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Old 10-13-2012
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Arrow Billy Step 1 Questions # 25

A 70-year-old woman comes to the physician because of an episode 2 days earlier during which she lost
consciousness for several minutes. Afterward, she had difficulty speaking clearly and had paresthesias in the lower right
arm that persisted for several minutes. On physical examination, there is 4/5 motor strength in the right upper extremity
and decreased sensation to pinprick on the ulnar aspect of the lower right arm and hand. There are bilateral carotid bruits.
A lumbar puncture is performed with normal opening pressure. Laboratory studies on 10 mL of clear, colorless CSF show
two mononuclear WBCs/mm3, no RBCs, protein concentration of 40 mg/dL, and glucose concentration of 70 mg/dL. The
serum glucose concentration is 95 mg/dL. CT scan of the head shows no intracranial hemorrhage, but there is a slight
midline shift; MRI of the brain shows an ill-defined area of edema near the left internal capsule. Which of the following
laboratory findings is most suggestive of the risk factor for this patient's disease?


□ (A) Positive antiphospholipid antibody test result
□ (B) Blood culture positive for Streptococcus pneumoniae
□ (C) Elevated serum concentration of very long chain fatty acids
□ (D) Hyperammonemia
□ (E) Hypercholesterolemia
□ (F) Oligoclonal bands on CSF electrophoresis
□ (G) Positive ANA test result
□ (H) Positive serologic test result for syphilis
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E. Hypercholesterolaemia
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E) hypercholesterolemia
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Will go with E!
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E.hypercholesterolemia..carotid bruits b/l..TIA atherosclerotic changes ..
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Correct Answer E is correct

This patient has findings consistent with an acute cerebral infarction from obstruction of blood flow causing focal
cerebral ischemia. After 2 days, there would be some cerebral softening and edema with ischemia of neurons, but little
else. Hypercholesterolemia is a risk factor for atherosclerosis, which is the major cause of thrombotic cerebral arterial
occlusions. The antiphospholipid syndrome can produce thrombotic and embolic disease, but an embolic “stroke” is
typically hemorrhagic, and antiphospholipid syndrome is uncommon at this age. A positive blood culture suggests sepsis
with the possibility of meningitis or cerebral abscess formation, but abscesses typically have ring enhancement on CT
scans. Elevated serum levels of very long chain fatty acids are present in patients with adrenoleukodystrophy, a rare
disorder that leads to myelin loss at an early age. Hyperammonemia occurs in hepatic encephalopathy with liver failure; it
produces Alzheimer type II gliosis, but no focal or gross lesions. Oligoclonal bands are characteristic of multiple sclerosis,
which typically has an onset in youth or middle age, with formation of plaques of demyelination in white matter. The ANA
test result is positive in many autoimmune diseases and may be accompanied by vasculitis, which can produce scattered
areas of ischemic injury, resulting in a clinical picture of encephalopathy. Neurosyphilis is now rare; it does not produce
focal ischemic lesions.
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