A 36-year-old woman complains to her physician of chronic fatigue.

On physical
examination, the patient is noted to have generalized pallor and koilonychia
(concavity of the outer nail surface).
Question 1 of 8

The combination of generalized pallor and chronic fatigue specifically

suggests which of the following general problems?

/ A. Anemia
/ B. Cancer
/ C. Granulomatous disease
/ D. Heart failure
/ E. Respiratory failure

Explanation - Q: 1.1 Close

The correct answer is A. This combination specifically suggests that anemia

is present, and should trigger at least a screening evaluation for this
condition. The other conditions listed in the choices may or may not also be
present, either incidentally or as a complication of or cause of the anemia.

Question 2 of 8

On further questioning, the patient notes that she has had a craving for ice lately,
often keeping a cup of ice handy to "chew on." Her hematocrit
is 25%. Which of the following is the most likely diagnosis?
/ A. Folate deficiency
/ B. Iron deficiency
/ C. Malaria
/ D. Sickle cell disease
/ E. Vitamin B12 deficiency

Explanation - Q: 1.2 Close

The correct answer is B. One of the more helpful clues to look for when
questioning people about a possible anemia is pagophagia (craving ice to
suck or chew), which is seen in up to one half of the patients with moderate
iron deficiency anemia. This may occur because the ice is soothing to these
patient's mouths, which are often irritated. Cheilosis (dry scaling and fissuring
of the lips), glossitis (inflammation of the tongue), and koilonychia (nails
whose outer surface is concave) may also be present. Pica refers to eating of
non-food substances such as dirt or paint. Pagophagia is surprisingly specific
for iron deficiency anemia, and is not seen with unusual frequency in the
other forms of anemia listed. While mild iron deficiency anemia is sometimes
 normocellular, moderate to severe iron deficiency usually is associated with
many hypochromic microcytes. None of the other disorders cause a craving
for ice.

Question 3 of 8

Examination of a peripheral blood smear would most likely reveal which of the
following?
/ A. Microcytes
/ B. Schistocytes
/ C. Sickled cells
/ D. Spherocytes
/ E. Spur cells

Explanation - Q: 1.3 Close

The correct answer is A. While mild iron deficiency anemia is sometimes

normocellular, moderate to severe iron deficiency anemia usually shows
many hypochromic microcytes.

Schistocytes (choice B) are seen in traumatic hemolytic anemia and

immunohemolytic anemia.

Sickled cells (choice C) are seen in the various sickle cell syndromes.

Spherocytes (choice D) are seen in hereditary spherocytosis.

Spur cells (choice E) are seen in spur cell anemia and paroxysmal nocturnal
hemoglobinuria.

Question 4 of 8
Which of the following conditions would be most likely to predispose for this
patient's disorde
/ A. Dermoid cyst of the ovary
/ B. E.Coli bladder infection
/ C. Intraductal carcinoma of the breast
/ D. Menorrhagia
/ E. Squamous cell carcinoma of the skin

Explanation - Q: 1.4 Close

The correct answer is D. Iron deficiency anemia in this country is most often
seen in the setting of chronic blood loss. Menorrhagia, or prolonged, heavy
menstrual flow, and occult gastrointestinal bleeding are the most commonly
encountered predisposing conditions. The other conditions listed in the
 choices are distracters that do not have a particular tendency to cause
chronic bleeding

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Question 5 of 8
The deficient substance in this patient is typically absorbed at which of the
following sites?
/ A. Colon
/ B. Distal small bowel
/ C. Esophagus
/ D. Proximal small bowel
/ E. Stomach

Explanation - Q: 1.5 Close

The correct answer is D. The proximal small bowel is the site of absorption
of many vitamins and minerals, including iron. The absorptive epithelial cells
of the proximal small bowel alter iron absorption to match the body losses,
and contain considerable intracellular iron in patients with adequate iron. In
iron deficient subjects (and also in hemachromatosis, possibly contributing to
the pathology), the stainable iron stores in these cells are nearly absent. The
iron that is absorbed can be in the forms of heme, ferric iron, and ferrous iron
(using different pathways). Unlike with many substances, the entire control of
body levels is at the stage of absorption, since there is no physiologic
mechanism other than bleeding for removal of large amounts of iron from the
body.

The colon (choice A) primarily absorbs water and electrolytes.

The distal small bowel (choice B) notably absorbs vitamin B12.

The esophagus (choice C) and stomach (choice E) are not absorptive sites.

Question 6 of 8
The substance deficient in this patient is typically delivered to non-intestinal cells
by which of the following?
/ A. Ceruloplasmin
/ B. Erythropoietin
/ C. Hematoxylin
/ D. Hemosiderin
/ E. Transferrin

Explanation - Q: 1.6 Close

The correct answer is E. The iron which is delivered to other tissues is

primarily delivered bound to transferrin. The transferrin-iron complex enters
 the cell within an endosome which forms after the complex binds to a
receptor on the cell surface. Subsequent acidification of the endosome
contents releases the iron so that it can be transported across the endosome
membrane and into the cytoplasm of the cell.

Ceruloplasmin (choice A) is a copper-transporting molecule.

Erythropoietin (choice B) is a hormone that stimulates erythrocyte

production.

Hematoxylin (choice C) is a commonly used stain in histology.

Hemosiderin (choice D) is a common storage form of iron in tissues.

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Question 7 of 8
The patient is prescribed supplementation for her deficiency. Her 3-year-old child
finds the bottle of pills, and ingests some of them. If the child
ingested enough to become clinically poisoned, which of the following symptoms
would most likely be seen earliest in the course?
/ A. Hepatic cirrhosis
/ B. Intestinal obstruction
/ C. Seizures
/ D. Shock
/ E. Vomiting and explosive diarrhea

Explanation - Q: 1.7 Close

The correct answer is E. Poisoning with iron supplements is always a

potential problem in households with young children and a mother with iron-
deficiency anemia, and the problem is exacerbated by the fact that some of
the commonly available iron supplements are small round pills with bright red
coating that very much resemble small candies such as M&M's and Skittles.
Fortunately, most commonly the poisoning is mild, although fatal cases of
poisoning have been encountered with doses as small as 130 mg of
elemental iron. The advice to parents about keeping the medication well out
of reach of little hands is obvious, but should be emphasized by the clinician
at the time of prescribing the supplementation.

The clinical course following iron poisoning has been divided into four stages.
Stage I occurs within 6 hours, and can be characterized by vomiting,
hematemesis, explosive diarrhea, irritability, and abdominal pain (choice E).
The presence of shock (choice D) or coma within the first 6 hours is
considered a grave prognostic sign. Other clinical features that can be
present in stage I if iron levels are particularly high include tachypnea,
tachycardia, hypotension, and metabolic acidosis. Stage II occurs 6-24 hours
 after ingestion and is characterized by a latent period of apparent (but
deceptive) clinical improvement. Stage III, which typically begins 12 to 48
hours after ingestion is a life-threatening stage characterized by liver damage,
shock (choice D), hypoperfusion, seizures (choice C), hypoglycemia, fever,
ECG changes, bleeding disorders, lethargy, coma, acidosis, and sometimes
death. Stage IV which occurs 2 to 5 weeks later in those patients that develop
late complications may manifest with gastrointestinal obstruction (choice B),
hepatic cirrhosis (choice A), or permanent CNS damage.

Question 8 of 8
Which of the following is the most appropriate pharmacotherapy for her child?
/ A. Deferoxamine
/ B. Dimercaprol
/ C. Edetate (EDTA)
/ D. Penicillamine
/ E. Protamine
/ F. Succimer

Explanation - Q: 1.8 Close

The correct answer is A. Deferoxamine is an iron chelator that binds the

absorbed iron, but not the iron in iron-carrying proteins such as hemoglobin,
myoglobin, hemosiderin, or ferritin. It is given parenterally; IV is generally the
preferred route.

Dimercaprol (choice B) is a chelator used for arsenic and mercury poisoning.

Edetate (EDTA) (choice C) is a chelator used for lead poisoning.

Penicillamine (choice D) is a chelator used for copper poisoning (and Wilson

disease). It is sometimes used for adjunctive therapy for gold, arsenic, and
lead poisoning.

Protamine (choice E) is used for heparin overdose.

Succimer (choice F) is used in the treatment of lead poisoning; it can be

given orally. It can also be used for arsenic and mercury poisoning if used
soon after exposure.

A 52-year-old woman presents with complaints of fatigue, mood changes, diffuse

joint aches, and dry skin. She also states that she has
gained about 10 pounds in the last few months, without any change in appetite.
Her last menstrual period was 2 months ago and she has been
having very irregular menses in the last 8 months. Review of systems is
significant for constipation, but she denies hot flashes or insomnia.
Physical examination is significant for an obese woman who appears tired. An
asymmetric goiter is noted, but no bruit is appreciated. Her
joint examination is unremarkable; there is no swelling/redness and no trigger
points are painful to palpation. Labs were sent.
Question 1 of 6
Which of the following is the most likely diagnosis?
/ A. Depression
/ B. Diabetes mellitus
/ C. Fibromyalgia
/ D. Hypothyroidism
/ E. Perimenopause

Explanation - Q: 2.1 Close

The correct answer is D. Any patient with symptoms of fatigue/dry

skin/weight loss/ constipation coupled with the presence of a goiter should be
investigated for hypothyroidism. About 8% of the population over the age of
65 has hypothyroidism. It can be diagnosed by a high serum TSH.

Depression (choice A) can account for most the above symptoms but
medical conditions such as hypothyroidism, anemia, and diabetes should be
excluded first.

Diabetes (choice B) can produce multiple symptoms and should be included

in any workup of fatigue/weight gain, etc.

Fibromyalgia (choice C) is a chronic pain syndrome characterized by

difficulty sleeping and having at least 11 out of 16 specific tender points
designated by the American College of Rheumatology. Hypothyroidism and
fibromyalgia can coexist and the former is always included in the initial
workup of the latter.

Perimenopausal women (choice E) can have similar complaints as those

with hypothyroidism but they will all have hot flashes. Hypothyroid patients
are actually cold intolerant.

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Question 2 of 6
The most common cause for this patient's condition is associated with which of
the following?
/ A. High antimitochondrial antibodies
/ B. High antithyroid peroxidase (anti-TPO) antibodies
/ C. High RAIU
/ D. Low anti-smooth muscle antibodies
/ E. Low antithyroglobulin antibodies

Explanation - Q: 2.2 Close

The correct answer is B. Hashimoto thyroiditis is the most common cause of

hypothyroidism. It is believed to be a result of an autoimmune response (T
cell-mediated hypersensitivity) against the thyroid. Clinically, it is associated
with an asymmetric nodular goiter with a high TSH and low T4. Like Graves'
disease, it has a strong autoimmune association and has high titers of
antithyroid peroxidase antibodies and high antithyroglobulin antibodies
(compare to choice E).

Antimitochondrial antibodies (choice A) are associated with primary biliary

cirrhosis.

A high RAIU (radioactive iodine uptake scan, choice C) is only seen in

patients who are hyperthyroid and is not used to diagnosis hypothyroidism.

Anti-smooth muscle antibodies (choice D) are associated with autoimmune

hepatitis.

Question 3 of 6

Which of the following would a thyroid biopsy most likely show?

/ A. Thyroid follicle destruction and fibrosis by macrophages and giant cells
/ B. Thyroid follicle destruction by lymphocytes; presence of Hurthle cells
/ C. Thyroid follicles with finger-Iike growths and "Orphan Annie eyes"
/ D. Thyroid follicles with large colloid and flattened epithelial cells
/ E. Thyroid follicles with scant colloid and hyperplastic epithelial cells

Explanation - Q: 2.3 Close

The correct answer is B. Thyroid follicular infiltration by lymphocytes along

with the presence of Hurthle cells is characteristic of Hashimoto disease.
Hurthle cells are the surviving follicular epithelial cells that are transformed
into large cells with abundant pink cytoplasm.

Thyroid follicle destruction by macrophages and giant cells (choice A) is

found in subacute thyroiditis.

Finger-like growths or papillary formation of the thyroid follicles (choice C) is

characteristic of papillary carcinoma of the thyroid; Orphan Annie eyes (clear
 nuclei in the follicular epithelial cells) are pathognomonic.

Thyroid follicles with large colloid centers (choice D) are typical for toxic
multinodular goiter.

Initially, the euthyroid multinodular goiter can also have findings similar to
Graves' disease, with hyperplastic epithelial cells with scant central colloids
(choice E).

Question 4 of 6
Which of the following is the most appropriate pharmacotherapy?
/ A. Amitriptyline
/ B. Aspirin or NSAIDS
/ C. Conjugated estrogen and progesterone
/ D. Levothyroxine
/ E. Selective serotonin reuptake inhibitors (SSRI)

Explanation - Q: 2.4 Close

The correct answer is D. Levothyroxine (T4) is the most commonly used

form of the thyroid hormone for supplement. It is converted to T3 (active form)
in the peripheral tissues and has a half-life of 7 days.

Amitriptyline (choice A), a tricyclic antidepressant, is used to correct the

disturbed stage 4 sleep in patients with fibromyalgia.

Aspirin/NSAIDS (choice B) is used to treat the discomfort of subacute

thyroiditis.

Hormone replacement (choice C) is very helpful to alleviate the hot flash

symptoms associated with perimenopause.

SSRI's (choice E), such as fluoxetine (Prozac), are used to treat depression.

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Question 5 of 6
The patient had unknown cardiac risk factors and developed a myocardial
infarction after therapy was initiated. Which of the following is the
most likely mechanism by which the therapy lead to this complication?
/ A. Enhances adrenergic effects
/ B. Enhances lipid turnover
/ C. Increases calcium mobilization in bone
/ D. Increases metabolic rate
/ E. Regulates body temperature
 Explanation - Q: 2.5 Close

The correct answer is A. Thyroxine has multiple effects on the body such as
improving the lipid profile (choice B); increasing calcium mobilization from
the bone (choice C), which can cause chronic hyperthyroid patients to be
osteoporotic; increasing the metabolic rate (choice D); and regulating body
temperature (choice E). It also enhances adrenergic actions thereby
increasing heart rate and cardiac contractility. For older patients or those with
coronary artery disease, thyroid supplements must be given in smaller and
slower titrations to prevent this complication.

Question 6 of 6

If the patient had a very tender and nodular goiter with pain radiating to the ear,
which of the following would be the most likely diagnosis?
/ A. Graves' disease
/ B. Hashimoto's thyroiditis
/ C. Lymphocytic thyroiditis
/ D. Subacute thyroiditis
/ E. Toxic multinodular goiter

Explanation - Q: 2.6 Close

The correct answer is D. Patients with subacute thyroiditis have very tender
asymmetrical goiters with pain radiating to the ear. It usually starts after a
viral infection. The patient may range from being hyperthyroid to hypothyroid,
but eventually will become euthyroid.

Graves' disease (choice A) occurs in patients who are hyperthyroid with a

goiter.

Hashimoto thyroiditis (choice B) is not associated with a painful goiter and

does not occur after a viral infection.

Lymphocytic thyroiditis (choice C) is a painless thyroiditis, which is self-

limited; it can progress from hyperthyroid to hypothyroid and then to the
euthyroid state. Some consider lymphocytic thyroiditis and subacute
thyroiditis variants of the same thyroid inflammation.

Patients with toxic multinodular goiter (choice E) will be hyperthyroid instead

of hypothyroid.
A 23-year old female student notices double vision while studying for her
examinations. She goes to see an ophthalmologist, who said she
had a "Iazy eye." These symptoms come and go for the next 2 years without
becoming significant. Then, she starts to have difficulties with
chewing food, and has troubles with getting in and out of the car. SIowly,
problems with using her arms and legs develop. She thinks she is out
of shape and needs more exercise. She begins spilling drinks and missing her
mouth when using utensils. Her vision is double by afternoon
each day, and by the evening, one eye is closed. The next morning, her situation
is improved, but again worsens by the evening. Finally, she
goes to see a neurologist. On examination, ptosis is noted. The ptosis worsens
when she is asked to sustain an upward gaze, and closing her
eyes for a short period improves it. Her voice has a nasal quality. Sensory
examination and deep tendon reflexes are normaI.
Question 1 of 5

Which of the following is the most likely diagnosis?

/ A. Botulism
/ B. Guillain-Barré syndrome
/ C. Lambert-Eaton syndrome
/ D. Myasthenia gravis
/ E. Wernicke syndrome

Explanation - Q: 3.1 Close

The correct answer is D. Myasthenia gravis (MG) is a chronic autoimmune

disease of neuromuscular transmission. It is characterized by fluctuating
weakness of commonly used voluntary muscles, causing symptoms such as
ptosis, diplopia, dysphagia, drooping head, poor posture, difficulty climbing
stairs, and difficulty chewing and talking. Weakness is improved by rest and
worsens with activity. Short-acting anti-cholinesterases transiently improve
the weakness. The disorder can occur at all ages, sometimes in association
with a thymic tumor, or thyrotoxicosis, rheumatoid arthritis, and systemic
lupus erythematosus. Extraocular muscles and other cranial muscles
(masticatory, facial, and pharyngeal) are especially likely to be affected, and
the respiratory and limb muscles may also be involved. Pupillary responses,
sensation, and deep tendon reflexes are normal. Symptoms often fluctuate in
intensity during the day, and these diurnal variations are superimposed on a
tendency to have spontaneous relapses and remissions. The disorder follows
a slowly progressive course and may have a terminal outcome due to
respiratory complications.

Botulism (choice A) is a potentially fatal paralytic illness caused by the

bacterium Clostridium botulinum. Botulism would not slowly worsen over two
years.
 Guillain-Barré syndrome (choice B) is an acute autoimmune demyelinating
neuropathy characterized by progressive symmetric ascending weakness,
bilateral hyporeflexia, paresthesias, pain, cranial nerve involvement,
dysautonomia, and eventually, respiratory insufficiency.

Lambert-Eaton syndrome (choice C) is an autoimmune disease of

neuromuscular transmission, often associated with malignancy, which is
characterized by weakness of proximal muscles and facilitation (strength
improvement) after exercise.

Chronic progressive external ophthalmoplegia (choice E) is a disorder

characterized by slow progressive paralysis of extraocular muscles.

Question 2 of 5
The underlying pathophysiology in this disease involves which of the following
mechanisms?
/ A. Antibodies to nicotinic acetylcholine receptors
/ B. Antibodies to voltage-gated calcium channels
/ C. Bacterial toxin
/ D. Infection-induced autoimmune response
/ E. Thiamine deficiency

Explanation - Q: 3.2 Close

The correct answer is A. Myasthenia gravis (MG) is an acquired

autoimmune disorder characterized by autoantibodies directed to
acetylcholine receptors (AChR) at the neuromuscular junction. Specific
acetylcholine receptor autoantibodies lead to reduced impulse transmission in
the neuromuscular junction. Cholinergic receptors of smooth and cardiac
muscle (muscarinic) have a different antigenicity and therefore are not
affected by the disease. T-helper cells, which have been activated in the
thymus, probably stimulate the production of these antibodies. They react
mainly with the alpha subunit of the receptor, reducing the functional activity
at the postsynaptic membrane. There are several postulated mechanisms of
autoimmune damage: modulation (increased endocytosis and degradation of
AChR), blocking the binding site for ACh on AChR, and initiating
complement-binding to ACh-AChR complex and damage to postjunctional
membranes.

In Lambert-Eaton myasthenic syndrome antibodies induce downregulation of

voltage-gated calcium channels (VGCC) at the presynaptic terminal of
neuromuscular junction (choice B). This reduces calcium-dependent
acetylcholine release, which leads to fatigable muscle weakness and loss of
 tendon reflexes.

Clostridium botulinum neurotoxin causes botulism by binding to peripheral

cholinergic synapses and preventing neurotransmitter release, which leads to
muscle paralysis (choice C).

Guillain-Barré syndrome is considered to be a postinfectious, autoimmune

disease (choice D). The mechanism most likely involves cross-reactivity
between antibodies against infectious agents and axonal and/or myelin
components e.g., GM1, GM2, GD1b.

Thiamine deficiency is associated with Wernicke encephalopathy, (choice E)

characterized by ataxia, ophthalmoplegia, and confusion. This disorder
usually occurs in alcoholics, or those with severe nutritional deficiencies.

Question 3 of 5
The structures primarily affected in this disease belong to which of the following
superfamilies?
/ A. Cytokine receptors
/ B. Intracellular receptors
/ C. Ligand-gated ion channels
/ D. Receptors linked to effectors via G proteins
/ E. Receptors located on a membrane-spanning enzyme

Explanation - Q: 3.3 Close

The correct answer is C. The structures involved in this disease are the
nicotinic cholinergic receptors, which are ligand-gated ion channels. The
receptor located at the neuromuscular junction is a pentamer composed of 5
polypeptide units (2α, 1β, 1γ, and 1δ). Each polypeptide has four
transmembrane-spanning regions, which form a cylindrical structure when all
five are joined together. ACh binds to the α subunits, producing a
conformational change that results in the opening of the channel, allowing
sodium to enter the cell.

Cytokine receptors (choice A) respond to a variety of peptide ligands,

including erythropoietin, several types of interferon, growth hormone, and
other regulators of growth and differentiation. Their mechanism is similar to
the receptor tyrosine kinases (e.g., insulin receptor), however, in this case,
the tyrosine kinase is not actually part of the receptor. Instead, a separate
tyrosine kinase (Janus kinases; JAKs) binds noncovalently to the receptor.
Once the receptor is activated, the cytokine receptors dimerize (like the EGF-
receptor), activating the JAKs to phosphorylate tyrosine residues on the
receptor. This leads to activation of another set of proteins (STATs, signal
 transducers and activators of transcription), which dimerize, detach from the
receptor, and travel to the nucleus where it regulates specific gene
transcription.

Intracellular receptors (choice B) can bind lipid-soluble agents that diffuse

across the lipid bilayer (e.g., steroid hormones), which then stimulate gene
transcription by binding to specific DNA sequences. A specialized
transmembrane signalling device is not needed with this type of receptor.

Receptors linked to effectors via G proteins (choice D) are comprised of one

polypeptide chain that crosses the membrane seven times. The receptor
activates a G protein, which mediates a variety of effects. There are several
different types of G proteins, e.g., Gs (stimulates adenylyl cyclase), Gi
(inhibits adenylyl cyclase, opens cardiac K+ channels), and Gq (activates
phospholipase C).

Receptors located on a membrane-spanning enzyme (choice E) are

polypeptides with an extracellular hormone-binding domain and an
intracellular enzyme domain, which may be a tyrosine kinase, a serine
kinase, or a guanylyl cyclase. The two domains are connected via a
hydrophobic spanning region. Insulin and many growth factors stimulate
receptors that dimerize and initiate a tyrosine kinase signalling pathway.

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Question 4 of 5
Which of the following would be likely to exacerbate this patient's symptoms?
/ A. Aminoglycosides
/ B. Edrophonium
/ C. Neostigmine
/ D. Pyridostigmine
/ E. Thymectomy

Explanation - Q: 3.4 Close

The correct answer is A. Patients with MG are extremely sensitive to the

action of curariform drugs or other drugs that interfere with neuromuscular
transmission. Aminoglycosides (e.g., streptomycin, neomycin, gentamycin,
tobramycin, amikacin) are antibacterial agents that inhibit protein synthesis by
acting directly on the ribosome. Ototoxicity and neurotoxicity are the most
serious side effects. Neuromuscular blockade may result when an
aminoglycoside is used in high doses, or with curariform drugs. The
mechanism is probably decreased presynaptic release of ACh and decreased
sensitivity of the postsynaptic membrane. Many other agents can exacerbate
MG symptoms, e.g., chloroquine, ciprofloxacin, muscle relaxants, botulinum
 toxin, quinidine, procainamide, phenytoin, and d-penicillamine.

Edrophonium (choice B) is a rapidly-acting, short-duration, parenteral

cholinesterase inhibitor. It is used as a diagnostic test for MG.

Anticholinesterase agents are used for symptomatic therapy of myasthenia

gravis. Neostigmine (choice C) is a synthetic reversible acetylcholinesterase
inhibitor that is used for long-term therapy of MG. Neostigmine does not
penetrate blood-brain barrier, and provides an additional direct nicotinic
agonist effect. Pyridostigmine (choice D) is another anticholinesterase drug
used in the treatment of MG.

The role of the thymus in the pathogenesis of MG is not clear, but it was
found that 75% of MG patients has some type of thymic abnormality. That is
the rationale for thymectomy (choice E) as a therapeutic tool. Thymectomy
usually improves symptoms, and should be considered in patients younger
than 60, unless the disease has affected only extraocular muscles. Plasma
exchange may also be used in patients unresponsive to other treatments, but
produces only short-term clinical improvement.

Question 5 of 5

Administration of which of the following agents would confirm the diagnosis of

this disease?
/ A. Edrophonium
/ B. Nicotine
/ C. Pilocarpine
/ D. Pralidoxime
/ E. Succinylcholine

Explanation - Q: 3.5 Close

The correct answer is A. An edrophonium (Tensilon) IV challenge (double

blind) test is used to confirm the diagnosis of MG. Edrophonium is a drug of
choice for diagnosing MG because of its rapid onset of action and
reversibility. If the patient has MG, an improvement in muscle strength that
lasts 5 minutes or so will usually be seen. Other uses include assessing the
treatment of MG with longer-acting cholinesterase inhibitors (too much or too
little), differentiating cholinergic and myasthenic crises (in myasthenic crisis,
edrophonium improves muscle strength, but in cholinergic crisis, it further
reduces muscle strength) and reversing the effects of nondepolarizing
blocking agents after surgery.

Nicotine (choice B) is a natural alkaloid found in tobacco that mimics the

effects of ACh at nicotinic receptors. It has no therapeutic actions but is
important for its toxicity.
Pilocarpine (choice C) is a direct-acting muscarinic receptor agonist. It is
used in glaucoma to produce pupillary miosis and ciliary muscle contraction,
thereby increasing aqueous humor outflow.

Pralidoxime (2-PAM, pyridine-2-aldoxime methyl chloride, choice D) reverses

the effects of organophosphates, which are irreversible anticholinesterase
agents. Treatment must be within hours because of the "aging" phenomenon,
i.e., establishing a form that cannot be reversed.

Succinylcholine (choice E) is a depolarizing neuromuscular blocking agent. It

has the briefest duration of action of all neuromuscular blocking drugs.
Therefore, it is a drug of choice for endotracheal intubation, electroconvulsive
shock therapy, and termination of laryngospasm.