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Question 1: A 69-year-old female with no prior medical problems presents with 1 day of severe headache and fever up to 104°F. She reports nausea, photo- and phonophobia, and intermittent episodes of expressive aphasia. Physical exam is remarkable for an ill-appearing woman with a temperature of 103.8°F orally, BP of 150/70, and pulse of 100. She appears to be in moderate distress from the headache, is keeping her eyes closed, and resists passive flexion of the neck. Motor and sensory exams are normal with no evidence of papilledema. After drawing 2 sets of blood cultures and initiating treatment, the patient undergoes a CT of her head that is “normal.” Lumbar puncture yields cloudy CSF with 400 WBC, 42% neutrophils, 35% lymphocytes, 6% monocytes, and 3% basophils; glucose of 35mg/dL; and protein 380mg/dL. CSF Gram stain reveals few polymorphonuclear cells and Gram-positive bacilli. What are potential risk factors for this patient’s meningitis?


  1. Age >50 and consumption of soft cheese

  2. Lack of vaccination to Neisseria meningitidis

  3. Age >65 and lack of immunization against Strep. Pneumoniae

  4. Exposure to 2-year-old granddaughter who is unvaccinated against Haemophilus influenzae type b


Reference: 1. Centers for Disease Control and Prevention (CDC). Listeria (Listeriosis). 2015. Available from: 2. Cohn AC, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR02):1-22. 3. Wenger J, et al. Bacterial meningitis in the United States, 1986: report of a multistate surveillance study. The Bacterial Meningitis Study Group. J Infect Dis. 1990 Dec;162(6):1316-23.

NBME Internal Medicine Shelf Exam Review Questions and Practice Tests

500 challenging Internal Medicine Shelf Board Review Questions targeted for use during clerkship rotations. These questions are selected from the Cleveland Clinic Internal Medicine Review Series and additional questions are written by Internal Medicine faculty. The National Board of Medical Examiners (NBME) administers Subject Exams, or “shelf exams” as they are colloquially referred to.


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