |
During the summer, a previously healthy 10-year- old boy living in rural Louisiana presents with a brief illness characterized by 2 days of fever, headache, and vomiting that progresses to lethargy, disorientation, and most recently a grand mal seizure. Laboratory examination is remarkable for peripheral blood leukocytosis and a normal CSF examination except for the presence of 35 monocytes per microliter. An IgM enzyme-linked immunoassay for the LaCrosse virus returns positive. Anticonvulsive medicine has been administered. At this point the physician should |
| | A) | tell the family that there is a high likelihood of improvement during the coming week and a good chance for discharge within 2 weeks |
| | B) | order a brain biopsy to exclude herpes encephalitis |
| | C) | administer empirical acyclovir |
| | D) | administer empirical chloramphenicol and ampicillin |
| | E) | share with the parents your concern that this illness, for which there is no specific therapy, is often fatal |
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17 | |
The most common source of bacterial infection of intravenous cannulas is |
| | A) | contamination of fluids during the manufacturing process |
| | B) | contamination of fluids during insertion of the cannula |
| | C) | contamination at the site of entry through the skin |
| | D) | (D) contamination during the injection of medications |
| | E) | seeding from remote sites as a result of intermittent bacteremia |
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18 | |
A 73-year-old previously healthy man is hospitalized because of the acute onset of dysuria, urinary frequency, fever, and shaking chills. His temperature is 39.5°C (103.1°F), blood pressure is 100/60 mmHg, pulse is 140 beats per minute, and respiratory rate is 30 breaths per minute. Which of the following interventions would be the most important in the treatment of this acute illness? |
| | A) | Catheterization of the urinary bladder |
| | B) | Initiation of antibiotic therapy |
| | C) | Infusion of Ringer's lactate solution |
| | D) | Infusion of dopamine hydrochloride |
| | E) | Intravenous injection of methylprednisolone |
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19 | |
Infection with Pseudomonas organisms is frequently associated with which of the following? |
| | A) | Pneumonia after a nail puncture wound of the foot |
| | B) | Pyoderma gangrenosum |
| | C) | Both a mild form and an invasive form of otitis externa |
| | D) | Meningitis in neonatal infants |
| | E) | Endocarditis in patients undergoing dental work |
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20 | |
A 65-year-old Greek woman visiting her children in New York City complains of upper abdominal pain. The patient is brought to the family physician, who notices icteric sclera and a mass in the right upper quadrant. CT reveals a 10-cm multiloculated cyst with mural calcification that is compressing the common bile duct. Which of the following statements is correct concerning this clinical situation? |
| | A) | Treatment with the antiamebic agent chloroquine is indicated. |
| | B) | Treatment with an antiechinococcal agent such as albendazole is sufficient. |
| | C) | The adult parasite resides in the patient's intestine. |
| | D) | Infection was probably caused by exposure to infected dogs. |
| | E) | Surgery is contraindicated because of the risk of anaphylaxis from dissemination of infectious material. |
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