Rosh Review Exam Questions With Verified Answers

Rosh Review Exam Questions With Verified Answers Which of the following patients is at greatest risk of developing West Nile meningoencephalitis? 22-year-old man status postrenal transplant 3-year-old girl who is unvaccinated 58-year-old man with diabetes and hypertension 82-year-old woman with dementia - answerCorrect Answer ( D ) Explanation: West Nile virus is a zoonotic infection that first appeared in the U.S. along the eastern seaboard in 1999 but can now be found nationwide. West Nile encephalitis (WNE) is endemic in the Middle East, Africa, and Asia. Birds serve as the primary host, and it is transmitted by the bite of a mosquito. WNE usually occurs in the summer, when mosquitoes, wild migratory birds, and humans are in close proximity outdoors. Most people infected with West Nile virus are asymptomatic. When present, symptoms are typically mild and include fever, headache, and fatigue. Severe disease, however, can cause central nervous system manifestations including meningitis, encephalitis, and myelitis. The biggest risk factor, by far, for neuroinvasive West Nile disease is advanced age. There are a handful of confirmed cases of transmission via organ transplantation or blood transfusion. Although immunosuppression (A and C) puts people at increased risk and invasive disease in young children can be more severe (B), West Nile meningoencephalitis is far more common in the geriatric population than in any other group. Question: What is the typical distribution of weakness caused by West Nile meningoencephalitis? - answerAnswer: Asymmetric; isolated facial involvement may also be seen. Rapid Review West Nile Virus Mosquitos Summer/fall Flulike sx, URI sx, rash Complication: meningoencephalitis Which of the following is associated with pernicious anemia? Homocysteine levels are decreased Methylmalonic acid is increased Normocytic erythrocytes Vitamin B12 elevation - answerCorrect Answer ( B ) Explanation: Vitamin B12 is found in animal products and binds to intrinsic factor (IF) secreted by gastric parietal cells. This complex is absorbed in the terminal ileum. Pernicious anemia is an autoimmune disorder in which antibodies act against intrinsic factor and gastric parietal cells leading to chronic atrophic gastritis and decreased production and function of intrinsic factor. This subsequently leads to vitamin B12 deficiency. In vitamin B12 deficiency, serum methylmalonic acid is increased. In elderly patients, this form of megaloblastic anemia is one of the leading causes of vitamin B12 deficiency. Pernicious anemia is associated with other immunologic diseases such as Sjögren's syndrome, Hashimoto's disease, type 1 diabetes mellitus, and celiac disease. It is also associated with an increased risk for gastric cancer and carcinoid tumors. Vitamin B12 deficiency caused by dietary deficiency or malabsorption is rare. Dietary causes of deficiency are limited to elderly people who are already malnourished. Since the 1980s, the malabsorption of vitamin B12 has become rare, due to the decreasing frequency of gastrectomy and surgical resection of the terminal small intestine Other disorders associated with vitamin B12 malabsorption include deficiency in the exocrine function of the pancreas after chronic pancreatitis (usually alcoholic), lymphomas or tuberculosis of the intestine, Crohn's disease, Whipple's disease, and celiac disease. Uncommon etiology also includes nitrous oxide anesthesia and abuse. In vitamin B12 deficiency (<150 pmol/L), homocysteine levels are increased (A), the erythrocytes are usually macrocytic (MCV >100 fL) (C), serum vitamin B12 level is low (<200 pg/mL) (D). In folate deficiency, testing the red cell folate concentration is more reliable than the serum level. Question: Will administering oral vitamin B12 help to treat B12 deficiency in pernicious anemia? - answerAnswer: No, intramuscular B12 should be administered. Oral will not be absorbed. Rapid Review Megaloblastic Anemia B12 deficiency: vegan, pernicious anemia Folate deficiency: alcoholic, antifolate therapy MCV > 100 Hypersegmented neutrophils B12 deficiency: neurologic findings A 54-year-old man with cirrhosis presents for evaluation of abdominal pain. The pain is diffuse throughout the abdomen and associated with subjective fever at home. He has no vomiting, diarrhea or change in mental status. His vital signs are T 100.6°F, HR 102, BP 140/88, RR 12, and oxygen saturation of 100% on room air. Bedside ultrasound demonstrates ascites. Which of the following is an indication for intravenous antibiotics? Ascitic fluid neutrophil count of 300 cells/mm3 Ascitic fluid pH of 7.35 AST of 340 mmol/L Peripheral white blood cell count of 15,000 cells/mm3 - answerCorrect Answer ( A ) Explanation: The patient's presentation is concerning for spontaneous bacterial peritonitis (SBP), an acute bacterial infection in the ascitic fluid of patients with ascites in the setting of liver disease. Most commonly, gram negative enteric organisms are responsible for the infection and the treatment of choice is an intravenous third generation cephalosporin. Diagnosis is made based on an ascitic neutrophil count > 250 cells. Other test results have been correlated with SBP, but treatment is guided based on the neutrophil count of the ascitic fluid. An ascitic pH of 7.35 (B) is nonspecific for this illness. A pH less than 7.34 or a gradient of more than 0.10 between the arterial and ascitic pH may be an earlier indicator of early SBP. An AST of 340 (C) is not predictive of SBP. Patients with cirrhosis will often have elevated transaminases, and particularly alcoholic patients will have an AST higher than ALT. The peripheral white blood cell count of 15,000 (D) may indicate the presence of infection, but is not specific and does not mandate the initiation of intravenous antibiotic therapy. Question: In patients identified as high risk for spontaneous bacterial peritonitis, which antibiotics are used prophylactically? - answerAnswer: Fluoroquinolones or TMP-SMX. Rapid Review Spontaneous Bacterial Peritonitis Patient will have a history of chronic liver disease or cirrhosis Complaining of fever, chills, and abdominal pain PE will show ascites, shifting dullness Labs will show PMNs > 250, WBC >1,000, pH <7.34 Diagnosis is made by analysis of the ascitic fluid Most commonly caused by E. coli, Streptococcus spp Treatment is immediate IV antibiotics (third-generation cephalosporin) A 63-year-old man presents with dizziness. He states that when he turns his head to the right, he gets an intense sensation of room spinning with nausea and vomiting. The symptoms resolve in minutes with rest. His physical examination is remarkable for right-beating nystagmus when his head is turned to the right but is otherwise normal. What management is indicated?