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A 35-year-old woman schedules an appointment in
an outpatient clinic for evaluation and treatment of
a “mouth problem.” She says that she has white
spots in her mouth that have been present for a few
weeks. In response to your questioning, she states
that she has been experiencing fatigue and a 20-lb
weight loss over the past several months, although
she attributes these symptoms to a dramatic
increase in work hours at her job over the same
period of time. She denies having any other chronic
medical issues and does not use any prescription or
OTC medications. As you examine her, you note the
presence of white plaques on her buccal mucosa,
palate, and tongue. Scraping of the plaques with a
tongue depressor elicits pain as well as a small
amount of bleeding. Nontender generalized cervical
and submandibular lymphadenopathy is
present.
107. Which of the following questions would potentially
yield the most useful information in this
patient’s diagnosis and treatment?
(A) “Do you have a family history of
cancer?”
(B) “Have you traveled outside of the country
within the past 12 months?”
© “Have you engaged in unprotected sexual
intercourse?”
(D) “Do you have any sick contacts?”
(E) “How much do you smoke?”


108. Which of the following immunizations is safe
to administer to this patient?
(A) inactivated influenza vaccine
(B) live attenuated influenza vaccine
(FluMist)
© varicella vaccine
(D) oral polio vaccine (OPV)
(E) measles mumps rubella (MMR) vaccine

C
A

C......A

cc
aa

you guys are ready for the exam


107. ©
108. (A)
Explanations 107 and 108
This patient’s presenting symptoms are consistent
with oropharyngeal candidiasis, or
thrush. While risk factors for the development
of thrush include recent antibiotic use, use of
inhaled corticosteroids, and head or neck radiation,
thrush is also commonly encountered in
immunocompromised patients, such as those
positive for HIV. Due to the patient’s apparently
benign prior medical history and the new
onset of multiple complaints in addition to her
oral candidal infection, an HIV infection should
be considered. In order to assess a patient’s risk
for HIV exposure, a thorough history should be
taken. Risk factors for HIV infection include
unprotected sexual intercourse, multiple sexual
partners, IV drug use, occupational exposure to
blood or bodily fluids, blood transfusion prior
to 1985, and use of nonsterile equipment in tattooing
or body piercing.

Generally, individuals positive for HIV
should not receive live vaccines. Administration
of inactivated influenza vaccine is recommended
annually in all individuals positive for HIV. Live
attenuated influenza vaccine was FDA
approved in 2003 in an intranasal formulation
but is contraindicated in individuals with
immunocompromise. The varicella and MMR
vaccines should not be administered to patients
with severely symptomatic HIV infection. The
OPV is no longer recommended for use in the
United States despite its continued use in
many other parts of the world. Instead, inactivated
polio vaccine (IPV) is recommended and
is safe for use in HIV-positive individuals.