ROSH Exam Review | Questions & Answers (100 %Score) Latest Updated 2024/2025
Comprehensive Questions A+ Graded Answers | With Expert Solutions
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 - Correct 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? - Answer: 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 - Correct 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? - Answer: 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 - Correct 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? - Answer: 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?
Antibiotics
Epley maneuver
Non-contrast head CT
Prednisone - Correct Answer ( B )
Explanation:
This patient presents with benign paroxysmal positional vertigo (BPPV), which can be
cured by the Epley maneuver. True vertigo is defined as a sensation of disorientation
along with a sensation of movement. It has a number of causes, which can be grouped
into central and peripheral categories. Peripheral causes, while causing distressing
symptoms, are generally benign and include BPPV, acute otitis media, labyrinthitis,
Meniere's disease, vestibular neuronitis and trauma. Central causes of vertigo are
usually more dangerous and potentially life threatening. These include infection
(meningitis, encephalitis), vertebral basilar artery insufficiency, cerebellar hemorrhage
or infarction, temporal lobe epilepsy and tumors. The table below delineates some of
the different characteristics.
BPPV presents with intermittent episodes of severe vertigo that are sudden in onset.
The episodes often are triggered with specific head movements and resolve with time
when not moving the head. In between episodes of vertigo, patients may have
continued nausea. BPPV is caused by the presence of an otolith in one of the
semicircular canals. Symptomatic treatment with antiemetics may be necessary
depending on the severity of nausea. A Dix-Hallpike procedure can be performed on
patients with vertigo to confirm the diagnosis. The Epley maneuver offers definitive
treatment via otolith expulsion from the semicircular canal.
Antibiotics (A) should be initiated in the treatment of suppurative labarynthitis or acute
otitis media. Patients with suspected central causes of vertigo should have a non-
contrast head CT (C) performed as part of their workup but this test plays no role in the
diagnosis or management of peripheral vertigo. Prednisone (D) is useful in the
treatment of vestibular neuronitis but no
Question: What diagnostic test should be ordered in a patient with vertigo concerning
for cerebellar infarction? - Answer: MRI/MRA of the brain is required as CT scan of the
head does not visualize the posterior fossae well.
