Suggested scheme for calcium supplementation in pregnant women
Dosage ~ 1.5–2.0 g elemental calcium/day
Frequency ~ Daily, with the total daily dosage divided into three doses (preferably taken at mealtimes)
Duration ~ From 20 weeks’ gestation until the end of pregnancy
Target group ~ All pregnant women, particularly those at higher risk of gestational hypertension
Settings ~ Areas with low calcium intake
(1 g of elemental calcium equals 2.5 g of calcium carbonate or 4 g of calcium citrate)
Q 1. An 86-year-old woman with chronic obstructive pulmonary disease (COPD), congestive heart failure, and insulin-requiring type 2 diabetes mellitus is admitted to the intensive care unit with an exacerbation of her COPD. She is intubated and treated with glucocorticoids and nebulized albuterol. She is also continued on her glargine insulin, aspirin, pravastatin, furosemide, enalapril, and metoprolol. On hospital day 8, parenteral nutrition is begun via catheter in the subclavian vein. Her insulin requirements increase on hospital day 9 due to episodes of hyperglycemia. On hospital day 10, she develops rales and an increasing oxygen requirement. A chest radiograph shows bilateral pulmonary edema. Laboratory data show hypokalemia, hypomagnesemia, and hypophosphatemia and a normal creatinine. Her weight has increased by 3 kg since admission. Urine sodium is <10 meq/dL. All of the following changes in her nutritional regimen will improve her volume status except
A.combination of glucose and fat in the parenteral nutrition mixture
B. decreasing the sodium content of the mixture to <40 meq per day
C.increasing the protein content of the parenteral nutrition mixture
D.reducing the overall glucose content
ANSWER . C
Q 2. A new study has been published showing a benefit of 25 mg/day of vitamin X. The recommended estimated average requirement of vitamin X is 10 mg/day, 2 standard deviations below the amount published in the study. The tolerable upper limit of vitamin X is unknown. Your patient wants to know if it is safe to consume 25 mg/day of vitamin X. Which is the most appropriate answer?
A.Two standard deviations above the estimated average requirement defines the tolerable upper limit.
B. 25 mg/day is probably too much vitamin X in 1 day.
C.25 mg/day is statistically in a safe range of the estimated average requirement.
D.The study was not designed to assess safety and therefore should not influence practice
ANSWER . C
Q 3. An elevation in which of the following hormones is consistent with the effects of anorexia nervosa?
A.Cortisol
B. Gonadotropin-releasing hormone (GnRH)
C.Leptin
D.Thyroxine (T4)
E. Thyroid-stimulating hormone (TSH)
ANSWER. A
Q 4. Which of the following statements regarding anorexia nervosa (AN) and bulimia nervosa (BN) is true?
A.Patients with the purging subtype of BN tend to be heavier than those with the nonpurging subtype.
B. Patients with the restricting subtype of AN are more emotionally labile than those with the purging subtype.
C.Patients with the restricting subtype of AN are more likely to abuse illicit drugs than those with the purging subtype.
D.The mortality of BN is lower than that of AN
ANSWER . D
Q 5. You are seeing a pediatric patient from Djibouti in consultation who was admitted with a constellation of symptoms including diarrhea, alopecia, muscle wasting, depression, and a rash involving the face, extremities, and perineum. The child has hypogonadism and dwarfism. You astutely make the diagnosis of zinc deficiency, and laboratory test confirm this (zinc level <70 µL/dL). What other clinical findings is this patient likely to manifest?
A.Dissecting aortic aneurysm
B. Hypochromic anemia
C.Hypoglycemia
D.Hypopigmented hair
E. Macrocytosis
ANSWER. D
Q 6. You are rotating on a medical trip to impoverished areas of China. You are examining an 8-year-old child whose mother complains of him being clumsy and sickly. He has had many episodes of diarrheal illnesses and pneumonia. His “clumsiness” is most pronounced in the evening when he has to go outside and do his chores. On examination, you notice conjunctival dryness with white patches of keratinized epithelium on the sclera. What is the cause of this child’s symptoms?
A.Autoimmune neutropenia
B. Congenital rubella
C.Spinocerebellar ataxia (SCA) type 1
D.Vitamin A deficiency
E. Vitamin B1 deficiency
ANSWER. D
Q 7. After being stranded alone in the mountains for 8 days, a 26-year-old hiker is brought to the hospital for evaluation of a right femoral neck fracture. He has not had anything to eat or drink for the past 6 days. Vital signs are within normal limits. Weight is 79.5 kg, which is 1.8 kg less than he weighed 6 months ago. Laboratory data show a creatinine of 2.5 mg/dL, blood urea nitrogen of 52 mg/dL, glucose 96 mg/dL, albumin 4.1 mg/dL, chloride 105 meq/L, and ferritin on 173 ng/mL. Which of the following statements is true regarding his risk of malnourishment?
A.He has protein-calorie malnutrition due to the rate of weight loss.
B. He has protein-calorie malnutrition due to his elevated ferritin.
C.He is at risk, but a normal individual can tolerate 7 days of starvation.
D.He is not malnourished because he is not hypoglycemic after 6 days of no food or water
ANSWER. C
Q 8. You are doing rounds in the intensive care unit on an intubated patient who is recovering from a stroke and has diabetic gastroparesis. When suctioning the patient in the morning, she coughs profusely, with thick green secretions. You are concerned about the possibility of aspiration pneumonia. All of the following measures are useful in preventing aspiration pneumonia in an intubated patientexcept
A.combined enteral and parenteral nutrition
B. elevating the head of the bed to 30°
C.physician-directed methods for formula advancement
D.post-ligament of Treitz feeding
ANSWER. C
Q 9. Which of these features represents a critical distinction between anorexia nervosa and bulimia nervosa?
A.Binge eating
B. Electrolyte abnormalities
C.Self-induced vomiting
D.Underweight
ANSWER. D
Q 10. You are counseling a patient who is recovering from long-standing anorexia nervosa (AN). She is a 22-yearold woman who suffered the effects of AN for 8 years with a nadir body mass index of 17 kg/m2 and many laboratory abnormalities during that time. Which of the following characteristics of AN is least likely to improve despite successful lasting treatment of the disorder?
A.Amenorrhea
B. Delayed gastric emptying
C.Lanugo
D.Low bone mass
E. Salivary gland enlargement
ANSWER. D
Q1 A 19-year-old woman with anorexia nervosa undergoes surgery for acute appendicitis. The postoperative course is complicated by acute respiratory distress syndrome, and she remains intubated for 10 days. She develops wound dehiscence on postoperative day 10. Laboratory data show a white blood cell count of 4000/ µL, hematocrit 35%, albumin 2.1 g/dL, total protein 5.8 g/dL, transferrin 54 mg/dL, and iron-binding capacity 88 mg/dL. You are considering initiating nutritional therapy on hospital day 11. Which of the following is true regarding the etiology and treatment of malnutrition in this patient? A.She has marasmus, and nutritional support should be started slowly. B. She has kwashiorkor, and nutritional support should be aggressive. C.She has marasmic kwashiorkor, kwashiorkor predominant, and nutritional support should be aggressive. D.She has marasmic kwashiorkor, marasmus predominant, and nutritional support should be slow
Ans is c
Q2 You are seeing a patient in follow-up 2 weeks after hospitalization. The patient is recovering from nosocomial pneumonia due to a resistant Pseudomonas spp. His hospital course was complicated by a deep venous thrombosis. The patient is currently on IV piperacillin/ tazobactam and tobramycin via a tunneled catheter, warfarin, lisinopril, hydrochlorothiazide, and metoprolol. Laboratory data this morning show an INR of 8.2. At hospital discharge his INR was stable at 2.5. He has no history of liver disease. What is the most likely cause of the elevated INR?
A.The patient has inadvertently overdosed.
B. The patient has developed a recurrent deep venous thrombosis, which has affected the laboratory data.
C.The patient is deficient in vitamin K and needs supplementation.
D.The warfarin prescription was written incorrectly at the time of discharge.
Ans is c
Q 3 A 51-year-old alcoholic man is admitted to the hospital for upper gastrointestinal bleeding. From further history and physical examination, it becomes apparent that his bleeding is from gingival membranes. He is intoxicated and complains of fatigue. Reviewing his chart you f ind that he had a hemarthrosis evacuated 6 months ago and has been lost to follow-up since then. He takes no medications. Laboratory data show platelets of 250,000, INR of 0.9. He has a diffuse hemorrhagic eruption on his legs . What is the recommended treatment for this patient’s underlying disorder?
A.Folate
B. Niacin
C.Thiamine
D.Vitamin C
E. Vitamin K
Ans is D
Q 4 While working in the intensive care unit, you admit a 57-year-old woman with acute pancreatitis and oliguric renal failure. Respiratory rate is 26 breaths/min, heart rate is 125 beats/min, and temperature is 37.2°C. Physical examination shows marked abdominal tenderness with normoactive bowel sounds. A CT scan shows an inflamed pancreas without hemorrhage. You calculate her APACHE-I score to be 28. When deciding on when to initiate nutritional replacement in this patient, which of the following statements is true?
A.Bowel rest is the cornerstone of treatment for acute pancreatitis.
B. Administering parenteral nutrition within 24 h will decrease the risk of infection and mortality.
C.Enteral feeding supports gut function by secretion of gastrointestinal hormones that stimulate gut trophic activity.
D.In severe systemic response to inflammation, feeding can be withheld initially because the patient is likely to have adequate, spontaneous oral intake in the first 7 days
Ans is C
Q 5 The resting energy expenditure is a rough estimate of total caloric needs in a state of energy balance. Of these two patients with stable weights, which person has the highest resting energy expenditure (REE): Patient A, a 40-year-old man who weighs 90 kg and is sedentary, or Patient B, a 40year-old man who weighs 70 kg and is very active?
A.40-year-old man who weighs 90 kg and is sedentary
B. 40-year-old man who weighs 70 kg and is very active
C.REE is the same
D.Not enough information given to calculate the REE
Ans is B
Q 6 All of the following clinical features are common in patients with anorexia nervosa except
A.Avoid food-related occupations
B. Distorted body image
C.Engage in binge eating
D.Exercise extensively
E. Rarely complain of hunger
F. Socially withdrawn
Ans is A
Q 7 You diagnose anorexia nervosa in one of your new clinic patients. When coordinating a treatment program with the psychiatrist, what characteristics should prompt consideration for inpatient treatment instead of scheduling an outpatient assessment?
A.Amenorrhea
B. Exaggeration of food intake
C.Irrational fear of gaining weight
D.Purging behavior
E. Weight <75% of expected body weight
Ans is E
Q 8 It is hospital day 16 for a 49-year-old homeless patient who is recovering from alcohol withdrawal and delirium tremens. She spent the first 9 days of this hospitalization in the intensive care unit but is now awake, alert, and conversant. She has a healing decubitus ulcer, and her body mass index is 19 kg/m2. Laboratory data show an albumin of 2.9 g/dL and a prothrombin time of 18 s (normal range). Is this patient malnourished?
A.Cannot be determined, need more information.
B. No. Given her heavy alcohol intake, her prothrombin time is expected to be delayed.
C.No. She has a low resting energy expenditure and her intact mental state argues against malnutrition.
D.Yes, this degree of hypoalbuminemia is uncommon in cirrhosis and is likely due to malnutrition
Ans is A
Q 9 A 42-year-old male patient wants your opinion about vitamin E supplements. He has read that taking high doses of vitamin E can improve his sexual performance and slow the aging process. He is not vitamin E deficient. You explain to him that these claims are not based on good evidence. What other potential side effect should he be concerned about?
A.Deep venous thrombosis
B. Hemorrhage
C. Night blindness
D.Peripheral neuropathy
E. Retinopathy
Ans is B
Q 10 Doing rounds in the oncology center, you are see a patient with carcinoid syndrome. Due to the increased conversion of tryptophan to serotonin, this patient has developed niacin deficiency. All of the following are components of the pellagra syndrome except
A.dermatitis
B. dementia
C.diarrhea
D.dyslipidemia
E. glossitis
Ans is D
