[MCQs] The Quizzes about Fever (23 test)

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Question 1

A 43-year-old man, who currently uses drugs intravenously (IV), presents to the emergency department (ED) with 2 weeks of fever, back pain, and progressive weakness in his legs He denies any history of trauma or prior surgery. His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 106 beats per minute, temperature is 103°F, and respiratory rate (RR) is 16 breaths per minute. On physical examination, he has ten- derness to palpation in the mid-lumbar spine, increased patellar reflexes, and decreased strength in the lower extremities bilaterally, with normal range of motion. Laboratory results reveal a white blood cell (WBC) count of 15,500/mL, hematocrit 40%, and platelets 225/mL. Urinalysis and spi- nal x-rays are unremarkable. Which of the following is the most likely diagnosis?

A	Fibromyalgia
B	Ankylosing spondylitis
C	Spinal epidural abscess
D	Vertebral compression fracture
E	Spinal metastatic lesion

Question 1 Explanation:

Spinal abscesses are most commonly found in immunocompromised patients, IV drug users, and the elderly. Signs and symptoms of epidural abscess usually develop over a week or two and include fever, localized pain, and progressive weakness. An elevated WBC count is also commonly seen. MRI is the most useful diagnostic test. Staphylococcus aureus is the most common causative organism, followed by gram-negative bacilli and tuberculosis bacillus. Fibromyalgia (a) is a common cause of chronic back pain, but one would not expect the physical findings (weakness, hyperreflexia) or laboratory abnormalities. Inflammatory conditions, including ankylosing spondylitis (b), may cause back pain. The key findings in this disease include gradual onset of morning stiffness improved with exercise in a patient younger than 40 years. On physical examination, these patients may have limited back flexion, reduced chest expansion, and sacroiliac joint tenderness, all of which are nonspecific. Fever and weakness would not be expected. Back pain may result from vertebral compression fractures (d). These may be secondary to trauma or may be atraumatic in a patient with osteoporosis. Osteoporotic compression fractures usually involve patients older than 70 years or patients with acquired bone weakness (eg, prolonged steroid use). Metastatic lesions (e) invade the spinal bone marrow, leading to compression of the spinal cord. Most common primary tumors include breast, lung, thyroid, kidney, prostate (BLT with Kosher pickles), as well as lymphoma and multiple myeloma. Maintain a high level of suspicion for any cancer patient who develops back pain; these patients must be investigated for spinal metastases.

Question 2

An 81-year-old woman is brought to the ED by her children who state that the patient is acting more tired than usual, has had fever for the last 2 days, and is more Ordinarily, the patient is high functioning: she is ambulatory, cooks for herself, and walks on a treadmill 30 minutes a day. Her vital signs are BP 85/60 mm Hg, HR 125, RR 20, temperature 101.3°F, and pulse oxygenation 97% on room air. On examination, the patient has dry mucous membranes but is otherwise unremarkable. She is oriented to person and place but states that the year is 1925. Her laboratory results show a WBC 14,300/mL, hematocrit 31%, and platelets 350/mL. Her elec- trolytes are within normal limits. Blood glucose is 92 mg/dL. A chest radio- graph does not show any infiltrates. Urinalysis reveals 2+ protein, trace ketones, WBC > 100/hpf, red blood cell (RBC) 5 to 10/hpf, nitrite positive, and leukocyte esterase positive. After administering a 500-cc normal saline fluid bolus and broad-spectrum antibiotics through her peripheral IV line, the patient’s BP is 82/60 mm Hg. You suspect that the patient is in septic shock due to an acute urinary tract infection. Which of the following is the next most appropriate course of action to manage this patient with early- goal-directed therapy (EGDT)?

A	Immediately start a norepinephrine infusion to increase the blood pressure given the low systolic blood pressure.
B	Prepare to transfuse uncrossed matched packed RBC to increase oxygen-carrying capacity given the low hematocrit.
C	Place a central venous line into the right internal jugular vein to measure central venous pressure (CVP).
D	Transport the patient to radiology for a stat CT scan of her head given the acute change in mental status.
E	Place a central venous line into the right internal jugular vein to measure mixed venous oxygen saturation (SVO2).

Question 2 Explanation:

The treatment for sepsis has evolved considerably over the past 10 years with emphasis on the early recognition and aggressive therapy. This approach is known as early-goal-directed therapy (EGDT). EGDT emphasizes early recognition of patients with potential sepsis in the ED, early broad-spectrum antibiotics, and a rapid crystalloid fluid bolus, followed by goal-directed therapy for those patients who remain hypotensive or severely ill after this initial therapy. EGDT is basically a three-step process, aimed at optimizing tissue perfusion: • The first step involves titrating crystalloid fluid administration (up to 2 L) to achieve a CVP between 8 and 12 mm Hg. CVP is a surrogate for intravascular volume, as excess circulating blood volume is contained within the venous system. • The second step, if the patient has not improved with fluid alone, is to administer vasopressors to attain a mean arterial pressure (MAP) > 65 mm Hg. • The third step is to evaluate the central venous oxygen saturation (SvO2). This is obtained from the central venous line, which, in turn, is a surrogate for peripheral tissue oxygenation and cardiac output. A central venous saturation of less than 70% is considered abnormal and indicative of suboptimal therapy. In this case, the hematocrit is checked and blood is transfused until a hematocrit > 30% is attained. Once this is attained and the central venous saturation is still low, dobutamine is initiated to increase cardiac output. Vasopressor therapy (a) should not be started until the patient receives at least normal saline fluid boluses to achieve a CVP between 8 and 12 mm Hg or to maintain a MAP of at least 65 mm Hg. Packed RBCs (b) can be transfused if the SvO2 is < 70% and the hematocrit is < 30%. However, this should not occur until after adequate fluid resuscitation. A CT scan (d) is not indicated at this time as the most reasonable explanation for the patient’s change in mental status is the acute infection and hemodynamic changes and there is a great deal of risk involved in moving a hemodynamically unstable patient to the CT scanner (e) Although this patient should have central venous (subclavian or internal jugular) access, the evaluation of SvO2 should occur after other resuscitative efforts have been maximized

Question 3

A 23-year-old man presents to the ED with left lower abdominal pain and left testicular pain that started 1 to 2 weeks ago and has gradually wors- He has some nausea and vomiting. His HR is 98 beats per minute, BP is 125/65 mm Hg, temperature is 100.9°F, and RR is 18 breaths per min- ute. Physical examination reveals a tender left testicle with a firm nodular- ity on the posterolateral aspect of the testicle. Pain is relieved slightly with elevation of the testicle and the cremasteric reflex in normal. You make the presumptive diagnosis of epididymitis. Which of the following is the next best step?

A	Prescribe pain medications and penicillin for coverage of syphilis, the most likely causative organism.
B	Recommend bed rest, ice, and scrotal elevation with prompt urology follow-up.
C	Give ceftriaxone 125 mg intramuscularly (IM), plus a one-time dose of azithro- mycin 1 g orally.
D	Give ceftriaxone 250 mg intramuscularly (IM), plus a 10-day course of oral doxycycline.
E	Confirm the diagnosis with transillumination of the testicle, and then consult urology for surgical drainage.

Question 3 Explanation:

Epididymitis is an inflammation of the epididymis and has two distinct causes. In patients younger than 35 years, sexually transmitted diseases (STDs), such as gonorrhea and Chlamydia, are most common while urinary pathogens, such as Escherichia coli and Klebsiella, are most common in patients older than 40 years. Unlike testicular torsion, the onset of pain in epididymitis is usually gradual and the cremasteric reflex should be intact. Scrotal elevation may transiently relieve pain (positive Prehn sign). Treatment includes bed rest, scrotal elevation or186 Emergency Medicine support when ambulating, avoidance of heavy lifting, and antibiotics for infection. There is no approved one-time dose of antibiotics to treat epididymitis and patients must be treated for a total of 10 to 14 days. This patient may require pain medications, (a) but coverage with appropriate antibiotics will help relieve symptoms. While penicillin is appropriate therapy for primary syphilis, it is not indicated to treat epididymitis. While scrotal elevation, ice, and rest (b) may be helpful, definitive treatment for epididymitis requires appropriate antibiotic coverage as described just previously. Although a lower dose of ceftriaxone and a one-time dose of azithromycin (c) are appropriate to treat urethritis, this is not adequate treatment of epididymitis. A hydrocele (e) is a fluid accumulation in a persistent tunica vaginalis owing to obstruction, which impedes lymphatic drainage of the testicle. On physical examination, transillumination may help confirm the diagnosis. Treatment includes reassurance, and possibly surgical follow-up for drainage.

Question 4

A 40-year-old man with insulin-dependent diabetes presents to the ED with complaints of 2 days of increasingly severe perineal pain and subjective fevers. His HR is 118 beats per minute, BP is 95/55 mm Hg, temperature is 4°F, and RR is 22 breaths per minute. The bedside sugar reading is “high.” Physical examination demonstrates crepitus over the medial thigh and widespread erythema and purple discoloration with sharp demarca- tion over the scrotum. The scrotum is markedly tender, warm, and edema- tous. Which of the following is the most likely diagnosis?

A	Cutaneous candidiasis
B	Fournier syndrome
C	Phimosis
D	Paraphimosis
E	Testicular torsion

Question 4 Explanation:

Fournier syndrome (also known as Fournier gangrene) is a polymicrobial necrotizing fasciitis of the perineal subcutaneous tissue that originates from the skin, urethra, or rectum. It is more common in male patients and usually begins as a simple abscess or benign infection that quickly spreads, especially in an immunocompromised patient. If not promptly diagnosed, it can lead to end-artery thrombosis in the subcutaneous tissue and widespread necrosis. Treatment includes aggressive fluid resuscitation; broad-spectrum antibiotics to cover gram-positive, gram-negative, and anaerobic bacteria; wide surgical debridement; and, possibly, hyperbaric oxygen therapy. Cutaneous candidiasis (a) is common in diabetics with poorly controlled blood sugar and may be a presenting complaint in new-onset diabetes. However, this rash is nontoxic, without systemic signs and symptoms, and often limited to moist areas such as between skin folds. Phimosis (c) is the condition where the foreskin cannot be retracted from the glans penis and can lead to urinary retention. Paraphimosis (d) is the inability to reduce the proximal foreskin over the glans penis (the foreskin becomes “stuck” behind the glans penis). It may lead to decreased arterial flow and eventual gangrene. Testicular torsion (e) is the twisting of a testicle on its root that usually occurs during strenuous activity or following trauma but can occasionally occur during sleep. It is most common in infants and young adults.

Question 5

A 55-year-old man with a history of diabetes presents with com- plaints of developed left knee pain several days following a fall from stand- ing The patient was brought to the ED by ambulance after being found on a park bench stating he was unable to walk because of the pain. On physical examination, there are no rashes or external signs of trauma. His left knee is warm, diffusely tender, and swollen with a large effusion. He has pain on passive range of motion and is refusing to walk. His BP is 150/85 mm Hg, HR is 105 beats per minute, temperature is 102.7°F, RR is 16 breaths per minute, and fingerstick glucose is 89 mg/dL. Which of the following is the most appropriate diagnostic test?

A	Knee radiographs
B	Magnetic resonance imaging (MRI)
C	Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
D	Arthrocentesis
E	Bone scan

Question 5 Explanation:

This patient is exhibiting the common signs and symptoms of septic arthritis, an infection of a joint space, most commonly the knee, followed by the hip, shoulder, and wrist. Preexisting arthritis (osteoarthritis or rheumatoid arthritis), immunocompromised states (alcoholism, diabetes, or cancer), and risky sexual behavior are risk factors for the development of septic arthritis. Patients present with a warm, tender, erythematous, swollen joint and pain with passive range of motion. Fever and chills are common. Arthrocentesis is diagnostic with joint fluid demonstrating a WBC count > 50,000/μL with > 75% granulocytes. Staphylococcus aureus remains the predominant pathogen for all age groups. However, in young adults gonococcal septic arthritis is common and should also be included in the selection of antibiotic coverage. Patients with septic arthritis should receive a first dose of antibiotics in the ED prior to admission. If a coincident cellulitis is present over the involved joint, arthrocentesis may need to be delayed. Plain radiographs (a) should be obtained to identify any underlying osteomyelitis or joint disease but are often nondiagnostic in acute septic arthritis. MRI (b) plays no role in the diagnosis of acute septic arthritis but may be useful in evaluating for chronic disease, osteomyelitis, and other musculoskeletal injuries involving the knee. The ESR and CRP (c) are often elevated in septic arthritis and can be trended to assess treatment success, but neither is specific or diagnostic. A bone scan (e) is useful in the detection of osteomyelitis that may not be immediately apparent on a plain radiograph, but is not sensitive in the diagnosis of septic arthritis

Question 6

A 35-year-old woman with systemic lupus erythematosus (SLE) is brought to the ED by her brother after he found her febrile and Physical examination reveals fever, tachycardia, a waxing and waning men- tal status, petechiae over her oral mucosa, pallor, and mildly heme-positive stool. Her urinalysis is positive for blood, red cell casts, and proteinuria. Laboratory results reveal blood urea nitrogen (BUN) of 40 mg/dL and crea- tinine of 2 mg/dL. Her bilirubin is elevated (unconjugated > conjugated) and her international normalized ratio (INR) is 0.98. Her complete blood count reveals WBC 12,000/mL, hematocrit 29%, and platelet count 17,000/mL with schistocytes on the peripheral smear. Which of the following is the most appropriate next step in management?

A	Admit to the intensive care unit (ICU) for plasmapheresis and close monitoring for acute bleeds.
B	Admit to the ICU for platelet transfusion and monitoring for acute bleeds.
C	Admit to the ICU for corticosteroid infusion, transfusion of platelets, and prompt surgical consultation for emergent splenectomy.
D	Admit to the ICU for dialysis and close monitoring for acute bleeds.
E	Perform a noncontrast head computed tomography (CT) to screen for intracra- nial bleeding and mass effect followed by a lumbar puncture (LP) for analysis of cerebrospinal fluid (CSF). If negative, admit to telemetry for hemodynamic monitoring.

Question 6 Explanation:

This patient has thrombotic thrombocytopenic purpura (TTP), caused by increased platelet destruction. In TTP, platelet-fibrin thrombi deposit in vessel and cause injury to RBCs and platelets, resulting in microangiopathy hemolytic anemia and thrombocytopenia. Patients tend to be females who are 10 to 45 years of age. Risk factors include pregnancy, autoimmune disorders (eg, SLE), infection, allogenic bone marrow transplantation, malignancy, and medications (such as quinine, clopidogrel, and ticlopidine). The pentad includes Fever, (microangiopathic hemolytic) Anemia, Thrombocytopenia, Renal (failure), and Neurologic changes (fluctuating symptoms with a waxing and waning mental status). Unfortunately, only 40% of patients presents with the classic pentad. Untreated, TTP carries a mortality rate up to 80%. Although steroids, splenectomy, anticoagulation, and exchange188 Emergency Medicine transfusion have been attempted, daily plasmapheresis until platelet count normalizes is the current initial treatment of choice. In addition, RBCs may be transfused in patients with symptomatic anemia. All patients with TTP should be admitted to an ICU for close monitoring of acute bleeds. The initial therapy for TTP generally does not include platelet transfusion (b), as this could worsen the condition and increase mortality. However, platelets should be administered in patients with a life-threatening bleed. Corticosteroids and splenectomy (c) are used in refractory cases but are not considered appropriate initial treatments. Fever and altered mental status may indicate meningitis, but this patient has other signs and symptoms consistent with TTP. A CT scan may be indicated to exclude intracranial bleeding but an LP (d and e) is unnecessary and could be dangerous given the very low platelet count. Additionally, this patient requires ICU monitoring.

Question 7

A 30-year-old woman presents to the ED with fever, headache, a “sunburn-like” rash, and A friend states that the patient has complained of nausea, vomiting, diarrhea, and a sore throat over the past few days. Her last menstrual period began 4 days ago. Vital signs are HR 110 beats per minute, BP 80/45 mm Hg, RR of 18 breaths per minute, and temperature of 103°F. On physical examination, you note an ill-ap- pearing woman with a diffuse blanching erythroderma. Her neck is supple without signs of meningeal irritation. On pelvic examination, you remove a tampon. You note a fine desquamation of her skin, especially over the hands and feet, and hyperemia of her oropharyngeal, conjunctival, and vaginal mucous membranes. Laboratory results reveal a creatine phospho- kinase (CPK) of 5000, WBC 15,000/mL, platelets of 90,000/mL, BUN 40 mg/dL, creatinine 2 mg/dL, and elevated liver enzymes. You suspect the diagnosis of toxic shock syndrome and initiate IV fluids. You target antibi- otics at which of the following causative organism?

A	Staphylococcus aureus
B	Staphylococcus aureus
C	Rickettsia rickettsii
D	Neisseria meningitidis
E	Neisseria gonorrhoeae

Question 7 Explanation:

This patient suffers from toxic shock syndrome (TSS), a toxin-mediated systemic inflammatory response that results in severe, rapidly progressive, life-threatening high fevers, diffuse macular erythroderma, profound hypotension, desquamation, and multisystem dysfunction (including vomiting or diarrhea, severe myalgias, mucous membrane hyperemia, renal or hepatic dysfunction, decreased platelets, and disorientation). TSS was initially recognized as a disease of young, healthy, menstruating women, in which tampon use increased the risk 33 times. With increased awareness and changes in tampon composition, cases of TSS have declined over the past 20 years. An exotoxin produced by S aureus is the presumed cause in menstrual-related TSS (MRTSS) and two endotoxins have been implicated in non–menstrual-related TSS (NMRTSS). TSS should be considered in any unexplained febrile illness associated with erythroderma, hypotension, and diffuse organ pathology. Patients with MRTSS usually present between the third and fifth day of menses. In severe cases, headache is the most common complaint. The rash is a diffuse, blanching erythroderma, often described as painless “sunburn” that fades within 3 days and is followed by desquamation, especially of the palms and soles. For severe cases, treatment includes aggressive IV fluid resuscitation, IV oxacillin or cefazolin, and hospital admission in a monitored setting. Rocky Mountain spotted fever (RMSF) (b) is caused by R rickettsii, which is transmitted by ticks. The organism multiplies in endothelial cells lining small vessels, causing generalized vasculitis as well as headache, fever, confusion, rash, myalgias, and shock. The rash usually appears on days 2 to 3, initially on the wrists, ankles, palms, and soles, spreading rapidly to the extremities and trunk. Lesions begin as small, erythematous blanching macules that become maculopapular and petechial. The location and type of rash, along with the history distinguish RMSF from TSS. Serologic tests are confirmatory, but treatment with doxycycline or chloramphenicol should be started prior to confirmation. Streptococcal scarlet fever (c) is an acute febrile illness primarily affecting young children, caused by S pyogenes (group A streptococci [GAS]). The “sandpaper” rash of scarlet fever differs from the macular sunburn rash of TSS. The treatment is penicillin or macrolide in penicillin-allergic patients. While S aureus is the causative organism of TSS, a less common, but more aggressive, TSS-like syndrome, streptococcal TSS (STSS), has also been identified. The treatment is similar to that of TSS, with aggressive fluid management along with IV penicillin and clindamycin. These patients may progress to a necrotizing fasciitis or myositis, requiring surgical intervention. Meningococcemia (d) is an infectious vasculitis caused by disseminated N meningitides, a gramnegative diplococcus. Fever, headache, arthralgias, altered mental status, and abnormal vitals may also be found, along with neck stiffness. There is no indication of meningeal irritation in this patient. Furthermore, the rash of meningococcemia is distinctly different from that of TSS, involving petechial, hemorrhagic vesicles, macules, and papules with surrounding erythema, especially on the trunk and extremities. The treatment is IV ceftriaxone. Disseminated gonococcemia (e), usually seen in young, sexually active female patients, is caused by N gonorrhoeae. The rash of gonococcemia is pustular with an erythematous base, rather than petechial and hemorrhagic, as are the lesions of RMSF and meningococcemia. It can also be associated with fever and arthralgias. The treatment is IV ceftriaxone or oral ciprofloxacin.

Question 8

A 32-year-old diabetic man presents to the ED with a fever and 1 week of increasing right foot He states he stepped on a nail while running barefoot 2 weeks ago but didn’t think much of it at that time. On physical examination, his heel is mildly erythematous and diffusely tender to palpation, with overlying warmth and edema. There is a small amount of purulent drainage through the puncture hole in his heel. A plain radio- graph of his foot demonstrates a slight lucency of the calcaneus. He has decreased range of motion, but you are able to passively dorsiflex and plan- tarflex his ankle without difficulty. His vital signs include a temperature of 101.4°F, HR of 98 beats per minute, BP of 130/75 mm Hg, and RR of 16 breaths per minute. Which of the following is the most common caus- ative organism of this condition?

A	Salmonella sp
B	Pseudomonas aeruginosa
C	Staphylococcus aureus
D	Group B streptococci
E	Pasteurella multocida

Question 8 Explanation:

Osteomyelitis is an infection or inflammation of a bone with an incidence following plantar puncture wounds of 0.1% to 2%. Pain, swelling, fever, redness, and drainage may all occur, but pain is the presenting complaint in most cases. Risk factors include trauma, surgery, soft tissue infections, and being immunocompromised (eg, human immunodeficiency virus [HIV], diabetes, IV drug user, sickle-cell disease, alcoholism). Overall, S aureus is the leading cause of osteomyelitis, followed by various Streptococcus species. Pseudomonas is also implicated in specific190 Emergency Medicine subpopulations, as discussed in the following text. Definitive diagnosis is made by bone scan, which will demonstrate osteomyelitis within 72 hours of symptom onset. Radiographs may be normal early on but will demonstrate periosteal elevation within 10 days. ESR and CRP are often elevated, but normal or slightly elevated levels do not rule out the diagnosis and they are most valuable in following response to treatment, as levels should fall as the infection resolves. Blood cultures, which are positive in 50% of cases, should be used to guide antibiotic treatment. All patients with puncture wounds should receive tetanus prophylaxis. Patients with sickle-cell disease and asplenism are at higher risk for Salmonella (a) osteomyelitis, although S aureus remains the most common cause. Pseudomonas (b) causes bone and joint infections primarily in three settings. First, patients receiving implanted prosthetic devices during orthopedic surgery are at higher risk for osteomyelitis from Pseudomonas. Puncture wounds to the foot also increase the risk of osteomyelitis from Pseudomonas. Second, Pseudomonas does not appear to grow on puncture objects but rather appears to grow on the footwear and may be inoculated into the wound. Third, IV drug users may develop hematogenous osteomyelitis, often in the spine, from Pseudomonas bacteria. (d) Overall, Streptococcus is the second most common cause of osteomyelitis; however, specific groups may be at increased risk. For example, in neonates group B Streptococcus is a common infecting bacterium of bone and joint infections, and in children aged 3 months to 14 years group A Streptococcus may be seen. Pasteurella multocida (e) is a common etiology of cellulitis following a cat bite.

Question 9

A 75-year-old woman is transferred to your ED from the local nurs- ing home for fever, cough, and increasing Over the past 3 days, the nursing home staff noticed increasing yellow sputum and decreasing urine output from the patient. Her BP is 118/75 mm Hg, RR is 20 breaths per minute, HR is 105 beats per minute, temperature is 100.9°F, and pulse oxygenation is 94% on room air. On examination, auscultation of the lungs reveals bibasilar crackles. Laboratory results reveal WBC 14,500/mL, hema- tocrit 39%, platelets 250/mL, sodium 132 mEq/L, potassium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 18 mEq/L, BUN 27 mg/dL, creatinine

1.5 mg/dL, and glucose 85 mg/dL. Serum lactate is 4.7 mmol/dL. Chest radiography reveals bilateral lower lobe infiltrates. Based on this patient’s presentation, which of the following is the most likely diagnosis?

A	Hospital-acquired pneumonia (HAP)
B	Community-acquired pneumonia (CAP)
C	Health care–associated pneumonia (HCAP)
D	Ventilator-associated pneumonia (VAP)
E	Atypical pneumonia

Question 9 Explanation:

HCAP is defined as the development of pneumonia in patients with recent (within 90 days) contact with the health care system, including hospitalization, outpatient dialysis, or residing in a nursing home or rehabilitation center. In comparison to CAP, HCAP tends to be caused by organisms with higher levels of resistance. Although specific treatments depend on local resistance patterns, hospital admission and initiation of broad-spectrum IV antibiotics that includes coverage for MRSA are generally recommended. HCP (a) is defined as the development of a new pneumonia following at least 48 to 72 hours in the hospital. It is a common cause of nosocomial infection and the most common cause of death in ICUs. CAP (b) is defined as the development of pneumonia in any patient without specific health careFever Answers 191 contact. VAP (d) is defined as a new pneumonia that develops in a patient who has been on a ventilator for at least 48 hours. Atypical pneumonia (e) is caused by organisms such as Mycoplasma pneumoniae, viruses, or Legionella, and typically begins as a flu-like illness and lack of signs of consolidation on examination and radiography. Patients typically appear nontoxic and can be treated as outpatients.

Question 10

A 55-year-old man presents to the ED with fever, drooling, tris- mus, and a swollen He reports a foul taste in his mouth caused by a tooth extraction 2 days ago. On physical examination, the patient appears anxious. He has bilateral submandibular swelling and elevation and pro- trusion of the tongue. He appears “bull-necked” with tense and markedly tender edema and brawny induration of the upper neck, and he is tender over the lower second and third molars. There is no cervical lymphade- nopathy. These lungs are clear to auscultation with good air movement. His vital signs are HR 105 beats per minute, BP 140/85 mm Hg, RR 26 breaths per minute, and temperature 102°F. Which of the following is the most appropriate next step in management?

A	Obtain a sample for culture, administer a dose of IV antibiotics, and obtain a soft tissue radiograph of the neck.
B	Obtain a sample for culture, perform a broad incision and drainage at bedside, and administer a dose of IV antibiotics.
C	Administer a dose of IV antibiotics and obtain a CT scan of the soft tissues of the neck.
D	Administer a dose of IV antibiotics, obtain a CT scan of the soft tissues of the neck, and obtain an emergent ENT consult.
E	Secure his airway, administer a dose of IV antibiotics, and obtain an emergent ENT (ear, nose, and throat) consult.

Question 10 Explanation:

Ludwig angina (LA) is a potentially life-threatening cellulitis of the connective tissue of the floor of the mouth and neck that begins in the submandibular space and is commonly caused by an infected or recently extracted tooth. Typically, it is a polymicrobial infection involving aerobic and anaerobic bacteria of the mouth, including streptococci, staphylococci, and bacteroides species. The most common physical findings are bilateral submandibular swelling and tongue protrusion or elevation. A tense edema and brawny induration of the neck above the hyoid may be present and is described as a “bull neck.” Marked tenderness to palpation of the neck and subcutaneous emphysema may be noted. Trismus and fever are often present but usually no palpable fluctuance or cervical lymphadenopathy. The involved teeth may be tender to palpation. Appropriate regimens include high-dose penicillin with metronidazole, or cefoxitin used alone. Clindamycin, ticarcillin-clavulanate, piperacillin-tazobactam, or ampicillin sulbactam may also be used. Oral antibiotics are not adequate. Importantly, patients with LA should be considered to have an unstable airway regardless of the initial examination and should never be left alone because airway impairment can suddenly occur. Signs of impending airway compromise include stridor, tachypnea, dyspnea, drooling, and agitation. Patients should be left sitting upright to increase airway diameter and aid with airway protection. Of note, the upper airway may be severely distorted making endotracheal intubation difficult or impossible. Cricothyrotomy may also be difficult due to the swelling and increases the risk of spreading infection into the mediastinum. Therefore, fiberoptic nasotracheal intubation is preferred. This is a clinical diagnosis, with soft tissue radiographs (a) and CT scans (c and d) of the neck confirm the diagnosis by demonstrating edema of the affected area, airway narrowing, and gas collections. However, radiographs must not delay treatment, compromise the patient’s ability to protect their airway (such as by lying supine), or place the192 Emergency Medicine patient in an area where emergent airway management is difficult. Therefore, these studies should be delayed until the airway is stabilized. Prior to broad-spectrum antibiotics, incision and drainage (b) was the treatment of choice. Today, surgery is used only for those patients who fail to respond to antibiotic therapy or those with purulent collections. In these rare cases, surgery, including incision and drainage then excision of facial planes, would best be performed in an operating room (OR), not at the bedside. Additionally, cultures are often of little utility given the polymicrobial nature of the infection.

Question 11

A 67-year-old woman with a history of steroid-dependent COPD, non–insulin-dependent diabetes, and hypertension presents to the ED with complaints of a painful, red, swollen left lower She states she noted a “bug bite” in that area 1 week ago and since then has had gradually increasing symptoms. On examination, you note a 12 cm ´ 10 cm sharply demarcated area of blanching erythema, warmth, and tenderness on the medial thigh with ascending erythema to the groin. You also note tender adenopathy in the left inguinal region. Her BP is 90/55 mm Hg, RR is 24 breaths per minute, HR is 105 beats per minute, temperature is 102.4°F, and pulse oxygenation is 98% on room air. Laboratory results reveal WBC 19,500/mL, hematocrit 39%, platelets 175/mL, sodium 132 mEq/L, potas- sium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 14 mEq/L, BUN 32 mg/dL, creatinine 1.7 mg/dL, and glucose 455 mg/dL. Serum lactate is 4.7 mmol/dL. Which of the following best describes her clinical state?

A	She has systemic inflammatory response syndrome (SIRS).
B	She has sepsis.
C	She has severe sepsis.
D	She is in septic shock.
E	She has multiple organ dysfunction syndrome (MODS).

Question 11 Explanation:

Sepsis represents the systemic inflammatory response, mediated by an inflammatory cascade triggered by an infection that overwhelms the body’s regulatory systems. Initially, this leads to tachycardia, tachypnea, and fever, and may progress to shock, multiorgan failure, and death if not treated. Sepsis is a common cause of death in the United States with a mortality rate estimated between 20% and 50%. The initiation of early, aggressive therapy (known as EGDT) has been shown to improve outcomes of septic patients. SIRS (a) is a systemic inflammatory response to a variety of clinical insults and can be defined according to various physiologic parameters, including elevated (or lowered) oral temperature, RR > 20, HR > 90, or elevated WBC count (or bandemia). Severe sepsis (c) is defined as sepsis with one or more SIRS Sepsis Severe Sepsis Septic Shock Two or more of the following criteria: HR > 90 SIRS Sepsis Sepsis Temperature > 100.4°F or < 96.8°F + + + Suspected or proven infections Acute organ dysfunction Refractory hypotension RR > 20, or PaCO2 < 32 WBC >12,000 cells/mm3, or < 4000 cells/mm3, or > 10% band formsFever Answers 193 signs of organ dysfunction, hypoperfusion, or hypotension such as metabolic acidosis, acute alteration in mental status, or respiratory distress syndrome. Septic Shock (d) is defined as severe sepsis with hypotension that is unresponsive to fluid resuscitation. These states are summarized in the following table. MODS (e) is defined as the dysfunction of more than one organ, requiring acute interventions to obtain homeostasis.

Question 12

An 84-year-old man presents to the ED with his family due to concerns that his condition is worsening despite being placed on levofloxacin for a urinary tract infection 5 days ago by his primary care His is obtunded and unable to give any additional history. Physical examination does not reveal the source of infection. His BP is 84/45 mm Hg, HR is 135 beats per minute, tem- perature is 102.8°F, and his RR is 28 breaths per minute. Laboratory results reveal WBC 24,500/mL, hematocrit 19%, platelets 90/mL, sodium 132 mEq/L, potas- sium 7.5 mEq/L, chloride 100 mEq/L, bicarbonate 12 mEq/L, BUN 37 mg/dL, creatinine 6.5 mg/dL, and glucose 255 mg/dL. Serum lactate is 11.3 mmol/ dL. Cardiac enzymes and troponin are mildly elevated, and he has hyperacute T-waves on electrocardiogram (ECG). His chest radiograph shows cardiomeg- aly with bilateral patchy opacities and pulmonary vascular congestion. Rapid urinalysis reveals 3+ WBCs and blood and nitrates. You secure his airway with intubation, initiate broad-spectrum antibiotics, IV fluids, and other supportive therapies, and emergently consult nephrology, cardiology, and pulmonology. Which of the following best describes his clinical state?

A	He has SIRS.
B	He has sepsis.
C	He has severe sepsis.
D	He is in septic shock.
E	He has MODS.

Question 12 Explanation:

This patient has a urinary tract infection that appears to be resistant to treatment and is exhibiting signs of multiple organ system dysfunction seen by elevated cardiac enzymes and cardiomegaly (cardiac), an elevated BUN/creatinine, hyperkalemia (renal), and altered mental status (neurologic). He requires intubation, dialysis, and other acute interventions for this dysfunction. SIRS (a) is defined according to various physiologic parameters, including elevated (or lowered) oral temperature, RR > 20, HR > 90, or elevated WBC count (or bandemia). Sepsis (b) is defined as SIRS that has a proven or suspected source of infection. Severe sepsis (c) is defined as sepsis with one or more signs of organ dysfunction, hypoperfusion, or hypotension such as metabolic acidosis, acute alteration in mental status, or respiratory distress syndrome. Septic shock (d) is defined as severe sepsis with hypotension that is unresponsive to fluid resuscitation.

Question 13

A 37-year-old man presents to the ED with complaints of 2 days of a sore throat and subjective fever at He denies cough or vomiting. His BP is 130/75 mm Hg, HR is 85 beats per minute, temperature is 101°F, and his RR is 14 breaths per minute. He has diffuse tonsillar swelling and bilateral exudates with bilaterally enlarged and tender lymph nodes of the neck. Which of the following is the next best step in management?

A	Administer penicillin and discharge the patient without further testing.
B	Perform a rapid antigen test. If it is negative, confirm with a throat culture, and administer penicillin if the results are positive.
C	Perform a rapid antigen test. If it is negative, administer penicillin and discharge the patient.
D	Perform a rapid antigen test. If it is positive, administer penicillin and discharge the patient.
E	Discharge the patient without treatment or further testing.

Question 13 Explanation:

The patient has a modified Centor score of 4 (history of fever, tender adenopathy, no cough, exudates, age 15-45 years). The Centor criteria, seen below, are used for predicting streptococcal pharyngitis and whether or not to treat the patient with antibiotics. Because of his high score, it is likely that the patient has group A β-hemolytic streptococcal infection and that he should receive antibiotics. In addition, he should be treated symptomatically with fluids, topical anesthetics, and acetaminophen or ibuprofen. Patients with a Centor criterion of 2 or 3 should have a rapid antigen test and a throat culture performed. If the rapid antigen test is negative, a confirmatory throat culture may be sent (b), but antibiotics (c) should not be initiated. If the rapid antigen test is positive, patients should be treated with an antibiotic (d). A patient with many predictive signs and symptoms should be treated with antibiotics rather than discharged (e).194 Emergency Medicine 172. The answer is a. (Rosen, pp 91

Question 14

A 37-year-old man who just finished a full course of penicillin for pharyngitis presents to the ED requesting to be checked out He states he took the antibiotics exactly as prescribed and initially felt some- what improved, but over the last 2 to 3 days has had increased pain and progressive difficulty swallowing. His BP is 130/65 mm Hg, HR is 95 beats per minute, temperature is 100.1°F, RR is 16 breaths per minute, and oxygen saturation is 99%. On examination, the patient is in no acute distress but has a fluctuant mass on the right side of his neck. You visualize a normal soft palate with swelling of the right tonsillar arch and deviation of the uvula to the left, but additional examination is limited because he is unable to open his mouth fully. Review of his records reveals a throat culture that was positive for Streptococcus. Which of the following is the most appropri- ate next step in management?

A	Attempt needle aspiration, treat him with a new course of antibiotics (either penicillin or clindamycin), and have him return in 24 hours.
B	Give him morphine for pain control, give him a dose of IV antibiotics, and observe him in the ED for 6 hours.
C	Admit him for incision and drainage in the OR under general anesthesia.
D	Switch his antibiotic to clindamycin and have him return in 24 hours.
E	Order a CT scan to visualize his neck, continue the penicillin, and have him return in 24 hours.

Question 14 Explanation:

The patient’s presentation is typical for a peritonsillar abscess. Signs and symptoms include a sore throat, muffled voice, trismus, fluctuant mass, deviation of the uvula, odynophagia, and drooling. Many of these patients have a history of being recently treated for strep throat. The abscess is usually unilateral and in the superior pole of the tonsil. Airway patency must be assessed because of the obstructing potential of an abscess. As with most abscesses, drainage—either through needle aspiration or incision and drainage—is the most important factor in treating these patients. However, antibiotics are useful adjunctive medications and should be prescribed. The abscess will not resolve without an attempt at drainage. Antibiotics and pain control alone (b) are not sufficient. Incision and drainage of Centor criteria 4 points 2-3 points 0-1 point No further tests No antibiotics Rapid antigen test Treat with antibiotic Throat culture Treat with antibiotics No further testing + − Centor Criteria Points Presence of tonsillar exudates +1 Tender anterior cervical adenopathy +1 Fever by history +1 Absence of cough +1 Age <15 years +1 Age >45 years −1Fever Answers 195 the abscess may be performed in the OR (c) if the abscess is large, complicated, or the patient’s airway shows signs of compromise. However, this is not necessary in the patient described. Drainage of the abscess is the most important factor in treating these patients. Antibiotics alone (d) are not sufficient. A CT scan (e) may aid in the diagnosis of a peritonsillar abscess in patients with severe trismus, but should be ordered with caution given the potential for airway compromise. In this patient, it would be an unnecessary risk as he could be examined adequately.

Question 15

A 50-year-old man presents to the ED complaining of fever, headache, and neck pain for 24 He states that 1 week ago he had rhinorrhea, nasal congestion, a sore throat, and occasional dry cough. He noted gen- eralized weakness, myalgias, and malaise yesterday afternoon, and woke up today “feeling terrible.” His BP is 145/75 mm Hg, HR is 102 beats per minute, temperature is 101.2°F, and his RR is 16 breaths per minute. On examination, he is awake, alert, and nontoxic appearing although he has discomfort in his neck with flexion. He has a nonfocal neurologic examina- tion without increased deep tendon reflexes or opthalmoplegia. There are no rashes. Which of the following CSF results is most consistent with your clinical diagnosis of viral meningitis?

A	Identification of viral particles on Gram stain with an elevated CSF-to-serum glucose level
B	A mildly elevated total protein level with a decreased glucose level
C	A mildly elevated total protein level with a WBC count of fewer than 500 cells/mm3
D	Increased turbidity with marked xanthochromia
E	A markedly elevated lymphocyte count, often exceeding 100,000 cells/mm3 with a mildly elevated total protein level

Question 15 Explanation:

Viral meningitis is an uncommon complication of viral infection and can follow seemingly mild respiratory, gastrointestinal, or urogenital infections. Viral meningitis is typically milder than bacterial meningitis and is often self-limited infection, though it may be associated with encephalitis (sometimes known as meningoencephalitis). Patients may often complain of preceding viral symptoms or have evidence of concurrent infection. Unfortunately, the physical findings in meningitis vary widely and many patients will lack the classic findings of meningeal irritation such as Kernig and Brudzinski signs. LP is necessary to confirm the diagnosis. Common CSF findings include mildly elevated protein levels and WBC counts with normal glucose levels and polymorphonuclear neutrophil (PMN) and eosinophil counts. There is no specific treatment for viral meningitis and treatment often is based on supportive care with antipyretics, pain medications, and fluids. While specific viruses (such as West Nile virus and herpes simplex virus) can be identified in the CSF, they are not identified (a) by Gram stain. Additionally, patients with viral meningitis should have normal glucose levels (b) and, therefore, also have normal CSF-to-serum glucose level. Turbidity (d) refers to cloudiness due to leukocytosis at levels above 200 cells/mm3 and should be only mild in cases of viral meningitis. Xanthochromia, a yellowish discoloration that results from RBC breakdown, raises the concern for subarachnoid hemorrhage. While the lymphocyte count may be mildly elevated (e), the WBC count is rarely elevated above 500 cells/mm3.

Question 16

A 32-year-old woman presents to the ED with 7 days of vaginal discharge and pelvic She is sexually active and admits to several recent “one night stands.” She denies trauma/injury and does not have any urinary or other abdominal complaints. Her HR is 85 beats per minute, BP is 135/90 mm Hg, RR is 18 breaths per minute, and temperature is 101.4°F. On bimanual examination, you note a copious, thin, white discharge with mild diffuse adnexal tenderness with significant cervical motion tender- ness. There are no rashes, skin lesions, or adenopathy. Laboratory results are notable for a WBC of 18,000/mL. A urinalysis shows WBCs but is other- wise within normal limits. Which of the following is the most appropriate next step in management?

A	Prescribe her a 14-day course of levofloxacin (500 mg PO once per day) and urgent gynecology follow-up within 1 week.
B	Give her a dose of metronidazole (2 g PO) and prescribe her a 14-day course of cephalexin (500 mg) with urgent gynecology follow-up within 1 week.
C	Give her a one-time dose of oral metronidazole (2 g PO), azithromycin (1 g PO), and ceftriaxone (250 mg IM) with gynecology follow-up if she is not feeling better.
D	Give her a one-time dose azithromycin (1 g PO), and ceftriaxone (250 mg IM) with urgent gynecology follow-up within 1 week.
E	Give her a dose of ceftriaxone (250 mg IM), and prescribe her a 10-day course of doxycycline (100 mg PO BID) with urgent gynecology follow-up within 1 week.

Question 16 Explanation:

The patient has pelvic inflammatory disease (PID), due to an ascending vaginal or cervical infection. Chlamydia trachomatis and N gonorrhoeae are the most common causative organisms, but PID is often polymicrobial and numerous other organisms have been implicated. PID may be difficult to diagnose because196 Emergency Medicine it has a wide variety of presenting signs and symptoms, including lower abdominal or pelvic pain, vaginal discharge, abnormal vaginal or cervical bleeding, low-grade fevers, and nonspecific systemic symptoms (such as myalgias, malaise, and nausea). However, a hallmark of PID is the finding of significant cervical motion tenderness on bimanual pelvic examination. Current recommendations for the treatment of PID are varied and change frequently but generally require 10 days of total treatment. Most patients with PID can be safely discharged from the ED, but consideration for admission should be given to patients who appear toxic, are pregnant, have failed outpatient therapy, or have a concurrent intrauterine device (IUD) or tubo-ovarian abscess. A 14-day course of levofloxacin (a) may be an appropriate treatment for pyelonephritis but is inappropriate antibiotic coverage for PID. A onetime dose of metronidazole (b) may treat trichomonas but is also inappropriate coverage for PID, even if combined with cephalexin. A one-time dose of the combination azithromycin and ceftriaxone (d) may be used to treat cervicitis but is not approved for the treatment of PID. When trichomonas cannot be excluded, metronidazole may be added (c) but is not approved for the treatment of PID.

Question 17

A 45-year-old woman presents to the ED complaining of 3 days of fever and worsening throat pain and painful odynophagia without cough or coryza. She sits on a chair, leaning forward with her mouth slightly She is refusing to swallow and has a cup of saliva and a box of facial tissues at her side. Vitals are HR of 120 beats per minute, BP of 110/70 mm Hg, RR of 22 breaths per minute, oxygen saturation of 99% on room air, and temperature of 102.8°F. You note a slight wheezing noise coming from her anterior neck. Her voice is hoarse and she is able to open her mouth fully, making her examination quite difficult. From what you can visualize, her posterior oropharynx is moderately hyperemic, without exudates or ton- sillar enlargement. A soft tissue lateral cervical radiograph shows marked edema of the prevertebral soft tissues and absence of the vallecular space. Which of the following is the most likely diagnosis?

A	Retropharyngeal abscess
B	Peritonsillar abscess
C	Epiglottitis
D	Pharyngitis
E	Laryngotracheitis

Question 17 Explanation:

Epiglottitis is a lifethreatening inflammatory condition, usually infectious, of the epiglottis and the aryepiglottic and periglottic folds. Because most children are immunized against Haemophilus influenzae type B (Hib), most cases of epiglottitis are now seen in adults, with an average age of 46 years. Signs and symptoms include a prodromal period of 1 to 2 days consisting of constitutional symptoms, and then the patient exhibits high fever, dysphagia, odynophagia, drooling, inspiratory stridor, and dyspnea. The “thumbprint sign” (described in the question) is seen on lateral cervical radiograph that demonstrates a swollen epiglottis obliterating the vallecula. Retropharyngeal abscess (a) can present with similar signs and symptoms as epiglottitis. Cervical lymphadenopathy is prominent and inflammation may be so severe that patients develop an inflammatory torticollis, causing the patient to rotate the head toward the affected side. Soft tissue cervical radiograph may demonstrate excess prevertebral swelling. Treatment is IV hydration and antibiotics, which should be started in the ED, and drainage in the OR. Peritonsillar abscess (b) presents with a unilaterally swollen and erythematous tonsil and uvula deviation toward the unaffected side. It is most common during the second and third decades of life. CT scan orFever Answers 197 ultrasound easily makes the diagnosis, but aspiration of purulent material is sufficient for diagnosis. Treatment is incision and drainage or needle aspiration, followed by high-dose penicillin or clindamycin. Pharyngitis (d) is an infection of the pharynx and tonsils that occur in adults, but has a peak incidence in children aged 4 to 7 years. The etiology is most often viral. Streptococcus pyogenes (group A β-hemolytic strep) is the most common cause of bacterial pharyngitis (5%-15%) in adults. Patients present with erythematous tonsils, tonsillar exudates, and enlarged and tender anterior cervical lymph nodes. Laryngotracheitis, or croup, (e) presents with stridor but lacks the other oropharyngeal findings and is generally seen in children aged 6 months to 3 years.

Question 18

A 19-year-old woman presents with 4 days of bilateral lower abdominal pain right greater than She also complains of a fever, nausea, vomiting, and general malaise. Her last menstrual period was 5 days ago. Vitals are HR 98 beats per minute, BP 110/65 mm Hg, RR 18 breaths per minute, and temperature of 102.7°F. Pelvic examination demonstrates exquisite cervical motion tenderness and right adnexal tenderness. Laboratory reports are notable for a WBC 15,000/mL, an ESR of 95 mm/h, and a negative urine

b-human chorionic gonadotropin (b-hCG). Transvaginal ultrasound dem- onstrates a right complex mass with cystic and solid components. Which of the following is the most appropriate next step in management?

A	Prescribe her a 14-day course of levofloxacin (500 mg PO once per day) and urgent gynecology follow-up within 1 week.
B	Give her a dose of metronidazole (2 g PO) and prescribe her a 14-day course of cephalexin (500 mg) with urgent gynecology follow-up within 1 week.
C	Give her a one-time dose of oral metronidazole (2 g PO), azithromycin (1 g PO), and ceftriaxone (250 mg IM) with gynecology follow-up if she is not feeling better.
D	Given her a one-time dose with emergent gynecology consultation for possible laparoscopic drainage.
E	Give her a dose of ceftriaxone (250 mg IM), and prescribe her a 10-day course of doxycycline (100 mg PO BID) with urgent gynecology follow-up within 1 week.

Question 18 Explanation:

This patient has a tuboovarian abscess (TOA), a common and potentially fatal complication of PID. While PID can usually be treated with outpatient antibiotics, patients with a TOA should be admitted for IV antibiotics, observation, and drainage if there is no response to medical management. Antibiotics should be directed at Chlamydia trachomatis and N gonorrhoeae, and may be curative in 60% to 80% of cases. A 14-day course of levofloxacin (a) may be an appropriate treatment for pyelonephritis but is inappropriate antibiotic coverage for TOA. A onetime dose of metronidazole (b) may treat trichomonas but is inappropriate coverage for TOA, even if combined with cephalexin. A one-time dose of the combination metronidazole, azithromycin, and ceftriaxone (c) may be used to treat cervicitis and bacterial vaginosis but is not approved for the treatment of PID or TOA. When bacterial vaginosis cannot be excluded, metronidazole may be added (c) but is not approved for the treatment of PID.

Question 19

A 42-year-old IV drug user presents to the ED with fever, chills, pleuritic chest pain, myalgias, and general The patient’s vitals include an HR of 110 beats per minute, BP of 110/65 mm Hg, RR of 18 breaths per minute, and temperature of 103.4°F. Physical examination is notable for retinal hemorrhages, petechiae on the conjunctivae and mucous mem- branes, a faint systolic ejection murmur, and splenomegaly. Which of the following is the most likely diagnosis?

A	Disseminated gonorrhea
B	Myocarditis
C	Pericarditis
D	Infectious mononucleosis
E	Endocarditis

Question 19 Explanation:

Symptoms of endocarditis are nonspecific and vary widely, but the most common include fever (85%) and malaise (80%). In IV drug users, fever is present 98% of the time. Other symptoms include weakness, myalgias, dyspnea, chest pain, cough, headache, and anorexia. Neurologic signs and symptoms (eg, confusion, personality changes, decreased level of consciousness, and focal motor deficits) are seen in 30% to 40% of patients. Vasculitic lesions, including petechiae, splinter hemorrhages, tender fingertip nodules (Osler nodes), and nontender palmar plaques (Janeway lesions), are seen in 35% of patients. Splenomegaly, new heart murmur, and retinal hemorrhages may also be detected on physical examination. Risk factors for infective endocarditis198 Emergency Medicine include rheumatic or congenital heart disease, calcific degenerative valve disease, prosthetic heart valve, mitral valve prolapse, a history of IV drug use, or a history of endocarditis. Although any valve can be affected, IV drug use is the most common cause of right-sided endocarditis. The recurrence rate in these patients is 41%, significantly higher than the rate of < 20% in non-IV drug users. Disseminated gonorrhea (a) often presents with the arthritis-dermatitis syndrome of fevers/chills, arthralgias, a rash, and tenosynovitis. One would not expect splenomegaly or vasculitic lesions. Myocarditis (b) is often infectious and results from inflammatory damage to the myocardium and presents with flu-like complaints, including fever, fatigue, and myalgias. Tachycardia out of proportion to the temperature or clinical picture may be present, but vasculitic lesions are not expected. Bacteria and enteroviruses, especially Coxsackie B virus and adenovirus, predominate as causative agents in the United States while Chagas disease is the leading cause, worldwide. Pericarditis (c) is caused by inflammation of the pericardial sac. The etiology is broad, including infection, trauma, metabolic diseases (eg, uremia), medications, systemic autoimmune diseases, and most often the cause is idiopathic. The diagnosis of infectious mononucleosis (d), a syndrome caused by the Epstein-Barr virus, is often made based on the triad of fever and chills, pharyngitis, and tender cervical lymphadenopathy.

Question 20

A 51-year-old diabetic man complains of intense right-ear pain and discharge. On physical examination, his BP is 145/65 mm Hg, HR 91 beats per minute, and temperature 101°F. He withdraws when you retract the pinna of his The external auditory canal is erythematous, edematous, and contains what looks like friable granulation tissue in the external audi- tory canal. The tympanic membrane is partially obstructed but appears to be erythematous, as well. You make the presumptive diagnosis of necrotiz- ing (malignant) otitis externa. Which of the following statements regarding this condition is true?

A	It is an uncommon complication of otitis media in otherwise healthy patients.
B	The mainstay of treatment is outpatient with oral antibiotics.
C	Cranial nerve IX palsy is the most common complication.
D	Pseudomonas aeruginosa is the most common causative organism.
E	Hearing loss is the most common complication.

Question 20 Explanation:

Necrotizing otitis externa (formerly known as malignant otitis externa) is an uncommon complication of otitis externa that occurs primarily in adult diabetics and other immunocompromised individuals. It is primarily caused by a very aggressive P aeruginosa infection and is associated with a high mortality rate. The infection typically starts in the external ear canal and then progresses through the tissues into the bony junction of the external auditory meatus, base of the skull, and adjacent soft tissues. Thus, the condition is actually better described as an osteitis of the bone of the external auditory canal. It is distinguished by fever, intense ear pain, erythema, edema, and granulation tissue in the external canal. Cranial nerve palsies (CN VII, IX, X, and XI) and trismus can also occur. These patients require hospitalization and treatment with broad-spectrum, antipseudomonal IV antibiotics. Patients also require emergent ENT consultation for possible surgical debridement. (a) Malignant otitis externa is rare in immunocompetent. Patients are usually diabetics, debilitated, or immunocompromised. (b) Owing to its high morbidity and mortality, this condition requires in-patient managementFever Answers 199 with IV antibiotics. Although hearing loss (e) is a possibility, the most common cranial nerves involved is the facial nerve (cranial nerve VII), (c) but cranial nerves IX, X, and XI can also be involved.

Question 21

A 26-year-old woman presents to the ED with fever, malaise, and an evolving rash in the right axilla that she initially thought was from an insect bite that she received while hiking 1 week She complains of generalized fatigue, nausea, headache, and joint pain over the past several days. Her vitals are BP of 120/75 mm Hg, HR of 75 beats per minute, RR of 16 breaths per minute, and temperature of 101°F. On physical exami- nation, she is awake and alert, with a nonfocal neurologic examination. Her neck is supple, but she is diffusely tender over the shoulder, knee, and hip joints bilaterally without any distinct effusions. Her abdomen is soft and nontender. She has a 9-cm erythematous annular plaque with partial central clearing and a bright red outer border and a target center under her right axilla. Which of the following is the next best step?

A	Treat empirically with broad-spectrum antibiotics and consult dermatology emergently for a biopsy of the rash.
B	Treat empirically for a cellulitis with cephalexin for 10 days and arrange follow-up with her primary care doctor.
C	Treat empirically for Lyme disease with doxycycline for 21 days and arrange follow-up with her primary-care doctor.
D	Treat empirically for an allergic dermatitis with prednisone, diphenhydramine, and famotidine for 3 days, and arrange follow-up with her primary care doctor.
E	Perform serologic testing for Borrelia burgdorferi to confirm the diagnosis of Lyme disease and arrange follow-up with her primary care doctor.

Question 21 Explanation:

Lyme disease is the most common vector-borne disease in the United States and is particularly prevalent in the northeast and upper midwest during late spring and early summer. It is caused by the spirochete B burgdorferi that is spread through the bite of the Ixodes tick. Lyme disease has three stages: early localized, early disseminated, and late. It typically begins with a target rash (known as erythema migrans [EM]) and associated flu-like symptoms. EM is the most characteristic clinical manifestation of Lyme disease and is recognized in 90% or more of patients. However, if untreated, neurologic, joint, or cardiac symptoms develop weeks to months later. These are followed by chronic arthritic and neurologic abnormalities weeks to years later. Recommended treatment for early Lyme disease includes doxycycline, amoxicillin (for children < 8 years or for pregnant or lactating women), or cefuroxime for a period of 3 weeks. The same drugs can be used for the second stage of disease, but their course of therapy needs to be longer. Neurologic disease requires long-term IV antibiotics. Unfortunately, routine laboratory studies are nonspecific and nondiagnostic. This patient has early localized Lyme disease, and should be treated empirically based on the presence of the rash. Serologic testing may be positive weeks after inoculation, but a biopsy of the rash (a) would neither be necessary nor informative. Although the patient presents with an erythematous rash surrounding a purported bug bite, the classic appearance indicates erythema migrans and treatment for cellulitis (b) is inappropriate. It would also be inappropriate to mistake this for an urticarial rash and thus treat the patient for a cutaneous allergic reaction (d). Confirmatory serologic testing should be performed (e), but empiric treatment based on the presumptive diagnosis should not be delayed.

Question 22

A 22-year-old man without medical complaints presents to the ED with a 3-day history of fever, malaise, and He denies chest pain, shortness of breath, nausea or vomiting, abdominal pain, cough, sore throat, genitourinary symptoms, or respiratory tract complaints. On exam- ination, the patient’s BP is 100/60 mm Hg, HR is 110 beats per minute, RR is 20 breaths per minute, and temperature is 102°F. He appears awake, alert, and comfortable. His physical examination is normal. Which of the following is the most appropriate next step in management?

A	Discharge him with antipyretics and follow up with his primary care doctor in 1 or 2 days for a repeat examination.
B	Order a CBC, urinalysis, and chest x-ray. If normal, discharge him with anti- pyretics and follow up with his primary care doctor in 1 or 2 days for a repeat examination.
C	Order a CBC, urinalysis, chest x-ray, and two sets of blood cultures. If normal, discharge him with antipyretics and follow up with his primary care doctor in 1 or 2 days for a repeat examination.
D	Order a CBC, urinalysis, chest x-ray, two sets of blood cultures, and perform an LP. If normal, discharge him with antipyretics and follow up with his primary care doctor in 1 or 2 days for a repeat examination.
E	Order a CBC, urinalysis, chest x-ray, two sets of blood cultures, and perform an LP. Start empiric IV antibiotics and admit him for observation.

Question 22 Explanation:

Fever is a very common presenting complaint to the emergency department and is associated with a high morbidity and mortality in pediatric and geriatric patients. In younger adults, however, fever is usually a benign disease or self-limited viral syndrome. Adult patients presenting with a fever should be assessed for the duration and magnitude of associated symptoms, recent travel, chronic illnesses, prior surgeries, and physical findings that suggest an infectious200 Emergency Medicine source. Stable, healthy patients without localizing signs and symptoms can be safely discharged with antipyretics. However, for elderly patients, the immunocompromised, and patients with chronic illness, admission to the hospital is usually warranted. Patients with unstable vital signs or lifethreatening symptoms should be admitted to the ICU. In this young, healthy adult man with stable vital signs and nonlocalizing signs and symptoms, additional evaluation (b, c, d) and initiation of antibiotics (e) is unnecessary.

Question 23

A 54-year-old man with a history of hepatitis C, alcohol abuse, and cirrhotic ascites presents with increasing abdominal girth and abdominal pain. He complains of increasing difficulty breathing, especially when lying down, caused by worsening On physical examination, the patient is cachectic and appears older than his stated age. He has a diffusely tender abdomen and tense ascites. The liver is palpable 4 cm below the costal margin. Vitals include a BP of 110/65 mm Hg, HR of 110 beats per minute, RR of 22 breaths per minute, and temperature of 102°F. Which of the follow- ing is the most common organism seen in spontaneous bacterial peritonitis?

A	Pseudomonas aeruginosa
B	Enterococcus
C	Streptococcus pneumoniae
D	Enterobacteriaceae
E	Streptococcus viridans

Question 23 Explanation:

Spontaneous bacterial peritonitis (SBP) is a common complication of cirrhotic ascites and should be suspected in all patients with a history of cirrhosis who present with fever, abdominal pain or tenderness, worsening ascites, or encephalopathy. Paracentesis should be performed to confirm the diagnosis. Ascitic fluid should be tested for glucose, total protein, lactate dehydrogenase (LDH), Gram stain, WBC count, and sent for culture. Total WBC count > 1000/μL or neutrophil count > 250/μL is diagnostic for SBP. Gram-negative Enterobacteriaceae (such as E coli and Klebsiella) account for up to 65% of all cases. Empiric treatment for suspected SBP includes third-generation cephalosporins, ticarcillin-clavulanic acid, piperacillin-tazobactam, or ampicillinsulbactam. (a, b, c, and e) Other causes of SBP include S pneumoniae and S viridans (15%), enterococci (6%-10%), and anaerobes (1%).

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II. Preview all questions below

1. A 43-year-old man, who currently uses drugs intravenously (IV), presents to the emergency department (ED) with 2 weeks of fever, back pain, and progressive weakness in his legs He denies any history of trauma or prior surgery. His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 106 beats per minute, temperature is 103°F, and respiratory rate (RR) is 16 breaths per minute. On physical examination, he has ten- derness to palpation in the mid-lumbar spine, increased patellar reflexes, and decreased strength in the lower extremities bilaterally, with normal range of motion. Laboratory results reveal a white blood cell (WBC) count of 15,500/mL, hematocrit 40%, and platelets 225/mL. Urinalysis and spi- nal x-rays are unremarkable. Which of the following is the most likely diagnosis?

Fibromyalgia
Ankylosing spondylitis
Spinal epidural abscess
Vertebral compression fracture
Spinal metastatic lesion

2. An 81-year-old woman is brought to the ED by her children who state that the patient is acting more tired than usual, has had fever for the last 2 days, and is more Ordinarily, the patient is high functioning: she is ambulatory, cooks for herself, and walks on a treadmill 30 minutes a day. Her vital signs are BP 85/60 mm Hg, HR 125, RR 20, temperature 101.3°F, and pulse oxygenation 97% on room air. On examination, the patient has dry mucous membranes but is otherwise unremarkable. She is oriented to person and place but states that the year is 1925. Her laboratory results show a WBC 14,300/mL, hematocrit 31%, and platelets 350/mL. Her elec- trolytes are within normal limits. Blood glucose is 92 mg/dL. A chest radio- graph does not show any infiltrates. Urinalysis reveals 2+ protein, trace ketones, WBC > 100/hpf, red blood cell (RBC) 5 to 10/hpf, nitrite positive, and leukocyte esterase positive. After administering a 500-cc normal saline fluid bolus and broad-spectrum antibiotics through her peripheral IV line, the patient’s BP is 82/60 mm Hg. You suspect that the patient is in septic shock due to an acute urinary tract infection. Which of the following is the next most appropriate course of action to manage this patient with early- goal-directed therapy (EGDT)?

Immediately start a norepinephrine infusion to increase the blood pressure given the low systolic blood pressure.
Prepare to transfuse uncrossed matched packed RBC to increase oxygen-carrying capacity given the low hematocrit.
Place a central venous line into the right internal jugular vein to measure central venous pressure (CVP).
Transport the patient to radiology for a stat CT scan of her head given the acute change in mental status.
Place a central venous line into the right internal jugular vein to measure mixed venous oxygen saturation (SVO2).

3. A 23-year-old man presents to the ED with left lower abdominal pain and left testicular pain that started 1 to 2 weeks ago and has gradually wors- He has some nausea and vomiting. His HR is 98 beats per minute, BP is 125/65 mm Hg, temperature is 100.9°F, and RR is 18 breaths per min- ute. Physical examination reveals a tender left testicle with a firm nodular- ity on the posterolateral aspect of the testicle. Pain is relieved slightly with elevation of the testicle and the cremasteric reflex in normal. You make the presumptive diagnosis of epididymitis. Which of the following is the next best step?

Prescribe pain medications and penicillin for coverage of syphilis, the most likely causative organism.
Recommend bed rest, ice, and scrotal elevation with prompt urology follow-up.
Give ceftriaxone 125 mg intramuscularly (IM), plus a one-time dose of azithro- mycin 1 g orally.
Give ceftriaxone 250 mg intramuscularly (IM), plus a 10-day course of oral doxycycline.
Confirm the diagnosis with transillumination of the testicle, and then consult urology for surgical drainage.

4. A 40-year-old man with insulin-dependent diabetes presents to the ED with complaints of 2 days of increasingly severe perineal pain and subjective fevers. His HR is 118 beats per minute, BP is 95/55 mm Hg, temperature is 4°F, and RR is 22 breaths per minute. The bedside sugar reading is “high.” Physical examination demonstrates crepitus over the medial thigh and widespread erythema and purple discoloration with sharp demarca- tion over the scrotum. The scrotum is markedly tender, warm, and edema- tous. Which of the following is the most likely diagnosis?

Cutaneous candidiasis
Fournier syndrome
Phimosis
Paraphimosis
Testicular torsion

5. A 55-year-old man with a history of diabetes presents with com- plaints of developed left knee pain several days following a fall from stand- ing The patient was brought to the ED by ambulance after being found on a park bench stating he was unable to walk because of the pain. On physical examination, there are no rashes or external signs of trauma. His left knee is warm, diffusely tender, and swollen with a large effusion. He has pain on passive range of motion and is refusing to walk. His BP is 150/85 mm Hg, HR is 105 beats per minute, temperature is 102.7°F, RR is 16 breaths per minute, and fingerstick glucose is 89 mg/dL. Which of the following is the most appropriate diagnostic test?

Knee radiographs
Magnetic resonance imaging (MRI)
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
Arthrocentesis
Bone scan

6. A 35-year-old woman with systemic lupus erythematosus (SLE) is brought to the ED by her brother after he found her febrile and Physical examination reveals fever, tachycardia, a waxing and waning men- tal status, petechiae over her oral mucosa, pallor, and mildly heme-positive stool. Her urinalysis is positive for blood, red cell casts, and proteinuria. Laboratory results reveal blood urea nitrogen (BUN) of 40 mg/dL and crea- tinine of 2 mg/dL. Her bilirubin is elevated (unconjugated > conjugated) and her international normalized ratio (INR) is 0.98. Her complete blood count reveals WBC 12,000/mL, hematocrit 29%, and platelet count 17,000/mL with schistocytes on the peripheral smear. Which of the following is the most appropriate next step in management?

Admit to the intensive care unit (ICU) for plasmapheresis and close monitoring for acute bleeds.
Admit to the ICU for platelet transfusion and monitoring for acute bleeds.
Admit to the ICU for corticosteroid infusion, transfusion of platelets, and prompt surgical consultation for emergent splenectomy.
Admit to the ICU for dialysis and close monitoring for acute bleeds.
Perform a noncontrast head computed tomography (CT) to screen for intracra- nial bleeding and mass effect followed by a lumbar puncture (LP) for analysis of cerebrospinal fluid (CSF). If negative, admit to telemetry for hemodynamic monitoring.

7. A 30-year-old woman presents to the ED with fever, headache, a “sunburn-like” rash, and A friend states that the patient has complained of nausea, vomiting, diarrhea, and a sore throat over the past few days. Her last menstrual period began 4 days ago. Vital signs are HR 110 beats per minute, BP 80/45 mm Hg, RR of 18 breaths per minute, and temperature of 103°F. On physical examination, you note an ill-ap- pearing woman with a diffuse blanching erythroderma. Her neck is supple without signs of meningeal irritation. On pelvic examination, you remove a tampon. You note a fine desquamation of her skin, especially over the hands and feet, and hyperemia of her oropharyngeal, conjunctival, and vaginal mucous membranes. Laboratory results reveal a creatine phospho- kinase (CPK) of 5000, WBC 15,000/mL, platelets of 90,000/mL, BUN 40 mg/dL, creatinine 2 mg/dL, and elevated liver enzymes. You suspect the diagnosis of toxic shock syndrome and initiate IV fluids. You target antibi- otics at which of the following causative organism?

Staphylococcus aureus
Rickettsia rickettsii
Streptococcus pyogenes
Neisseria meningitidis
Neisseria gonorrhoeae

8. A 32-year-old diabetic man presents to the ED with a fever and 1 week of increasing right foot He states he stepped on a nail while running barefoot 2 weeks ago but didn’t think much of it at that time. On physical examination, his heel is mildly erythematous and diffusely tender to palpation, with overlying warmth and edema. There is a small amount of purulent drainage through the puncture hole in his heel. A plain radio- graph of his foot demonstrates a slight lucency of the calcaneus. He has decreased range of motion, but you are able to passively dorsiflex and plan- tarflex his ankle without difficulty. His vital signs include a temperature of 101.4°F, HR of 98 beats per minute, BP of 130/75 mm Hg, and RR of 16 breaths per minute. Which of the following is the most common caus- ative organism of this condition?

Salmonella sp
Pseudomonas aeruginosa
Staphylococcus aureus
Group B streptococci
Pasteurella multocida

9. A 75-year-old woman is transferred to your ED from the local nurs- ing home for fever, cough, and increasing Over the past 3 days, the nursing home staff noticed increasing yellow sputum and decreasing urine output from the patient. Her BP is 118/75 mm Hg, RR is 20 breaths per minute, HR is 105 beats per minute, temperature is 100.9°F, and pulse oxygenation is 94% on room air. On examination, auscultation of the lungs reveals bibasilar crackles. Laboratory results reveal WBC 14,500/mL, hema- tocrit 39%, platelets 250/mL, sodium 132 mEq/L, potassium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 18 mEq/L, BUN 27 mg/dL, creatinine 1.5 mg/dL, and glucose 85 mg/dL. Serum lactate is 4.7 mmol/dL. Chest radiography reveals bilateral lower lobe infiltrates. Based on this patient’s presentation, which of the following is the most likely diagnosis?

Hospital-acquired pneumonia (HAP)
Community-acquired pneumonia (CAP)
Health care–associated pneumonia (HCAP)
Ventilator-associated pneumonia (VAP)
Atypical pneumonia

10. A 55-year-old man presents to the ED with fever, drooling, tris- mus, and a swollen He reports a foul taste in his mouth caused by a tooth extraction 2 days ago. On physical examination, the patient appears anxious. He has bilateral submandibular swelling and elevation and pro- trusion of the tongue. He appears “bull-necked” with tense and markedly tender edema and brawny induration of the upper neck, and he is tender over the lower second and third molars. There is no cervical lymphade- nopathy. These lungs are clear to auscultation with good air movement. His vital signs are HR 105 beats per minute, BP 140/85 mm Hg, RR 26 breaths per minute, and temperature 102°F. Which of the following is the most appropriate next step in management?

Obtain a sample for culture, administer a dose of IV antibiotics, and obtain a soft tissue radiograph of the neck.
Obtain a sample for culture, perform a broad incision and drainage at bedside, and administer a dose of IV antibiotics.
Administer a dose of IV antibiotics and obtain a CT scan of the soft tissues of the neck.
Administer a dose of IV antibiotics, obtain a CT scan of the soft tissues of the neck, and obtain an emergent ENT consult.
Secure his airway, administer a dose of IV antibiotics, and obtain an emergent ENT (ear, nose, and throat) consult.

11. A 67-year-old woman with a history of steroid-dependent COPD, non–insulin-dependent diabetes, and hypertension presents to the ED with complaints of a painful, red, swollen left lower She states she noted a “bug bite” in that area 1 week ago and since then has had gradually increasing symptoms. On examination, you note a 12 cm ´ 10 cm sharply demarcated area of blanching erythema, warmth, and tenderness on the medial thigh with ascending erythema to the groin. You also note tender adenopathy in the left inguinal region. Her BP is 90/55 mm Hg, RR is 24 breaths per minute, HR is 105 beats per minute, temperature is 102.4°F, and pulse oxygenation is 98% on room air. Laboratory results reveal WBC 19,500/mL, hematocrit 39%, platelets 175/mL, sodium 132 mEq/L, potas- sium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 14 mEq/L, BUN 32 mg/dL, creatinine 1.7 mg/dL, and glucose 455 mg/dL. Serum lactate is 4.7 mmol/dL. Which of the following best describes her clinical state?

She has systemic inflammatory response syndrome (SIRS).
She has sepsis.
She has severe sepsis.
She is in septic shock.
She has multiple organ dysfunction syndrome (MODS).

12. An 84-year-old man presents to the ED with his family due to concerns that his condition is worsening despite being placed on levofloxacin for a urinary tract infection 5 days ago by his primary care His is obtunded and unable to give any additional history. Physical examination does not reveal the source of infection. His BP is 84/45 mm Hg, HR is 135 beats per minute, tem- perature is 102.8°F, and his RR is 28 breaths per minute. Laboratory results reveal WBC 24,500/mL, hematocrit 19%, platelets 90/mL, sodium 132 mEq/L, potas- sium 7.5 mEq/L, chloride 100 mEq/L, bicarbonate 12 mEq/L, BUN 37 mg/dL, creatinine 6.5 mg/dL, and glucose 255 mg/dL. Serum lactate is 11.3 mmol/ dL. Cardiac enzymes and troponin are mildly elevated, and he has hyperacute T-waves on electrocardiogram (ECG). His chest radiograph shows cardiomeg- aly with bilateral patchy opacities and pulmonary vascular congestion. Rapid urinalysis reveals 3+ WBCs and blood and nitrates. You secure his airway with intubation, initiate broad-spectrum antibiotics, IV fluids, and other supportive therapies, and emergently consult nephrology, cardiology, and pulmonology. Which of the following best describes his clinical state?

He has SIRS.
He has sepsis.
He has severe sepsis.
He is in septic shock.
He has MODS.

13. A 37-year-old man presents to the ED with complaints of 2 days of a sore throat and subjective fever at He denies cough or vomiting. His BP is 130/75 mm Hg, HR is 85 beats per minute, temperature is 101°F, and his RR is 14 breaths per minute. He has diffuse tonsillar swelling and bilateral exudates with bilaterally enlarged and tender lymph nodes of the neck. Which of the following is the next best step in management?

Administer penicillin and discharge the patient without further testing.
Perform a rapid antigen test. If it is negative, confirm with a throat culture, and administer penicillin if the results are positive.
Perform a rapid antigen test. If it is negative, administer penicillin and discharge the patient.
Perform a rapid antigen test. If it is positive, administer penicillin and discharge the patient.
Discharge the patient without treatment or further testing.

14. A 37-year-old man who just finished a full course of penicillin for pharyngitis presents to the ED requesting to be checked out He states he took the antibiotics exactly as prescribed and initially felt some- what improved, but over the last 2 to 3 days has had increased pain and progressive difficulty swallowing. His BP is 130/65 mm Hg, HR is 95 beats per minute, temperature is 100.1°F, RR is 16 breaths per minute, and oxygen saturation is 99%. On examination, the patient is in no acute distress but has a fluctuant mass on the right side of his neck. You visualize a normal soft palate with swelling of the right tonsillar arch and deviation of the uvula to the left, but additional examination is limited because he is unable to open his mouth fully. Review of his records reveals a throat culture that was positive for Streptococcus. Which of the following is the most appropri- ate next step in management?

Attempt needle aspiration, treat him with a new course of antibiotics (either penicillin or clindamycin), and have him return in 24 hours.
Give him morphine for pain control, give him a dose of IV antibiotics, and observe him in the ED for 6 hours.
Admit him for incision and drainage in the OR under general anesthesia.
Switch his antibiotic to clindamycin and have him return in 24 hours.
Order a CT scan to visualize his neck, continue the penicillin, and have him return in 24 hours.

15. A 50-year-old man presents to the ED complaining of fever, headache, and neck pain for 24 He states that 1 week ago he had rhinorrhea, nasal congestion, a sore throat, and occasional dry cough. He noted gen- eralized weakness, myalgias, and malaise yesterday afternoon, and woke up today “feeling terrible.” His BP is 145/75 mm Hg, HR is 102 beats per minute, temperature is 101.2°F, and his RR is 16 breaths per minute. On examination, he is awake, alert, and nontoxic appearing although he has discomfort in his neck with flexion. He has a nonfocal neurologic examina- tion without increased deep tendon reflexes or opthalmoplegia. There are no rashes. Which of the following CSF results is most consistent with your clinical diagnosis of viral meningitis?

Identification of viral particles on Gram stain with an elevated CSF-to-serum glucose level
A mildly elevated total protein level with a decreased glucose level
A mildly elevated total protein level with a WBC count of fewer than 500 cells/mm3
Increased turbidity with marked xanthochromia
A markedly elevated lymphocyte count, often exceeding 100,000 cells/mm3 with a mildly elevated total protein level

16. A 32-year-old woman presents to the ED with 7 days of vaginal discharge and pelvic She is sexually active and admits to several recent “one night stands.” She denies trauma/injury and does not have any urinary or other abdominal complaints. Her HR is 85 beats per minute, BP is 135/90 mm Hg, RR is 18 breaths per minute, and temperature is 101.4°F. On bimanual examination, you note a copious, thin, white discharge with mild diffuse adnexal tenderness with significant cervical motion tender- ness. There are no rashes, skin lesions, or adenopathy. Laboratory results are notable for a WBC of 18,000/mL. A urinalysis shows WBCs but is other- wise within normal limits. Which of the following is the most appropriate next step in management?

Prescribe her a 14-day course of levofloxacin (500 mg PO once per day) and urgent gynecology follow-up within 1 week.
Give her a dose of metronidazole (2 g PO) and prescribe her a 14-day course of cephalexin (500 mg) with urgent gynecology follow-up within 1 week.
Give her a one-time dose of oral metronidazole (2 g PO), azithromycin (1 g PO), and ceftriaxone (250 mg IM) with gynecology follow-up if she is not feeling better.
Give her a one-time dose azithromycin (1 g PO), and ceftriaxone (250 mg IM) with urgent gynecology follow-up within 1 week.
Give her a dose of ceftriaxone (250 mg IM), and prescribe her a 10-day course of doxycycline (100 mg PO BID) with urgent gynecology follow-up within 1 week.

17. A 45-year-old woman presents to the ED complaining of 3 days of fever and worsening throat pain and painful odynophagia without cough or coryza. She sits on a chair, leaning forward with her mouth slightly She is refusing to swallow and has a cup of saliva and a box of facial tissues at her side. Vitals are HR of 120 beats per minute, BP of 110/70 mm Hg, RR of 22 breaths per minute, oxygen saturation of 99% on room air, and temperature of 102.8°F. You note a slight wheezing noise coming from her anterior neck. Her voice is hoarse and she is able to open her mouth fully, making her examination quite difficult. From what you can visualize, her posterior oropharynx is moderately hyperemic, without exudates or ton- sillar enlargement. A soft tissue lateral cervical radiograph shows marked edema of the prevertebral soft tissues and absence of the vallecular space. Which of the following is the most likely diagnosis?

Retropharyngeal abscess
Peritonsillar abscess
Epiglottitis
Pharyngitis
Laryngotracheitis

18. A 19-year-old woman presents with 4 days of bilateral lower abdominal pain right greater than She also complains of a fever, nausea, vomiting, and general malaise. Her last menstrual period was 5 days ago. Vitals are HR 98 beats per minute, BP 110/65 mm Hg, RR 18 breaths per minute, and temperature of 102.7°F. Pelvic examination demonstrates exquisite cervical motion tenderness and right adnexal tenderness. Laboratory reports are notable for a WBC 15,000/mL, an ESR of 95 mm/h, and a negative urine b-human chorionic gonadotropin (b-hCG). Transvaginal ultrasound dem- onstrates a right complex mass with cystic and solid components. Which of the following is the most appropriate next step in management?

Prescribe her a 14-day course of levofloxacin (500 mg PO once per day) and urgent gynecology follow-up within 1 week.
Give her a dose of metronidazole (2 g PO) and prescribe her a 14-day course of cephalexin (500 mg) with urgent gynecology follow-up within 1 week.
Give her a one-time dose of oral metronidazole (2 g PO), azithromycin (1 g PO), and ceftriaxone (250 mg IM) with gynecology follow-up if she is not feeling better.
Given her a one-time dose with emergent gynecology consultation for possible laparoscopic drainage.
Give her a dose of ceftriaxone (250 mg IM), and prescribe her a 10-day course of doxycycline (100 mg PO BID) with urgent gynecology follow-up within 1 week.

19. A 42-year-old IV drug user presents to the ED with fever, chills, pleuritic chest pain, myalgias, and general The patient’s vitals include an HR of 110 beats per minute, BP of 110/65 mm Hg, RR of 18 breaths per minute, and temperature of 103.4°F. Physical examination is notable for retinal hemorrhages, petechiae on the conjunctivae and mucous mem- branes, a faint systolic ejection murmur, and splenomegaly. Which of the following is the most likely diagnosis?

Disseminated gonorrhea
Myocarditis
Pericarditis
Infectious mononucleosis
Endocarditis

20. A 51-year-old diabetic man complains of intense right-ear pain and discharge. On physical examination, his BP is 145/65 mm Hg, HR 91 beats per minute, and temperature 101°F. He withdraws when you retract the pinna of his The external auditory canal is erythematous, edematous, and contains what looks like friable granulation tissue in the external audi- tory canal. The tympanic membrane is partially obstructed but appears to be erythematous, as well. You make the presumptive diagnosis of necrotiz- ing (malignant) otitis externa. Which of the following statements regarding this condition is true?

It is an uncommon complication of otitis media in otherwise healthy patients.
The mainstay of treatment is outpatient with oral antibiotics.
Cranial nerve IX palsy is the most common complication.
Pseudomonas aeruginosa is the most common causative organism.
Hearing loss is the most common complication.

21. A 26-year-old woman presents to the ED with fever, malaise, and an evolving rash in the right axilla that she initially thought was from an insect bite that she received while hiking 1 week She complains of generalized fatigue, nausea, headache, and joint pain over the past several days. Her vitals are BP of 120/75 mm Hg, HR of 75 beats per minute, RR of 16 breaths per minute, and temperature of 101°F. On physical exami- nation, she is awake and alert, with a nonfocal neurologic examination. Her neck is supple, but she is diffusely tender over the shoulder, knee, and hip joints bilaterally without any distinct effusions. Her abdomen is soft and nontender. She has a 9-cm erythematous annular plaque with partial central clearing and a bright red outer border and a target center under her right axilla. Which of the following is the next best step?

Treat empirically with broad-spectrum antibiotics and consult dermatology emergently for a biopsy of the rash.
Treat empirically for a cellulitis with cephalexin for 10 days and arrange follow-up with her primary care doctor.
Treat empirically for Lyme disease with doxycycline for 21 days and arrange follow-up with her primary-care doctor.
Treat empirically for an allergic dermatitis with prednisone, diphenhydramine, and famotidine for 3 days, and arrange follow-up with her primary care doctor.
Perform serologic testing for Borrelia burgdorferi to confirm the diagnosis of Lyme disease and arrange follow-up with her primary care doctor.

22. A 22-year-old man without medical complaints presents to the ED with a 3-day history of fever, malaise, and He denies chest pain, shortness of breath, nausea or vomiting, abdominal pain, cough, sore throat, genitourinary symptoms, or respiratory tract complaints. On exam- ination, the patient’s BP is 100/60 mm Hg, HR is 110 beats per minute, RR is 20 breaths per minute, and temperature is 102°F. He appears awake, alert, and comfortable. His physical examination is normal. Which of the following is the most appropriate next step in management?

Discharge him with antipyretics and follow up with his primary care doctor in 1 or 2 days for a repeat examination.
Order a CBC, urinalysis, and chest x-ray. If normal, discharge him with anti- pyretics and follow up with his primary care doctor in 1 or 2 days for a repeat examination.
Order a CBC, urinalysis, chest x-ray, and two sets of blood cultures. If normal, discharge him with antipyretics and follow up with his primary care doctor in 1 or 2 days for a repeat examination.
Order a CBC, urinalysis, chest x-ray, two sets of blood cultures, and perform an LP. If normal, discharge him with antipyretics and follow up with his primary care doctor in 1 or 2 days for a repeat examination.
Order a CBC, urinalysis, chest x-ray, two sets of blood cultures, and perform an LP. Start empiric IV antibiotics and admit him for observation.

23. A 54-year-old man with a history of hepatitis C, alcohol abuse, and cirrhotic ascites presents with increasing abdominal girth and abdominal pain. He complains of increasing difficulty breathing, especially when lying down, caused by worsening On physical examination, the patient is cachectic and appears older than his stated age. He has a diffusely tender abdomen and tense ascites. The liver is palpable 4 cm below the costal margin. Vitals include a BP of 110/65 mm Hg, HR of 110 beats per minute, RR of 22 breaths per minute, and temperature of 102°F. Which of the follow- ing is the most common organism seen in spontaneous bacterial peritonitis?

Pseudomonas aeruginosa
Enterococcus
Streptococcus pneumoniae
Enterobacteriaceae
Streptococcus viridans

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