Topic: Hepatic Encephalopathy
Subject: Medicine
A 50-year-old man with a history of hemochromatosis presents to the emergency room vomiting up bright red blood. He had his most recent phlebotomy yesterday. His blood pressure is 110/85 mm Hg, his pulse 115/min; his face is flushed, and he is diaphoretic. During the physical examination splenomegaly and a venous pattern on his chest and abdomen are noted. He seems somewhat drowsy and confused but has no focal neurologic signs.
What is the probable source of this patient's confusion?
Severe anemia
Hepatic encephalopathy
Subarachnoid hemorrhage
Vitamin B12 deficiency
Correct Answer :
B. Hepatic encephalopathy
Hemochromatosis is the abnormal accumulation of iron in parenchymal organs, leading to organ toxicity. It is the most common inherited liver disease in whites and the most common autosomal recessive genetic disorder. Hemochromatosis can cause liver damage and lead to hepatic encephalopathy
Hepatic encephalopathy is a neuropsychiatric syndrome. It most often results from high gut protein or acute metabolic stress (eg, GI bleeding, infection, electrolyte abnormality) in a patient with portal-systemic shunting. Symptoms are mainly neuropsychiatric (eg, confusion, flapping tremor, coma). Diagnosis is based on clinical findings.
Treatment usually is correction of the acute cause, restriction of dietary protein, and administration of oral lactulose.
Related Questions
Topic: Seizure
Subject: Medicine
A 32-year-old female experiences an episode of unresponsiveness associated with jerking movements of her arms and legs. Which one of the following presentations would make a diagnosis of true seizure more likely?
Post-event confusion
Eye closure during the event
A history of fibromyalgia
A history of chronic back pain
Topic: Essential Tremor
Subject: Medicine
A 75 year old white male complains of a tremor which has been progressive over the past 2 years. The tremor interferes with writing, pouring liquids, and eating soup. He has no other medical problems. He abstains from alcohol and tobacco products. Physical examination is remarkable for an action tremor of the upper extremities and a head tremor. No rigidity or gait disorder is noted. Of the following agents, which one is most appropriate as initial drug therapy for this problem?
Alprazolam (Xanax)
Clonazepam (Klonopin)
Carbamazepine (Tegretol)
Propranolol (Inderal)
Topic: Seizure
Subject: Medicine
A 52-year-old male with a history of seizure attacks suffered from loss of consciousness and tonic-clonic muscular contractions. His tongue fell back into his throat and he choked.
What is the medication of choice for the treatment of this patient's condition?
Phenytoin
Valproic acid
Tiagabine
Phenobarbital
Topic: Mini Mental Status Exam (or MMSE)
Subject: Medicine
While performing the Mini-Mental State Exam the PCP asks her patient to copy the following design. What cognitive function is being assessed by this request?
Language
Orientation
Registration
Visual-motor integrity
Topic: Amnesia
Subject: Medicine
Which of the following medications may cause amnesia as a side effect?
Hydroxyzine
Fluoxetine
Triazolam
Clonidine
Topic: Seizure
Subject: Medicine
A 52-year-old man with a history of seizure attacks suffered from loss of consciousness and tonic and clonic muscular contractions. His tongue fell back into his throat and he choked. What is the best diagnostic test for assessment of the presenting condition of this patient?
X-rays
CT-Scan
Electroencephalogram
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Topic: Tension headache.
Subject: Medicine
A woman presents with chief complaint of tightening, band-like headaches that usually occur upon rising in the morning. What is the most likely diagnosis?
Migraine headache
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Tension headache
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Topic: Cauda Equina Syndrome
Subject: Medicine
A 65-year-old male presents with a 1-month history of problems passing urine. He says that his bladder will feel full when he needs to urinate, but the urine stream is weak and his bladder does not feel as if it has emptied completely. The symptoms have become increasingly severe over the past week. Other symptoms include upper respiratory congestion for 3 days which he has treated with an over-thecounter decongestant with some relief, constipation with no passage of stool in the past 9 days, and increasing low back pain incompletely relieved with ibuprofen, with associated weakness in both legs. Examination shows a healthy-appearing male who is moderately overweight. He is afebrile and vital signs are normal. There is no abdominal tenderness and no masses are detected. A rectal examination reveals a large amount of hard stool in the rectum; a markedly enlarged (4+), boggy, tender prostate gland; laxity of the anal sphincter; and numbness in the perianal area. Urinalysis shows trace protein and 10-20 WBCs/hpf. Ultrasonography shows a post-void residual volume of 250 mL (normal for age <100).
Which one of the following must be done urgently in this patient?
Foley catheterization
Hospitalization for intravenous antibiotics
Digital disimpaction of the rectum, and Fleet enemas until clear
MRI of the lumbosacral spine
Topic: Glasgow Coma Scale
Subject: Medicine
A 27 year old man is brought into the ER after a bicycling accident. A car door suddenly opened in front of him, of which he smashed into and was thrown 15 feet. On examination, he is drowsy and confused. He opens his eyes when his name is called. When he speaks, you understand his words but the sentences do not make sense. He moves all four limbs but does not respond to any commands. He is able to pull both hands away when pinched and squirms when his sternum is rubbed, making no effort to stop you.
What is his Glasgow Coma Scale score?
11
10
9
8
Topic: Cholinergic Toxidrome
Subject: Medicine
A 37 year old male arrives at the Emergency Department unconscious. He is warm and sweaty. His heart rate is 52 bpm, his BP is 90/60. His pupils are constricted, his eyes are teary, and he is drooling. You assume he is suffering from a toxidrome.
What antidote will you give him?
Flumazenil
Naloxone
Glucagon
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Topic: Status Epilepticus
Subject: Medicine
A 58-year-old male with a history of seizure attacks suffered from a 30min loss of consciousness with repetitive seizures with no recovery of consciousness between attacks. What is the best initial treatment for his condition?
Lorazepam
Phenytoin
Phenobarbital
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Subject: Medicine
A 54-year-old white male presents with drooping of his right eyelid for 3 weeks. On examination, he has ptosis of the right upper lid, miosis of the right pupil, and decreased sweating on the right side of his face. Extraocular muscle movements are intact. In addition to a complete history and physical examination, which one of the following would be most appropriate at this point?
A chest radiograph
MRI of the brain and orbits
131 Iodine thyroid scanning
A fasting blood glucose level
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Subject: Medicine
The treatment of choice for absence seizures is:
Lamotrigine
Ethosuximide
Phenobarbital
Phenytoin
Topic: Bell's Palsy
Subject: Medicine
A 53-year-old male accountant comes to your office with progressive facial weakness on the left side that began yesterday. He also reports pain behind the left ear and decreased lacrimation from the left eye. He has been in good health and had his yearly physical examination 1 week ago, which was normal. His lipid levels, chemistry profile, and CBC were all normal. He has not been involved in any outdoor activities, nor does he engage in any high-risk sexual behavior. On examination, there is flattening of the left nasolabial fold and decreased ability to close the left eye. The mouth appears to be drawn to the right. The remainder of his general examination and neurologic examination are normal.
Which one of the following would be the most appropriate management at this time?
Carotid ultrasonography
High-resolution CT
MRI with gadolinium enhancement
Prednisone and valacyclovir (Valtrex)
Topic: Essential Tremor
Subject: Medicine
Which one of the following is most likely to be of benefit in patients with essential tremor of the hand?
Isoniazid
Diazepam
Primidone
Clonidine
Topic: Delirium Tremens
Subject: Medicine
You see a 49-year-old man in the emergency room with a 20-year-history of alcohol abuse. He is agitated and floridly psychotic, with visual hallucinations and persecutory delusions. On examination his blood pressure, heart rate and respiratory rate are all increased. He is disoriented, sweaty, and has abdominal cramps.
What is the most likely diagnosis?
Subdural hematoma
Alcohol intoxication
Hepatic encephalopathy
Delirium tremens
Topic: Analgesics
Subject: Medicine
A 74-year-old black female has moderately severe pain due to osteoarthritis. However, she is also on medication for a seizure disorder. When choosing medications to manage her chronic pain, which one of the following should be used with caution because of her history of seizures?
Salsalate (Disalcid)
Celecoxib (Celebrex)
Hydrocodone (Lortab)
Tramadol (Ultram)
Topic: Dementia
Subject: Medicine
An 85 year old white male is brought to you for the first time by his son. The father has recently seen a neurologist who performed a workup for dementia and diagnosed moderate Alzheimers disease. Which one of the following is true regarding the use of a cholinesterase inhibitor in this patient?
It is too late to initiate cholinesterase therapy
Agitation is often intensified by these agents
Memory is likely to improve significantly
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Topic: Alzheimer's Disease
Subject: Medicine
Which one of the following tests is most useful for the initial workup of suspected Alzheimers disease?
Carotid Doppler ultrasonography
An erythrocyte sedimentation rate
A cardiac stress test
A TSH level
Topic: Trigeminal Neuralgia
Subject: Medicine
A man complains that recently when he shaves he has a shooting type of pain in his face. It happens once in a while and then goes away. You suspect trigeminal neuralgia.
What is the treatment of choice?
Fluoxetine
Prednisone
Acyclovir
Carbamazepine
Topic: Fragile X Syndrome
Subject: Medicine
You are asked to see a mentally challenged 45-yearold male from a nearby group home who has groin pain. On examination you notice that he has large ears, a prominent jaw, and large symmetric testicles.
These findings are consistent with:
A variant form of Down syndrome
Aspergers syndrome
Klinefelters syndrome
Fragile X syndrome
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Subject: Medicine
During the physical exam of a patients foot, you notice an inability to dorsiflex. What nerve root(s) is most likely affected?
T12
L1
L2
L4 - L5
Topic: Alzheimer's Disease
Subject: Medicine
Which one of the following is associated with an increased risk of developing Alzheimers disease?
A positive homozygous genotype for apolipoprotein E4
Elevated serum aluminum
Elevated serum alpha-tocopherol
Decreased serum Beta-carotene
Topic: Seizure
Subject: Medicine
A 68-year-old man with a history of urolithiasis, suffered from a seizure attack which involved loss of consciousness with tonic and clonic muscular contractions. His tongue fell back into his throat and he choked.
Which of the following medications is contraindicated in this patient's treatment?
Levetiracetam
Phenytoin
Topiramate
Carbamazepine
Topic: Postherpetic Neuralgia
Subject: Medicine
A 78-year-old male comes to your office with a 3- day history of pain in the right side of his chest. The pain is described as burning and intense. Two days ago he noted a rash at that site. Examination reveals groups of vesicles on an erythematous base in a T-5 dermatome distribution on the right.
Which one of the following would be the most appropriate treatment to minimize the chance of post-herpetic neuralgia?
Famiciclovir (Famvir)
Prednisone
Capsaicin (Zostrix)
Carbamazepine (Tegretol)
Topic: Seizure
Subject: Medicine
A 52-year-old male with a history of seizure attacks suffered from loss of consciousness and tonic and clonic muscular contractions. His tongue fell back into the throat and he choked. What is the most likely diagnosis of this presentation?
Petit mal seizure
Grand mal seizure
Myoclonic seizure
Atonic seizure
Topic: Benign Positional Vertigo
Subject: Medicine
Which one of the following is characteristic of benign positional vertigo?
A duration of 10-15 minutes
Associated hearing loss and tinnitus
Associated diplopia and facial numbness
Being triggered by turning the head
Topic: Guillain-Barr� syndrome
Subject: Medicine
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Proximal muscle weakness
Areflexia
Infection with C. jejuni
Treatment with corticosteroids
Topic: Adverse Drug Effect
Subject: Medicine
Which one of the following is most associated with falls in older adults?
Diphenhydramine (Benadryl)
Atorvastatin (Lipitor)
Metformin (Glucophage)
Memantine (Namenda)
Topic: Hepatic Encephalopathy
Subject: Medicine
A 50-year-old man with a history of hemochromatosis presents to the emergency room vomiting up bright red blood. He had his most recent phlebotomy yesterday. His blood pressure is 110/85 mm Hg, his pulse 115/min; his face is flushed, and he is diaphoretic. During the physical examination splenomegaly and a venous pattern on his chest and abdomen are noted. He seems somewhat drowsy and confused but has no focal neurologic signs.
What is the probable source of this patient's confusion?
Severe anemia
Hepatic encephalopathy
Subarachnoid hemorrhage
Vitamin B12 deficiency