A 22-year-old woman is brought to the emergency department due to fever, headaches, nausea, vomiting, and myalgias that began suddenly last night.  This morning, the patient was lethargic, difficult to arouse, and confused.  She is an exchange student who came to the United States 3 months ago, and her medical history is unknown.  Temperature is 39.4 C (102.9 F), blood pressure is 100/60 mm Hg, pulse is 112/min, and respirations are 18/min.  Physical examination shows nuchal rigidity.  Skin examination findings are shown in the image.

Leukocyte count is elevated, and lumbar puncture with cerebrospinal fluid Gram stain establishes the diagnosis.  Which of the following is most likely to be the primary antigenic component of the vaccine that could have prevented this patient’s infection?

A 64-year-old man comes to the emergency department after developing fever and chills during hemodialysis.  He still feels feverish but has no sore throat, cough, abdominal pain, nausea, or diarrhea.  Temperature was 38.9 C (102 F) at the dialysis center.  The patient has a history of poorly controlled type 2 diabetes mellitus and hypertension, which led to end-stage renal disease.  He was initiated on long-term intermittent hemodialysis 2 months ago.  The patient has no known drug allergies.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 38 C (100.4 F), blood pressure is 120/62 mm Hg, pulse is 105/min, and respirations are 22/min.  Oxygen saturation is 96% on room air.  There is a tunneled central venous catheter in the right internal jugular vein, and the skin around the insertion site is not erythematous or tender.  Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds.  The abdomen is soft and nontender.  No skin rash or neck stiffness is present.  Leukocyte count is 14,000/mm³ with 90% neutrophils.  Chest-x ray reveals no infiltrate or consolidation.  Two sets of blood cultures, one from a peripheral vein and the other from the central venous catheter, are obtained.

Item 1 of 2

Which of the following is the most appropriate immediate next step in management of this patient?

Item 2 of 2

Both sets of blood cultures grow methicillin-resistant Staphylococcus aureus.  The patient’s antibiotic regimen is narrowed to vancomycin alone, and the tunneled catheter is removed.  On day 4 of hospitalization, he continues to have intermittent fevers.  He has no cough, abdominal pain, or diarrhea but does note worsening back pain in his lumbar region, which he attributes to inactivity and the uncomfortable hospital bed.  The pain is a dull ache and does not radiate.  Examination reveals midline tenderness in the lower lumbar area.  Neurological examination shows no abnormalities.  Leukocyte count remains elevated at 16,000/mm³.  Repeat blood cultures performed after venous catheter removal show no growth.  Plain radiographs of the lumbosacral spine reveal no abnormalities.  Echocardiography reveals no valvular vegetations.  Which of the following is the most appropriate next step in management of this patient?

A 31-year-old man comes to the physician after experiencing a week of generalized weakness, decreased appetite, and nausea.  He is an intravenous drug user enrolled in a methadone program but has relapsed due to family problems.  The patient was hospitalized for aspiration pneumonia 2 years ago.  He does not use alcohol or prescription or over-the-counter medications.  The patient’s temperature is 37.2 C (99 F), blood pressure is 114/78 mm Hg, and pulse is 88/min.  Examination shows mild tenderness in the right upper quadrant.  Laboratory results are as follows:

Which of the following is most likely to indicate the diagnosis in this patient?

A 44-year-old man comes to the office due to concern for hepatitis infection.  The patient donated blood at an office blood drive event, and a few days later received a letter saying that hepatitis testing performed on his sample was positive.  He has no chronic medical issues and feels healthy.  He takes no medications.  The patient does not smoke cigarettes and drinks alcohol at social events.  He used injection drugs for several years in his 20s but not since then.  He is in a monogamous relationship with his wife, who is also healthy.  The patient works in a car dealership and is fairly active.  Family history is significant only for hypertension in his father.  Vital signs are normal.  The sclerae are anicteric and mucous membranes are moist with no lesions.  No lymphadenopathy is present.  Lung fields are clear to auscultation and heart sounds are normal with no murmur.  The abdomen is soft, nondistended, and nontender.  There is no hepatomegaly or splenomegaly.  He has no skin rash or extremity edema.  Laboratory results are as follows:

Which of the following is the best next step in management of this patient?