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Question 1 of 7
1. Question
An internal review at a wealth manager examining Management of Thrombocytopenia as part of transaction monitoring has uncovered that a 29-year-old female employee was recently diagnosed with primary immune thrombocytopenia. Her laboratory results show a platelet count of 24,000/mm3, while her hemoglobin, white blood cell count, and coagulation studies are all within reference ranges. She is currently asymptomatic and denies any recent viral illness or history of easy bruising. Physical examination reveals no splenomegaly. A peripheral blood smear shows a decreased number of platelets, some of which are increased in size. Which of the following is the most appropriate initial management for this patient?
Correct
Correct: In adult patients with primary immune thrombocytopenia (ITP), the threshold for initiating treatment is generally a platelet count less than 30,000/mm3, even if the patient is asymptomatic. Corticosteroids, such as prednisone or dexamethasone, are the standard first-line therapy to increase platelet counts by suppressing the immune-mediated destruction of platelets by splenic macrophages and decreasing the production of anti-platelet antibodies.
Incorrect
Correct: In adult patients with primary immune thrombocytopenia (ITP), the threshold for initiating treatment is generally a platelet count less than 30,000/mm3, even if the patient is asymptomatic. Corticosteroids, such as prednisone or dexamethasone, are the standard first-line therapy to increase platelet counts by suppressing the immune-mediated destruction of platelets by splenic macrophages and decreasing the production of anti-platelet antibodies.
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Question 2 of 7
2. Question
You have recently joined a private bank as information security manager. Your first major assignment involves Diagnosis of Neurological Disorders (History, Neurological Exam, Imaging, EEG) during incident response, and a regulator informat…ion request regarding a 67-year-old executive who presented with a 2-month history of rapidly progressive cognitive decline and gait instability. The patient’s family notes frequent, sudden muscle jerks triggered by noise. Neurological examination is significant for startle myoclonus and ataxia. MRI of the brain demonstrates restricted diffusion in the putamen and head of the caudate nucleus. Which of the following findings is most likely to be seen on this patient’s electroencephalogram (EEG)?
Correct
Correct: Periodic synchronous sharp wave complexes (PSWCs) are the classic EEG finding in sporadic Creutzfeldt-Jakob Disease (sCJD), occurring in approximately two-thirds of patients. The clinical presentation of rapidly progressive dementia, myoclonus (especially startle-induced), and ataxia, combined with MRI findings of restricted diffusion in the basal ganglia (caudate and putamen) or cortical ribboning, is highly diagnostic for sCJD.
Incorrect
Correct: Periodic synchronous sharp wave complexes (PSWCs) are the classic EEG finding in sporadic Creutzfeldt-Jakob Disease (sCJD), occurring in approximately two-thirds of patients. The clinical presentation of rapidly progressive dementia, myoclonus (especially startle-induced), and ataxia, combined with MRI findings of restricted diffusion in the basal ganglia (caudate and putamen) or cortical ribboning, is highly diagnostic for sCJD.
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Question 3 of 7
3. Question
In managing Pathophysiology of Psychiatric Disorders, which control most effectively reduces the key risk? A 24-year-old male is brought to the clinic by his family due to a six-month history of hearing voices that others do not hear and believing that the government is monitoring his thoughts through his home appliances. He has become increasingly socially withdrawn and has stopped attending his university classes. To address the underlying pathophysiology of his positive symptoms, which of the following mechanisms should be targeted?
Correct
Correct: The mesolimbic pathway, which projects from the ventral tegmental area to the nucleus accumbens, is primarily associated with the positive symptoms of schizophrenia, such as hallucinations and delusions. According to the dopamine hypothesis, hyperactivity of dopaminergic neurons in this pathway is the key pathophysiological driver of these symptoms. Therefore, the most effective pharmacological control is the antagonism of D2 receptors in this specific pathway, which is the primary mechanism of action for both first-generation and second-generation antipsychotics.
Incorrect
Correct: The mesolimbic pathway, which projects from the ventral tegmental area to the nucleus accumbens, is primarily associated with the positive symptoms of schizophrenia, such as hallucinations and delusions. According to the dopamine hypothesis, hyperactivity of dopaminergic neurons in this pathway is the key pathophysiological driver of these symptoms. Therefore, the most effective pharmacological control is the antagonism of D2 receptors in this specific pathway, which is the primary mechanism of action for both first-generation and second-generation antipsychotics.
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Question 4 of 7
4. Question
How can Psychiatry be most effectively translated into action? A 52-year-old male with a history of schizophrenia and atrial fibrillation is evaluated in the clinic. He was recently started on ziprasidone for worsening hallucinations. His current medications include amiodarone and lisinopril. He reports a recent episode of lightheadedness and palpitations. An ECG shows a corrected QT (QTc) interval of 515 ms. Which of the following is the most appropriate next step in the management of this patient’s psychiatric treatment?
Correct
Correct: Ziprasidone is a second-generation antipsychotic known for its potential to prolong the QT interval. When the QTc exceeds 500 ms, there is a significantly increased risk for polymorphic ventricular tachycardia, specifically Torsades de Pointes. In the setting of symptoms like lightheadedness and a QTc of 515 ms, the most appropriate action is to stop the offending agent (ziprasidone) and monitor the patient with serial ECGs until the interval normalizes to prevent a life-threatening arrhythmia.
Incorrect: Decreasing the dose is unsafe when the QTc is already above the 500 ms threshold and the patient is symptomatic. Discontinuing amiodarone is not the primary solution because amiodarone has an exceptionally long half-life (up to 100 days), meaning its removal would not acutely resolve the risk, and it is necessary for his rhythm control. Thioridazine is a first-generation antipsychotic with a boxed warning for significant QTc prolongation, making it a dangerous alternative that would likely worsen the cardiac risk.
Takeaway: Antipsychotic-induced QTc prolongation exceeding 500 ms or associated with symptoms requires immediate discontinuation of the offending drug to prevent Torsades de Pointes.
Incorrect
Correct: Ziprasidone is a second-generation antipsychotic known for its potential to prolong the QT interval. When the QTc exceeds 500 ms, there is a significantly increased risk for polymorphic ventricular tachycardia, specifically Torsades de Pointes. In the setting of symptoms like lightheadedness and a QTc of 515 ms, the most appropriate action is to stop the offending agent (ziprasidone) and monitor the patient with serial ECGs until the interval normalizes to prevent a life-threatening arrhythmia.
Incorrect: Decreasing the dose is unsafe when the QTc is already above the 500 ms threshold and the patient is symptomatic. Discontinuing amiodarone is not the primary solution because amiodarone has an exceptionally long half-life (up to 100 days), meaning its removal would not acutely resolve the risk, and it is necessary for his rhythm control. Thioridazine is a first-generation antipsychotic with a boxed warning for significant QTc prolongation, making it a dangerous alternative that would likely worsen the cardiac risk.
Takeaway: Antipsychotic-induced QTc prolongation exceeding 500 ms or associated with symptoms requires immediate discontinuation of the offending drug to prevent Torsades de Pointes.
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Question 5 of 7
5. Question
If concerns emerge regarding Diagnosis of Infectious Diseases (Cultures, Serology, PCR), what is the recommended course of action for a 28-year-old male who presents with a 5-day history of fever, sore throat, malaise, and a generalized maculopapular rash? He reports unprotected sexual intercourse with a new partner 2 weeks ago. Physical exam shows cervical lymphadenopathy and oropharyngeal erythema without exudates. Laboratory studies show a mild leukopenia and thrombocytopenia.
Correct
Correct: The patient’s presentation is highly suggestive of acute HIV infection (mononucleosis-like syndrome). The current diagnostic standard is the fourth-generation HIV-1/2 antigen/antibody immunoassay, which detects both the p24 antigen and HIV antibodies. The p24 antigen becomes detectable approximately 15 to 20 days after infection, which is earlier than antibodies. However, if the immunoassay is negative or indeterminate but clinical suspicion remains high (especially during the early window period), a nucleic acid test (NAT) such as HIV-1 RNA RT-PCR is the recommended next step to detect viral load directly.
Incorrect: A heterophile antibody test is used to diagnose infectious mononucleosis (EBV), which is a common differential but does not address the high-risk exposure for HIV. Antibody-only ELISA (third-generation) has a longer window period and is less sensitive for acute infection compared to fourth-generation tests. Western blot is no longer the preferred confirmatory test in the modern CDC diagnostic algorithm and is frequently negative during the acute phase of infection. Starting antiretroviral therapy without a confirmed diagnosis is not standard practice in this clinical scenario.
Takeaway: Acute HIV infection should be diagnosed using a fourth-generation antigen/antibody immunoassay, followed by HIV-1 RNA PCR if the initial screen is negative but clinical suspicion is high.
Incorrect
Correct: The patient’s presentation is highly suggestive of acute HIV infection (mononucleosis-like syndrome). The current diagnostic standard is the fourth-generation HIV-1/2 antigen/antibody immunoassay, which detects both the p24 antigen and HIV antibodies. The p24 antigen becomes detectable approximately 15 to 20 days after infection, which is earlier than antibodies. However, if the immunoassay is negative or indeterminate but clinical suspicion remains high (especially during the early window period), a nucleic acid test (NAT) such as HIV-1 RNA RT-PCR is the recommended next step to detect viral load directly.
Incorrect: A heterophile antibody test is used to diagnose infectious mononucleosis (EBV), which is a common differential but does not address the high-risk exposure for HIV. Antibody-only ELISA (third-generation) has a longer window period and is less sensitive for acute infection compared to fourth-generation tests. Western blot is no longer the preferred confirmatory test in the modern CDC diagnostic algorithm and is frequently negative during the acute phase of infection. Starting antiretroviral therapy without a confirmed diagnosis is not standard practice in this clinical scenario.
Takeaway: Acute HIV infection should be diagnosed using a fourth-generation antigen/antibody immunoassay, followed by HIV-1 RNA PCR if the initial screen is negative but clinical suspicion is high.
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Question 6 of 7
6. Question
The operations team at an investment firm has encountered an exception involving Management of Parathyroid Disorders during regulatory inspection. They report that a 62-year-old woman is evaluated for an incidental finding of elevated calcium. Laboratory results show a serum calcium of 10.9 mg/dL (normal 8.5-10.5 mg/dL) and a parathyroid hormone level of 82 pg/mL (normal 10-65 pg/mL). She has no history of nephrolithiasis or fractures. Her 24-hour urinary calcium excretion is 220 mg. A dual-energy X-ray absorptiometry (DEXA) scan reveals a T-score of -1.5 at the lumbar spine and -1.3 at the femoral neck. Her serum creatinine is 0.7 mg/dL. Which of the following is the most appropriate next step in management?
Correct
Correct: The patient has asymptomatic primary hyperparathyroidism (PHPT) and does not meet the established criteria for surgical intervention. Guidelines for parathyroidectomy in asymptomatic patients include: serum calcium 1.0 mg/dL or more above the upper limit of normal, age less than 50 years, bone mineral density T-score of -2.5 or less at any site, or evidence of renal complications such as a creatinine clearance less than 60 mL/min, 24-hour urine calcium greater than 400 mg/day, or nephrolithiasis. Since this patient is 62, has a calcium level only 0.4 mg/dL above normal, has osteopenia rather than osteoporosis, and has normal renal function, the most appropriate management is conservative observation with annual monitoring of calcium and creatinine.
Incorrect: Referral for parathyroidectomy is incorrect because the patient does not meet the clinical thresholds for surgery in asymptomatic PHPT. Sestamibi scintigraphy is incorrect because it is a preoperative localization tool used only after the decision for surgery has been made; it is not used for diagnosis or to determine the need for treatment. Initiation of cinacalcet therapy is incorrect as this calcimimetic is typically reserved for patients with symptomatic or severe hypercalcemia who are unable to undergo surgery, or for those with parathyroid carcinoma.
Takeaway: Asymptomatic primary hyperparathyroidism is managed with annual monitoring unless the patient meets specific criteria for surgery, such as age under 50, significant hypercalcemia, or evidence of end-organ damage like osteoporosis or renal dysfunction.
Incorrect
Correct: The patient has asymptomatic primary hyperparathyroidism (PHPT) and does not meet the established criteria for surgical intervention. Guidelines for parathyroidectomy in asymptomatic patients include: serum calcium 1.0 mg/dL or more above the upper limit of normal, age less than 50 years, bone mineral density T-score of -2.5 or less at any site, or evidence of renal complications such as a creatinine clearance less than 60 mL/min, 24-hour urine calcium greater than 400 mg/day, or nephrolithiasis. Since this patient is 62, has a calcium level only 0.4 mg/dL above normal, has osteopenia rather than osteoporosis, and has normal renal function, the most appropriate management is conservative observation with annual monitoring of calcium and creatinine.
Incorrect: Referral for parathyroidectomy is incorrect because the patient does not meet the clinical thresholds for surgery in asymptomatic PHPT. Sestamibi scintigraphy is incorrect because it is a preoperative localization tool used only after the decision for surgery has been made; it is not used for diagnosis or to determine the need for treatment. Initiation of cinacalcet therapy is incorrect as this calcimimetic is typically reserved for patients with symptomatic or severe hypercalcemia who are unable to undergo surgery, or for those with parathyroid carcinoma.
Takeaway: Asymptomatic primary hyperparathyroidism is managed with annual monitoring unless the patient meets specific criteria for surgery, such as age under 50, significant hypercalcemia, or evidence of end-organ damage like osteoporosis or renal dysfunction.
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Question 7 of 7
7. Question
What factors should be weighed when choosing between alternatives for Management of Anemias (Iron Deficiency, B12 Deficiency, Folate Deficiency, Hemolytic)? A 68-year-old man presents to the clinic with a 4-month history of progressive fatigue and a “pins and needles” sensation in his feet. He underwent a Roux-en-Y gastric bypass ten years ago for morbid obesity. Physical examination reveals pallor and decreased vibration sense in the lower extremities. Laboratory studies show a hemoglobin of 9.2 g/dL and a mean corpuscular volume (MCV) of 114 fL. A peripheral blood smear demonstrates hypersegmented neutrophils. Which of the following is the most appropriate next step in management to prevent irreversible complications?
Correct
Correct: The patient presents with macrocytic anemia (MCV > 100 fL) and neurologic symptoms (paresthesia, loss of vibration sense), which is classic for Vitamin B12 deficiency. His history of gastric bypass surgery is a significant risk factor because it bypasses the stomach and proximal duodenum, leading to a lack of intrinsic factor and gastric acid necessary for B12 absorption. Measuring methylmalonic acid (MMA) is useful because it is specifically elevated in B12 deficiency but not in folate deficiency. Parenteral (intramuscular) B12 is the preferred treatment for patients with significant malabsorption or neurologic symptoms to ensure adequate levels and prevent permanent spinal cord damage (subacute combined degeneration).
Incorrect: Initiating folic acid without checking B12 levels is dangerous because folate can correct the hematologic abnormalities (the anemia and hypersegmented neutrophils) but will not treat the underlying B12 deficiency, allowing the neurologic damage to progress and become irreversible. Oral iron supplementation is the treatment for microcytic anemia, not macrocytic anemia with neurologic signs. Corticosteroids and the Coombs test are used for autoimmune hemolytic anemia, which typically presents with jaundice, elevated lactate dehydrogenase, and low haptoglobin, rather than the subacute neurologic deficits seen here.
Takeaway: In macrocytic anemia with neurologic symptoms, Vitamin B12 deficiency must be identified and treated specifically because folate supplementation can mask the hematologic signs while allowing irreversible neurologic progression.
Incorrect
Correct: The patient presents with macrocytic anemia (MCV > 100 fL) and neurologic symptoms (paresthesia, loss of vibration sense), which is classic for Vitamin B12 deficiency. His history of gastric bypass surgery is a significant risk factor because it bypasses the stomach and proximal duodenum, leading to a lack of intrinsic factor and gastric acid necessary for B12 absorption. Measuring methylmalonic acid (MMA) is useful because it is specifically elevated in B12 deficiency but not in folate deficiency. Parenteral (intramuscular) B12 is the preferred treatment for patients with significant malabsorption or neurologic symptoms to ensure adequate levels and prevent permanent spinal cord damage (subacute combined degeneration).
Incorrect: Initiating folic acid without checking B12 levels is dangerous because folate can correct the hematologic abnormalities (the anemia and hypersegmented neutrophils) but will not treat the underlying B12 deficiency, allowing the neurologic damage to progress and become irreversible. Oral iron supplementation is the treatment for microcytic anemia, not macrocytic anemia with neurologic signs. Corticosteroids and the Coombs test are used for autoimmune hemolytic anemia, which typically presents with jaundice, elevated lactate dehydrogenase, and low haptoglobin, rather than the subacute neurologic deficits seen here.
Takeaway: In macrocytic anemia with neurologic symptoms, Vitamin B12 deficiency must be identified and treated specifically because folate supplementation can mask the hematologic signs while allowing irreversible neurologic progression.
