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#35 Rosh Review Practice Questions and Answers (Graded A+)
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©PREP4EXAMS@2024 [REAL EXAM DUMPS] Friday, July 19, 2024 6:13 AM#35 Rosh Review Practice Questions and
Answers (Graded A+)
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.
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,©PREP4EXAMS@2024 [REAL EXAM DUMPS] Friday, July 19, 2024 6:13 AM
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
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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
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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
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