USMLE Step 3 : Part 1

64 YO M comes to clinic c/o ED. He is not able to generate an erection. His PMH is significant for CABG many years ago, s/p carotid endarterectomy, and a mildly reduced LVEF. His medications include ASA, carvedilol, simvastatin, lisinopril, and furosemide. He does not take nitrates. On PE, you note normal-sized testes and normal prostate. There are no fibrotic changes along the penile corpora. His libido is intact. What is the most likely cause of this patients ED? A: disturbance of blood flow B: low testosterone C: medication related D: psychogenic

A ED increases with age, but is not considered a normal part of the aging process. This patient has evidence of atherosclerosis, which is the MC organic cause of ED in males. Meds account for 25% of ED: diuretics, beta blockers, and other antiHTN being a common culprit. Psychogenic ED can cause or be caused by organic ED. We are given no indication that this patient is experiencing a relationship conflict or that he has developed performance anxiety. This patient is not clinically hypogonadal.

56 YO M patients arrives in clinic with worsening somnolence, per his wife. You have followed him for several years for his long-standing liver disease related to heavy alcohol use in the past and HCV infection, as well as chronic lower back pain 2/2 trauma. He has recently developed ascites but has had a good response to diuretics. He has no history of GI bleeding, he denies fever, chills, ABD pain, tremors, or any recent change in the medication, which includes furosemide 40 mg qd, spironolactone 80 mg qd, and extended release morphine 30 mg bid. He is afebrile and normal VS. His weight is down 5 kg since doubling the diuretic. PE is notable for a somnolent but conversant man with mild jaundice, pinpoint pupils, palmar erythema, spider hemangiomas, a palpable nodular liver edge at the costal margin, and bilateral 1+ LE edema. He does not have asterixis, ABD tenderness, or abdominal fluid wave. Labs compared to 3 months ago reveal increased INR (1.4, 2.1), elevated total bili (1.8, 3.6), and decreased albumin (3.4, 2.9). He also has baseline elevations in AST and ALT (54, 78). Serum NH4 is 16. What is the next step? A: decrease his morphine dose by 50% and reevaluate in a few days B: Initiate antibiotics C: Initiate haloperidol D: Initiate lactulose E: Perform a paracentesis

A The patient is developing full-blown cirrhosis and as a result has impaired hepatic clearance of his morphine. This is due to impaired first pass metabolism, as a consequence of abnormal liver architecture, depressed p450, and perhaps portocaval shunting. PE and albs reveal worsening cirrhosis and opiate toxicity. Hepatic encephalopathy and subacute bacterial peritonitis are considerations in cirrhotics with impaired AMS, however, the patient has no discernible ascites and no evidence of encephalopathy on exam. The focus should be on reducing centrally acting therapies such as morphine, rather than adding on haloperidol.

23 YO F c/o visual blurriness. On exam, her pupils are equal round. Shining a flashlight into her R eye causes equal, strong constriction of both pupils. When the light is flashed into her L eye, both pupils dilate slightly though not to their previous size prior to light confrontation. Where is there likely to be anatomic damage?

L-optic nerve or retina This patient has a Marcus Gunn pupil, or afferent pupil defect. As the response is only abnormal when light is shown in the L eye, this implies an afferent defect in that eye mediated by retinal or optic nerve damage. The R and L efferent systems are intact, based on the normal pupillary response bilaterally when light was exposed to the R eye. A corneal defect in the L eye may impair vision but would not block the light transmission to the L retina and optic disc; pupillary response would therefore remain intact. Common causes of Marcus Gunn pupils include retrobulbar optic neuritis and other optic nerve diseases.

a young man is brought to the ED by his parents. For the past 12 hours, he has barricaded himself in his room out of fear of being "taken away by the guys in black." He fears he is losing control and fears that he is going to die. His parents found him trembling and sweating in his room with various pills and plant leaves in his possession. He feels like he is choking and that he is about to die at any minute. On exam, his pupils are dilated and his HR is 143. What substance is most likely to have caused this?

LSD although LSD abuse has been a well-known public health hazard, the use of LSD may be increasing in some communities in the US among adolescents and young adults. LSD causes a variety of bizarre perceptual changes that can last for up to 18 hours. Panic episodes due to LSD use ("bad trip") are the most frequent medical emergencies a/w LSD. These episodes may last up to 24 hours and are best treated in a specialized psych setting. Marijuana intoxication causes a feeling of euphoria and is a/w some impairment in cognition similar to alcohol intoxication. Heroin intoxication usually produces a feeling of euphoria and intoxication; panic attacks during usage are uncommon. Methamphetamine intoxication produces euphoria and decreases the fatigue a/w difficult life situations. Psychosis is possible with the ingestion of most illicit substances, depending on the user and environmental setting; however, the classic panic attack a/w the "bad trip" of LSD is distinct in the predominance of paranoia and fear of imminent doom

FOBT was shown to decrease CRC mortality from 8.8/1000 persons to 5.9/1000 persons over a 13-year period. What is the approx ARR of this intervention in the studied population?

0.3% It is important to contrast the RRR of an intervention versus the ARR. The ARR is 0.88% - 0.59% = 0.29%. The RRR in this case is ~30%. It might be predicted, therefore, that this intervention might result in a 30% decrease in CRC if widely implemented in a target population. However, the ARR is much smaller; 1 divided by the ARR (1/0.29), equals the NNT to prevent 1 colon cancer death. In this case that number is ~330. Therefore, while the impact on a population level might be large, it takes a large number of patients to prevent one event with the FOBT intervention.

A stage I decubitus ulcer (nonblanchable erythema of intact skin or edema and induration over a bony pressure point) can progress to a stage 4 decubitus ulcer (full thickness skin loss with tissue necrosis as well as damage to bone, ms, and tendons) over what period of time?

1-2 days PE of all immobilized or bed-bound patients must include careful exam of common sites for pressure sores. The heels, lateral malleoli, sacrum, ischia, and greater trochanters account for 80% of pressure sores. Shear forces and moisture are predisposing factors. In older adults and nursing home residents, the development of a pressure sore increases mortality fourfold. Infectious complications include osteomyelitis and sepsis. A fairly innocuous appearing lesion can progress to a deep, easily infected, and very difficult to manage stage 4 decubitus ulcer in a very short period of time without aggressive wound care and off-loading by nursing staff.

Anthrax spores can remain dormant in the respiratory tract for how long?

6 weeks anthrax is caused by the gram-positive spore-forming rod Bacillus anthracis. Anthrax spores may be the prototypical disease of bioterrorism. Although not spread person to person, inhalation anthrax has a high mortality, a low ineffective dose (5 spores), and may be spread widely with aerosols after bioengineering. It is well-documented that anthrax spores were produced and stored as potential bioweapons. In 2001, US was exposed to anthrax spores delivered as a powder in letters. Of 11 patients with inhalation anthrax, 5 died. All 11 with cutaneous anthrax survived. Because anthrax spores can remain dormant in the respiratory tract for 6 weeks, the incubation period can be quite long and post-exposure abx are recommended for 60 days. Trials of recombinant vaccine are underway.

Which of the following methods is most effective for the diagnosis of corneal abrasion? A: fluorescein and cobalt blue light exam B: intraocular pressure measurement C: lid eversion for foreign body exam D: oculoplegia and dilation E: viral culture of the cornea

A a red and painful eye is often caused by a corneal abrasion. Hx is very useful to determine the pretest prob of this type of lesion, because it will be increased in the context of contact lens use, recent eye trauma, or particulate exposure. Cobalt-blue exam with fluorescein is then used to confirm the presence of corneal abrasion. It is particularly important as it occasionally reveals a dendritic pattern c/w Herpes simplex virus keratitis, a diagnosis that necessitates a very different type of treatment. Lid eversion is useful if there is suspicion that the foreign body is still present. Corneal abrasion should be treated with topical antibiotic ointment and patching. Cycloplegia may reduce pain by relaxing the ciliary body.

35 YO F with hx of degenerative joint disease comes to clinic c/o dark urine over the past several weeks. She has had arthritis in her hips, knees, and shoulders for 2 years. On exam, she is noted to have gray-brown pigmentation of the helices of both ears. Which disorder is likely? A: alkaptonuria B: hawkinsinuria C: homocystinuria D: hyperprolinemia Type 1 E: tryptophanuria

A alkaptonuria is a rare disorder of homogentisic acid oxidase deficiency which leads to urinary excretion and tissue accumulation of oxidized homogentisic acid. Patients may present in their 30s or 40s with arthritis and darkly colored urine, as well as tissue pigmentation (ochronosis) from homogentisic acid. The arthritis is typically in the large joints (hips, knees, shoulders) and lower back. The gray-brown pigmentation is characteristic and involves the sclera and ear. The dx should be suspected in a patient whose urine darkens to blackness. Hawkinsinuria is a related disorder of AA metabolism, where 4-hydroxyphenylpyruvate dioxygenase enzyme defect leads to failure to thrive in infancy. Unlike most AA disorders, it is AD. Tryptophanuria results in MR, skin photosensitivity, and ataxia; however, the enzyme defect leading to this phenotype has not been identified. Hyperprolinemia type 1 is caused by proline oxidase defect and is typically benign. Homocystinuria is caused by cystathionine B-synthase defect and leads to MR.

All of these clinical features are common in patients with anorexia nervosa, except: A: avoid food-related occupation B: distorted body image C: engage in binge eating D: exercise extensively E: rarely c/o hunger F: socially withdrawn

A anorexia nervosa (AN) is a much less common disorder in men than in women, and is more prevalent in cultures where food is plentiful and where thinness is a/w attractiveness. Individuals who pursue occupations that place a premium on thinness, such as ballet or modeling, are at greater risk of developing AN. In patients with aN, as weight loss increases, thoughts of food dominate mental life. AN patients may obsessively collect cookbooks and recipes and tend to be drawn to food-related occupations. These patients become socially withdrawn and may engage in binge eating, similar to bulimia nervosa patients. AN patients rarely c/o hunger or fatigue and will exercise extensively as a means to achieve wt loss

A recent 18 YO immigrant from Kenya presents to clinic with fever, nasal congestion, severe fatigue, and a rash. The rash started with discrete lesions at the hairline that coalesced as the rash spreads caudally. There is sparing of the palms and soles. Small, white spots with a surrounding red halo are noted on exam of the palate. The patient is at risk for developing which of the following in the future? A: encephalitis B: epiglottitis C: opportunistic infections D: postherpetic neuralgia E: splenic rupture

A based on this characteristic rash and Koplik's spots, this patient has measles. A rare, but feared cx is subacute sclerosing panencephalitis. His exam does not support epiglottitis as he has no drooling or dysphagia. His rash is not characteristic of acute HIV infection, and he lacks the pharyngitis and arthralgias commonly seen with this diagnosis. The rash is not consistent with herpes zoster, and he is quite young to invoke this diagnosis. Splenic rupture occasionally occurs with infectious mononucleosis, but this patient has no pharyngitis, LAD, or splenomegaly to suggest this diagnosis.

Diagnostic criteria for delirium as a cause of confused state in a hospitalized patient include all of the following, except: A: agitation B: altered level of consciousness C: disorganized thinking D: fluctuating mental status E: poor attention

A delirium can cause prolonged hospitalization and may be life threatening. It is often under diagnosed. The confusion assessment method (CAM) is highly sensitive and specific for identifying delirium. One common misconception is that all delirious patients are agitated. In fact, delirium is often a/w a decreased level of consciousness, and patients can appear withdrawn or aloof, rather than agitated, combative, or anxious. Another crucial diagnostic criterion is that the patient's mental state represents a clear, acute deviation from their baseline status.

You are conducting research on a novel NSAID. To ascertain the safety profile of the drug you recruit 100 volunteers who lack the ability to produce IgE. All subjects receive the drug. A minority of the patients experience an anaphylactic reaction within minutes of ingesting the drug. IgE levels are undetectable in all 100 subjects. What is the most likely explanation for this phenomenon? A: the drug itself triggered the immune system in the minority of patients B: the IgE-receptor in the patients with anaphylaxis is constitutively activated C: the patients who had anaphylaxis have received the drug before D: the patients who had anaphylaxis overexpress CD8+ T cells

A drugs can trigger inflammatory mediators (histamine, leukotrienes, etc) directly; i.e., the pharmacoimmune concept. These "anaphylactoid" responses are not IgE mediated. NSAIDs, ASA, and radiocontrast media are frequent causes of pharmacologically mediated anaphylactoid reactions. Given that this is an investigational drug, it is improbable that the patients in the study have taken this drug before. T cell clones have been obtained after pharmacologically mediated anaphylactoid reactions, with a majority being CD4+. A constitutively IgE-receptor would not manifest solely after drug exposure.

Which of the following is the best indicator of prognosis and longevity in a geriatric patient? A: functional status B: life span of 1st degree relatives C: marital status D: # of medical comorbidities E: SES

A functional status, as defined by the patient's ability to provide for his or her own daily needs, is the most important indicator for prognosis. A decline in functional status should prompt a search for medical illness, dementia, change in social support, or depression. Screening for functional status should include assessment of ADLs, gait and balance, cognition, vision, hearing, and dental and nutritional health

Which of the following class of meds has been linked to occurrence of hip fx in the elderly? A: benzodiazepines B: opiates C: ACE inhibitors D: Beta blockers E: Atypical antipsychotics

A in population surveys of non institutionalized elderly, up to 10% had at least 1 AE in the prior year. Adverse events are common in elderly and are related to the altered drug sensitivity, impaired renal or hepatic clearance, impaired homeostatic mechanisms, and drug interactions. Long half life Benzos are linked to an increase in hip fx in the elderly. The assoc may be due to increased risk of falling (related to sedation) in a population with high incidence of osteoporosis. This assoc may also be true for other drugs with sedative properties like opioids or antipsychotics. Exaggerated responses to cardiovascular drugs such as ACE inhibitors may occur because of blunted vasoconstrictor or chronotropic response to reduced BP. Conversely, elderly patients often display decreased sensitivity to beta blockers

68 YO alcoholic male arrives in the ED after being found in the snow on a cold winter night in Chicago. His core temperature based on rectal and esophageal probe is 27C. HR 30 and BP 75/40. He is immobile and lacks corneal, oculocephalic, and peripheral reflexes. He is immediately intubated and placed on a cardiac monitor. He then converts to ventricular fibrillation: a defibrillator attempt at 2J/kg is not successful. What should be the next step in management? A: active rewarming with forced-air heating blankets, heated humidified oxygen, heated crystalloid infusion B: amiodarone infusion C: insertion of a trans venous pacemaker D: passive rewarming with numerous blankets for insulation E: repeat defibrillation

A initial focus should be aggressive rewarming. Further attempts at defibrillation are unlikely to work until core temperature is normalized. Pharm strategies are also ineffective in the setting of hypothermia, though the possibility of toxicity based on accumulation of drug does exist once successful rewarming is achieved. If initial active rewarming techniques are ineffective, cardiopulmonary bypass, warmed HD, peritoneal lavage with warmed fluid, or pleural lavage with warmed fluid should be considered on an emergent basis. A pacemaker will not be effective for Vfib and may provoke arrhythmias due to ventricular irritation

It is hospital day 16 for a 49 YO homeless patient who is recovering from ETOH withdrawal and delirium tremens. She spent the first 9 days of this hospitalization in the ICU but is now awake, alert, and conversant. She has a healing decubitus ulcer, and her BMI is 19 kg/m2. Labs show an Alb 2.9 and a PT of 18 s (normal). Is this patient malnourished? A: cannot be determined, need more info B: no; given her heavy ETOH use, her PT is expected to be delayed C: no; she has a low resting energy expenditure and her intact mental state argues against malnutrition D: yes; this degree of hypoAlbuminemia is uncommon in cirrhosis and is likely 2/2 malnutrition

A interactions between illness and nutrition are complex, therefore many physical and lab findings reflect both underlying disease and nutritional status. The nutritional evaluation of a patient requires an integration of history, PE, anthropometrics, and labs. The finding of isolated hypoAlbuminemia may be due to her underlying liver disease and does not necessarily indicate malnutrition. This patient is at high risk for malnutrition, but her current status may reflect malnutrition or sequelae of chronic alcoholism.

A patient with metabolic acidosis, reduced anion gap, and increase osmolal gap is most likely to have which of the following toxic ingestions? A: lithium B: methanol C: oxycodone D: propylene glycol E: salicylate

A lithium interferes with cell membrane ion transport, leading to nephrogenic DI and falsely elevated chloride. This can cause the appearance of a low anion gap metabolic acidosis. Sequelae include n/v, ataxia, encephalopathy, coma, seizures, arrhythmia, hyperthermia, permanent movement disorder, and/or encephalopathy. Severe cases are treated with bowel irrigation, endoscopic removal of long-acting formulations, hydration, and sometimes HD. Care should be taken because toxicity occurs at lower levels in chronic toxicity compared to acute. Salicylate toxicity leads to a normal osmolal gap as well as elevated anion gap metabolic acidosis, respiratory alkalosis, and sometimes a normal anion gap metabolic acidosis. Methanol toxicity is a/w blindness and is characterized by an increased anion gap metabolic acidosis, with normal lactate and ketones, and a high osmolal gap. Propylene glycol toxicity causes an increased anion gap metabolic acidosis with elevated lactate and a high osmolal gap. The only -lyte abnormalities a/w opiate overdose are compensatory to a primary respiratory acidosis.

An elevation in which of these hormones is c/w the effects of anorexia nervosa? A: cortisol B: GnRH C: leptin D: thyroxine (T4) E: TSH

A regulation of virtually every endocrine system is disturbed in patients with AN. Hypothalamic amenorrhea reflects diminished production of GnRH. Serum leptin levels are reduced due to decreased mass of adipose tissue, and this is thought to be the mediator of the other neuroendocrine abnormalities a/w AN. Thyroid function tests resemble the pattern seen in euthyroid sick syndrome (low normal or depressed TSH and T4, depressed T3, increased reverse T3). Serum cortisol and 24h urine free cortisol are generally elevated without the expected clinical consequences of hypercortisolism.

Which is true regarding infection risk after elective splenectomy? A: patients are at no increased risk of viral infection after splenectomy B: patients should be vaccinated 2 weeks s/p splenectomy C: splenectomy patients >50 YO are at greatest risk for post-splenectomy sepsis D: S aureus is the MC implicated organism in post-splenectomy sepsis E: The risk of infection after splenectomy increases with time

A splenectomy leads to increased risk of overwhelming post-splenectomy sepsis, an infection with a high MR. The MC infectious organisms are encapsulated. Strep pneumoniae, HiB, and sometimes gram-negative enteric organisms are most frequently isolated. There is no known increased risk for any viral infections. Vaccination for S pneumonia, HiB, and Neisseria meningitides is indicated for any patient who undergoes splenectomy. The vaccines should be given at least 2 weeks before surgery. The highest risk of sepsis occurs in patients <20 YO because the spleen is responsible for 1st pass immunity and younger patients are more likely to have primary exposure to implicated organisms. The risk is highest during the first 3 years s/p splenectomy and persists at a lower rate until death.

69 YO M on HD with poorly controlled DM, heart failure, and chronic indwelling catheters presents with fever and loss of vision in the L-eye developing over the past 6 hours. VS are notable for 101.3F, HR 105, and BP 125/85. Which test is most likely to confirm the diagnosis? A: blood cx B: blood smear C: brain MRI D: rheumatic panel E: RPR

A sudden blindness in a patient with fever and high risk of endovascular infection is endocarditis until proven otherwise. Even primary bacteremia in the absence of cardiac vegetation can seed the eye, often leading to endogenous endophthalmitis or central retinal artery occlusion. Another consideration in this patient would be septic thrombophlebitis with septic emboli to the eye. Stroke, vasculitis, syphilis, and heme malignancy are possible causes of acute blindness, but are less likely given the acute presentation with fever.

40 YO F is exposed to mustard gas during a terrorist bombing of her office building. She presents to the ED immediately after exposure w/o complaint. The PE is wnl. What is next? A: admit the patient for observation because ssx are delayed 2h - 2 days after exposure and treat supportively prn B: administer 2-pralidoxime as an antidote and observe for ssx C: irrigate the patients eyes and apply ocular glucocorticoids to prevent ssx from developing D: discharge the patient home as she is unlikely to develop ssx later E: d/c the patient home but ask that she return in 7 days for monitoring of her WBCs

A sulfur mustard was the first weaponized chemical and was used in WWI, accounting for 70% of the estimate 1.3 M chemical casualties in the war. It remains a significant threat today because of its simplicity to manufacture. Sulfur mustard constitutes both a vapor and a liquid chemical threat. It acts as a DNA-alkylating agent and affects rapidly dividing cells. The effects are delayed 2h-2days, depending on the severity of exposure. The organs most affected are skin, eyes, and airways. Late BM suppression occurs 7-21 days s/p exposure. Erythema resembling a sunburn is the mildest form of the injury. This progresses to large, flaccid bullae, containing sterile serous fluid. Large portions of the BSA may be affected, as in burn victims. The primary airway lesions is necrosis of the mucosa. Clinically, this causes pseudomembrane formation and, in the most severe cases, airway obstruction. Laryngospasm may also occur. The effects on eyes include conjunctivitis, blepharospasm, pain, and corneal damage. Death results from airway obstruction, PNA, secondary skin infections, or sepsis with neutropenia. There is no antidote to mustard gas or liquid exposure. Treatment is supportive, ensuring adequate analgesia and hydration. Application of topical glucocorticoids before denudation of skin may be useful. Small blisters should be left intact, but large bullae should be unroofed. The fluid is sterile and does not contain mustard derivatives. Silver sulfadiazine or other topical abx should be used to prevent 2nd bacterial infections. Conjunctival irritation should be treated with topical solutions, including abx. Petroleum jelly should be applied to the eyelids to prevent them from sticking together. Intubation may be necessary for protection from airway obstruction. Repeated bronchoscopy may also be needed to remove pseudomembranes. Finally, careful f/up for development of BM suppression is needed.

A 32 YO M with pmh of HIV presents with nausea, ABD distension, and projective vomiting which developed over the previous 8-12 hours. He denies fever, chills, diaphoresis, melena, or diarrhea. Over the past 3 months, he has lost 30 lbs in the context of advanced HIV. He has never had ABD surgery. On exam, his abdomen is distended, with high-pitched intermittent bowel sounds and guarding, but no rebound. A periumbilical bruit is also detected. ABD XR reveals a SBO with probable cut-off point in the mid duodenum. What is the diagnostic test of choice for diagnosing the cause of the underlying obstruction? A: ABD Ct with ABD angiogram B: Enteroscopy C: Laparscopy D: Serum CEA E: Stool AFB cx F: Upper GI series with small bowel follow through

A the patient's weight loss predisposes him to superior mesenteric artery (SMA) syndrome. Due to loss of mental fat pad, the SMA compresses the duodenum in this condition, leading to obstruction. Laparoscopy is less likely to be of diagnostic benefit (i.e., for adhesion), as this patient has never had ABD surgery. An upper GI series may be useful for evaluation of an obstructing mass, though SMA syndrome is more likely here. While patients with advanced HIV are at risk for a variety of infectious causes of diarrhea, they are unlikely to present with acute SBO. Serum CEA may be elevated in CRC, but would not be helpful in explaining the cause of acute SBO.

the presence of Howell-Jolly bodies, Heinz bodies, basophilic stippling, and nucleated RBCs in a patient with hairy cell leukemia prior to any treatment intervention implies which of these: A: diffuse splenic infiltration by tumor B: DIC C: hemolytic anemia D: pancytopenia E: transformation to acute leukemia

A the presence of HJ bodies (nuclear remnants), Heinz bodies (denatured Hgb), basophilic stippling, and nucleated RBCs in the PBS implies that the spleen is not properly clearing senescent or damaged RBCs from the circulation. This usually occurs because of surgical splenectomy, but is also possible when there is diffuse infiltration of the spleen with malignant cells. Hemolytic anemia can have various peripheral smear findings depending on the etiology of the hemolysis. Spherocytes and bite cells are an example of damaged RBCs that might appear due to AIHA and oxidative damage, respectively. DIC is characterized by schistocytes and thrombocytopenia on smear, with elevated INR and aPTT as well. However, in these conditions, damaged RBCs are still cleared effectively by the spleen. Transformation to acute leukemia does not lead to splenic damage.

35 YO F comes to your clinic c/o SOB. It is immediately apparent that she has a bluish tinge to her face, trunk, extremities, and mucus membranes. Which of the diagnoses is most likely? A: ASD B: myocarditis C: Raynaud's phenomenon D: sepsis E: vasospasm due to cold temperatures

A this patient has central cyanosis, which is due to arterial desaturation. In central cyanosis, skin and mucus membranes are affected. Peripheral cyanosis is the result of peripheral hypo perfusion of various causes either due to hypotension, as with HF (e.g., MI, myocarditis) or sepsis, or due to peripheral vasoconstriction, as with cold exposure or Raynaud's phenomenon. In these cases, the extremities are most affected, with the mucus membranes usually spared. This patient has Eisenmenger's physiology with R-->L shunting of deoxygenated blood. Other causes of central cyanosis include severe lung disease, pulmonary arteriovenous malformations, alveolar hypoventilation, or hemoglobin abnormalities

Drug X is investigated in a meta-analysis for its effect on mortality after a MI. It is found that mortality drops from 10% to 2% when the drug is given. What is the ARR of drug x? How many patients will need to be treated with drug X to prevent one death?

ARR is the difference in mortality (or other endpoint) between the treatment and the placebo arms. In this case, the ARR is 10% - 2% or 8%. From this number, we can calculate the NNT, which is 1/ARR. The NNT here is 1/.08 or 12.5 patients.

Which of the following is an effective method to evaluate for cortical sensory deficits? A: Graphesthesia (capacity to recognize letters drawn by the examiner on the patient's hand) B: stereognosis (the ability to recognize common objects, such as coins, by palpation) C: touch localization D: 2-point discrimination testing E: all of the above

All of the above abnormal tests listed with intact primary sensation in an alert cooperative patient identifying lesions in the parietal cortex or the thalamocortical projection to the parietal lobe. Though 2-pt discrimination is a common screening technique for cortical sensory deficits, each of the above techniques is a quick and helpful alternative to evaluate for cortical sensory deficit. 2-pt discrimination is best tested with set of calipers which simultaneously touch the skin. Normally, one can distinguish 3-mm separation of points on the pads of the fingers. Touch localization is performed by having the patient close her eyes and ID the examiner touching lightly with the finger or cotton swab.

An unknown chemical agent was released into a food court of a shopping mall. Several victims died prior to arrival in the ED. Upon arrival, the survivors were c/o difficulty with vision and stated that they felt the world was "going black." The victims were also noted to be drooling and have increased nasal secretions. A few individuals were SOB with wheezing. The most severely affected victims fell unconscious and soon after developed seizures. What meds should be given immediately to survivors? A: Atropine, 6 mg IM B: 2-pralidoxime chloride, 1800 mg IM C: Diazepam, 5 mg IV D: A and B E: B and C F: All of these

All of these these have been exposed to organophosphate nerve agents (soman, sarin, tabun, cyclosarin, and VX) that act by inhibiting tissue synaptic ACh-ase. The ssx of nerve agents are those of cholinergic crisis. SSX manifest in the order in which organ systems are exposed. When nerve agents are released as vapor, the first organ affected is the eyes with miosis and feeling the world is "going black", as reported in the Tokyo subway terrorist attack in which sarin was released. Exposure of the nasopharynx to organophosphates causes rhinorrhea, excessive salivation, and drooling. Bronchorrhea and cough frequently occur. After inhalation, it is rapidly absorbed into the blood across the alveolar-capillary membrane. The GIT is usually rapidly affected once the agent hits the bloodstream, with resultant diarrhea, cramping, nausea, and vomiting. When death occurs it is because CNS effects. Each and its receptor are widely distributed in the brain, and exposure leads to rapid unconsciousness, seizures, and central apnea. Nerve agents have a short half life and thus improvement should be rapid, without recurrence of ssx. The initial treatment is administration of Atropine, which is widely available. Atropine acts quickly at the muscarinic ACh receptor to alleviate the central apnea, but does not reverse the NM effects. In addition, use of oximes is also recommended, such as 2-pralidoxime, which reactivates the cholinesterase to restore normal enzyme function. In individuals with severe CNS toxicity and seizures, BDZ are the treatment of choice. Typical anticonvulsants such as phenytoin, carbamazepine, phenobarbital, and valproate are ineffective in treating seizures caused by these agents.

All of the following statements regarding meds in the geriatric population are true, except: A: falling Albumin levels in the elderly lead to increased free (active) levels of some meds, including Warfarin B: fat-soluble drugs have a shorter half life in geriatric patients C: hepatic clearance decreases with age D: the elderly have a decreased Vd for many medications because of a decrease in total body water E: older patients are 2-3x more likely to have adverse drug reactions

B Adverse drug reactions in the geriatric population are common, occurring 2-3x more frequently than in younger patients. This is 2/2 several factors. Drug clearance is altered because of decreased renal plasma flow and GFR, as well as decreased hepatic clearance. Furthermore, the Vd of many drugs is decreased with a drop in TBW. However, in older persons there is a relative increase in fat, which will lengthen the half-life of fat-soluble medications. Serum Alb levels decline in general in the elderly, particularly in those in hospital or sick. As a result, drugs that are primarily protein bound, such as warfarin and phenytoin, will have a higher free or active levels at similar doses. Care must be taken in interpreting total serum levels for these drugs because a low total level may be accompanied by a normal free level and thus be appropriately therapeutic.

22 YO F is referred to clinic after being started on glucocorticoids for a new diagnosis of L-optic neuritis seen on exam with disc pallor, and is confirmed with quantitative visual field mapping. What further evaluation is indicated? A: ANA B: brain MRI C: ESR D: No further evaluation unless ssx recur E: temporal artery biopsy

B Optic neuritis is an inflammatory lesion of the optic nerve. In a large study, the mean age of patients was 32 YO and 75% were female. Pain is common with eye movement. Vision loss usually recovers somewhat even without treatment. Steroids hasten vision gain, but do not alter the final visual acuity. MS is a primary concern for all newly diagnosed cases of optic neuritis. The 10-year cumulative likelihood of developing MS after an episode of optic neuritis is almost 40%. Patients with a first episode of optic neuritis should receive a brain MRI to evaluate for MS. It may show the characteristic lesions of the disease prior to the development of CNS ssx and is a helpful tool for monitoring progression of disease of this condition while on therapy.

Parkinson's disease can often be ddx from the atypical Parkinsonian syndromes (multiple system atrophy, progressive supra nuclear palsy) by the presence of which of the following? A: axial stiffness B: pill-rolling tremor C: shuffling gait D: stooped posture E: turning en bloc

B Parkinson's disease is common, affecting 1-2% of the population >65 YO. Axial stiffness, stooped posture, shuffling gait, and pill-rolling tremors are distinctive. Other progressive neurologic disorders such as those listed may be present with Parkinsonian features. The atypical Parkinsonian syndromes can be difficult to ddx, but the presence of a pill-rolling tremor is specific for Parkinson's.

Which of the following criteria best ddx episcleritis from conjunctivitis? A: concurrent connective tissue disease such as lupus B: lack of discharge C: more diffuse ocular involvement D: reduced eye motility E: severe pain

B conjunctivitis is the MC cause of a red, irritated eye. Pain is minimal and visual acuity is only minimally impacted. It is usually due to Adenovirus infection. Bacterial infection causes mucopurulent discharge. Conjunctivitis invariably presents with ocular discharge, whereas episcleritis does not. Episcleritis, inflammation of the episclera, a thin layer between the sclera and the conjunctiva, is often more localized than conjunctivitis, but this cannot always be used to discriminate the two. Scleritis, a deeper, more intense inflammatory condition than episcleritis, is a/w various connective tissue disorders and should always be considered in patients with these conditions

all of these patients should receive a lipid screening profile, except: A: 16 YO male with DM1 B: 17 YO female teen who recently began smoking C: 23 YO healthy male who is starting his first job D: 48 YO F beginning menopause E: 62 YO M with no PMHx

B current guidelines from National Cholesterol Education project Adult Treatment Panel III recommend screening in all adults >20 YO. The testing should include fasting total cholesterol, TAGs, LDL, and HDL. The screening should be repeated q/5 years. All patients with DM1 should have lipids followed closely to decrease CV risk by combining the results of lipid screening with other RF to determine risk category and intensity of recommended treatment.

the resting energy expenditure is a rough estimate of total caloric needs in a state of energy balance. Of these two patients with stable weights, which person has the highest resting energy expenditure: Patient A: 40 YO M who weighs 90 kg and is sedentary Patient B: 40 YO M who weighs 70 kg and is very active A: 40 YO M who weighs 90 kg and is sedentary B: 40 YO M who weighs 70 kg and is very active C: REE is the same D: Not enough information given

B for stable weights, REE can be calculated if the gender, weight, and activity level are given. For males, REE = 900 + 10w and females REE = 700 + 7w (w = wt in kilograms). The REE is then adjusted for activity level by multiplying 1.2 for sedentary, 1.4 for moderately active, and 1.8 for very active. Patient A has REE 2160 kcal/day. Patient B has REE 28880 kcal/day. For a given weight, a higher level of activity increases the REE more than a 20 kg change in wt at a given level of activity

Prader-Willi syndrome is a rare disorder that is characterized by diminished fetal activity, obesity, MR, and short stature. A deletion on the paternal copy of Chromosome 15 is the cause. A deletion on the same site on chromosome 15, but on the maternal copy, results in a different syndrome: Angelman's syndrome. This is characterized by MR, seizures, ataxia, and hypotonia. What is the name of the genetic mechanism that results in this phenomenon? A: genetic anticipation B: genetic imprinting C: lyonization D: somatic mosaicism E: uniparental disomy

B genetic imprinting is gene inactivation that result in preferential expression of an allele depending on its parental origin. It is important in many diseases, including malignancies. Abnormal expression in the paternally derived copy of insulin-like growth factor (IGF-II) results in the cancer predisposing Beckwith-Wiedemann syndrome. Uniparental disomy is the inheritance of two copies of either maternal or paternal chromosomes. This may result in similar phenotypes, as is the case in imprinting. The PWS and Angelman's syndromes may result from uniparental disomy involving inheritance of defective maternal or paternal chromosomes, respectively. Similarly, hydatidiform moles may contain normal numbers of diploid chromosomes, all of which are paternal. The opposite occurs in some teratomas. Lyonization is the epigenetic inactivation of one of the two X chromosomes in every cell of the female. Somatic mosaicism is the presence of 2 or more genetically distinct cell lines in the tissue of an individual. The term anticipation is often used to refer to diseases caused by trinucloetide repeats that are often characterized by worsening of clinical phenotypes in successive generations. These diseases, such as Huntington's and fragile X, are characterized by expansion of these repeats in subsequent generations of individuals, resulting in earlier and often more severe clinical phenotypes.

42 YO M wants your opinion about Vitamin E supplementation. He has read that taking high doses of Vitamin E can improve his sexual performance and slow the aging process. He is not Vitamin E deficient. You explain to him that these claims are not based on good evidence. What other potential AE should he be concerned about? A: DVT B: hemorrhage C: night blindness D: peripheral neuropathy E: retinopathy

B high doses of vitamin E (>800 mg/day) may reduce PLT aggregation and interfere with Vitamin K metabolism. Doses >400 mg/day may increase mortality from any cause. Vitamin E excess is not related to increased risk of DVT. Peripheral neuropathy and a pigmented retinopathy may be seen in Vitamin E deficiency. Vitamin A deficiency is a cause of night blindness.

54 YO M presents to clinic with unexplained weight loss. On review, you do notice that he has lost 8% of his TBW in the past year. He has well-treated HTN for which he takes a thiazide. Other than recently been widowed, he has no pertinent social history. He is a lifelong nonsmoker and worked as a hospital administrator. An extensive review of systems is unrevealing. Your PE reveals no masses or other pathology. A brief psych exam shows no signs of depression. You perform initial testing with a CBC, -lytes, renal function, LFTs, UA, TSH, and a CXR, which are unrevealing. He is UTD on his routine cancer screening. What is the next step? A: Chest CT B: close follow-up C: PET scan D: total body CT e: upper endoscopy

B patients with unintentional weight loss >5% of the TBW over a 6-12 month period should prompt an evaluation. In the elderly, weight loss is an independent predictor of M/M. Studies in elderly have found MR of 10-15%/year in patients with significant unintentional weight loss. It is important to confirm the weight loss and duration of time over which it occurred. The causes are protean and usually become apparent after a careful evaluation and directed testing. A thorough review of systems should be performed including constitutional, respiratory, GIT, and psych. Travel history and Rf for HIV are also important. Meds and supplements should be reviewed. The PE must include an exam of skin, oropharynx, thyroid, lymphatics, ABD, rectum, prostate, neurologic, and pelvis. A reasonable lab approach would include initial phase of testing including the tests outlined here. In the absence of ssx, close follow-up rather than undirected testing is appropriate. Total-body scanning with PET or CT has not been shown to be effective as screening tests without a clinical indication.

72 YO white male with NYHA II ischemic cardiomyopathy, DM, and chronic renal insufficiency (Cr Cl = 42 mL/min) undergoes dobutamine ECHO prior to carotid endarterectomy. He is found to have 7-mm ST depressions in his lateral leads during the test and develops SOB @ 70% maximal expected dosage, requiring early cessation of the test. His current meds include ACE, Beta blocker, and ASA. What would be your advice? A: cancel the carotid endarterectomy B: proceed to cardiac catheterization C: maximize medical management D: proceed directly to carotid endarterectomy E: proceed directly to carotid endarterectomy and CABG

B pharmacologic stress tests, such as dopamine, persantine, or adenosine, are more useful than exercise testing in patients with functional limitation. While their PPV is poor, they have excellent NPV for ID patients at risk for perioperative MI or death. The patient is on adequate medical therapy for his ischemic cardiomyopathy but nevertheless had a very high-risk stress test. He should proceed to cardiac catheterization for either endovascular stenting or referral for bypass surgery

Which preventative intervention leads to the largest average increase in life expectancy for a target population? A: a regular exercise program for a 40 YO M B: getting a 35 YO smoker to quit smoking C: Mammography in women aged 50-70 D: Pap smears in women aged 18-65 E: PSA and DRE for a man > 50 YO

B predicted increases in life expectancy are average numbers that apply to populations, not individuals. Because we often do not understand the true nature of risk of disease, screening and lifestyle interventions usually benefit a small proportion of the total population. For screening tests, FP may also increase the risk of diagnostic tests. While Pap smears increase life expectancy overall by only 2-3 months, for the individual at risk of cervical cancer, it may add many years to life. The average life expectancy increases resulting from mammography (1 month), PSA (2 weeks), or exercise (1-2 years) are less than those from quitting smoking (3-5 years)

Which of the following is true regarding drug effects after an overdose in comparison to a reference dose? A: drug effects begin earlier, peak earlier, and last longer B: drug effects begin earlier, peak later, and last longer C: drug effects begin earlier, peak later, and last shorter D: drug effects begin later, peak earlier, and last shorter E: drug effects begin later, peak later, and last longer

B the clinical ramifications of this question are critical. Drug effects begin earlier, peak later, and last longer in the context of an overdose, compared to commonly referenced values. Therefore, if a patient has a known ingestion of a toxic dose of a danger substance and ssx have not yet begun, then aggressive gut decontamination should ensue, because ssx are apt to ensure rapidly. The late peak and longer duration of action are important as well. A common error in practice is for patients to be released or watched less carefully after reversal of toxicity a/w opiate agonist or BDZ. However, the duration of activity of the offending toxic agent often exceeds the half-life of the antagonists, naloxone or flumazenil, requiring the administrations of subsequent doses several hours later to prevent further CNS or physiologic depression

All of the following should be components of the routine evaluation of any patient undergoing medium or high risk non-cardiac surgery, except: A: 12-lead resting EKG B: CXR C: detailed history D: PE E: treadmill stress test

B the goal of the evaluation is to identify patients at intermediate or high risk for post-op complications. The hx and PE should focus on detecting ssx or signs of occult cardiac or pulmonary disease. Preop testing should be carried out for specific conditions based on clinical exam. Many questionnaires exist to ID patients at intermediate or high risk. There is no proven rule for CXR in this context provided that the cardiopulmonary hx and PE are wnl.

64 YO alcoholic presents to ED with occasional hemoptysis, productive cough, and low grade fever over the past several weeks. His CT shows an abnormality in the RLL. He reports several contacts with TB-infected patients while in prison several years ago. Sputum exam reveals putrid-smelling thick green sputum streaked with blood. The gram stain shows polymorphonuclear leukocytes and a mix of gram+ and gram- organisms. What is the dx? A: bronchogenic carcinoma B: polymicrobial lung abscess C: pulmonary TB D: tricuspid valve endocarditis E: wegener's granulomatosis

B the putrid smell and polymicrobial gram stain suggests a polymicrobial lung abscess consisting of normal oral flora, including anaerobes and Strep viridans. The anaerobes contribute to the putrid smell of the sputum. The patient's protracted, mild clinical course is typical for this process, and his alcoholism is a clear RF. The superior segment of the RLL is the MC site of aspiration PNA and lung abscesses, followed by the posterior segment of the RUL and the superior segment of the LLL. Tricuspid valve endocarditis may cause lung abscesses due to S aureus bacteremia. The patient is clearly at risk for TB given his imprisonment; however, the sputum would not likely be putrid and purulent with this microscopic appearance. The cavitary lesions of TB are typically in the upper lobes. Wegener's granulomatosis may cause cavitary masses, but they are usually multiple and would not have putrid sputum. Squamous lung cancer may also capitate by outgrowing its blood supply and may be secondarily infected, although usually not with this degree of anaerobic characteristics.

7 MO child is brought to ED by parents. He was the product of a healthy pregnancy, and there were no perinatal cx. The parents are concerned something is wrong; he is very hyperactive and noted to have a "mousy" odor. On exam, he has microcephaly, hypo pigmentation, and eczema. Labs are sent and diagnosis is made. How could this scenario been prevented? A: screening at 6 months for urine ketones B: screening at birth for phenylalanine in blood C: screening at birth for chromosomal abnorm D: genetic screening of parents prior to delivery E: cord blood sampling at 2 months pregnancy for glutamine synthase

B this child has classic findings of PKU, an AR disorder of AA metabolism in which phenylalanine cannot be converted to tyrosine. It is the MC inherited disorder of AA metabolism. Untreated or unrecognized cases will usually have a normal birth, but will rapidly begin to show signs of this illness, which include microcephaly, mental retardation, and seizures. The "mousy" odor is due to phenyl acetate accumulation in the skin, hair, or urine. The toxicity of phenylalanine is due to inhibition of transport of other AA necessary for normal protein, myelin, and NT synthesis. Screening should be done in the blood prior to 3 weeks of age (usually at birth) to prevent ssx. Treatment consists of lifelong dietary phenylalanine restriction and tyrosine supplementation. If detected at birth, affected children do not develop the cx. Women with PKU who become pregnant must maintain strict control before and during pregnancy to avoid congenital defects, microcephaly, growth retardation, and mental retardation in the baby.

30 YO M seen for PE when obtaining life insurance. The last time he saw a physician was 15 years ago. He has no complaints. PMH is notable for scoliosis that was surgically corrected when he was a teenager and recent shoulder dislocation. He takes no meds and does not smoke, drink, or use illicit drugs. FamHx is notable for a father and brother with CRC at 45 and 50 years. PE is notable for normal VS, a tall habitus with hyper mobile joints, normal skin, and ectopia lentis. Rectal exam is wnl, stool guaiac-negative. The remainder of exam is wnl. Appropriate recommendation for follow-up includes which of the following annual studies? A: colonoscopy B: ECHO C: FOBT D: serum periodic acid-schiff (PSA) measurement E: serum TSH

B this patient has classic findings c/w inherited connective tissue disorder, particularly Marfan. The presentation is not c/w bony deformities or blue sclera of OI, and he is tall with long extremities, which makes achondroplasia very unlikely. However, his hyper mobility and lens disorders suggest Marfan, or, less commonly, Ehlers-Danlos. Given the high risk of aortic root disease in Marfan, ECHO is indicated. The other screening tests are not specific to Marfan and are not appropriate in a 30 YO male.

a homeless male is evaluated in the ED and is noted that after he slept outside during a particularly cold night his left foot has become clumsy and feels "dead." On exam, the foot has hemorrhagic vesicles distributed throughout the foot distal to the ankle. The foot is cool and has no sensation to pain or temperature. The right foot is hyperemic but does not have vesicles and has normal sensation. The remainder of the PE is wnl. Which of the following statements regarding the management of this disorder is true? A: active foot rewarming should not be attempted B: during the period of rewarming, intense pain can be anticipated C: heparin has been shown to improve outcomes in this disorder D: immediate amputation is indicated E: normal sensation is likely to return with rewarming

B this patient has frostbite of the left foot. The MC presenting ssx is sensory changes that affect pain and temperature. PE can have a multitude of findings, depending on the degree of tissue damage. Mild frostbite will show erythema and anesthesia. With more extensive damage, bullae and vesicles will develop. Hemorrhagic vesicles are due to injury to the microvasculature. The prognosis is most favorable when the presenting area is warm and has normal color. Treatment with rapid rewarming, which is usually accomplished by a 37-40 C degree water bath can be intensely painful for the patient, and often narcotic analgesia is warranted. If the pain is intolerable, the temperature of the bath can be dropped slightly. Compartment syndrome can develop with rewarming and should be investigated if cyanosis persists after rewarming. No meds have shown improvement in outcomes, including heparin, steroids, CCBs, and hyperbaric oxygen. In the absence of wet gangrene or another emergent surgical indication, decisions about amputation should be deferred until the boundaries of tissue injury are well demarcated. After initial recovery, these patients often have neuronal injury with abnormal sympathetic tone in the extremity. Other remote cx include cutaneous carcinoma, nail deformities, and in children, epiphyseal damage.

Which of these would be present in an individual who has lost non declarative memory? A: inability to recall spouse's birthday B: inability to recall how to tie a tie C: inability to recognize a photo taken at one's wedding D: inability to recognize a watch as an instrument for keeping time E: inability to remember the events of one's high school graduation

B to be able to ddx among the disorders that cause memory loss, it should be determined whether the patient has declarative or non declarative memory loss. A simple way to think of the difference is to consider the difference between "knowing how" (non declarative) and "knowing what or who" (declarative. Nondeclarative memory refers to loss of skill, habits, or learned behaviors that can be expressed without an awareness of what was learned. Procedural memory is a type of non declarative memory and may involve motor, perceptual, or cognitive processes. Examples of non declarative procedural memory include how to tie one's shoes (motor), responding to the tea kettle (perceptual), or increasing ability to complete a puzzle (cognitive). Nondeclarative memory involves several brain areas, including the amygdala, basal ganglia, cerebellum, and sensory cortex. Declarative memory refers to the conscious memory for facts and events and is divided into (2) categories: semantic and episodic. Semantic refers to general knowledge about the world without specific recalling how or when the information was learned. An example is the recollection that a wristwatch is an instrument for keeping time. Vocabulary and the knowledge of associations between verbal concepts comprise a large portion of semantic memory. Episodic memory allows one to recall specific personal experiences. Examples of episodic memory include recall of a birthday of a spouse, recognition of a photo from a wedding, or recall high school graduation events. The areas of the brain involved in declarative memory include the hippocampus, entorhinal cortex, maxillary bodies, and thalamus 64

23 YO F referred to clinic after being seen in the ED for intermittent, severe CP. During her visit, she is ruled out for ischemia with negative biomarkers and EKG. An exercise single photon emission CT (SPECT) myocardial perfusion scan was performed, and a reversible exercise-induced perfusion defect was noted. The test was read as positive. The patient was placed on ASA. She is concerned that she continues to have CP on a daily basis without any consistency in regards to time or antecedent activity. She is otherwise well. She smokes socially on weekends. She has no famhx of early coronary artery disease. What should you do next? A: cardiac cath B: CT coronary arteries C: dobutamine stress echo D: evaluate her for non-cardiac source of CP E: repeat exercise SPECT test

Based on her age and hx, the patients pretest prob of CAD is extremely low. Even though the SPECT is a test with good performance characteristics, a positive test is only meaningful in a patient with a medium pretest prob of CAD. This patient's posttest prob is still low to medium. The test should not have been ordered in the first place and is an example of defensive medicine. Any further testing could expose the patient to undue invasive testing and further anxiety. Her ASA should be stopped, she should be reassured, and other causes of her CP should be evaluated

Exposure to which of the types of radiation would result in thermal injury and burns but would not cause damage to internal organs because the particle size is too large to cause internal penetration?

Beta radiation consists of small, negatively charged electrons; these particles can only travel short distances in tissue and lead primarily to burns similar to thermal injury. Plastic layers and clothing can prohibit penetration of most beta particles. Beta radiation is frequently released in radiation accidents, and radioactive iodine is the best recognized member of the group. Alpha radiation consists of heavy positively charged particles consisting of two protons and two neutrons. Because of the large size, alpha particles cannot penetrate tissue. However, if alpha particles are internalized, they will cause damage to cells within the immediate proximity. The most damaging particles emitted during a nuclear explosion are gamma rays, XR, and neutrons. Gamma rays and XR are both photons and have similar ability to penetrate through matter. They are the principal type of radiation to cause total body exposure. Neutrons are heavy, but uncharged, and possess a range of energy. These neutrons can ionize DNA directly or through generation of free radicals.

Which of the following statements regarding gender health is true? A: Alzheimer's disease affects men and women at equal rates B: Alzheimer's disease affects men 2x more than women C: in a recent placebo-controlled trial, postmenopausal hormone therapy did not show improvement in disease progression in women with Alzheimer's D: women with Alzheimer's have higher levels of circulating estrogen than women without Alzheimer's

C Alzheimer's disease (AD) affects women 2x as commonly as men. Women with AD have lower levels of circulating estrogen than age-controlled women without disease. Despite this, the placebo controlled trials have shown no benefit in terms of cognitive decline for estrogen replacement in women with AD

A 64 YO M with primary light chain amyloidosis develops orthostatic symptoms despite maintaining adequate po intake. He also notes early satiety, with bloating and vomiting if he eats too rapidly. To combat this, he has decreased the size of his meals, but eats twice as frequently during the day, with some positive effect. What is the most likely explanation for his GI ssx? A: diverticulosis B: gastric cancer C: gastroparesis D: irritable bowel syndrome E: small bowel obstruction

C Amyloidosis predisposes to ANS neuropathy, which in turn causes both orthostasis and gastroparesis. GI amyloidosis is another possibility in this patient, though his early satiety and bloating are typical for gastroparesis. Tx can include pro-motility agents, such as Metoclopramide as well as dietary changes that this patient has instituted. SBO would not be relieved by smaller, frequent meals. Gastric cancer may present with early satiety and vomiting, as well as weight loss. Diverticulosis and IBS present with lower GI ssx.

32 YO M seeks evaluation for ongoing fevers of uncertain cause. He first noted a feeling of malaise about 3 months ago, and for the past 6 weeks, he has been experiencing daily fevers to has high as 103F. He awakens with night sweats once per week and has lost 4.5 kg. He c/o nonspecific myalgia and arthralgia. He has no rash and reports no ill contacts. He has seen his PCP on three separate occasions during this time and has documented temperature of 101.7F. Multiple labs have shown nonspecific findings only. CBC shows WBC 15.7 with 80% PMNs, 15% Lymphocyte, 3% eosinophils, and 2% monocytes. The PBS is wnl. The HCT 34. ESR is elevated at 57. Liver and kidney function are normal, HIV, EBV, and CMV are negative. Routine blood cx for bacteria, CXR, and PPD are negative. In large groups of patients similar to this one with fever of unknown origin, which of the following categories comprises the largest group of diagnoses if one is able to be determined? A: drug or other ingestion B: hereditary periodic fever syndromes, such as familial Mediterranean fever C: infection D: neoplasm E: noninfectious inflammatory disease

C FUO is defined as the presence of fevers to >101F on several occasions for >3 weeks without a defined cause after appropriate investigation into potential causes have failed to yield a diagnosis. Initial labs should include CBC with diff, PBS, ESR, CRP, -lytes, Cr, Ca, LFTs, UA, and ms enzymes. In addition, specific testing for a variety of infections should be performed, including VDRL, HIV, CMV, EBV, PPD, and blood, sputum, and Urine cx if appropriate. Finally, workup should include inflammatory disorders, including ANA, RF, ferritin, iron, and transferrin. In several large studies, infectious etiologies are the MC identified source of FUO. In earlier studies, infectious etiologies accounted for 32-36% of all FUO. In more recent studies, up to 30% will have not have identified cause of FUO, and infectious etiologies continue to comprise 25% of all FUO. The MC infectious cause is extra pulmonary TB. Viral and fungal etiologies are also common. In addition, intraabdominal, retroperitoneal, renal, and paraspinal abscesses should be considered. In earlier studies, neoplasm was the 2nd most common source of FUO. However, given improvements in imaging and diagnosis, neoplasm now accounts for fever cases of FUO. Presently, the 2nd most common cause is noninfectious inflammatory disorders. In the elderly, giant cell arteritis can present as FUO, as can polymyositis, Behcets, and adult Still's disease. Drug fever and hereditary periodic fever syndromes are grouped into "miscellaneous" category and are among the least common causes of prolonged fever of unknown origin.

46 YO F presents to her PCP complaining of a feeling of anxiety. She notes that she always had been what she describes as a "worrier", even in grade school. The patient has always avoided speaking in public and recently is becoming anxious to the extent where she is having difficulty functioning at work and in social situations. She has difficulty falling asleep at night and finds that she is always "fidgety" and has a compulsive urge to move. The patient owns a real estate company that has been in decline since a downturn in the economy. She recently has been avoiding showing homes for sale. Instead, she defers to her partners because she finds that she is nervous to the point of being unable to speak to her clients. She has two children, ages 16 and 12, who are very active in sports. She feels overwhelmed with worry over the possibility of injury to her children and will not attend their sporting events. You suspect that the patient has GAD. All of the following are true about this diagnosis, except: A: the age of onset of ssx is usually before 20 years, although the diagnosis usually occurs much later in life B: over 80% of these patients have a concomitant mood disorder, such as MDD, dysthymia, or social phobia C: as in panic disorder, SOB, tachycardia, and palpitations are common D: experimental work suggests that the pathophysiology of GAD involves impaired binding of benzodiazepines at the GABA receptor E: the therapeutic approach to patients with GAD should include both pharmacologic agents and psychotherapy, although complete relief of ssx is rare

C GAD is common, with a lifetime prevalence of approx 5% and with the onset of ssx often occurring before 20 YO. These patients frequently report having feelings of anxiety and social phobia that date back to childhood. Clinically, these patients report persistent, excessive, and unrealistic worries that prevent normal functioning. In addition, there is often the complaint of feeling "on edge" with nervousness, arousal, and insomnia. However, unlike panic disorder, palpitations, tachycardia, and SOB are rare. Pathophysiologically, there is likely to be impaired function of the GABA-receptor with decreased binding of BDZ at that receptor. Therapy should include a combination of drugs and psychotherapy. Drugs that may be used include BDZ, buspirone, and anticonvulsants with GABAergic properties, such as gabapentin, tiagabine, and divalproex.

45 YO M evaluated for weakness and a progressive change in mental status. After extensive evaluation, he is diagnosed with a mitochondrial disorder. All of these are true about the disorder, except: A: the mitochondrial genome does not recombine B: inheritance is maternal C: the proportion of WT and mutant mitochondria in different tissues is identical D: cardiomyopathy is a feature of many mitochondrial disorders E: acquired somatic mitochondrial mutations play a role in age-related degenerative disorders.

C Mendelian inheritance patterns do not apply to mitochondrial genetics. MtDNA consists of small encoding transfer and ribosomal RNAs and various proteins that are involved in oxidative phosphorylation and ATP generation. MtDNA exists as a circular chromosome within cells. The genome does not recombine. The genetic material that is introduced into the egg by the sperm does not contain MtDNA, therefore, inheritance is maternal. All the children of an affected mother will inherit the disorder. An affected father will not transmit the disorder. The clinical manifestations of the various disorders in the mitochondrial genetics are characterized by alterations in oxidative phosphorylation which lead to reductions in ATP supply and apoptosis. Areas of high dependence on oxidative phosphorylation include skeletal and cardiac ms and the brain. During replication, the number of mitochondria can drift among various cells and tissues, resulting in heterogeneity, or heteroplasty. This results in further variation in the clinical phenotype. Acquired mutations in the MtDNA are thought to play a significant role in the age-related degenerative disorders such as Alzheimers and Parkinsons

the CDC has designated several biologic agents as category A in their ability to be used as a bioweapon. Category A agents include agents that can be easily disseminated or transmitted, result in high MR, cause public panic, and require special action for public health preparedness. All of these agents are category A, except: A: Bacillus anthracis B: Francisella tularensis C: ricin toxin from Ricinus communis D: smallpox E: Yersinia pestis

C The CDC developed classifications of biologic agents that are based on potential to be used as bioweapons. 6 types of agents are category A 1. Bacillus anthracis 2. Botox toxin 3. Yersinia pestis 4. smallpox 5. tularemia 6. viruses which cause hemorrhagic fever, such as Lassa virus, Rift Valley fever virus, Ebola, and yellow fever virus

You are working in an urban-based ICU and two cases of severe PNA are admitted. Francisella tularensis is cultured from both patient's sputum. Neither recalls contact with wild or domesticated animals in the past 2 weeks. You should do all of these, except: A: alert CDC for potential bioterrorism B: alert the micro lab director C: institute drops precaution for the patients D: treat with broad spectrum abx

C Tularemia, caused by the small, nonmotile gram-negative coccobacillus has been proposed as a potential bioweapon (CDC-A) because of its high degree of environmental infectiousness, potential for aerosolization, and ability to cause severe PNA. It is not as lethal as anthrax or plague. Infection with tularemia is MC in rural areas where small mammals serve as a reservoir. Human infections may occur from tick or mosquito bites or from contact with infected animals during hunting. The isolation of this pathogen in two patients w/o obvious exposure RF should prompt concern that a terrorist intentionally aerosolized F tularensis as an agent of terrorism. It is highly infectious, with as few as 10 organisms causing infection, and outbreaks have been reported in microbiology workers streaking Petri dishes. However, it is not infectious person-to-person. Streptomycin, doxycycline, gentamicin, chloramphenicol, and ciprofloxacin are less likely effective agents; however, given the possibility of genetically altered organisms, broad-spectrum abx are indicated pending sensitivity testing. In outbreaks, tularemia PNA has a mortality of 30-60% in untreated patients and <2% with appropriate therapy.

21 YO F comes to clinic to establish new primary care. She has a hx of Type III glycogen storage disease (debranching deficiency), for which she takes a high-protein, high-carbohydrate diet. She has a normal PE, except for short stature, mild weakness, and a slightly enlarged liver. She works as an administrative assistant and is planning to be married in the next 6 months. She is concerned about her long-term prognosis and the chances of the disease developing in a child. All of the following statements about her prognosis are true, except: A: cardiomyopathy is a possible cx B: chronic liver disease is a possible cx C: dementia is a possible cx D: her child will not have the disease, unless her fiancé is a carrier E: prenatal testing is available for the disease

C Type III glycogen storage disease, a deficiency in debranching enzyme, causes abnormalities in glycogen degradation. Clinical manifestations include hepatomegaly, hypoglycemia, short stature, variable skeletal myopathy, and cardiomyopathy. Dementia does not occur. When liver and muscle are involved, the disease is termed type IIIa; however, in 15% of patients, liver disease predominates and these patients are characterized has having type IIIb disease. Fasting ketosis will occur if glucose/protein intake is not maintained. In most patients, hepatomegaly improves with age; however, chronic liver disease and cirrhosis may occur in adulthood, requiring liver transport. HCC has also been reported. Treatment consists of dietary management with frequent high-carb meals and possible nocturnal drip feeding to avoid hypoglycemia. Linkage analysis markers can be used for screening carriers and prenatal diagnosis.

chronic hypoxia causes biochemical changes whereby oxygen delivery to tissues is not impaired. In comparison to someone living at sea level, which of the following changes would be expected in a healthy person acclimated to living at a high altitude? A: basal temperature <37 C B: serum pH >7.45 C: increase RBC levels of 2,3-DPG D: Hgb concentration of <10 E: arterial PCO2 < 30 mm Hg

C chronic hypoxia, seen in people acclimated to high altitudes, causes a shift in the oxygen dissociation curve to the right (decreased affinity) causing more oxygen to be released into tissues deprived of oxygen. This is achieved by increased RBC production of 2,3-DPG. Four factors decrease the affinity of Hgb for oxygen: high temperature, increased partial pressure of CO2 (Bohr effect), increased levels of 2,3-DPG, increase in acidity. The opposite changes in these four factors increase Hgb affinity for oxygen and impair delivery of oxygen to peripheral tissue. Healthy men acclimated to altitudes of 1400 m have an average pH/PaCO2 of 7.43/34 and healthy women 7.44/33. Hgb concentration will increase due to stimulatory effect of hypoxia on EPO.

43 YO M with alcoholic liver disease c/o SOB upon sitting up. PE is notable for chest spider angiomas and palmar erythema. His arterial O2 sats fall from 96 to 88 upon sitting upright. His lung fields are clear and heart sounds are crisp. ABD exam is notable for palpable nodular liver edge with no fluid wave or shifting dullness. He has 1+ lower extremity edema. What is the cause of the SOB? A: chronic thromboembolic disease B: CHF C: pulmonary AVF D: portal HTN E: VSD

C cirrhotic patients are at risk of developing pulmonary AVF. These, as well as portopulmonary shunts, cause platypnea and orthodeoxia (SOB and desaturation with sitting up). The fistulas, which are preferentially at the base of the lungs, increase the R-->L shunting (and therefore hypoxemia) when upright. In the supine position, the apex of the lung is better perfused and the hypoxemia improves. The O2 desaturation in the upright position causes the platypnea. Congenital pulmonary AV malformations may also cause platypnea and orthodeoxia. VSD will not cause hypoxemia until they develop R-->L shunting.

all of the following diseases are a/w massive splenomegaly (spleen < 8cm below the costal margin or weighs >1000 g), except: A: autoimmune hemolytic anemia B: chronic lymphocytic leukemia C: cirrhosis with portal HTN D: myelofibrosis with myeloid metaplasia E: none of these

C portal HTN causes splenomegaly via passive congestion of the spleen. It generally causes only mild enlargement of the spleen as expanded varies provide some decompression for elevated portal pressures. Myelofibrosis necessitates extra medullary hematopoiesis in the spleen, liver, and even peritoneum, leading to massive splenomegaly due to myeloid hyperplasia. AIH requires the spleen to dispose of massive amounts of damaged RBCs, leading to RES hyperplasia and frequently an extremely large spleen. CML and other leukemias/lymphomas can lead to massive splenomegaly due to infiltration with an abnormal clone of cells. If a patient with cirrhosis or RHF has massive splenomegaly, a cause other than passive congestion should be considered.

The wife of a patient with vasculogenic ED also reports that she has experienced low sexual desire lately. She is not distressed by this and the couple reports no conflict as a result of low desire. She is 61 YO and has a hx of CABG remotely. She experienced menopause at the age of 53. Her meds include ASA, metoprolol, simvastatin, verapamil, and a multivitamin. She asks whether an oral agent will assist her sexual desire. What is the best answer for her? A: PDE-5 inhibitors have been shown to improve sexual function in pre-menopausal women B: PDE-5 inhibitors have been shown to improve sexual function in post-menopausal women C: PDE-5 inhibitors have no role in the treatment of female sexual dysfunction D: PDE-5 inhibitors treat organic disorder but not sexual arousal disorder

C female sexual dysfunction (FSD) includes disorders of desire, arousal, pain, and muted orgasm. The RF are similar to those in men, including CVD, endocrine, neurologic, and smoking. The female sexual response requires the presence of estrogens and possibly androgens. While the neurotransmission for clitoral corporal engorgement are the same as for men and include NO, the use of PDE-5 inhibitors for FSD have not been proven efficacious and should be discouraged until proof is available that they are effective. PDE-5 inhibitors have not been shown to be more or less benefit in pre- or post- menopausal women. For FSD, behavioral and nonpharmacologic therapies including lifestyle modifications, medication adjustment, and use of lubricants should be the first step.

Patients taking which of these drugs should be advised to avoid drinking grapefruit juice? A: amoxicillin B: ASA C: atorvastatin D: prevacid E: sildenafil

C grapefruit juice inhibits CYP3A4 in the liver, particularly at high doses. This can cause a decreased drug elimination via hepatic metabolism and increase potential drug toxicities. Atorvastatin is metabolized via this pathway. Drugs that enhance atorvastatin toxicity via this path include: phenytoin, ritonavir, clarithromycin, and azole antifungals. ASA is cleared via renal. Prevacid can cause impaired absorption of other drugs via its effect on gastric pH. Sildenafil is a PDE4 inhibitor that may enhance the effects of other nitrates and cause hypotension.

hyperthermia is defined as A: core temperature >40C B: core temperature >41.5C C: an uncontrolled increase in body temperature despite a normal hypothalamic temperature setting D: an elevated temperature that normalizes with antipyretic therapy E: temperature >40C, rigidity, and ANS dysfunction

C hyperthermia occurs when exogenous heat exposure or an endogenous heat producing process, such as neuroleptic malignant syndrome or malignant hyperthermia, leads to high internal temperatures despite a normal hypothalamic temperature set point. Fever occurs when a pyrogen such as microbial toxin, microbe particle, or cytokine resets the hypothalamus to a higher temperature. Rigidity and ANS dysfunction are characteristics of malignant hyperthermia, a subset of hyperthermia. Fever, not hyperthermia, responds to antipyretics.

While working in the ICU, you admit a 57 year old F with acute pancreatitis and oliguric renal failure. RR is 26, HR 125, and T 37.2C. PE shows marked ABD tenderness with normative BS. A CT scan shows inflamed pancreas without hemorrhage. You calculate her APACHE-I score to be 28. When deciding on when to initiate nutritional replacement in this patient, which is true? A: bowel rest is the cornerstone of treatment for acute pancreatitis B: administering parenteral nutrition within 24 hour will decrease the risk of infection and mortality C: enteral feeding supports gut function by secretion of GIT hormones that stimulate gut trophic activity D: in severe systemic response to inflammation, feeding can be withheld initially because the patient is likely to have adequate, spontaneous oral intake in the first 7 days

C in the past, bowel rest was the cornerstone of treatment; however, the value of adding minimal amounts of enteral nutrition (EN) is widely accepted. Timing of enteral therapy is important. Although administering EN can improve mortality, there is an increased risk of infection. Patients with severe SRI are unlikely to be able to take adequate, spontaneous oral intake within the first week of their hospitalization. Therefore, enteral nutrition should be considered early for severely sick patients

Several victims are brought back to ED after a terrorist attack in the train station. An explosive was detonated that dispersed an unknown substance throughout the station, but several people reported a smell like that of horseradish or garlic. Prior to transport to ED, exposed individuals had their clothing removed and underwent showering and decontamination. On initial presentation, there is no apparent injury except eye irritation. Over the next few hours, most of those exposed complain of nasal congestion, sinus pain, and burning in the nares. Beginning about 2 hours after exposure, many of the exposed began to notice diffuse redness of the skin, particularly in the neck, axillae, antecubital fossae, and external genitalia. In addition, a few people also developed blistering of the skin. Hoarseness, cough, and SOB are noted as well. What is the most likely chemical agent that was released in the terrorist attack? A: chlorine B: cyanide C: mustard gas D: phosgene oxime E: soman

C mustard gas (sulfur mustard) is a vesicant agent that has been used for chemical warfare and terrorism since WWI. In WW1, it was responsible for 70% of the 1.3 M individuals killed by chemical warfare, but overall, it had a MR of 1.9%. Sulfur mustard is both vapor and liquid components which cause damage to the epithelial surfaces. However, the effects of mustard gas exposure are delayed several hours after exposure. An initial clue to which agent the individuals were exposed was the smell of horseradish or burned garlic, which is characteristic of mustard gas. The earliest effects of mustard gas exposure involve the nose, sinus, and pharynx. Common ssx include burning in the nares, epistaxis, sinus pain, and pharyngeal pain. Damage to upper airways may cause laryngitis and nonproductive cough. Lower airway involvement results in nonproductive cough and SOB, but pulmonary hemorrhage is rare. Pseudomembranes may form and cause obstruction. The eyes are the most sensitive organ to mustard gas injury with shorter latency to ssx than skin. Erythema of the skin begins 2h-2d after exposure and is greatest at warm, moist locations such as the axillae, neck, fossae, perineum, and genitalia. Small vesicles may develop, which coalesce into bullae. Death is usually from sepsis and ARF, although high doses can cause BM failure 7-21 days after exposure. Phosgene oxime is also a vesicant that may present with similar ssx, but can be ddx from mustard gas by its pungent pepperish odor. Further, it has immediate ssx. Chlorine causes inhalation damage to lungs and with noncardiogenic pulmonary edema as the primary presentation. Cyanide is an asphyxiant with rapid onset, including death. Soman is a nerve agent that would present with cholinergic ssx of miosis, salivation, ms fasciculations, and copious secretions. The ssx have rapid onset with respiratory depression and death within minutes.

All the following diseases are caused by errors in DNA repair, except: A: ataxia-telangiectasia (AT) B: Fanconi anemia (FA) C: fragile X (FX) syndrome D: hereditary nonpolyposis colorectal cancer (HNPCC) E: xeroderma pigmentosum

C neoplastic disorders may arise from mutations in DNA that affect oncogenes, tumor suppressors, apoptotic genes, and DNA repair genes. Several disorders involving DNA repair enzymes underscore the importance of these mutations. Patients with XP have defects in DNA damage recognition and in nucleotide excision and repair. These patients often have skin cancers as a result of mutagenic effects of UV light. AT is characterized by large telangiectatic lesions on the face, cerebellar ataxia, immunologic defects, and HSN to ionizing radiation. Mutation in the ATM gene that causes AT gives rise to defects in meiosis and increasing damage from ionizing radiation. Fanconi is caused by mutations in multiple complementation groups that are characterized by various congenital anomalies and a marked predisposition to aplastic anemia and AML. HNPCC is caused by mutations in one of several MMR genes that result in MSI and high incidence of colon, ovarian, and uterine cancer. Fragile X is caused by unstable trinucleotide repeats that destabilizes DNA. It is characterized by X-linked inheritance and atypical large ears, macroorchidism, and mental retardation

27 YO F develops LLE swelling during week 20 of her pregnancy. LLE US reveals a L iliac vein DVT. Proper management includes: A: bedrest B: catheter-directed thrombolysis C: enoxaparin D: inferior vena cava filter placement E: Coumadin

C pregnancy causes a hypercoagulable state, and DVT occurs in 1 in 2000 pregnancies. DVT occurs more commonly in LLE than RLE during pregnancy due to compression of the L-iliac vein. Approximately 25% of pregnant women with DVT have a Factor V Leiden mutation, which also predisposes to preeclampsia. Prothrombin G20210A mutation (homozygous and heterozygous) and methylenetetrahydrofolate reductase C677 mutation (homozygotes) are also RF for DVT during pregnancy. Coumadin is strictly contraindicated during the 1st/2nd trimester due to risk of fetal abnormality. LMWH is appropriate therapy but may be switched to heparin infusion at delivery, if an epidural is likely. Ambulation, rather than bedrest, should be encouraged as with all DVTs. There is no proven role for local thrombolytics or an IVC filter in pregnancy. The latter would be considered only in scenarios where AC is not possible.

36 YO M comes to your office asking for genetic testing for Alzheimers disease. He has no cognitive complaints but notes that all four of his grandparents have had Alzheimer's and his father has mild cognitive impairment at the age of 62. His MMSE is 29/30, losing only 1 point on the serial 7s exam. He requests testing for apolipoprotein E allele (e4). This request is an example of which of these: A: early onset dementia B: genetic discrimination C: predisposition testing D: presymptomatic testing

C presymptomatic testing applies to diseases where a specific genetic alteration is a/w a near 100% likelihood of developing the disease, such as Huntington's disease. In contrast, predisposition testing predicts a risk for disease that is <100%. The presence of apolipoprotein E allele (e4) does not predict with 100% accuracy individuals who will develop Alzheimers; therefore, this patient's testing is an example of predisposition testing. Not everyone with this marker will develop disease, and individuals without this marker will develop it. Other examples of predisposition testing include BRCA hereditary breast cancer. The patient does not have any ssx of dementia, and he is not being discriminated against in this scenario.

86 YO F with COPD, congestive HF, and insulin-requiring Type II DM is admitted to the ICU with an exacerbation of her COPD. She is intubated and treated with glucocorticoids and nebulized albuterol. She is also c/w her glargine, insulin, ASA, pravastatin, furosemide, enalapril, and metoprolol. On hospital Day 8, IV-nutrition is begun via catheter in the subclavian vein. Her insulin requirements increase on Day 9 due to episodes of hyperglycemia. On Day 10, she develops rales and an increasing O2 requirement. A CXR shows bilateral pulmonary edema. Labs show hypoK, hypoMg, and hypoPhos and a normal Cr. Her wt has increased by 3 kg since admission. Urine sodium is <10 meEq/dL. All of the following changes in her nutritional regimen will improve her volume status, except: A: combination of glucose and fat in the IV-nutrition mix B: decreasing the sodium content of the mixture to <40 mEQ per day C: increasing the protein content of the IV-nutrition mixture D: reducing the overall glucose content

C the MC metabolic problems related to parenteral nutrition (PN) are fluid overload and hyperglycemia. Hypertonic dextrose stimulates a much higher insulin level than normal feeding, which is evident on hospital day 9 in this scenario. Hyperinsulinemia stimulates antinatriuretic and antidiuretic hormone, which leads to sodium and fluid retention as well as increased intracellular transport of K, Mg, and phosphorous. It is not uncommon to see an increase in weight and a low urine sodium in patients with normal renal function. Providing sodium in limited amounts of 40 meEQ/day and the use of both glucose and fat in the PN mixture will help reduce fluid retention. Reducing the overall glucose content will also abate the need for higher insulin level. The fluid retention in this scenario is not mediated by low protein levels.

all of these are well-documented physical effects of smoking marijuana, except: A: decreased sperm count B: chronic bronchial irritation C: delayed gastric emptying D: exercised-induced angina E: impaired single-breath CO diffuse capacity (DLCO)

C the MC physical effects of smoking marijuana are conjunctival infection and tachycardia; however, tolerance for the tachycardia develops quickly among habitual users. Smoking marijuana can ppt angina in those with a hx of CAD, and such patients should be advised to abstain from smoking marijuana or using cannabis. This effect may be more pronounced with smoking marijuana than cigarettes. Because chronic use typically involves deep inhalation and prolonged retention, chronic smokers may develop chronic bronchial irritation and impaired single-breath CO diffuse capacity. Decreased sperm count, impaired motility, and morphologic abnormalities of spermatozoa have been reported. Prospective studies demonstrated a correlation between impaired fetal growth and development with heavy marijuana use during pregnancy

After being stranded alone in the mountains for 8 days, a 26 YO hiker is brought to the hospital for evaluation of a R-femoral neck fracture. He has not had anything to eat or drink for the past 6 days. VS are wnl. Wt is 79.5 kg, which is 1.8 kg less than he weighed 6 months ago. Labs show Cr 2.5, BUN 52, glucose 96, Alb 4.1, Cl 105, and ferritin 173. Which statement is true about the risk of malnourishment? A: he has protein-calorie malnutrition due to rate of wt loss B: he has protein-calorie malnutrition due to elevated ferritin C: he is at risk, but a normal individual can tolerate 7 days of starvation D: he is not malnourished because he is not hypoglycemic after 6 days of no food or water

C the energy stores in a healthy 70 kg man include about 15 kg of fat, 6 kg of protein, and 500 mg of glycogen. During the first day of the fast, most needs are met by consumption of liver glycogen. During longer fasting, energy expenditure will decrease by up to 25%. In the presence of water intake and no inflammation, a normal individual may fast for months. A well nourished individual can tolerate ~7 days of starvation while experiencing a systemic response to inflammation. The hiker in this scenario has starved for 6 days and, except for mild acute renal failure, he has compensated well for his starvation. Greater than 10% wt loss in 6 months represents significant protein-calorie malnutrition. This person's ferritin is only mildly elevated, although a true systemic response on inflammation does increase the rate of lean tissue loss. Moreover, he has no other indicators that he is experiencing the SIRS. This would often cause hyperglycemia, not hypoglycemia.

A new study has been published showing a benefit of 25 mg/day of Vitamin X. The recommended estimated average requirement of Vitamin X is 10 mg/day, 2 standard deviations below the amount published in the study. The tolerable upper limit of Vitamin X is unknown. Your patient wants to know if it is safe to consume 25 mg/day of Vitamin X. Which is the most appropriate answer? A: 2 SD above the estimated average requirement defines the tolerable limit B: 25 mg/day is probably too much vitamin in 1 day C: 25 mg/day is statistically in a safe range of the estimated average requirement D: the study was not designed to assess safety and therefore should not influence practice

C the estimated average requirement (EAR) is the amount of a nutrient estimated to be adequate for half of the individuals of a specific age and sex. It is not useful clinically for estimating nutritional adequacy because it is a median requirement for a group. A person taking the EAR of a vitamin has a 50% risk of inadequate intake. The recommended daily allowance (RDA) is defined statistically as 2 SD above the EAR to ensure that the needs of most individuals are met. In this case the study used a dosage of 2 SD above the EAR, which would be the RDA. Data on the tolerable upper limit of a vitamin are usually inadequate to establish a value for UL of tolerability. The absence of a published tolerable upper limit does not imply that the risks are nonexistent.

45 YO M is stranded overnight in the cold after an avalanche. He is airlifted to your medical center and found to have anesthesia and a clumsy sensation in the distal extent of the fingers on the LE. What is the best initial management of his hand? A: IV nitroglycerine B: oral nifedipine C: rapid rewarming D: surgical debridement E: topical nitroglycerine paste

C the patient has severe frostbite vesiculations implying deep tissue injury, including the microvasculature. Medical therapy with IV or topical vasodilators is not effective. Decisions regarding surgical debridement and amputation are best made in the chronic stage of management rather than acutely in the absence of infection. Initially, rewarming and aggressive analgesia with opiates are the mainstay of therapy

Noninvasive cardiac imaging/stress testing should be considered in patients with how many of the following proven RF (high risk surgery, ischemic heart disease, CHF, CVA, DM, and renal insufficiency) for perioperative cardiac events (including pulmonary edema, MI, and heart block)? A: 1 B: 2 C: 3 D: 4 E: 5

C the six criteria listed represent the revised cardiac risk index (RCRI). A patient with non of the RF has <1% chance of post-op major cardiac event. Patients with 3 or more of the criteria have a 10% chance of having a cardiac event in the perioperative or post-op period. This is therefore considered an appropriate cut-off point for noninvasive cardiac imaging/stress testing to occur.

19 YO F with anorexia nervosa undergoes surgery for acute appendicitis. The post-op course is complicated by ARDS, and she remains intubated for 10 days. She develops wound dehiscence on post-op day 10. Labs show WBC 4, HCT 35, Albumin 2.1, total protein 5.8, transferrin 54, and TIBC 88. You are considering initiating nutritional support on hospital day 11. Which is true regarding the etiology and treatment of malnutrition in this patient? A: she has marasmus, and nutritional support should be started slowly B: she has kwashiorkor, and nutritional support should be aggressive C: she has marasmic kwashiorkor, kwashiorkor predominant, and nutritional support should be aggressive D: she has marasmic kwashiorkor, marasmus predominant, and nutritional support should be slow

C the two major types of protein energy malnutrition are marasmus and kwashiorkor; differentiating the two is extremely important in malnourished patients since this directly affects your therapy. This patient has marasmic kwashiorkor due to the impact of her anorexia, the acute stressor of the surgery, and the 10 days of starvation. This patient has chronic starvation (marasmus) as well as the major sine qua non of kwashiorkor; i.e., reduction of levels of serum proteins. She is kwashiorkor predominant because of the acute starvation and the severely low levels of serum proteins. Vigorous nutritional therapy is indicated for kwashiorkor. Marasmus: - decreased energy intake - develops months - years - starve appearance, weight <80% standard for ht, triceps skin fold <3 mm, mid-arm ms circumference <15 cm - labs show Cr-Ht index <60% standard - clinically, there is reasonable response to short-term stress - MR is low, unless underlying disease - dx: triceps skinfold <3 mm, mid-arm ms circumference <15 cm Kwashiorkor: - decreased protein intake during stress state - develops in weeks - well-nourished appearance, easy hair pluck ability, edema - labs show albumin <2.8, TIBC <200, Lymphocytes <1500, anergy - clinically, there are infections, poor wound healing, decubitus ulcers, and skin breakdown - mortality is high - dx: albumin <2.8 + at least one of the following: poor wound healing, decubitus ulcers, skin breakdown, hair pluck ability, and edema

You are seeing a patient in follow-up 2 weeks after hospitalization. The patient is recovering from nosocomial PNA due to resistant Pseudomonas spp. His hospital course was complicated by DVT. The patient is currently on IV-piperacillin-tazobactam and tobramycin via a tunneled catheter, warfarin, lisinopril, HCTZ, and metoprolol. Labs this morning show an INR 8.2. At hospital discharge, INR was stable at 2.5. He has no hx of liver disease. What is the cause of the elevated INR? A: the patient has inadvertently overdosed B: the patient has developed a recurrent DVT, which has affected labs C: the patient is deficient in Vitamin K and needs supplementation D: the warfarin Rx was written incorrectly at discharge

C there are two natural sources of Vitamin K. Vitamin K1 comes from vegetable and animal sources. Vitamin K2 is synethized by enteric bacterial flora and is found in hepatic tissue. Vitamin K deficiency in adults can be seen with chronic, small-intestinal disease, in those with obstructed biliary tracts, after small bowel resection, or those on broad-spectrum abx. As a result of reducing gut bacteria, abx can ppt vitamin K deficiency. Overdose and medication error are plausible explanations, but are less likely to be the root cause given the abx exposure. Acute DVT can deplete levels of coagulant proteins (esp Protein C and S), but the INR should not be affected

All of these disorders can cause ambiguous sexual differentiation, except: A: 21-hydroxylase deficiency B: androgen insensitivity syndrome C: Klinefelter syndrome D: mixed gonadal dysgenesis E: testicular dysgenesis

C this group of genetic conditions often presents with disorders of sexual differentiation. Genetically, Klinefelter syndrome results from a meiotic nondysjunction of sex chromosomes during gametogenesis, producing a 47 XXY individual. Phenotypically, these individuals are male but have eunuchoid features, small testes, decreased virilization, and gynecomastia. The other disorders in this question may result in sexual ambiguity, more commonly in males. In mixed gonadal dysgenesis, there is mosaicism resulting from the genotype 46XY/45X. Depending on the proportion of cells with the 46 XY genotype, the phenotype can be either male or female. Testicular dysgenesis result from the absence of the mullerian inhibiting substance during embryonic development and may be caused by multiple genetic mutations and may be a/w absence of MIS and reduced testosterone production. Feminization may also occur through AIS and mutations in the AR. Virilization of females with resultant ambiguous sexual differentiation MC occurs in patients with CAH. The MC CAH is 21-hydroxylase def, which results in ambiguous female genitalia, hypotension, and salt wasting

23 YO F with chronic LE ulcer related to prior trauma presents with rash, hypotension, and fever. She has had no recent travel or outdoor exposure and is UTD on vaccines. She does not use IVD. On exam, the ulcer looks clean with a well-granulated base and no erythema, warmth, or pustular discharge. However, the patient does have diffuse erythema that is most prominent on her palms, conjunctiva, and oral mucosa. Other than profound hypotension and tachycardia, the remainder of the exam is non-focal. Labs show Cr 2.8, AST 250, ALT 328, total bilirubin 3.2, direct bilirubin 0.5, INR 1.5, aPTT 1.6, PLT 94K. Ferritin is 1300. The patient is started on broad-spectrum abx after appropriate blood cx are drawn and is resuscitated with IVF and vasopressors. Her blood cx are negative at 72h; at this point her fingertips start to desquamate. What is the dx? A: juvenile RA B: leptospirosis C: staphylococcal toxic shock syndrome D: streptococcal toxic shock syndrome E: typhoid fever

C this is likely toxic shock syndrome, given the appearance of septic shock without positive blood culture. The characteristic diffuse rash, as well as lack of primary infected site, makes Staphylococcal more likely. Strep shock usually has a prominent primary site of infection, but the diffuse rash is usually much more subtle than this. Staph shock can be a/w immunosuppression, surgical wounds, or retained tampons. Mere Staph aureus colonization (with appropriate toxic strain) can incite toxic shock. CDC states that measles, RM spotted fever, and leptospirosis need to be r/o serologically to confirm the diagnosis. However, this patient is very low risk for these diagnoses based on vaccination and travel hx. JRA would become a consideration only if the fevers were more prolonged and there was documented evidence of organomegaly and LAD.

24 YO healthy man who has just returned from a 1-week summer camping trip to the Ozarks presents to the ED with fever, a severe HA, mild ABD pain, and severe myalgia. He is d/c home but 1 day later feels even worse and therefore returns. T 38.4C, HR 113, BP 120/70. PE is notable for well-developed, well-nourished, but diaphoretic and distressed man. He is AAOx2. His lungs are clear. He has no murmur. His ABD is mildly tender with normal BS. Neuro exam is non-focal. There is no rash. Labs show PLT 84,000. LP is notable for 5 monocytes, no RBC, normal protein, and normal glucose. What should be next? A: atovaquone B: blood cx and observation C: doxycycline D: rimantadine E: vancomycin, ceftriaxone, and ampicillin

C this patient likely has Rocky Mtn Spotted Fever. The HA and thrombocytopenia after a recent camping trip in a rickettsial endemic region are typical. As this is usually a serologic dx requiring significant lab processing time, and can be fatal, empiric tx with doxycycline is warranted. The lack of rash does not preclude the dx because the characteristic macular rash spreading from wrists and ankles centripetally appears 2-5 days after the first fever. Atovaquone is used for babesiosis, a disease defined by hemolysis and is not prevalent in the Ozarks. The patient has no evidence of bacterial meningitis to warrant empiric coverage. While fever and myalgia are typical of influenza, it is most common in winter and does not typically cause thrombocytopenia.

What is the main contributor to the resting energy expenditure of an individual? A: adipose tissue B: exercise level C: lean body mass D: resting HR E: none of these

C to keep BW stable, energy intake must match energy output. Energy output has 2 main determinants: resting energy expenditure and physical activity. Other, less clinically important determinants include energy expenditure to digest food and thermogenesis from shivering. Resting energy expenditure can e calculated is is 900 + 10w (w=weight) in males and 700 + 7w in females. This calculation is then modified for physical activity. The main determinant of energy expenditure is lean body mass

You are doing rounds in the ICU on an intubated patient who is recovering from a stroke and has diabetic gastroparesis. When suctioning the patient in the morning, she coughs profusely, with thick green secretions. You are concerned about the possibility of aspiration PNA. All of these measures are useful in preventing aspiration PNA in an intubated patient, except: A: combined enteral and parenteral nutrition B: elevate the head of the bed to 30 degrees C: physician-directed methods for formula advancement D: post-ligament of treitz feeding

C tracheal suctioning induces coughing and gastric regurgitation and cuffs on endotracheal tubes seldom protect against aspiration. Effective ppx measures include elevate the head of the bed to 30 degrees, nurse-directed algorithms for formula advancement, combining enteral and parenteral feeding, and using post-ligament of Treitz feedings. Recent studies have suggested that constant suction above the endotracheal cuff may reduce VA-PNA

78 YO F is seen in clinic with cc of urinary incontinence for several months. She finds that she is unable to hold urine at random times throughout the day; this is not related to coughing or sneezing. The leakage is preceded by an intense need to empty the bladder. She has no pain a/w these episodes, though she finds them very distressing. The patient is otherwise independent in her ADLs. Which is true? A: the abrupt onset of similar ssx should prompt cystoscopy B: first line tx for this condition consists of desmopressin C: indwelling catheters are rarely indicated for this disorder D: referral to the GU surgeon is indicated for surgical correction E: urodynamic testing must be performed before the prescription of antispasmodic medications

C urinary incontinence occurring randomly w/o any assoc Valsalva or other stress is most likely detrusor overactivity. This disorder is the MC type of incontinence in the elderly, both males and females. In females there is no need to do further testing in a patient with long-standing incontinence; however, in males urethral obstruction is often coexistent, and urodynamic testing is indicated to investigate the possibility. An abrupt onset of ssx or assoc suprapubic pain in either sex should prompt cystoscopy and urine cytology to evaluate for stones, tumor, or infection. 1st line tx is behavioral tx w/ or w/o biofeedback. Frequent timed voiding is often successful. If drugs are imperative, oxybutynin or tolterodine can be tried with close f/up to ensure that retention does not occur. Desmopressin must be used with extreme caution in this population. Indeed, patients with HF , CKD, or hypoNa should not take this med. Indwelling catheters are rarely indicated for this disorder; instead, external collection devices or protective pads or undergarments are favored.

Which of the alternative medicines has shown proven benefit compared to placebo in a large RCT? A: echinacea root for respiratory infection B: Ginko biloba for improving cognition in the elderly C: glucosamine/chondroitin sulfate for improving performance and slowing narrowing of joint space in patients with moderate to severe OA D: saw palmetto for men with symptomatic BPH E: St johns wort for MDD of moderate severity

C Echinacea constituents have in vitro activity to stimulate humoral and cellular immune responses. Yet, clinical trials have not shown convincing evidence for respiratory infections. Ginko biloba is being evaluated, however, there is no current evidence that it improves cognition. Saw palmetto and African plum are widely purchased to relieve symptomatic BPH, yet clinical trials have not shown efficacy. While St Johns wort showed benefit in small and non-controlled trials, high quality placebo controlled trials have not shown superiority for MDD. Only glucosamine/chondroitin sulfate have proven benefit in a large multi center controlled trial. It is not known if it slows cartilage degeneration.

The prevalence of HTN in American persons aged >65 YO is: A: 10-35% B: 35-60% C: 60-85% D: >85%

C: 60-85% HTN and DM are the most important chronic diseases whose prevalence increases with age. In those >65 YO, the prevalence of HTN is estimated to be 60-85%. These numbers will likely increase in the future as the population ages and obesity is more prevalent. Recent data suggests that the frequency of uncontrolled HTN is increasing in older adults in the US. The presence of uncontrolled HTN accelerates the functional and cognitive decline in older adults. These data also have important implications on the frequency of CVD and stroke in older adults.

Which health care delivery system encourages physicians to see more patients, but provide fewer services?

Capitation provides physicians with a fixed payment per patient per year; this has the potential to encourage physicians to take on more patients, but provide fewer services as the physician is liable for expenses fixed salary system = encourages fewer patients fee for service = encourages more services

24 YO M is brought to ED s/p cyanide in suicide attempt. He is unconscious on presentation. What drug should be used as an antidote?

Cyanide is an asphyxiant that causes death by inhibiting cellular respiration. It is a colorless liquid or gas and has a typical smell of almonds. The onset after exposure is rapid and usually begins with eye irritation. The skin is flushed. The patient rapidly develops confusion, tachypnea, and tachycardia. With severe poisoning, death results from ARDS and hypoxemia with lactic acidosis. The antidote is a combination of sodium nitrite and sodium thiosulfate.

Which of these features represents a critical distinction between AN and BN? A: binge eating B: electrolyte abnormalities C: self-induced vomiting D: underweight

D AN and BN are distinct clinical entities but share certain features. Many patients with BN have hx of anorexia, and patients with AN engage in binge eating and abnormal compensatory behaviors such as purging. The critical distinction between AN and BN depends on body weight: patients with AN are significantly underweight, whereas patients with BN have normal weight or are overweight. The presence of -lyte disturbances confers an increased morbidity for both disorders

25 YO F visits your office during the 5th month of her pregnancy. Her BP is 142/86. What should your next step be in management? A: have her return to clinic in 2 weeks for BP check B: initiate ACE inhibitor C: initiate Beta blockers D: recheck her BP in the seated position in 6 hours E: recheck her BP in the lateral recumbent position in 6 hours

D BP > 140/90 in 2nd trimester is markedly abnormal. During the second trimester, BP should fall due to a decrease in SVR. Elevated BP is a/w increased perinatal mortality and morbidity. Delaying dx may be harmful. BP should be performed in the sitting position because in the lateral recumbent position the decrease in preload may cause a reduced BP. The diagnosis of HTN requires measurement of 2 elevated BP at least 6 hours apart. HTN may be caused by preeclampsia, chronic HTN, gestational HTN, or renal HTN. If HTN is diagnosed, a safe anti-HTN should be used and referral to high risk obstetrician should be considered.

All of the following are inherited disorders of connective tissue, except: A: Alport syndrome B: Ehlers-Danlos syndrome C: Marfan syndrome D: McArdle's disease E: Osteogeneis imperfecta

D CT is composed of macromolecules (collagen, elastin, fibrillin, proteoglycans, etc) that are assembled into an insoluble extracellular matrix. Disorders of any of these macromolecules may result in a disorder of CT. OI is caused by mutations in Type I collagen. Over 400 mutations have been found in OI. Clinically, it is characterized by decreased bone mass, brittle bones, blue sclerae, dental abnormalities, joint laxity, and progressive hearing loss. The phenotype may range from severe in utero death to milder forms with less severity and survival into adulthood. ED is a heterogenous set of disorders characterized by joint laxity, hyperelasticity of the skin, and other collagen defects. A variety have been ID in different types of collagen as well as in enzymes which facilitate collagen cross links. Marfan is characterized by triad of long, thin extremities (with arachnodactyly and loose joints), reduced vision from ectopia lentis, and aortic aneurysms. Defects in the fibrillin gene are responsible. Alport syndrome is a mutation in type IV collagen, resulting in the MC phenotype of XL inheritance, hematuria, sensorineural defects, and lenticonus. McArdle's disease is a defect in glycogenolysis that results from myophosphorylase deficiency

All of the following statements about Gaucher disease are true, except: A: bone pain is common B: disease frequency is highest in Ashkenazi Jews C: inheritance is AR D: splenomegaly is rare E: the disease is caused by mutations in the gene for acid B-glucosidase

D Gaucher disease is an AR lysosomal storage disease caused by decreased activity of acid B-glucosidase. Nearly 200 mutations have been described. Type 1 can present from childhood to early adulthood. The average age at diagnosis is 20 YO in white people. Clinical features result from the accumulation of lipid-laden macrophages, termed Gaucher cells, throughout the body. HSM is present in virtually all symptomatic patients. BM involvement is common, with subsequent infarction, ischemia, and necrosis. Anemia and thrombocytopenia may occur. Bone pain is common. Although the liver and spleen may become massive, severe liver dysfunction is very rare. The disease is MC in Ashkenazi Jewish populations. The diagnosis is made by measuring enzyme activity. Enzyme therapy is currently the treatment of choice in significantly affected patients. Other therapies include symptomatic management of the blood cytopenias and joint replacement surgery for bone injury. Type 2 Gaucher disease is a rare, severe CNS disease that leads to death in infancy. Type 3 disease is nearly identical to type 1 disease except that the course is more rapidly progressive.

30 YO M comes to the clinic for genetic counseling. His brother died at 13 YO with Tay-Sachs disease. His sister is unaffected. The patient and his wife wish to have children. Which of these is true about Tay-Sachs? A: it is seen most commonly in Scandinavian populations B: It is caused by mutations in the galactosidase gene C: Most patients die in the 3rd or 4th decade of life D: Death occurs as a result of progressive neurologic decline E: Splenomegaly is common in these patients

D Lysosomes are sub cellular organelles which contain specific hydrolyases that allow the processing and degradation of proteins, nucleic acids, carbs, and lipids. Lysosomal storage diseases result from mutations in various genes for these hydrolyases. Clinical ssx result from the accumulation of the undegraded macromolecule. Tay-Sachs is caused by a deficiency of a hexosaminidase A. Build up of GM2 gangliosides result in a phenotype that is characterized by a fatal progressive neurodegenerative disease. In the infantile form, these patients have macrocephaly, loss of motor skills, and increased startle reaction, and a macular cherry red spot. The juvenile-onset presents with ataxia and progressive dementia that result in death by 15 YO. The adult-onset form is characterized by clumsiness in childhood, progressive motor weakness in adolescence, and neurocognitive decline. Death occurs in early adulthood. Survival to the third or fourth decade is rare. Splenomegaly is uncommon. The disease is seen MC in Ashkenazi jews, with a carrier frequency of about 1 in 30. Inheritance is AR.

Which cardiac valve disorder is the most likely cause death during pregnancy? A: AR B: AS C: MR D: MS E: TR

D Mitral stenosis is a/w flash pulmonary edema, atrial arrhythmias, and risk of maternal death. The risk is likely 2/2 the increase in CO and circulating blood volume during pregnancy. Sudden death due to arrhythmias or pulmonary HTN may occur. During delivery, patients with MS should be managed with careful HR control. Balloon valvuloplasty may be performed during pregnancy. The decrease in SVR during pregnancy makes mitral, tricuspid, and aortic regurgitation generally well tolerated because HF is not likely. If AS is severe, balloon valvuloplasty may be necessary.

Which of these is a distinguishing feature of amphetamine overdose versus other causes of SNS overstimulation due to drug overdose or withdrawal? A: hallucination B: hot, dry, flushed skin and urinary retention C: hx of benzodiazepine abuse D: markedly increased BP, HR, and end-organ damage in the absence of hallucination E: nystagmus

D Sympathetic toxidromes share many features including increased BP, HR, neuromuscular activity, tremulousness, delirium, and agitation. In many cases, these syndromes can be sub classified according to other features or relative strengths of the above ssx. Sympathomimetics like cocaine and amphetamines cause extreme elevations in VS and organ damage due to peripheral vasoconstriction, usually in the absence of hallucinations. BDZ and ETOH withdrawal present similarly but hallucinations, and often seizures, are common in these conditions. Hot, dry, flushed skin, urinary retention, and absent BS characterize anticholinergic syndromes a/w antihistamines, antipsychotics, antiparkinsonian agents, ms relaxants, and TCAs. Nystagmus is a unique feature of ketamine and PCP overdose.

You are counseling a patient who is recovering from long-standing anorexia nervosa. She is 22 YO woman who suffered the effects of AN for 8 years with a nadir BMI of 17 and many lab abnormalities during this time. Which of the following characteristics of AN is least likely to improve despite successful lasting treatment of the disorder? A: amenorrhea B: delayed gastric emptying C: lanugo D: low bone mass E: salivary gland enlargement

D approximately 25-50% of patients with AN recover fully with few physiologic or psychological sequelae. However, many patients have persistent difficulties with wt maintenance, depression, and eating disturbances. Approximately 5% of patients die per decade, usually 2/2 physical effects of chronic starvation from suicide. Virtually all of the physiologic derangements a/w AN will improve with wt gain. One exception is the loss of bone mass, which may not recover fully when AN occurs during adolescence (i.e., during peak bone mass formation). Psychological health also improves with successful treatment, although these patients remain at risk for depression, recurrence, and development of BN

For which of the following herbal remedies is there the best evidence for efficacy in treating the ssx of BPH? A: St Johns wort B: Gingko C: Kava D: Saw palmetto E: No herbal therapy is effective

D because plant products are in widespread use in the well-accepted therapeutic armamentarium of Western medicine (e.g., digoxin, taxol, penicillin), it should not be surprising that several "herbal remedies" have been demonstrated in prospective clinical trials to be beneficial. For example, St Johns wort is more effective than placebo for mild-moderate depression, likely for its inhibition of the metabolism of several neurotransmitters. Kava has anxiolytic activity. Extracts of the fruit of the saw palmetto, Serona repens, have been shown to decrease nocturia and improve peak urinary flow compared to placebo in males with BPH. Saw palmetto extracts affect the metabolism of androgens, including the inhibition of DHT binding to androgen receptors.

Which of the following is not a common cause of persistent cough lasting more than 3 months in a non-smoker? A: asthma B: GERD C: Lisinopril D: Mycoplasma infection E: postnasal drip

D chronic cough is defined as a cough present for >8 weeks. Mycoplasma infection can cause a cough acutely or a post infectious cough that persists for as long as 8 weeks. Asthma, postnasal drip, and GERD are the most common causes of chronic cough in a nonsmoker who is not taking ACE inhibitors. All ACE-inh, including Lisinopril, can cause chronic cough, possibly due to altered metabolism of bradykinin. Patients with ACE cough can be switched to an ARB.

74 YO M with known endobronchial carcinoma of his L-mainstem bronchus develops massive hemoptysis (1 L of frank hemoptysis productive of bright red blood) while hospitalized. All of the following should be considered in his initial management, except: A: bronchial artery embolization B: cough suppressants C: direct bronchoscopic electrocautery D: placing the patient in the lateral decubitus position with his right side down E: selective intubation of the R-mainstem bronchus under bronchoscopy

D hemoptysis in these conditions originates from the bronchial circulation that is supplied by the aorta or intercostal arteries, not the pulmonary artery. Because of the high pressures, bleeding may be sudden and massive. Embolization of bronchial arteries feeding the suspected area may stop the bleeding. Cough suppressants may help decrease the irritating effects on the submucosa of coughing. Direct bronchoscopic cautery may be beneficial for friable tumors. Selective intubation of the R-mainstem bronchus may be supportive by protecting the non-bleeding R lung. Occlusion of the R lung bronchus by coagulating blood could lead to respiratory failure. The patient should be placed with his non-bleeding lung up, not down, as the goal is to prevent blood from entering the non-bleeding lung.

You are seeing a pediatric patient from Djibouti in consultation who was admitted with a constellation of ssx including diarrhea, alopecia, ms wasting, depression, and a rash involving the face, extremities, and perineum. The child has hypogonadism and dwarfism. You astutely make the diagnosis of zinc deficiency, and labs confirm this (Zn <70). What other clinical findings in this patient is likely to manifest? A: dissecting aortic aneurysm B: hypochromic anemia C: hypoglcyemia D: hypopigmented hair E: macrocytosis

D hypozincemia is MC due to poor oral intake of zinc, although some meds can also inhibit zinc absorption (e.g., sodium valproate, penicillamine, ethambutol). Severe chronic Zn deficiency has been described among children from Middle Eastern countries as a cause of hypogonadism and dwarfism. Hypopigmented hair is also a part of this syndrome. Hypochromic anemia can be seen in a number of vitamin deficiencies, including Zn toxicity and copper deficiency. Cu deficiency is also a/w dissecting aortic aneurysm. Hypoglycemia does not c/w hypozincemia. Macrocytosis is a/w folate and B12 deficiency.

A "dirty" bomb is detonated in downtown Boston. The bomb was composed of Cesium-137 with TNT. In the immediate aftermath, an estimated 30 people were killed due to the power of the blast. The fallout area was about 0.5 mile, with radiation exposure of ~1.8 Gray. An estimated 5,000 people have been potentially exposed to beta and gamma radiation. Most of these individuals shown no sign of injury, but about 60 people have evidence of thermal injury. What is the most appropriate approach to treating these victims? A: all who have been exposed should be treated with potassium iodide B: all who have been exposed should be treated with Prussian blue C: all should be decontaminated prior to transportation to the nearest medical center for emergency care to prevent exposure fo healthcare workers D: severely injured individuals should be transported to the hospital for emergency care after removing their clothes, as the risk of exposure to healthcare workers is low E: with this degree of exposure, no further testing or treatment is needed

D much of the initial damage related to a "dirty" bomb is related to the power of the blast rather than the radiation. Following a terrorist attack, its important to ID all individuals who might have been exposed. The initial treatment of these individuals should be to stabilize and treat the most severely injured. Those with severe injuries should have contaminated clothing removed prior to transport to the local medical center. A further consideration regarding treatment following exposure is the total dose of radiation that an individual was exposed to. At a dose of <2 Gy, there are usually no significant AE, and no specific treatment is recommended unless ssx develop.

All of these factors are a/w greater risk of ventricular arrhythmia versus anxiety/panic attack in a patient c/o palpitations, except: A: hx of CHF B: hx of CAD C: hx of DM D: palpitations lasting > 15 mins E: palpitations provoked by ethanol

D palpitations are a common complaint among patients who report fluttering, pounding, or thumping sensation in the chest. Palpitations may arise from cardiac, psychiatric, miscellaneous (thyrotoxicosis, drugs, ethanol, caffeine, cocaine), or unknown causes. While most arrhythmias do not cause palpitations, patients with palpitations and known heart disease or RF are at risk of atrial or ventricular arrhythmias. Overall, patients c/o palpitations >15 mins are more likely to have psychiatric causes. Most patients with palpitations do not have serious arrhythmias. Hx, PE, Holter monitoring, and EKG may be used to evaluate for arrhythmias.

Doing rounds in the oncology center, you are seeing a patient with carcinoid syndrome. Due to increased conversion of tryptophan to serotonin, this patient has developed niacin deficiency. All of the following are components of pellagra, except: A: dermatitis B: dementia C: diarrhea D: dyslipidemia E: glossitis

D pellagra (niacin deficiency) is MC a disorder among people eating corn-based diets but can be seen in ETOH abuse. Tryptophan is converted to niacin with an efficiency of 60:1 by weight. Therefore, in a patient with congenital defects in tryptophan absorption or with increased conversion of tryptophan to serotonin, niacin deficiency can develop. The early ssx of pellagra include anorexia, irritability, abdominal pain, vomiting, and glossitis. Vaginitis and esophagitis may also occur. The four Ds of pellagra: dermatitis, dementia, diarrhea, and death. Dyslipidemia is not part of it.

You prescribe an extended-release antiHTN agent for your patient at a dosing interval of 24h. The half-life of the agent is 48h. Three days later the patient's BP is not controlled. At this point, you should: A: add a second agent B: double the dose of the current agent C: increase the frequency of the dose to bid D: recheck the BP in 1 week E: switch to an agent from a different class

D steady state serum levels are achieved after 5 half lives, when the dosing interval is 50% of the half life. Therefore, from a Pharmacokinetic standpoint, the patient many not achieve full steady state and efficacy until 10 days into the therapy. Therefore, checking BP at 3 days is premature. Doubling the dose or increasing the frequency may predispose to toxicity. There is not reason to add a second agent or switch until completing a trial of adequate duration on the current agent

Which of the following statements regarding AN and BN is true? A: patients with the purging subtype of BN tend to be heavier than those with non purging subtype B: patients with the restricting subtype of AN are more emotionally labile than those with purging subtype C: patients with the restricting subtype of AN are more likely to abuse illicit drugs than those with the purging subtype D: the mortality of BN is lower than that of AN

D the mortality of AN is ~5% per decade and is much lower in patients with BN. This is probably mediated by the weight loss and malnutrition a/w AN. There are two subtypes of BN: purging and non purging. Patients with the non purging subtype tend to be heavier and are less prone to -lyte disturbances. There are also two mutually exclusive subtypes of AN: restricting and purging. Patients with the purging subtype are more emotionally labile and tend to have other problems with impulse control such as illicit drug abuse.

Which of the following personality traits is most likely to describe a young female with anorexia nervosa? A: depressive B: borderline C: anxious D: perfectionist E: impulsive

D the most important feature of patients with anorexia nervosa is refusal to maintain even a low-normal body weight. The full syndrome of anorexia nervosa occurs in 1 in 200 individuals. These patients are always markedly underweight, hardly ever menstruate, and often engage in binge eating. The MR is 5% per decade. The etiology of this disorder is unknown, but probably involves a combination of psychological, biologic, and cultural RF. This illness often begins in an obsessive or perfectionist patient who starts a diet. As weight loss progresses, the patient has increasing fears of gaining weight and engages in stricter dieting practices. This disorder essentially occurs only in cultures where thinness is valued, suggesting a strong cultural influence. Bulimia nervosa, in which patients continue to maintain a normal BW, but typically engage in overeating with binges followed by compensatory purging or purging behavior, has a higher than expected prevalence in patients with childhood or parental obesity. It is unclear whether anorexia is hereditary in nature.

30 YO F c/o LE swelling and ABD distension. It is particularly troublesome after her daily shift as a tollbooth operator and is at its worst during hot weather. She denies SOB, orthopnea, DOE, jaundice, foamy urine, or diarrhea. Her ssx occur independently of her menstrual cycle. PE is notable for 2+ LE edema, flat JVP, no HJ reflux, normal S1 and S2 with no extra heart sounds, clear lung fields, and benign, slightly distended ABD with no organomegaly, and normal skin. A CMP is wnl, and a UA shows no proteinuria. What is the dx? A: cirrhosis B: CHF C: cyclical edema D: idiopathic edema E: GI malabsorption F: nephrotic syndrome

D the patient's positional edema that is worse in hot weather strongly suggests idiopathic edema. Idiopathic edema occurs mostly in women and is characterized by episodes of edema that may include ABD dissension. It is typically diurnal, with worsening after being upright for prolonged periods or in hot weather. Cyclical edema occurs with menstruation and is related to estrogen stimulation of fluid retention. CHF, nephrotic syndrome, and cirrhosis are r/o by HP and labs. Initially, therapy should include patient education regarding the need to lie flat for a few hours each day, as well as compression stockings put on in the mornings. Idiopathic edema may be related to abnormal activity of RAAS and ACE inhibitors may play a role if conservative interventions are not effective. Diuretics may be beneficial initially, but will lose effectiveness if used continuously.

42 YO M with hx of ESRD is on HD and has been taking medications chronically for nausea and vomiting. Over the past week, he has developed new onset involuntary lip smacking, grimacing, and tongue protrusion. This AE is most likely due to which antiemetic? A: erythromycin B: methylprednisolone C: ondansetron D: prochloperazine E: scopolamine

D this patient has developed tardive dyskinesia that may be irreversible. Prochlorperazine is an anti-Dopa agent that suppresses emesis by acting centrally at the dopamine D2 receptors. This class of agents is most effective for the treatment of medication, toxin, and metabolic induced emesis. However, these agents freely cross the BBB and cause anxiety, galactorrhea, sexual dysfunction, and dystonic reactions. TD is the most serious of these neurologic toxicities. Erythromycin is a pro kinetic that may worsen n/v. Ondansetron acts on the 5-HT3 receptor and has no anti-Dopa activity. Scopolamine is an anticholinergic that may cause delirium, stupor, and other neurologic AE, but not TD. Glucocorticoids do not cause TD.

33 YO F with DM and HTN presents to the hospital with seizures during week 37 of her pregnancy. Her BP is 156/92. She has 4+ proteinuria. Management should include all of these, except: A: emergent delivery B: IV-Labetalol C: IV-magnesium sulfate D: IV-phenytoin

D this patient has severe eclampsia, and delivery should be performed as rapidly as possible. Mild eclampsia is the presence of new onset HTN and proteinuria in a pregnant woman > 20 weeks gestation. Severe eclampsia is eclampsia complicated by CNS ssx (seizures), marked HTN, severe proteinuria, renal failure, pulmonary edema, thrombocytopenia, or DIC. Delivery in a mother with severe eclampsia before 37 weeks decreases maternal morbidity but increases fetal risks of cx of prematurity. Aggressive management of BP, usually with Labetalol, decreases maternal risk of stroke. ACE and ARBS should not be used for potential AE of fetal development. Eclamptic seizures should be controlled with mag sulfate. It is superior to phenytoin.

51 YO ETOH abuser is admitted to the hospital for an UGIB. From further hx and PE, it becomes apparent that his bleeding is from gingival membranes. He is intoxicated and c/o fatigue. Review of his chart shows he had a hemarthrosis evacuated 6 months ago and has been LTFU since then. He takes no meds. Labs show PLT 250K, INR 0.9. He has a diffuse hemorrhagic eruption on his legs. What is the recommended treatment for the underlying disorder? A: folate B: niacin C: thiamine D: Vitamin C E: Vitamin K

D this patient has the classic perifollicular hemorrhagic rash of scurvy (Vitamin C def). In the US, scurvy is primarily a disease of ETOH and the elderly who consume <10 mg/d of Vitamin C. In addition to nonspecific ssx of fatigue, these patients also have impaired ability to form mature CT and can bleed into various sites, including the skin and gingiva. A normal INR excludes symptomatic Vitamin K deficiency. Thiamine, niacin, and folate deficiencies are also seen in patients with ETOH abuse. Thiamine deficiency may cause a peripheral neuropathy (beri beri). Folate deficiency causes macrocytic anemia and thrombocytopenia. Niacin deficiency causes pellagra, which is characterized by glossitis and a pigmented, scaling rash that may be particularly noticeable in sun exposed areas.

You perform a nocturnal tumescence study on the patient who was previously described to have ED. He does not have any erections during REM sleep. Which treatment modality do you offer at this time? A: couple sex therapy B: implantation of a penile prosthesis C: intraurethral alprostadil D: vardenafil

D this patient has vasculogenic ED. Sildenafil, tadalafil, and vardenafil are the only approved and effective agents for ED due to psychogenic, diabetic, or vasculogenic causes or resulting from post radical prostatectomy and spinal cord injury. As such, they should be considered as 1st line therapy. If the patient were to fail to respond to oral agents, intraurethral vasoactive substances are a reasonable next choice. Implantation of a penile prosthesis would be of consideration if intraurethral or intracavernosal injections failed. Sex therapy will not address the organic dysfunction that this patient has, as evidenced by lack of nocturnal erections.

All of the following statements about women's health are true, except: A: CAD mortality rates have been falling in men over the past 30 years, while increasing in women B: women have longer QT intervals on resting EKG, predisposing them to higher rates of ventricular arrhythmias C: women are more likely than men to have atypical symptoms of angina, such as nausea, vomiting, and upper back pain D: women with MI are more likely to present with Vtach, whereas men are more likely to present with cariogenic shock E: women <50 years old experience 2x the MR compared to men after MI

D is false Men more commonly present with Vtach and women more commonly present with cardiogenic shock after MI. Younger women with MI are more likely to die than their male counterparts of similar age. This may be partly related to the observation that physicians are less likely to suspect heart disease in women with CP and are less likely to perform diagnostic and therapeutic procedures in women.

when ordering an evaluation of CAD in a female patient, all of the following are true, except: A: exercise stress testing has more FP in women than in men B: exercise stress testing has more FN in women than in men C: women are less likely than men to undergo angioplasty and CABG D: women undergoing CABG have lower 5 and 10 year survival rates than men E: women undergoing CABG have less relief of angina and less graft patency than men

D is false exercise EKG testing has both higher FP and FN in women than in men. Women with MI less often receive angioplasty, thrombolytics, ASA, beta blockers, or CABGs then men. While women have a greater perioperative mortality, lower graft patency rate, and less angina relief from CABG compared to men, their 5 and 10 year MR are not different.

which of the following statements regarding cardiovascular risk is true? A: ASA is effective as a means of primary prevention in women for coronary heart disease B: cholesterol-lowering drugs are less effective in women than in men for primary and secondary prevention of coronary heart disease C: low HDL and DM are more important RF for men than for women for coronary disease D: total TAG levels are an independent RF for CAD in women, but not in men

D is true ASA does not provide primary prevention for MI for women with CAD, but it does provide primary prevention for ischemic stroke, and is therefore useful for women at risk for atherosclerotic disease. Cholesterol-lowering drugs are as effective in women as in men for primary and secondary prevention of CAD. Low HDL and DM are more important RF in women than in men. Overall, women receive fewer risk modification interventions than men, likely because the perception that they are at a lower risk of heart disease

37 YO F arrives in the ED s/p transient state of AMS on route to the US as an immigrant from Nigeria. From the reports of other passengers on the plane, she was normally interactive throughout most of the flight but was difficult to arouse from sleep upon landing. Upon trying to exit the plane, she fell over and became disarticulate. Her mental status immediately improved when she received naloxone, thiamine, and IV-glucose via emergency response. Upon arrival in the ED 1 hour later, she appears anxious but is AAO. Temp is 36.8C, BP 162/84, HR 108, RR is 22 and O2 Sat is 99% on RA. Her pupils are ERRLA. CN intact. Her oropharynx is slightly dry. There is no LAD. Lungs are clear. She has a regular heart beat with normal S1, S2 and no extra sounds. Her ABD has normal BS with slight epigastric tenderness. Her skin is normal without track marks or rash. A CMP and CBC are wnl. A Utox reveals heroin metabolites. Further evaluation should include: A: ABG B: blood cx C: CSF analysis D: ECHO E: orifice exam

E "body packing" is a common practice among members of the illicit drug trade for transport of illicit drugs across International borders. Human "mules" swallow sealed packages of illicit drugs in special bags to conceal the drug from drug enforcement. Because these bags may rupture while in the GIT, all persons who are unconscious at airports, or who develop ssx after returning from a country where trafficking is common should be evaluated for this. Initial exam is cursory orifice exam, but ABD imaging and bowel lavage are necessary in many cases. Confirmed cases need to be followed closely as further absorption of the drug is possible. Blood cx and ECHO are only necessary if IE is suspected. However, this patient has no fevers or indication of active drug abuse. CSF analysis would be necessary only if no obvious cause of the patient's mental status change were available. As her RR is now elevated rather than low, her mental status is normal, and her O2 sats are high, there is little reason to suspect CO2 retention or hypoxemia. ABG can likely be avoided unless her clinical status changes.

Which of these findings is a/w LAD and is usually suggestive of mets rather than benign etiology? A: hard, matted texture of involved nodes B: splenomegaly C: supraclavicular LAD D: tender adenopathy of the anterior cervical chain E: A and B F: A and C G: A and D

E Hard, matted, NT lymph nodes are worrisome for tumor and should prompt a workup, including excisional biopsy, if possible, and exam for a primary source depending on the location of the nodes. Supraclavicular LAD should always be considered abnormal, particularly if on the L-side. A thorough investigation for cancer, particularly with a primary GIT source, is necessary. Splenomegaly a/w diffuse LAD can be a/w tumor, particularly lymphoma, but is most often a/w systemic infections such as mononucleosis, CMV, or HIV, that cause diffuse LAD. General LAD and splenomegaly may be found in AID such as SLE or mixed CT disorder. Tender adenopathy of the cervical chain is nearly always a/w infection from the head and neck, MC a viral URT infection.

You diagnose AN in one of your new clinic patients. When coordinating a treatment plan with the psychiatrist, what characteristics should prompt consideration for inpatient treatment instead of outpatient assessment? A: amenorrhea B: exaggeration of food intake C: irrational fear of gaining weight D: purging behavior E: weight <75% of expected body weight

E Inpatient treatment or partial hospitalization is indicated for patients whose weight <75% of expected for age or height, have severe metabolic disturbances (e.g., -lyte disturbances, bradycardia, hypotension), or who have serious concomitant psych problems (e.g., suicidal ideation, substance abuse). There should be a low threshold for inpatient treatment if there has been rapid wt loss or if wt <80% of expected. Amenorrhea, exaggeration of food intake, and fear of gaining wt are part of the diagnostic criteria for AN, and purging is not uncommon in this population. Wt restoration to 90% of predicted wt is the goal of nutritional therapy.

In which of the following categories should women undergo routine screening for gestational diabetes? A: age > 25 years B: BMI > 25 C: FamHx of DM in a first degree relative D: African American E: All of the above

E Pregnancy complicated by DM is a/w greater maternal and perinatal morbidity/mortality. Women with gestational DM are at increased risk of preeclampsia, delivering infants LFGA, and birth lacerations. Their infants are at risk of hypoglycemia and birth injury. Appropriate therapy can reduce these risks. Not performing DM screening during pregnancy should be considered only in low-risk patients (age <25, no obesity, no hx of gestational or other diabetes, no diabetes in family)

50 YO alcoholic woman with well-controlled cirrhosis eats raw oysters from Chesapeake Bay at a cookout. 12 hours later, she presents to the ED with fever, hypotension, and AMS. Her extremity exam is notable for diffuse erythema with areas of hemorrhagic bullae on her shins. What is the diagnosis? A: E coli sepsis B: HUS C: Meningococcemia D: Staphy toxic shock syndrome E: Vibrio vulnificus infection

E Vibrio vulnificus is a marine-borne gram negative rod that causes overwhelming sepsis in the immunocompromised host, particularly cirrhotics. Modes of infection are direct wound inoculation or ingestion via raw seafood. Presentation is rapid with the classic skin findings described, which approx purport fulminans as the illness progresses. Mortality is >50%, even with appropriate and early abx.

fall risks in the elderly include all of these, except: A: Cr clearance <65 mL/min B: DM C: fear of falling D: hx of falls E: HTN F: psychotropic meds

E fall rates increase with age and have a substantial effect on mortality and morbidity. Some 3-5% of falls result in fracture, and falls are an independent RF for nursing home placement. All older adults should have at least annual fall risk assessment and be asked about falls during clinic visits. Fall prevention necessitates a multidisciplinary approach including management of medical conditions a/w falls, limitation of psychotropic drugs (esp Benzos), frequent visual exams, interventions such as tai-chi geared toward gait stabilization, and close exam of circumstances surrounding past falls.

Which of these statements regarding gastric decontamination for toxin ingestion is true? A: activated charcoal's most common AE is aspiration B: gastric lavage via nasogastric tube is preferred over the use of activated charcoal in situations where therapeutic endoscopy may also be warranted c: syrup of ipecac has no role in the hospital setting D: there is insufficient data to support or exclude a benefit when gastric decontamination is used more than 1 hour after toxin ingestion E: all are true

E gastric decontamination is controversial because there are few data to support or refute its use more than 1 hour s/p ingestion. It remains a very common practice in most hospitals. Syrup of ipecac is no longer endorsed for in-hospital use and is controversial even for home use, though its safety profile is well documented and therefore is likely low harm risk. Activated charcoal is generally the decontamination method of choice as it is the least aversive and least invasive option available. It is effective in decreasing systemic absorption if given within an hour of poison ingestion. It may be effective even later after ingestion fro drugs with significant anticholinergic effect (e.g., TCA). Considerations are poor visibility of the GIT on endoscopy following charcoal ingestion, and perhaps decreased absorption of oral drugs. Gastric lavage is the most invasive option and is effective, but occasionally a/w endotracheal intubation and bowel-wall perforation. It is also the least comfortable option for the patient. Moreover, aspiration risk is highest in those undergoing gastric lavage. All 3 of the MC options for decontamination carry at least a 1% risk of an aspiration event, which warrants special consideration in the patient with AMS.

In what % of pregnancies do chromosomal disorders occur? A: 0.01% B: 0.1-0.5% C: 1-2% D: 2-5% E: 10-25%

E human cells contain 46 chromosomes: 22 pairs of autosomal chromosomes and 1 pair of sex chromosomes (XX in females, and XY in males). Deviation in the number or structure of these chromosomes is common and is estimated to occur in 10-25% of all pregnancies. They are the MC cause of fetal loss. In pregnancies surviving to term, they are leading cause of birth defects and MR

28 YO M with bipolar disorder, who is on Lithium, is found in his room 2 days after not showing up to work. He is arousable, but dysarthric and has a markedly abnormal gait when trying to walk. Upon arrival at the ED, he has a grand Mal seizure. The seizure is not sustained but recurs an hour after 6 mg Lorazepam is infused IV. In the post-ictal stage, he is not arousable to sternal rub and lacks a gag reflex. His serum Na returns at 158. In reference to his seizures, all of these are next steps in his management, except: A: barbiturates B: benzodiazepines C: endotracheal intubation D: free water replacement E: phenytoin

E management of the toxin-induced seizure includes addressing the underlying cause, anti epileptics, reversal of the toxin effect, and supportive management. In this patient, lithium toxicity has led to DI and encephalopathy. The patient was unlikely to take in free water due to his incapacitated state, and as a result developed hyperNa. The hyperNa and lithium toxicity are contributing to his seizure and should be addressed with careful free water replacement and bowel irrigation, plus HD. As he is not protecting his airway, supportive management will include intubation. Antiseizure ppx with first line agents, a BDZ, has failed, and therefore should be treated with a barb as well as a BDZ. BDZ should be continued as they work by a different mechanism than barbs in preventing seizures. Phenytoin is contraindicated for the use of toxic seizures due to worse outcomes documented in clinical trials for this indication.

Independent of insurance status, income, age, and comorbid conditions, African Americans are less likely to receive equivalent levels of care when compared to white patients for the following scenarios: A: prescription of analgesia for pain B: referral to renal transplantation C: surgical treatment for lung cancer D: utilization of cardiac diagnostic and therapeutic procedures E: all of these

E minority patients have poorer health outcomes from many preventable and treatable conditions such as CVD, asthma, DM, cancer, and others. The causes of these differences are multifactorial and include SES (education, environment, income) and access to care (which often leads to more serious illness before seeking care). However, there are also clearly described racial differences in QOC once patients enter the system. These differences have been found in CVS, oncology, renal, diabetic, and palliative care. Eliminating these differences will require systematic changes in both health system factors, provider level factors, and patient level factors.

Which of the following suggests an opiate overdose? A: anion gap metabolic acidosis with a normal lactate B: hypotension and bradycardia in an alert patient C: mydriasis D: profuse sweating and drooling E: therapeutic response to naloxone

E opiate overdose falls broadly into a toxidrome characterized by physiologic depression and sedation. If a hx suggests a toxic ingestion or injection, then the diagnosis is straightforward. However, the hx is often absent and can be challenging to ddx opiate toxicity from other CNS and physiologic depressants. Therefore, naloxone should always be given as a diagnostic and therapeutic trial under circumstances of unexplained AMS, especially in the presence of coma or seizures. An immediate clinical improvement characterizes opiate overdose. In opiate overdose, abnormal VS occur exclusively as a result of CNS depression and the accompanying hypoxemia. Low BP in an alert patient should prompt a search for an alternative explanation for the hypotension. An anion gap metabolic acidosis with normal lactate is seen in syndromes such as methanol or ethylene glycol ingestion: mental status change usually precedes VS changes, and VS are often discordant as a result of physiologic adjustments to the severity of the acidosis. Mydriasis is a result of stimulant use. Miosis is a/w CNS depression. Sweating and drooling are manifestations of cholinergic agents such as muscarinic and micotinic agonists

Which of the following conditions is a/w increased susceptibility to heat stroke in the elderly? A: heat wave B: antiparkinsonian therapy C: bedridden status D: diuretics E: all of the above

E the elderly and very young are at a higher risk of non-exertional heat stroke. Environmental stress (heat wave) is the MC precipitating factor, particularly in the bedridden or those living in poorly ventilated or non air-conditioned conditions. Meds such as antiparkinsonian treatment, diuretics, or anticholinergics increase the risk of heat stroke.

A recently married couple comes to see you in clinic for prenatal counseling. They are both in their mid-30s and have read extensively on the internet about pregnancy and increasing maternal age. They want to know the risk of miscarriage as well as the risk of having a child with Downs syndrome. Which of these is true about chromosome disorders and increasing maternal age? A: about 50% of trisomy conceptions will survive to term B: in women <25, trisomy occurs in <1% of all pregnancies C: lower SES is a recognized RF in trisomic conceptions D: the risk of Down syndrome increases 1% per year of maternal age E: women >42 have a 33% chance of trisomic conception

E there is a very tight association between increasing maternal age and trisomy. Race, geography, and SES factors do not affect this relationship. In women <25, 2% of all conceptions are trisomic. The vast majority of trisomic conceptions will spontaneously abort; only Trisomy 13, 18, 21 and sex chromosome trisomies survive to term in measurable numbers. Women >42 have a 33% chance of trisomic conception. Despite this well-described association, little is known about the mechanism which drives it.

A 54 YO M is admitted with severe nausea/vomiting/diarrhea. These began 36 hours ago. He briefly improved for a few hours yesterday, but today has progressively worsened. He is concerned about possible poisoning because of his role in espionage and counterterrorism for US government. He met an informant 2 days ago and drank three cups of coffee. He is otherwise healthy and takes no medications. On exam, he appears ill. BP 98/60, HR 112, RR 24, SaO2 94%, and T 37.4C. Head, ears, eyes, nose, and throat exam show pale mucus membranes. CVS shows tachycardia, but regular. His lungs are clear. ABD is distended with hyperactive BS. There is no tenderness or rebound. Extremities show no edema, but a few scattered petechiae. Neuro exam is wnl. CBC shows WBC 150, RBC 1.5 uL, Hgb 4.5, HCT 15, PLT 11K. The ddx on WBC is 98% PMNs, 2% monocytes, and 0% lymphocytes. A blood sample for HLA testing is held. A urine sample is positive for radioactive isotopes, which are determined to be polonium-210, a strong emitter of alpha radiation. The mode of exposure is presumed to be ingestion. What is the best approach? A: BMT B: gastric lavage C: potassium iodide D: supportive care only E: supportive care and dimercaprol

E this patient has been exposed to radioactive polonium-210, a strong emitter of alpha radiation, which can be used as a calibration source or neutron source in nuclear reactors. This patient is presenting with acute radiation sickness after an unknown ingestion amount. However, his ssx began early after ingestion, and there is also severe BM aspiration, suggesting that the dose was >2 Gy. Polonium accumulates in the spleen and kidneys. In addition to supportive care with transfusions and CSFs, chelation with dimercaprol should be attempted as polonium has a radiologic half-life of 138.4 days and a biologic half life of 60 days. A BMT could be considered if his BM fails to recover. The presumed ingestion occurred >36 hours previously, and a gastric lavage is unlikely to be helpful. Potassium iodide is useful in radioactive iodine poisoning or overdose.

A patient c/o blurred vision in both eyes, particularly in the periphery with the R worse than L. Visual field exam with finger confrontation reveals a decreased vision in the L-periphery in the L eye and R periphery in the R eye. Where is the lesion? A: bilateral optic nerves B: L lateral geniculate body C: L occipital cortex D: Post-chiasmic optic tract E: Suprasellar space

E this patient has bitemporal hemianopia implying a lesion at the optic chiasm. Crossed fibers are more damaged than uncrossed lesions by compression. Therefore mass lesions at the chiasm may cause bilateral temporal visual field defects. Sellar lesions such as pituitary adenoma, meningioma, craniopharyngioma, and aneurysm can lead to this, which may be subtle to the patient and the examiner. Optic nerve lesions such as ischemic optic neuropathy, retinal vascular occlusion, advanced glaucoma, or optic neuritis will cause a horizontal scotoma. Post-chiasmatic lesions, cortical lesions, or geniculate body lesions will cause homonymous hemaniopia.

74 YO F complains of leaking urine when she coughs, laughs, or lifts groceries. She denies polydipsia and polyuria. She delivered four children vaginally and underwent TAH for fibroids x20 years ago. She has mild fasting hyperglycemia that is controlled with diet. What is the best management for her problem? A: bladder retraining exercises (planned urinations q/2 h) B: Doxazosin plus finasteride C: Metformin D: Oxybutynin E: Surgery

E this patient has stress incontinence. It is due to dysfunction of the urethral sphincter, is common in women and uncommon in men. It is most often a/w activities that increase intraABD pressure. The most common RF are previous childbearing, GYN surgery, and menopause. Kegel exercises may be helpful, but surgery is the most effective intervention. Oxybutynin and bladder training are sometimes effective for urge incontinence, which is more common in men. Alpha blockers and 5Areductase inhibitors are used for BPH in men. Close monitoring for hyperglycemia and DM is useful in elderly patients with incontinence, but this patient does not describe polyuria and her past vaginal deliveries and pelvic surgery put her at risk for stress incontinence.

34 YO M is referred to your clinic after a new diagnosis of anterior uveitis. All of these diseases should be screened for by H&P and or labs because they may cause anterior uveitis, except: A: ankylosing spondylitis B: lyme disease C: sarcoidosis D: syphilis E: toxoplasmosis

E uveitis involving the anterior portion of the eye is referred to as iritis or iridocyclitis. It is diagnosed by slit-lamp exam. The ddx for anterior uveitis includes sarcoidosis, ankylosing spondylitis, JRA, IBD, reactive arthritis, and Behcet's disease. It may also be a/w Lyme disease, syphilis, and other infections. Often, no cause is found. Posterior uveitis involves the vitreous, retina, or choroid. It may also accompany autoimmune disease, Behcet's disease, sarcoid, and IBD. A wide variety of infections may cause posterior uveitis. Toxoplasmosis specifically causes a posterior uveitis rather than an anterior uveitis. The extent of screening for diseases a/w anterior uveitis should depend on a risk assessment for each disorder based on the H&P.

Typical Variola major (small pox) infection can be distinguished from Varicella (chicken pox) based on which of the following characteristics? A: lesions at different stages of development at any location B: lesions in the same stage of development at any location C: maculopapular rash that begins on the face and trunk and spreads to the extremities (centrifugal) D: maculopaupular rash that begins on the face and extremities and spreads to the trunk (centripetal) E: B and C F: B and D

F smallpox has been proposed as a potential bioweapon. It is essential that clinicians be able to recognize this inflection clinically and distinguish it from varicella. Infections with smallpox occur principally with close contact, although saliva droplets or aerosols may also spread disease. Approximately 12-14 days s/p exposure, the patient develops high fever, malaise, nausea/vomiting, HA, and a maculopapular rash that begins on the face and extremities and spreads centripetally to the trunk with lesions at the same stage of development at any given location. This is in contrast to varicella, which begins on the face and trunk and spreads centrifugally to the extremities with lesions at all stages of development at any given location. Smallpox is a/w 10-30% MR. Vaccination with vaccinia (cowpox) is effective, even if given during the incubation period

24 YO F presents for routine checkup and c/o small masses in her groin. She states they have been present for ~3 years. On PE, she is noted to have several palpable 1-cm inguinal LNs that are mobile, NT, and discrete. There is no other LAD on exam. What is the next step in management? A: BM biopsy B: CT of the chest, abdomen, and pelvis C: excisional biopsy D: FNA for culture and cytopathology E: Pelvic US F: Reassurance

F the patient's LAD is benign. Inguinal nodes <2cm are common in population at large and need no further workup provided there is no evidence of disseminated infection or tumor, and that the nodes have qualities that do not suggest tumor (not hard or matted). A practical approach would be to measure the nodes or photograph them, and following them serially over time. Occasionally, inguinal nodes can be a/w STDs. However, these are usually ipsilateral and tender, and evaluation would include bimanual exam and appropriate cultures, not necessarily pelvic US. Total body CT would be indicated if other pathologic nodes suggest lymphoma or granulomatous disease. BM biopsy would be indicated if the diagnosis of lymphoma is made.

in the evaluation of malnutrition, which protein has the shortest half life and thus is most predictive of recent nutritional status?

Fibronectin Albumin has a half life of 2-3 weeks and is sensitive, but not specific measure of protein-calorie malnutrition. Other situations in which albumin is low include sepsis, surgery, over hydration, and increased plasma volume, including CHF, renal failure, and chronic liver disease. Among the other markers, transferrin has a half life of 1 week. Prealbumin and retinol-binding protein complex have a half life of 2 days. Fibronectin has the shortest half life: 1 day.

A patient with proteinuria has a renal biopsy that reveals segmental collapse of the glomerular capillary loops and overlying podocyte hyperplasia. The patient most likely has what disease?

HIV a collapsing variant of focal segmental glomerulosclerosis is typically diagnostic of HIV nephropathy, which presents with proteinuria and subacute loss of renal function. DM typically causes thickening of GBM, mesangial sclerosis, and arteriosclerosis. MM causes proteinuria via deposition of light chains in the glomeruli and tubules and the development of renal amyloidosis. Microscopy shows amyloid protein with Congo red staining. SLE causes membranous and proliferative nephritis due to immune complex deposition. Wegener's granulomatosis and microscopic polyangitis causes pauci-immune necrotizing glomerulonephritis

Which dx can be easily confused with Adenoviral conjunctivitis and is a major cause of blindness in the US?

HSV keratitis a major cause of blindness in the developed world. Several clues to its diagnosis may be present on exam, including periocular vesicles on the skin and a dendritic pattern of cornea ulceration on fluorescein exam (pathognomonic). However, these are not always present. Viral cx and corneal exam by ophthalmology should always be performed if unclear. Angle-closure glaucoma is rare but can be easily r/o by ophthalmology with a measure of ocular pressure and slit lamp exam. Uveitis is notable for "cells and flare" and occasionally hypopyon in the iris and perilimbic sparing. Endophthalmitis involves the entire globe and evokes pain with ocular movement. Internationally, keratitis due to trachoma is a common cause of blindness, but is uncommon in the developed world.

22 YO M presents to ED with severe ms cramps and exercise intolerance. His ssx have been worsening over a period of months. He has noticed that his urine is frequently dark. Exam reveals tenderness over all major ms groups. A CK is markedly elevated. He reports a normal childhood but since age 18 has noticed worsening exercise intolerance. He no longer plays basketball and recently noticed leg fatigue at two flights of stairs. After intense exercise, he occasionally has red-colored urine. Which is the diagnosis? A: G6PD deficiency B: Lactate dehydrogenase deficiency C: McArdle disease (Type V glycogen storage) D: pyruvate kinase deficiency E: von gierke's disease (Type I glycogen storage) What is the major source of morbidity in this disease which should be explained to the patient?

McArdle's disease; rhabdomyolysis leading to renal failure Myophosphorylase deficiency (type V glycogen storage), AKA McArdle's disease, is the MC adult glycogen storage disorder. The enzyme deficiency limits ATP production via glycogenolysis. It is characterized by exercise intolerance, ms cramping, myoglobinuria, and +CKs (at rest and increased with exercise). SSX usually develop in adulthood as a result of either brief intense activity or sustained exercise. Rhabdomyolysis after intense activity may cause myoglobinuria and subsequent renal failure and is the major clinical risk about which patients should be warned. Heart disease does not occur. The MC childhood disorder glycogen storage disease is G6PD deficiency (type 1), aka von gierke's disease, which presents at 3-4 months with growth retardation and hepatosplenomegaly. Lactate dehydrogenase deficiency and pyruvate kinase deficiency present similarly to McArdle's disease, but are very rare.

20 recent attendees at a NFL game arrive to the ED c/o SOB, fever, and malaise. Chest roentgenograms show mediastinal widening on several of these patients, prompting a concern for inhalation anthrax as a result of a bioterrorism attack. Abx are initiated and the CDC is notified. What form of isolation should be instituted?

None the three major clinical forms of anthrax are GIT, cutaneous, and inhalation. GI anthrax results from eating contaminated meat and is an unlikely bioweapon. Cutaneous anthrax results from contact with the spores and results in a black eschar lesion. Cutaneous had a 20% mortality before abx became available. Inhalational anthrax typically presents with the most deadly form and is the most likely bioweapon. The spores are phagocytosed by alveolar macrophages and transported to the mediastinum. Subsequent germination, toxin elaboration, and hematogenous spread cause septic shock. A characteristic radiograph finding is mediastinal widening and pleural effusion. Prompt initiation of abx is essential as mortality is likely 100% without specific treatment. Inhalation is not known to be contagious. Provided that there is no concern for release of another highly infectious agent such as smallpox, only routine precautions are warranted.

A patient with narrow-based gait instability complains that he needs to look at his feet while he walks to prevent falling. He feels wobbly standing with his eyes closed and notes frequent falls. On exam, he has no difficulty initiating gait, his stride is regular, strength is normal, and there is no tremor. Review of routine labs drawn 3 months prior reveals HCT 29, with elevated MCV. What is the diagnosis?

Pernicious anemia the inability to walk in a stable fashion without direct visual observation of the feet suggests a deficit in proprioception due to large-fiber neuropathy. The narrow-based gait with no difficulty initiating gait and normal strength is c/w sensory ataxia. Classically, this was caused by tabes dorsals, although B12 deficiency is a treatable disease that may present with this form of neuropathy and gait disorder. This suspicion is even greater in the context of a microcytic anemia, a finding c/w B12 deficiency. Further signs of impaired proprioception, such as decreased ability to sense joint position, are even more suggestive. Cerebellar ataxia will have a wide-based gait with a lurching stride. CVA may present with frontal gait disorder, which is characterized by wide-based, slow, shuffling gait. Parkinson's also causes a shuffling gait with difficulty initiating and turning en bloc. ALS does not cause a sensory or proprioceptive neuropathy, but ill alter gait due to ms weakness.

The curve that graphically represents the family of cutoff points for a positive vs negative test The area under this curve is a quantitative measure of the information content of the test, what are its axes?

ROC curve plots sensitivity on the y-axis and (1-spec) on the x-axis each point on the curve represents a cutoff point of sensitivity and specificity the area under the curve can be used as a quantitative measure of the information content of the test values range from 0.5 (45 degree line) representing no diagnostic information to 1.0 for a perfect test

You are a physician working in an urban ED when several patients are brought in after the release of an unknown gas at the performance of a symphony. You are evaluating a 52 YO F who is not able to talk clearly because of excessive salivation and rhinorrhea, although she is able to tell you that she feels as if she lost her sight immediately upon exposure. At present, she has vomiting, nausea, diarrhea, and ms twitching. On PE, the patient has BP 156/92, HR 92, RR 30, and a temp of 99.3F. She has pinpoint pupils with profuse rhinorrhea and salivation. She also is coughing profusely, with production of copious amounts of clear secretions. A lung exam reveals wheezing on expiration in bilateral lung fields. The patient has a regular rate and rhythm with normal heart sounds. Bowel sounds are hyperactive, but the ABD is not tender. She is having diffuse fasciculations. At the end of your exam, the patient abruptly develops tonic-clonic seizures. Which agent was she poisoned with? A: arsine B: cyanogen chloride C: nitrogen mustard D: sarin E: VX All of the following should be used in the treatment, except: A: atropine B: decontamination C: diazepam D: phenytoin E: 2-pralidoxime chloride

SARIN gas this patient has ssx of acute cholinergic crisis as seen in organophosphate poisoning. These are "classic" nerve agents, and several different compounds may act in this manner, including sarin, tabun, woman, and cyclosarin. Except for agent VX, all the organophosphates are liquid at standard room temp and pressure and are highly volatile, with the onset of ssx occurring within mins - hours s/p exposure. VX is an oily liquid with a low vapor pressure; therefore, it does not acutely cause ssx. However, it is an environmental hazard because it can persist in the environment for a longer period. Organophosphates act by inhibiting tissue synaptic ACh. SSX differentiations between vapor exposure and liquid exposure because they act in the tissue upon contact. The first organ exposed with vapor is the eye, causing rapid and persistent pupillary constriction. After the sarin gas attacks in Tokyo subway in 94 and 95, survivors frequently complained that their world went black as the first symptom. This is rapidly followed by rhinorrhea, excessive salivation, and lacrimation. In the airways, there is bronchorrhea and bronchospasm. It is in the alveoli that they gain the greatest extent of entry into the blood. As they circulate, other ssx appear such as nausea, vomiting, diarrhea, and ms fasciculations. Death occurs with CNS penetration causing central apnea and status epilepticus. The effects on the HR and BP are unpredictable. Treatment requires a multifocal approach. Initially, decontamination of clothing and wounds is important for both patient and caregiver. Clothing should be removed before contact with provider. In Tokyo, 10% of ED personnel developed miosis. 3 Classes of meds are important in treatment: anticholinergics, oximes, and anti-convulsants. Initially, atropine at doses of 2-6 mg should be given IV or IM to reverse the muscarinic effects; it has no effect on nicotinic receptors. Thus, atropine rapidly treats life-threatening respiratory depression, but does not affect NM or SNS effects. This should be followed by administration of oxime, which is a nucleophile compound that reactivates cholinesterase whose active site has been bound to a nerve agent. Depending on the agent, oxime may not be helpful because it is unable to bind to "aged" complexes that have undergone degradation of a side chain of the nerve agent, making it negatively charged. Soman undergoes aging within 2 mins, thus rendering oxime useless. The currently approved oxime in the US is 2-pralidoxime. Finally, the only anticonvulsant class of drugs that is effective in seizures caused by this poison is benzodiazepines. The dose required is frequently higher than that use for epileptic seizures, requiring the equivalent of 40 mg of diazepam given in frequent doses. All other anticonvulsants, including phenytoin, barbs, carbamazepine, and valproate will not improve the seizures.

A wide-based gait with irregular lurching and erratic foot placement but no subjective dizziness characterizes which type of gait ataxia?

The gait of cerebellar dysfunction most closely resembles a drunk gait with very poor balance, frequent lurching, and high risk of fall. However, unlike patients with inner ear dysfunction, these ssx are usually not a/w subjective dizziness, vertigo, and nausea. Frontal gait disorder or gait apraxia is common in the elderly and has a variety of causes. Typical features include a wide base of support, short strides, shuffling, and difficulty with starts and turns. The MC cause of frontal gait is subcortical small-vessel cerebrovascular disease. Patients with Parkinson's have a shuffling gait, with difficulty initiating and turning en bloc. Sensory ataxia may be caused by tabes dorsals or B12 neuropathy. Patients have a narrow base and look down; their gait is regular with path deviation. They have no difficulty initiating the gait, but have postural instability and falls.

35 YO F with no PMHx presents to clinic with chest pain. She reports occasional intermittent CP unrelated to exercise, but is related to spicy food. Pre-test prob for CAD is low; however, the patient is referred to exercise treadmill stress test, which shows ST depression after moderate exercise. Using Bayes Theorem, how do you interpret these results?

The pretest prob is low, and the sensitivity and specificity of exercise treadmill testing in females is poor; therefore, the treadmill stress test is not helpful in clinical decision making in this case Bayes Theorem is used in an attempt to quantify uncertainty by employing an equation that combines pretest prob with the testing characteristics of specificity and sensitivity. The pretest prob quantitatively describes the clinician's certainty of a diagnosis after H&P. This equation is: Posttest prob = pretest prob x test sens // [pretest prob x test sens + (1-disease prev) x test FP rate]

18 YO F is evaluated in clinic for c/o amenorrhea. She reports that she feels as if she has never developed normally compared with other girls her age. She has never had a menstrual period and complains that she has only minimal breast growth. PMH is significant for a diagnosis of borderline HTN. In childhood the patient frequently had otitis media and varicella infections. She received her standard vaccinations. She recently graduated from HS and has no learning difficulties. She is on no meds. On PE, the patient is short stature with height 56 inches. BP is 142/88. The posterior hairline is low. The nipples are widely spaced, with only breast buds apparent. The patient has minimal escutcheon c/w Tanner stage 2 development. Her external genitalia appear normal. Bimanual vaginal exam reveals anteverted, anteflexed uterus. The ovaries are not palpable. What is the diagnosis?

Turner syndrome (gonadal dysgenesis) common chromosomal disorder which affects 1 in 2500 female births. The most common defect is the 45XO, which causes half of all phenotypic cases of this syndrome. Age at dx is variable, based on clinical manifestations. Most cases are dx perinatally on the basis of reduced fetal growth or LAD at birth with nuchal folds, a low posterior hairline, or L-sided cardiac defects. Some girls may not be dx in childhood and come to attention later in life because of delayed growth and lack of sexual maturation. Limited pubertal development occurs in 30% of girls with Turner, with approximately 2% reaching menarche. Owing to the frequency of congenital heart and genitourinary defects, a thorough workup should be done after dx, including ECHO and renal imaging. Long-term management includes GH replacement during childhood and estrogen replacement to maintain bone mineralization and feminization.

You are rotating on a medical trip to impoverished areas of China. You are examining an 8 YO child whose mother c/o him being clumsy and sickly. He has had many episodes of diarrheal illnesses and PNA. His "clumsiness" is most pronounced in the evening when he has to go outside and do chores. On exam, you notice conjunctival dryness with white patches of keratinized epithelium on the sclera. What is the cause?

Vitamin A deficiency this remains a problem in children with chronically poor diets in parts of Asia, Africa, and China. This child has xerophthalmia with evidence of mild night blindness. He also has Bitot's spots (white patches on sclera). Vitamin A deficiency also impairs the host ability to fight infection. Mortality amongst vitamin A deficient children is substantially higher when infected with diarrhea, dysentery, measles, malaria, or respiratory disease. Supplementation improves the mortality.

Why is it necessary to coadminister Vitamin B6 (pyridoxine) with INH?

because INH interacts with pyridoxal phosphate certain meds, including INH used for TB, L-dopa for Parkinson's, and penicillamine for scleroderma, promoted B6 deficiency by reacting with a carbonyl group on 5-pyridoxal phosphate, which is a cofactor for a host of enzymes involved in AA metabolism. Foods which contain B6 include legumes, nuts, wheat bran, and meat. B6 deficiency produces seborrheic dermatitis, glossitis, stomatitis, and cheliosis (as seen with other B deficiencies). A microcytic, hypochromic anemia may result from the fact that the first enzyme in heme synthesis (ALA synthetase) requires pyridoxal phosphate as a cofactor. However, B6 is also necessary for conversion of homocysteine to cystathionine. Consequently, a deficiency of this vitamin could produce an increased risk of CVD caused by the resultant homocystinemia.

a patient in the ICU develops a temperature of 40.8C, profound rigid tone, and hemodynamic shock 2 mins after a succinylcholine infusion is started. Immediate therapy should include what two therapies?

dantrolene and external cooling this patient has malignant hyperthermia, for which dantrolene and external cooling are appropriate. Malignant hyperthermia occurs in individuals with a genetic predisposition that causes elevated skeletal ms intracellular calcium concentration after exposure to some inhaled anesthetics or succinylcholine. Cardiovascular instability is common within minutes. Although malignant hyperthermia is rare, these drugs are commonly used, and without prompt recognition the condition may be fatal. There is no role for antipyretics as the thalamic set point for temperature is likely not altered in the setting of hyperthermia.

An effective way to measure the accuracy of a diagnostic test is a positive likelihood ratio [sensitivity/(1-specificity)], which is also defined as the ratio of the prob of a positive test result in a patient with the disease to the probability of a positive test result in a patient without the disease. What other piece of information is needed along with the PLR to estimate the possibility of a given disease in a certain patient with a positive test?

pretest prob of disease a PLR can only be interpreted in the context of a pretest prob of disease. Disease prevalence in certain regions contributes to the patient's pretest probability. However, other RF like age, clinical hx, etc are also important in pretest prob

Diabetes is a/w all the following in the elderly, except: A: CVA B: cognitive decline C: fall risk D: MI E: urinary incontinence

the prevalence of DM in older adults is ~18-21%. This rate will likely increase with increasing obesity in adults. DM has been linked with physical decline, while HTN has been linked with cognitive decline. However, both disorders are commonly present in the elderly. DM and stroke are most consistently a/w a diminished capacity for functional recovery in the elderly

38 YO M with MS develops acute, flaccid weakness in his LE and LLE. PE reveals normal sensorium, normal CN function, 1/5 strength in his L-UE, 0/5 strength in his L-LE, impaired proprioception in his L-LE, intact proprioception in his R-LE, decrease pain and temperature in his R-UE and R-LE, and normal light touch/pain and temperature sensation in his R-LE. Where is the lesion?

this patient has Brown Sequard syndrome, likely because of new multiple sclerosis plaques. The lack of CN involvement and other cortical deficits, in the presence of UE and LE deficits, suggests a high cord lesion. These often lead to differing ipsilateral and contralateral sensory deficits, as here. The combination of L-sided motor deficits and R-sided sensory deficits makes a cortical lesion unlikely. Brainstem lesions will also not account for the localization and bilaterally. A cervical cord root lesion would not be bilateral.