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Self-Assessment Questions

Emergency Medicine

Infectious Diseases in the Emergency Department: Review Questions

Christopher Fee, MD, and Susan B. Promes, MD

Dr. Fee is an assistant clinical professor of emergency medicine, and Dr. Promes is a professor of emergency medicine and residency program director; both are at the Department of Emergency Medicine, University of California San Francisco, San Francisco, CA.

Choose the single best answer for each question.

Questions 1 and 2 refer to the following case.
An 82-year-old man weighing 154 lb with chronic kidney disease and a history of hemorrhagic stroke that occurred 2 months prior presents to the emergency department (ED) with cough and confusion. Rectal temperature is 104.1°F, respiratory rate is 32 breaths/min, and oxygen saturation is 91% on room air. On examination, rhonchi are noted as well as a pronounced neurologic deficit from his previous stroke. Laboratory testing reveals leukopenia and a blood urea nitrogen level of 70 mg/dL. A chest radiograph reveals a left lower lobe consolidation. The patient is diagnosed with community-acquired pneumonia (CAP).

1. In addition to providing supplemental oxygen and antipyretics, which of the following is the most appropriate in the management of this patient?
  1. Administer an intravenous (IV) macrolide and discharge home on oral formulation
  2. Administer oral doxycycline within 4 hours and admit to a floor bed for observation
  3. Obtain blood cultures, administer IV piperacillin-tazobactam, and admit to the intensive care unit (ICU)
  4. Obtain blood cultures, administer IV ceftriaxone and a respiratory fluoroquinolone, and admit to the ICU
  5. Obtain blood cultures, administer IV vancomycin within 4 hours, and admit to the ICU
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2. While in the ED, the patient becomes transiently hypotensive, which resolves with 1 L of normal saline administered as an IV bolus. A serum lactate level is 6.2 mmol/L. Which of the following interventions has been shown to reduce mortality in this setting?

  1. Corticosteroids
  2. Early goal-directed therapy (EGDT)
  3. Mechanical ventilation with tidal volumes of 10 mL/kg and low respiratory rate
  4. Procalcitonin
  5. Recombinant-activated protein C
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3. A 77-year-old man presents to the ED with a 5-day history of burning and aching on his left flank. He developed a rash 1 day prior to presentation. Physical examination reveals an erythematous rash with clusters of clear vesicles in a single dermatome distribution on his back. Which of the following is the preferred treatment?

  1. Acyclovir
  2. Gabapentin
  3. Lidocaine 5% patch
  4. Prednisone
  5. Valcyclovir
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4. A 25-year-old man presents to the ED for evaluation of multiple skin eruptions. The patient reports that he may have been bitten by a spider. Physical examination reveals a well-appearing man with normal vital signs and multiple raised red lesions with necrotic areas. Given the high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in the area, the patient is diagnosed with community-acquired MRSA (CA-MRSA). Which of the following is the most appropriate antibiotic?

  1. Cephalexin orally
  2. Ciprofloxacin orally
  3. Erythromycin orally
  4. Trimethoprim-sulfamethoxazole (TMP-SMX) orally
  5. Vancomycin intravenously
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5. A 44-year-old man presents to the ED with 16 hours of fever, headache, and neck stiffness. On physical examination, the patient is alert and oriented with a normal neurologic examination except for meningismal signs. Antibiotics and dexamethasone are ordered. Which of the following is true when using dexamethasone to treat meningitis?

  1. Administration increases the risk of gastrointestinal bleeding
  2. Administration should occur before or with the first dose of antibiotics
  3. Administration increases blood-brain permeability
  4. Administration should continue until symptoms resolve
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