Office 48q Q

Item: 1 of 48 ill f Mark -<J t>-
Q. ld: 5823 Prevtous Next
iThe following vignette a~~"!

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A 9-year-old boy is brought to the office by his parents. He complains of intermittent left knee discomfort and
8 sw elling for 2 w eeks that has w orsened over the past 5 days. He plays soccer but has had no recent trauma .
9 Review of the boy's past medical history is notable for a tick bite 3 months ago during a camping trip in
10 Pennsylvania . He does not remember developing any rash at that time. His temperature is 38.2 C (100.9 F).
11 Physical examination show s a w ell-appearing child w ith a moderately sw ollen, w arm, and mildly tender left
:I ~; I knee. There is no erythema . Minimal pain is elicited w ith full extension of the knee. The child is able to stand
and bear w eight. He has no rashes, and the remainder of his examination is normal.
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Item 1 of 2
. L2U W hich of the follow ing is the most appropriate next step in management of this patient?
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19 r A. Ibuprofen, rest, and follow -up in 1 w eek
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r B. l eft knee arthroscopy
r C. l eft knee x-ray
r D. Serum anti-citrullinated peptide antibodies
r E. Serum Lyme enzyme-linked immunosorbent assay
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Item 2 of 2
A left knee arthrocentesis is performed, greatly relieving the patient's swelling. He is now able to walk almost
normally. Blood tests are also performed. After 3 days, the patient comes to the office with his parents for a
8 follow-up visit. A mild effusion is present on left knee examination.
9
10 Laboratory results are as follows:
11 Complete blood count
:I ~; I
Hemoglobin 13.8 g/dL
Platelets 400,000/~L
14 Leukocytes 7,500/~L
:I ~~ I
Segmented neutrophils 68%
Bands 3%
. L2U Lymphocytes 29%
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19 Erythrocyte sedimentation rate 30 mm/h
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Immunologic and rheumatologic studies
Anti-cyclic citrullinated peptide antibody Pending
C-reactive protein 5 mg/L
Rheumatoid factor 30 U/mL
ELISA test for Lyme disease Pending
Western blot for Lyme disease Pending
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28 Synovial fluid
29 Cell count 12,000/~L
30 Neutrophils 75%
31 Lymphocytes 25%
32 Gram stain Negative
33 Bacterial culture No growth to date
34 Crystals Absent
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~ The parents are concerned about the boy's prognosis and ability to participate in sports. Which of the
37 following is the most accurate statement regarding this patient?
~Tal
~ r A. The prognosis is excellent. Patients can resume sports after arthrocentesis.
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Complete blood count

Hemoglobin 13.8 g/dL
Platelets 400,000/IJL
Leukocytes 7,500/IJL
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Bands 3%
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Lymphocytes 29%
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:I ~; I Erythrocyte sedimentation rate 30 mm/h

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Immunologic and rheumatologic studies
:I ~~ I Anti-cyclic citrullinated peptide antibody
C-reactive protein
Pending
5 mg/L
. L2U Rheumatoid factor 30 U/mL
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ELISA test for Lyme disease Pending
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Western blot for Lyme disease Pending
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Synovial fluid
Cell count 12,000/IJL
Neutrophils 75%
Lymphocytes 25%
Gram stain Negative
Bacterial culture No growth to date
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Crystals Absent
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The parents are concerned about the boy's prognosis and ability to participate in sports. Which of the
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following is the most accurate statement regarding this patient?
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33 r A. The prognosis is excellent. Patients can resume sports after arthrocentesis.
34 r B. The prognosis is fair. He should be hospitalized for intravenous ceftriaxone.
1351 r C. The prognosis is fair. Most patients experience recurrent arthritis throughout life and are unable to
~ return to sports.
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~Tal r D. The prognosis is good. Most patients are cured by antibiotics and are disease-free after 1 year.
~ r E. The prognosis is poor. Most patients require knee-replacement surgery.
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iThe following Vignette a~~'l!

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You are the physician for the Employee Health Center at a local community hospital. A 25-year-old Asian man
8 comes for a physical examination before starting volunteer w ork in the hospital. He has volunteered in
9 different hospitals in his country, and appears very enthusiastic about the opportunity to volunteer in your
10 hospital. He does not have any past medical or family history of contagious illness. He received the
11 necessary immunizations at appropriate times, and brought all the relevant documents as evidence of his
:I ~; I prior immunization history. He w as given a vaccine against tuberculosis in childhood, and his records
show ed that he received a BCG vaccination at 15 months of age. He never had a PPD test before, and does
14 not recall being exposed to tuberculosis in his life. His physical examination is unremarkable. You decide to
:I ~~ I
perform a PPD test. Tw o days later, the test site show s a 17 mm induration. The chest x-ray show s no
abnormalities.
. L2U
18 Item 1 of 2
19
20 W hat is the next step in the management of this patient?
r A. Start antitubercular therapy

r B. Send sputum and bronchial w ashing specimens for acid-fast staining
r C. Ask him to use respiratory isolation w hile w orking in the hospital
27 r D. Recommend isoniazid and vitamin 8 6 for nine months
28 r E. Reassure the patient and tell him that PPD positivity is due to his past BCG immunization
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Item 2 of 2
The patient refuses any further intervention . W hat is the most appropriate next step in the management of
9 this situation?
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r A. Tell him that he cannot volunteer in the hospital unless he complies w ith your recommendations
:I ~; I r B. Report a case of tuberculosis to the CDC
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r C. Document this discussion w ith the patient, his decision and his w ritten agreement to continue
:I ~~ I regular follow -up appointments
. L2U r D. Refer the patient to see an infectious disease specialist

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E. Ask him to reconsider acid-fast staining of sputum samples
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2 Item: 5 of 48 ill f Mark -<J t>-
The following vignette applies to the next 3 items
8 A 26-year-old man complains of intermittent headaches, forgetfulness, and blurry vision over the last several
9 w eeks. He attributes his symptoms to stress as one of his partners w as recently diagnosed w ith HIV
10 infection. His past medical history is insignificant. He has no genital discharge or ulcers, rash, w eight loss, or
11 gland sw elling. The patient smokes a pack of cigarettes daily and consumes alcohol occasionally. He does
not use illicit drugs. He has had multiple sexual partners over the last several years and rarely uses condoms
:I ~; I because "they make sex less sensitive." The patient has never been tested or treated for sexually transmitted
infections. Physical and neurologic examinations are unremarkable. His HIV antibody screen test and a
14
confirmatory W estern blot return positive. His rapid plasma reagin test is positive, w ith a titer of 1:64.
:I ~~ I Confirmatory testing w ith fluorescent treponema! antibody-absorption test is also positive. His CD4 count is
. L2U 350/j.Jl.
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19 Item 1 of 3
20 W hat is the best next step in management of this patient?
r A. Antibiotic therapy w ithout further testing for syphilis

r B. Confirmation w ith another treponema! test
r C. Echocardiogram
27 r D. Lumbar puncture
28 r E. Obtain serum vitamin B 12 levels
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Item 2 of 3
The additional tests on this patient have normal results. W hich of the follow ing is the best treatment option?
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r A. Aqueous crystalline penicillin G intravenously for 2 w eeks
:I ~; I
r B. Benzathine penicillin G intramuscularly in a single dose
14 r C. Benzathine penicillin G intramuscularly each w eek for 3 w eeks
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r D. Ceftriaxone intravenously for 2 w eeks
. L2U r E. Tetracycline orally for 3 w eeks
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Item 3 of 3
8 The patient comes to the emergency department 6 hours after the initiation of treatment w ith severe headache
9 and muscle pain . He w as shaking a w hile ago, but he now feels w arm . His temperature is 38.1 C (100.6 F)
10 and his heart rate is 105/min. W hich of the follow ing could have prevented this patient's condition?
11
:I ~; I r A. Assessment of drug interaction

14 r B. Careful allergic history taking
:I ~~ I r C. No effective prevention is available

. L2U r D. Pretreatment w ith corticosteroids
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19 r E. Pretreatment w ith antihistamines
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o. ld: 5068 Prevtous Next
A 77 -year-old male patient calls you in your office and complains of fever, chills, shortness of breath, and
productive cough for the last two days. His symptoms have been getting progressively w orse. His symptoms
started w ith malaise, generalized body aches, nasal congestion, and a mild cough about a w eek ago. He has
9 a history of coronary artery disease, congestive heart failure, diabetes, renal insufficiency, and chronic
10 obstructive pulmonary disease. He lives by himself, and he says that he w ill not have any means of
11 transportation until tomorrow , w hen his daughter w ill come to visit him. He has a 50-pack year history of
:I ~; I smoking. The last time you saw him w as a month ago, w hen he w ent to the office for a regular follow -up visit.
He had refused to get an influenza vaccine at that visit. He received a pneumococcal vaccine six years ago.
14 W hich of the follow ing is the most appropriate next step in the management of this patient?
:I ~~ I r A. Arrange a home visit by a visiting nurse

. L2U
18 r B. Ask him to see you in the office the next day and make arrangements
19 r C. Prescribe antitussives and decongestants for symptomatic relief
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r D. Ask him to call 911 and come to the hospital
E. Prescribe a course of outpatient azithrom ycin and ask him to come tomorrow
r
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After drawing blood from a w oman w ith a know n history of intravenous drug abuse, a 23-year-old male nursing
aide at the local free clinic accidentally pricks his finger w ith the needle. According to the patient's record, she
has not received any immunizations in the past twenty years and recently tested positive for HBsAg but
negative for HIV and hepatitis C. The nursing aide has no significant medical history and takes no
10 medications. One year ago, he received a series of three HBV vaccines and shortly afterward, his titer w as
11 found to be < 10 miU/mL (> 10 miU/mL is considered protective). W hat is the best w ay to handle this
:I ~; I situation?
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r A. Initiate revaccination w ith a series of three HBV vaccines
:I ~~ I r B. Give hepatitis B immune globulin and initiate revaccination
. L2U r C. Give hepatitis B immune globulin and lamivudine
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19 r D. Give pegylated interferon and lamivudine
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r E. No need for treatment because the patient w as vaccinated
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2 Item: 10 of 48 illl f' Mark -<J t>-
a. ld: 5929 PreVIOUS Next
A 26-year-old male comes to your office because of periodic flank pain . His urine has been red in color during
the last several days. He is HIV-positive. One month ago, he presented w ith thrush . At that time, his CD4
count w as 1OO/mm3, and anti-retroviral therapy w as started. His current CD4 count is 250/mm3. Physical
examination reveals no oral cavity lesions. The lungs are clear on auscultation. The serum creatinine level is
2.2 mg/dl. Urinalysis show s hematuria and needle-shaped crystals in the sediment. W hich of the follow ing
11 is the most likely cause of this patient's current condition?
:I ~; I r A. Abacavir
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r B. Didanosine
r C. lndinavir
. L2U
18 r D. Nevirapine
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r E. Neoplastic process
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A 29-year-old Caucasian female presents to your office 24 hours after unprotected intercourse w ith an
individual w ho just learned that he is HIV-positive. She is scared and asks you to "do something.'" Her past
8 medical history is insignificant. She has had two sexual partners over the last year, but she "faithfully" used
9 condoms for contraceptive purposes before this episode. She has never been tested for HIV or other sexually
10 transmitted diseases. She has no know n allergies. Physical examination is w ithin normal limits. An
immediate HIV test is negative. W hich of the follow ing is the best next step in the management of this patient?
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r A. Re-test for HIV in 4-6 months.
r B. Give lamivudine for 4 w eeks.
l!l
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r C. Give tenofovir and lamivudine for 4 w eeks.
. L2U
18 r D. Reassure and provide routine care.
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r E. Refer to psychotherapy.
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2 Item: 12 of 48 illl f ' Mark -<J t>-
The following vignette applies to the next 2 items.
8 A 20-year-old w oman w ho recently immigrated from Russia comes to the physician complaining of
9 unintentional w eight loss. Her appetite is good, but she keeps losing w eight. She has no fever, chills, night
sw eats, or hand tremors. The patient coughs occasionally, especially in the evening. She has no other
medical conditions and currently takes no medications. She does not use tobacco, alcohol, or recreational
drugs. The patient is not sexually active. She had received the Bacillus Calmette-Guerin vaccine as a child.
Her blood pressure is 120/70 mm Hg and pulse is 90/min. Chest x-ray show s a cavitary lesion in the right
14 upper lobe.
:I ~~ I Item 1 of 2
. L2U W hich of the follow ing is the most appropriate next step for diagnosing this patient's condition?
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20 r A. Bronchoscopy
r B. Gastric aspiration
r C. Interferon-gamma release assay testing (eg, QuantiFERON gold)
r D. Purified protein derivative skin testing
r E. Sputum studies
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Item 2 of 2
8 Three sputum smears are negative for acid-fast bacilli. Results from bronchial w ashing culture are pending.
9 Subsequent purified protein derivative testing in this patient shows 15 mm induration 48 hours after injection.
10 W hich of the following is the best statement about this patient's condition?
11
r A. The patient can be considered noninfectious for tuberculosis

14 r B. The patient is anergic to tuberculin
:I ~~ I r C. The patient is unlikely to have tuberculosis

. L2U r D. The patient is unlikely to respond to traditional therapy
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r E. The patient should be hospitalized
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2 Item: 14 of 48 illl f Mark -<J t>-
6 A 26-year-old Caucasian male comes to your office because he discovered a lump on his neck w hile taking a
. L2J show er. He has no other symptoms. His past medical history is insignificant. Physical examination show s
8 w hite plaques on his buccal mucosa and palate that can be easily scraped off, revealing hyperemia . W hich of
9 the follow ing is the best next step in the management of this patient?
10
r A. HIV testing
r B. Monospot test
r C. Lymph node biopsy
r D. Tzanck smear
r E. Topical antifungals
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iThe following vignette a~~'l!

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A previously healthy 25-year-old Caucasian w oman comes to the physician because of sore throat and
8 persistent w eakness. She also complains of fever and headache. Her symptoms started ten days ago and
9 have not improved since then . Her boyfriend had similar symptoms. She has no other medical problems and
10 takes no medication. She drinks approximately one ounce of alcohol daily and does not smoke. Her
11 temperature is 38.3C (101 F), blood pressure is 120/70 mmHg, pulse is 82/min and respirations are 16/min.
:I ~; I Physical examination show s tonsillar exudates. Enlarged, tender posterior and anterior cervical nodes are
present. There is palpable splenomegaly.
14
Item 1 of 3
W hat is the most appropriate next step in management?
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19 r A. Prescribe ampicillin
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r B. Order Monospot test
r C. Order EBV-specific antibodies
r D. Obtain chest x-ray
r E. Obtain lymph node biopsy
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Item 2 of 3
8 The appropriate action w as taken . What is the next best step?

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r A. Recommend bed rest and NSAIDs

r B. Prescribe prednisone
r C. Prescribe penicillin
r D. Prescribe clindamycin
r E. Prescribe acyclovir
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Item 3 of 3
8 The appropriate action w as taken and the patient w as sent home. Tw o days later, she presents to the
9 emergency department after developing shortness of breath in the recumbent position. On examination,
10 pharyngeal edema and sw elling of the soft tissues of the neck is noted. W hat is the most appropriate next
11 step in managing her condition?
:I ~; I r A. Admit the patient and start IV ampicillin

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15 r B. Admit the patient and start IV acyclovir
r C. Admit the patient and start IV ribavirin
18 r D. Admit the patient and start IV corticosteroids
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r E. Provide reassurance and schedule a follow -up appointment
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6 A 28-year-old w oman comes to the primary care physician's office complaining about a new rash and "feeling
. L2J rundow n and achy." After appearing on her face yesterday, the rash steadily spread dow nw ards until it
8 included her trunk. The rash is maculopapular and not confluent. Over the past three days she experienced
9 fever to 38.5C (101.3F), headache, and runny nose. Today she also noticed significant pain in the joints of her
10 fingers, w rists, and knees. She states she has had no ill contacts, has not traveled recently, and is not aware
11 of any recent insect bites. Her past medical history is unremarkable and she takes no medications. She has
:I ~; I no know n drug allergies. She lives w ith her boyfriend of two years and w orks in an office. She denies usage
of tobacco or recreational drugs and consumes 1-3 drinks of alcohol on social occasions. Given her clinical
14 presentation, w hat is the most likely diagnosis?
:I ~~ I r A. Lyme disease
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r B. Rocky Mountain Spotted Fever
r C. Roseola
r D. Rubella
r E. Rubeola
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A 16-year-old male comes to your office for a routine check-up. He w as diagnosed w ith asthma six months
ago and started on inhaled corticosteroids as w ell as an albuterol inhaler as needed. He reports a modest
8 improvement in his symptoms using this regimen. He has no complaints currently. Physical examination
9 reveals w hite plaques on his buccal mucosa that can be scraped off, leaving hyperemic spots. The lungs are
10 clear on auscultation. W hich of the follow ing is the best initial therapy for the oral lesion?
11
:I ~; I r A. Nystatin suspension
14 r B. Oral fluconazole
:I ~~ I r C. Oral acyclovir
. L2U r D. Topical steroid therapy
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r E. Biopsy of the lesion
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A 49-year-old male is brought to the emergency department by police after he w as found w andering the
streets, mumbling incoherently. He has been homeless for several years and occasionally stays in local
8 shelters. He is mildly agitated and coughs frequently. Vital signs include a temperature of 38.3C (100.9F),
9 blood pressure of 11 0/74 mm Hg, pulse of 84/min, and respirations 20/min. Physical examination show s an
10 unkempt, cachectic man in some distress. Generalized lymphadenopathy is apparent. An eye examination
11 reveals choroidal tubercles. No masses or lesions are visible in the oropharynx . Multiple dental caries are
:I ~; I present and the majority of teeth are missing. Lung auscultation reveals pleural rub bilaterally. Normal S1 and
S2 are heard. The abdomen is nontender and there is some hepatosplenomegaly. A chest x-ray show s a
14 miliary reticulonodular pattern bilaterally. The patient is immediately quarantined and all exposed health care
:I ~~ I
w orkers are tested w ith purified protein derivative (PPD). One of the aides, a 66-year-old Caucasian w oman,
has a positive PPD after testing negative three months ago. She agrees to begin isoniazid therapy and is
. L2U prescribed isoniazid and pyridoxine for a period of nine months. W hich of the follow ing therapeutic side
18 effects is she most likely to experience?
r A. Drug-induced lupus
r B. Hepatotoxicity
r C. Ocular toxicity
r D. Orange-colored urine
r E. Peripheral neuropathy
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ifhe follow ing vignette a !J!J!"

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o-"
th
'l'e
~ ne
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t :,
2'-"it~
e!l s,__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___.
m!.'
A 26-year-old Caucasian female comes to see you in the office w ith complaints of fatigue, headache,
8 generalized body aches, and low -grade fever for the past four days. She has just returned from a hiking and
9 camping trip in Long Island, New York, two days ago. She saw a local physician there on the first day of her
10 symptoms. He sent her for serologic testing for Rocky Mountain spotted fever, the results of w hich w ere
11 inconclusive at that time. She goes to the same place in Long Island w ith her friends during spring break
:I ~; I every year, and has never had any problems in the past. She is otherwise in good health, and does not take
any medications regularly. On examination, her temperature is 37.8C(1OOF), heart rate is 92/min, blood
14 pressure is 122/74 mmHg, and respiratory rate is 16/min. ifhere is evidence of a fine petechial rash over both
:I ~~ I
w rists and the left ankle. ifhe rest of her physical examination is unremarkable.
. L2U Item 1 of 2
18
19 W hich of the follow ing is the m ost appropriate next step in her management?
20
r A. Repeat the serologic testing for Rocky Mountain spotted fever in one w eek.
r B. Perform W eii-Felix test now .
r C. Obtain a skin biopsy of the petechial lesions.
r D. Follow her platelet counts serially.
27 r E. Start the patient on treatment for Rocky Mountain spotted fever.
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Item 2 of 2
8 W hich of the following is the most appropriate treatment for patients diagnosed w ith Rocky Mountain spotted
9 fever?
10
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r A. Doxycycline
:I ~; I r B. Erythrom ycin
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r C. Cephalexin
:I ~~ I r D. Chloramphenicol
. L2U r E. Levofloxacin
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8 A 40-year-old male accountant presents to clinic for a follow -up visit regarding his recent exposure to HIV.
9 W hile on a business trip two w eeks ago, he had unprotected anal intercourse w ith a man w ho confided that
10 he w as HIV positive a few days later. Immediately after discovering this, the patient purchased an
11 over-the-counter home kit for HIV testing at a local pharmacy. The kit uses a double ELISA test w ith a
confirmatory W estern Blot, and its sensitivity and specificity approach 100%. He w as informed by telephone
:I ~; I that the ELISA test w as negative, but finds that he is still extremely anxious about the possibility of contracting
the virus. His medical complaints at this time include fatigue, a sore throat, and some muscle aches, w hich
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he attributes to his long w ork hours and poor sleep. His medical history is significant for psoriasis and an
:I ~~ I episode of renal calculi. He does not take medications at this time. He does not smoke cigarettes and
. L2U restricts his alcohol intake to social occasions. His temperature is 38.4C (101.1F), blood pressure is 122/82
mm Hg, pulse is 72/min, and respirations are 15/min. On physical examination, he appears anxious and
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19 tired. There is no erythema, exudate, or ulcer visible in the mouth or throat. There is some generalized
20 lymphadenopathy. Chest auscultation is unremarkable and heart sounds are normal. His abdomen is
nontender and nondistended and there is no palpable hepatosplenomegaly. Bow el sounds are normal.
Rectal tone is normal and a small laceration is visible on the anus. The laceration is healing w ell and
granulation tissue is present. Genital exam is normal.
Item 1 of 2
W hich of the follow ing should be recommended at this time?

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29 r A. No further testing is necessary
30 r B. Obtain biopsy of anal lesion
31
r C. Order lgM HIV antibody assay
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33 r D. Order HIV RNA PCR assay
34 r E. Order W estern Blot
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Item 2 of 2
8 Further testing reveals that the accountant is indeed HIV positive. His baseline viral load and CD4 count levels
9 are measured on two separate occasions. The risks and benefits of antiretroviral therapy are discussed, and
10 the decision is made to defer the initiation of therapy until a later date. He asks how frequently his immune
11 status w ill be monitored. In light of the circumstances, w hich of the follow ing is most appropriate?
:I ~; I r A. Evaluate his CD4 count and HIV load once every 6-9 months
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:I ~~ I
r B. Evaluate his CD4 count and HIV load once every 3-4 months
r C. Evaluate his CD4 count and HIV load once every 12 months
. L2U
18 r D. Evaluate his CD4 count and HIV load once every month
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r E. Evaluate his CD4 count and HIV load once every 2 w eeks
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iThe following vignette a~~'l!

lie~s~to~t~h!.'!e'-'n~e~x~tc!2;..!i~
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A 47-year-old Caucasian man comes to a homeless clinic w ith complaints of a skin rash for the past two
8 w eeks. He w as diagnosed w ith HIV infection 10 years ago, and is currently on antiretroviral therapy. His last
9 CD4 count two months ago w as 100/cu. mm. He admits that he has been very erratic w ith his medications
10 and follow -up visits w ith his primary care physician due to insurance reasons. He w as recently hospitalized
11 and treated for some fungal infection, but he does not know the details of his hospitalization. He does not
:I ~; I have his discharge papers w ith him. Examination of his skin show s multiple small papules w ith central
umbilication over his trunk and upper thighs. These lesions are covered w ith a hemorrhagic crust.
14
:I ~~ I
Item 1 of 2
. L2U W hich of the follow ing is the most likely diagnosis?

18
19 r A. Impetigo
20
r B. Cutaneous cryptococcosis
r C. Pyoderma
r D. Cutaneous tuberculosis
r E. Allergic reaction to the antifungal treatment
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Item 2 of 2
8 W hich of the following is the diagnostic method of choice in this patient?

9
10
r A. Blood cultures
11
:I ~; I
r B. Microscopic examination of scrapings from the lesion
14 r C. Biopsy of the lesion
:I ~~ I
r D. Antigen testing
. L2U r E. India-ink preparation

18
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6 A 25-year-old HIV-positive man presents to the physician w ith a history of painful sw allow ing and burning
. L2J chest pain . His medications include zidovudine, didanosine, and indinavir. He w as started on fluconazole, but
8 his symptoms did not improve. Esophagoscopy w ith biopsy, cytology, and culture is performed, w hich show s
9 giant ulcers w ith no viruses. W hat is the most appropriate next step in the management of this patient?
10
11
r A. Continue fluconazole.
:I ~; I r B. Start ganciclovir.
14
r C. Start acyclovir.
:I ~~ I r D. Start prednisone.
. L2U
18 r E. Start ranitidine.
19
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A 38-year-old HIV-positive homosexual male presents to the clinic for a follow -up visit. He has no complaints
at this time. Laboratory testing reveals a CD4 count of 260/IJL and HIV load <5000 copies/ml. Current
8 medications include efavirenz, lamivudine, and tenofovir, and the patient states he is tolerating this regimen
9 w ell. He has not received any other form of treatment for his HIV status. W hat do you recommend as the
10 next best step?
11
:I ~; I r A. Administer HBV vaccination

14 r B. Prescribe trimethoprim/sulfamethoxazole
:I ~~ I r C. Prescribe azithrom ycin

. L2U r D. Prescribe ganciclovir
18
19
r E. Discontinue the anti-retroviral therapy
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A 32-year-old w oman comes to the office w ith a three day history of sore throat. She denies any fever, chills,
headaches, m yalgias, or shortness of breath but she complains of mild non-productive cough. She has no
8 other medical problems. She has smoked two packs of cigarettes daily for 5 years. She takes no
9 medications. Her temperature is 36.6C (98F), blood pressure is 122171 mm Hg, pulse is 83/min, and
10 respirations are 14/min. Examination show s pharyngeal erythema w ithout exudates. The lung fields are clear
11 on auscultation. There is a 1.5cm right-sided submandibular lymph node w hich is tender to palpation. W hat
:I ~; I is the most appropriate next step in her management?
14
r A. Empiric antibiotics
:I ~~ I r B. Lymph node biopsy
. L2U r C. Rapid streptococcal antigen test
18
19 r D. Symptomatic treatment
20
r E. Throat culture
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A 24-year-old Caucasian male bartender presents to clinic with the complaint that he is "feeling terrible and
can barely get out of bed." He reports that two days ago, he began to feel feverish and sw eaty, especially at
8 night. He then developed a persistent headache and sore throat, and noticed that his muscles and joints w ere
9 aching as w ell. He feels extremely fatigued and had some difficulty making it to the clinic because of this. His
10 past medical history is unremarkable and he takes no medications. He is single and admits to being sexually
11 active with two w omen in the past few months. He smokes one pack of cigarettes and drinks 2-4 alcohol
:I ~; I beverages every day. His temperature is 38.6C (101.4F), blood pressure is 130/88 mm Hg, pulse is 94/min,
and respirations are 16/min. On physical examination, he appears acutely ill. His skin is flushed and damp,
14 and an erythematous maculopapular rash is evident on his face, trunk, and palms and soles. There are some
:I ~~ I
w ell-healed puncture w ounds on the inside of his forearms. There is a shallow, tender ulcer on his posterior
oropharynx . A generalized lymphadenopathy is noted, and the nodes are discrete and mobile. Chest
. L2U auscultation is unremarkable and heart sounds are normal. His abdomen is nontender and nondistended and
18 there is no palpable hepatosplenomegaly. Rectal tone is normal. Laboratory evaluation reveals the following:
19
Hb 15.7 g/dL
20
Hct 47%
Platelet count 120,000/cmm
Leukocyte count 1,600/cmm
Lymphocytes 8%
Monocytes 5%
Eosinophils 2%
HIV ELISA Antibody Negative
Heterophile Antibody Negative
Blood cultures No growth after 48 hours
Which of the following is the most likely diagnosis?

33
34 r A. Acute retroviral syndrome
1351 r B. Infectious mononucleosis
~ r C. Influenza
37
~Tal r D. Primary herpes simplex virus infection
~ r E. Viral hepatitis
40
1
A 30-year-old Caucasian man w ith no significant past medical history presents to his primary care physician
complaining of nausea, vomiting, diarrhea, abdominal cramping, and fever to 38.3C (100.9F). The symptoms
8 started 12 hours after the man consumed a beverage that contained pureed fruit, pow dered protein, and three
9 raw eggs. Physical examination of the man is unremarkable. Salmonella enteritidis is subsequently isolated
10 from his stool culture. W hat is the best means of managing this patient's care?
11
:I ~; I r A. Treatment w ith ampicillin

14
r B. Treatment w ith ciprofloxacin
:I ~~ I r C. Treatment w ith trimethoprim/sulfamethoxazole
. L2U r D. Treatment w ith ceftriaxone
18
19 r E. Supportive therapy and observation
20
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A healthy, 27-year-old Guatemalan-American woman comes to the physician because of weight loss, nausea,
abdominal pain, abdominal distention, and diarrhea. She has no other medical problems. The patient is a
8 schoolteacher, and has lived in America for two years. She does not use tobacco, alcohol, or drugs. She is a
9 vegetarian. Her family history is not significant. She takes no medication. She has no known drug allergies.
10 She has just received a visit from her relatives who came from Guatemala four months ago, and who are now
11 living in her home. Her vital signs are within normal limits. Examination shows that the abdomen is soft,
:I ~; I mildly tender, and distended, with increased bowel sounds. There is no rebound tenderness or rigidity. There
is no hepatomegaly or splenomegaly. The patient's labs reveal:
14
:I ~~ I
CBC
Hb 10 g/dL
. L2U Ht 38%
18 Platelet count 200,000/cmm
19
Leukocyte count 8,000/cmm
20 Segmented neutrophils 63%
Bands 3%
Eosinophils 17%
Lymphocytes 14%
Monocytes 3%
Which of the following is the most appropriate pharmacotherapy?

27
28
29 r A. Trimethoprim-sulfamethoxazole
30 r B. Ciprofloxacin
r C. Metronidazole
r D. Albendazole
34
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A 24-year-old Caucasian female presents to your office w ith a two day history of progressive leg w eakness,
ascending paresthesias, and dull back pain . Today, she has developed urinary retention. Her past medical
8 history is insignificant, except for a recent episode of an upper respiratory tract infection two w eeks ago. She
9 is not taking any medications and denies drug abuse. Her blood pressure is 11 0/70 mmHg, and heart rate is
10 80/min. Physical examination reveals low er paraplegia w ith decreased reflexes and decreased pain
11 sensation up to the umbilical level. Bladder catheterization reveals a volume of 500 cc. W hich of the follow ing
:I ~; I is the next best step in the management of this patient?
14
r A. Lumbar puncture
:I ~~ I r B. Plain x-ray of the vertebrae
. L2U r C. CT scan of the brain and spine
18
19 r D. MRI of the spine
20
r E. High-dose corticosteroids
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A 25-year-old w oman comes to the physician because of 3 w eeks of sinus congestion. She initially developed
subjective fever, chills, and cough productive of yellow sputum that resolved after 5 days. She subsequently
8 developed sinus congestion that has persisted for the past 2 w eeks. She has no other medical problems and
9 takes no medication. She does not use tobacco, alcohol, or illicit drugs. Her temperature is3s.oc (100.4.F),
10 blood pressure is 11 0/70 mm Hg, pulse is 84/min, and respirations are 12/min. Physical examination reveals
11 sinus tenderness to palpation over both maxillary sinuses, fullness in both tympanic membranes, and purulent
:I ~; I nasal discharge. The remainder of the examination show s no abnormalities. W hich of the follow ing is the
most appropriate next step in management?
14
:I ~~ I r A. Bacterial culture of nasal discharge

. L2U r B. CT scan of the sinuses
18
19
r C. Plain x-rays of the sinuses
20 r D. Referral to a specialist for sinus surgery
r E. Treatment w ith antibiotics
27
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1
iThe following vignette a~~"!

lie
~s~to~t~h!.'!e'-'n~e~x~tc!2;..!i~
te
...,m
~ s------------------.....
A 35-year-old homosexual male presents to the office complaining of increasing difficulty in carrying out basic
8 day-to-day activities such as dressing and grooming himself. His speech is slow and halting, and he has
9 noticeable difficulty w alking and low ering himself into a chair. His partner, w ho scheduled the appointment
10 after returning from an extended out-of-tow n trip, accompanies him. The partner states that the patient's
11 mental function and alertness have significantly w orsened w ithin a matter of w eeks. The partner adds that a
:I ~; I neighbor w itnessed the patient having w hat appeared to be a brief seizure w hile in his backyard approximately
one w eek ago. The patient w as diagnosed as HIV positive ten years ago and is not on any medications at this
14 time. A stereotactic brain biopsy reveals oligodendrocytes w ith intranuclear inclusions, demyelination, and
:I ~~ I
astrogliosis .
. L2U Item 1 of 2
18
19 W hich of the follow ing is the most appropriate treatment for this patient?
20
r A. Acyclovir
r B. Foscarnet
r C. Highly active antiretroviral therapy (HAART)
r D. Oseltamivir
27 r E. No know n effective treatment
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Item 2 of 2
8 The patient refuses the recommended treatment. His partner asks about the prognosis for untreated
9 patients. Given the circumstances, w hat is the most appropriate response?
10
11
r A. Spontaneous complete recovery occurs in a substantial percentage of untreated patients
:I ~; I r B. A relapsing-remitting course is common in untreated patients, and the prognosis is therefore
14 extremely unpredictable
:I ~~ I r C. Intravenous acyclovir can prolong survival in the majority of patients

. L2U r D. W ithout treatment, the majority of patients w ith this condition w ill die w ithin 3-6 months of the onset
18 of symptoms
19
r E. Most patients w ith this condition w ill develop a severe but stable dementia and live 4-6 years after
20
the onset of symptoms
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1
6 A 25-year-old w oman presents to your office w ith complaints of frequency, dysuria, and burning on urination .
. L2J She says that for the past six months, these symptoms have occurred repeatedly. She particularly noticed
8 that the symptoms appear a few days after sexual intercourse. She regularly uses condoms for protection.
9 She visited several doctors w ho prescribed antimicrobials, such as trimethoprim-sulfamethoxazole,
10 nitrofurantoin and ampicillin, after w hich her symptoms improved. W hich of the follow ing is the most
11 appropriate next step in the management of this patient?
:I ~; I r A. Complete blood count

14
:I ~~ I
r B. Urinalysis and urine culture
r C. Abdominal and pelvic ultrasound
. L2U
18 r D. Intravenous pyelogram
19
20
r E. CT of the abdomen
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28
29
30
31
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33
1
8 A 54-year-old male comes for a routine follow -up visit and states that he has been gaining w eight. He has HIV
9 infection, for w hich he has been receiving highly active antiretroviral therapy (HAART) for one year. Follow ing
10 his HAART treatment, he show ed a significant improvement in his CD4 lymphocyte count. His past medical
11 history, aside from his HIV infection, is unremarkable. He does not have hepatitis C or hepatitis B infection.
His father had coronary artery disease and died of a heart attack at the age of 55 years. He does not drink
:I ~; I alcohol. He has smoked one pack of cigarettes daily for the last 28 years. He has a history of intravenous
drug abuse in the past, but he is currently not using any recreational drugs. On examination, he w eighs 172
14
pounds (his w eight one year ago w as 160 pounds). His height is 5'9"(175cm). His blood pressure is 112172
:I ~~ I mmHg and his heart rate is 76/min. He has fat tissue depositions on the back of his neck and on his
. L2U abdomen. His extremities and face appear thin . There is palpable hepatomegaly w ith a soft, non-tender liver
18 edge.
19
20 Item 1 of 2
W hich of the follow ing most likely contributes to this patient's condition?
r A. Adrenal hyperplasia
r B. High viral load
r C. Insulin resistance
27
28 r D. Liver cirrhosis
29 r E. Pituitary adenoma
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31
32
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1
Item 2 of 2
8 Laboratory studies reveal a normal complete blood count and routine basic chemistry. His lipid profile show s
9 a total cholesterol level of 280 mg/dl , triglyceride level of 630 mg/dl , and high-density lipoprotein level of 29
10 mg/dl. His fasting blood sugar is 105 mg/dl and LFTs show s mild elevations of AST and ALT levels. W hat
11 is the next best step in the management of this patient?
:I ~; I r A. Measure 24-hour urinary cortisol levels

14
:I ~~ I
r B. Order ACTH stimulation test
r C. Stop antiretroviral therapy
. L2U
18 r D. Start gemfibrozil
19
r E. Start nicotinic acid
20
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1
6 A 54-year-old man comes to the office because of dysuria, urgency and frequency. He also has some
. L2J perineal discomfort. His symptoms have been intermittent for the past two months. The patient is
8 hypertensive, and takes amlodipine and propranolol. He w orks as a taxi driver. He drinks alcohol
9 occasionally, and has smoked one pack of cigarettes daily for the past thirty years. Rectal examination
10 reveals a mildly tender and enlarged prostate. A four-glass test is done, with the third sample of urine taken
11 after prostatic massage. The laboratory test results show the following:
:I ~; I Urinalysis
Prostatic massage
30-40 WBCs/hpf, 2-4 RBCs.
24 WBCs/hpf
14
Prostatic culture E coli> 100,000 colonies
:I ~~ I Antibiogram Resistant to: ciprofloxacin, levofloxacin, ofloxacin.
Sensitive to: amikacin, gentamycin, penicillin, ampicillin,
. L2U cefuroxime, ceftriaxone, trimethoprim-sulfamethoxazole,
18
tetracyclines
19
20
Which of the following will be the most effective pharmacotherapy?
r A. Start amikacin .
r B. Start trimethoprim-sulfamethoxazole.
r C. Start ceftriaxone.
27 r D. Start ampicillin .
28
r E. Start cefuroxime.
29
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1
6 An 18-year-old female presents to your office w ith dysuria and urinary frequency. She denies any fever, chills,
. L2J or flank pain . She has a history of recurrent urinary tract infections, including two episodes over the last six
8 months. She is otherwise healthy. She had no urinary problems in childhood. She has been sexually active
9 w ith one partner during the last year. She takes oral contraceptives. Urine dipstick is positive for leukocyte
10 esterase and nitrites. Urine cultures are sent. Polymerase chain reaction (PCR) is negative for gonorrhea
11 and chlamydia. Pregnancy test is negative. W hich of the follow ing is the best management step for this
:I ~; I patient?
14
r A. Abdominal ultrasound
:I ~~ I r B. Antibiotic prophylaxis
. L2U r C. Cystoscopy
18
19 r D. Non-contrast CT scan of the abdomen
20
r E. Potassium citrate
27
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6 A 23-year-old G2P 1 Caucasian female w ho lives in central Connecticut comes to the office at the 26"' w eek of
. L2J pregnancy for regular follow -up. She denies any skin rash, joint pains, extremity sw elling, headaches, or
8 palpitations. Her first pregnancy w as uncomplicated. She expresses some concern because her husband
9 w as recently diagnosed w ith Lyme disease after an episode of arthritis. She know s that she lives in a
10 high-risk area and she is afraid that acquiring Lyme disease may affect her baby. W hich of the follow ing
11 statements best addresses this patient's concerns?
:I ~; I r A. Lyme disease can be transmitted by breastfeeding

14
:I ~~ I
r B. Lyme disease can be transmitted by close household contact
r C. Lyme disease can be transmitted sexually
. L2U
18 r D. Lyme disease during pregnancy carries no risk for the fetus if treated appropriately
19
20
r E. Lyme disease during pregnancy has been associated w ith a congenital syndrome that mimics
congenital syphilis
27
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1
6 A 26-year-old Caucasian male presents to the office w ith a two-day history of mild headache, fatigue, malaise,
. L2J m yalgias, high-grade fever, and a rash on his w aist. The rash is asymptomatic, but has expanded over the
8 last two days. He is otherwise healthy. Social history is notable for a camping trip to Vermont two w eeks
9 ago. On physical examination, there is a single, oval, erythematous, 6 em patch w ith central clearing on the
10 w aist. The remainder of the examination is unremarkable. W hat is the most appropriate next step in the
11 management of this patient?
:I ~; I r A. Perform ELISA for Lyme disease

14
:I ~~ I
r B. Perform lumbar puncture
r C. Perform W estern blot for Lyme disease
. L2U
18 r D. Start intravenous ceftriaxone
19
20
r E. Start oral doxycycline
27
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1
6 A 45-year-old female presents to your office w ith fever, malaise and facial rash . The symptoms started
. L2J acutely one day ago, and she took two tablets of ibuprofen to relieve the fever. Her past medical history is
8 insignificant. She w orks as a clerk at a private office, and is not physically active. She smokes two packs of
9 cigarettes daily, and consumes alcohol occasionally. She denies any recreational drug use. She has no
10 know n allergies. She is sexually active in a monogamous relationship w ith her husband. The rash is show n
11 below .
:I ~; I
14
:I ~~ I
. L2U
18
19
20
27
28
Other physical findings are w ithin normal limits. W hich of the follow ing is the most likely cause of this
29
patient's problem?
30
31
32 r A. Hemophilus influenz ae
33 r B. Staphylococcus aureus
34
r C. Group-A streptococcus
1351
~ r D. Neisseria meningitidis
37
r E. Herpes simplex virus (HSV)
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40
1
6 A 33-year-old HIV-positive Caucasian man recently diagnosed w ith tuberculosis presents to clinic w ith the
. L2J complaint of increasing fever and fatigue. He says his respiratory symptoms w ere improving steadily until
8 yesterday, w hen they rapidly began to w orsen. He says that his "cough is quite bad, such that I'm bringing
9 up sputum sometimes and having these chest pains that make it uncomfortable to breathe." Treatment w ith
10 antiretroviral therapy and antibiotics w as begun immediately after he w as diagnosed w ith AIDS-defining
11 tuberculosis over two w eeks ago. He has not been treated for AIDS or tuberculosis before this. He feels
:I ~; I certain that he is taking all of the medications as prescribed. His temperature is 39.6C (103.2F), blood
pressure is 126/82 mm Hg, pulse is 92/min, and respirations are 20/min. On physical examination, increasing
14 congestion is audible in both the right and left lungs. Chest radiograph reveals new parenchymal opacities
:I ~~ I
and w orsening intrathoracic lymph node enlargement. Aspiration of fluctuant lymph nodes produces purulent
material, but the cultures are sterile and no organisms are seen w ith acid fast stains. Gram stain and culture
. L2U of the expectoration is negative. At the time of diagnosis two w eeks ago, his CD4 count w as 1OO/mm3 and
18 his HIV viral load w as 125,000 copies/ml. Today, his CD4 count is 220/mm3 and his HIV viral load is < 10,000
19 copies/ml. W hat w ould be the most appropriate means of managing his condition?
20
r A. Discontinuation of HAART and antibiotics

r B. Replacement of HAART w ith corticosteroids
r C. Replacement of antibiotics w ith corticosteroids
r D. Attempt to locate source of occult infection
27
r E. Provide reassurance and continue treatment
28
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6 A 38-year-old w oman from Indonesia comes to the physician for an evaluation. She immigrated to the United
. L2J States a year ago. W hen she first arrived, she had a tuberculin skin test that show ed 12 mm induration. She
8 then had a chest x-ray but does not recall the results. The patient w as treated w ith isoniazid for 9 months,
9 w hich she completed 2 months ago. She recently moved and applied for a new job as a nurse. She
10 underwent a repeat tuberculin skin test that show ed 11 mm induration. A chest x-ray show ed a small calcified
11 granuloma in the right upper lobe. The patient has no fever, chills, w eight loss, anorexia, cough, or night
:I ~; I sw eats. She has no other medical history and takes no medications. She does not smoke. W ith regard to
her risk of tuberculosis, w hich of the follow ing is the most appropriate next step in management of this patient?
14
:I ~~ I r A. Obtain induced sputum samples for m ycobacterial culture and drug susceptibility testing
. L2U r B. Perform an interferon-gamma release assay
18
19 r C. Prescribe isoniazid for 9 months
20 r D. Prescribe rifampin, isoniazid, pyrazinamide, and ethambutol
r E. Reassure patient that no further tuberculosis treatment is needed at this time
27
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1
6 A 33-year-old Caucasian nurse undergoes an evaluation after a patient she cared for w as diagnosed w ith
. L2J active tuberculosis. She has no present complaints. Her past medical history is insignificant. She does not
8 smoke or consume alcohol. She has been sexually active w ith one partner over the last four years. She is
9 currently not taking any medications, except for low estrogen/low progesterone oral contraceptive pills. Lungs
10 are clear on auscultation. PPD test show s 16 mm induration after 24 hours. Chest x-ray is normal.
11 You prescribe oral isoniazid (INH), and schedule a routine follow -up visit. She visits you after six months and
:I ~; I says that she w as adherent to therapy. You check liver enzymes, w hich turn out to be normal. W hat is the
best next step in the management of this patient?
14
:I ~~ I r A. Perform PPD testing annually until negative.

. L2U r B. Perform chest x-ray annually until 3 negative results are obtained.
18
r C. Treat w ith INH for an additional 3 months.
19
20 r D. Treat w ith INH for an additional 6 months.
E. Stop the therapy and do routine check-ups.
27
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6 A 52-year-old Asian male comes to see you in the office for a follow -up visit. He had a pre-employment
. L2J tuberculin skin test done three days ago, and had a skin reaction w ith 16 mm of induration. He denies any
8 history of cough, fever, w eight loss, night sw eats, or recent exposure to patients w ith tuberculosis. He has a
9 40-pack-year history of smoking and continues to smoke heavily. He immigrated from South Korea to the
10 United States about eight years ago. He had BCG vaccination as a child, but never had a tuberculin skin test
11 done in the past. You send him to the radiology department for a chest x-ray. Tw o hours later, the radiologist
:I ~; I calls to inform you that the patient has right upper lobe fibrosis w ithout signs of active tuberculosis. W hich of
the follow ing is the most appropriate next step in the management of this patient?
14
:I ~~ I r A. Observation and close follow -up of the patient for development of symptoms of pulmonary
tuberculosis .
. L2U
18 r B. Repeat the chest x-ray in one month.
19
r C. Start the patient on treatment w ith isoniazid for nine months.
20
r D. Start the patient on treatment w ith isoniazid and rifampin for nine months.
r E. Treat the patient w ith isoniazid and rifampin for two months, and then continue isoniazid for
another seven months.
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Item: 1 of 48 ill f Mark -<J t>-

Q. ld: 5823 Prevtous Next

iThe following vignette a~~"!

Complete blood count

:I ~; I Erythrocyte sedimentation rate 30 mm/h

iThe following Vignette a~~'l!

r A. Start antitubercular therapy

. L2U r D. Refer the patient to see an infectious disease specialist

The following vignette applies to the next 3 items

r A. Antibiotic therapy w ithout further testing for syphilis

:I ~; I r A. Assessment of drug interaction

:I ~~ I r C. No effective prevention is available

:I ~~ I r A. Arrange a home visit by a visiting nurse

The following vignette applies to the next 2 items.

r A. The patient can be considered noninfectious for tuberculosis

:I ~~ I r C. The patient is unlikely to have tuberculosis

iThe following vignette a~~'l!

8 The appropriate action w as taken . What is the next best step?

r A. Recommend bed rest and NSAIDs

:I ~; I r A. Admit the patient and start IV ampicillin

ifhe follow ing vignette a !J!J!"

The following vignette applies to the next 2 items

W hich of the follow ing should be recommended at this time?

iThe following vignette a~~'l!

. L2U W hich of the follow ing is the most likely diagnosis?

8 W hich of the following is the diagnostic method of choice in this patient?

. L2U r E. India-ink preparation

:I ~; I r A. Administer HBV vaccination

:I ~~ I r C. Prescribe azithrom ycin

:I ~; I is the most appropriate next step in her management?

Which of the following is the most likely diagnosis?

:I ~; I r A. Treatment w ith ampicillin

Which of the following is the most appropriate pharmacotherapy?

:I ~; I is the next best step in the management of this patient?

:I ~~ I r A. Bacterial culture of nasal discharge

iThe following vignette a~~"!

:I ~~ I r C. Intravenous acyclovir can prolong survival in the majority of patients

:I ~; I r A. Complete blood count

The following vignette applies to the next 2 items

:I ~; I r A. Measure 24-hour urinary cortisol levels

:I ~; I r A. Lyme disease can be transmitted by breastfeeding

:I ~; I r A. Perform ELISA for Lyme disease

r A. Discontinuation of HAART and antibiotics

:I ~~ I r A. Perform PPD testing annually until negative.

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