A 32 year-old male comes to your ophthalmology clinic complaining of increasingly blurry vision and headaches. His wife reports that his gait became clumsy, his speech became slurred. On review of systems, you discover that he has difficulty swallowing, and having frequent headaches. Patient reports that some of his relatives also have similar medical problems. On physical examination, you notice a sweaty, anxious looking male. Cardiac exam is significant for palpitations. In retinal exam, you find dilation and tortuosity of retinal vessels, angiomatous lesions with hemorrhages and exudates in both eyes. Suspecting a systemic disorder, you order some investigative studies, which reveal hemangioblastomas in the cerebellum, two nodules in the pancreas and a large tumor in the kidney. The lesions have a striking appearance of a cyst with a nodule contained in its wall, and angiography demonstrates the highly vascular nature of the nodules. The laboratory tests reveal elevated plasma free fractionated metanephrines, and elevated white blood cells, red blood cells and platelets. The diagnosis of this disease can be confirmed by the presence of a mutation on which of the following chromosomes?

A 46 yo male is brought to your office by his wife for the evaluation of his symptoms. She reports that for the last 8 months, the patient has lost all ‘norms of decency’. He is touching his private parts in public places. He is undressing and exposing his genitals to strangers. He has difficulty remembering things. A few months ago, on a flight from Los Angeles to New York, he allegedly touched a fellow passenger inappropriately and was arrested by the federal aviation authorities. He pleaded guilty to a misdemeanor and was sentenced to a federal prison for 3 months. Prison health records show that he has had a tendency to explore objects by placing them in the mouth together with the indiscriminate eating or chewing of objects and all kinds of food. He reports that he has no other way to recognize objects as he cannot see them properly. His past medical history is significant for herpes simplex encephalitis and a head injury a year ago. In the physical examination, you notice a very passive individual with a flat affect and reduced response to your greetings,but he follows your commands well. He exhibits excessive attentiveness to visual stimuli with a tendency to touch every object. This disorder is due to lesions affecting which of the following regions in the brain?

A 46 yo male is brought to your office by his wife for the evaluation of his symptoms. She reports that for the last 8 months, the patient has lost all ‘norms of decency’. He is touching his private parts in public places. He is undressing and exposing his genitals to strangers. He has difficulty remembering things. A few months ago, on a flight from Los Angeles to New York, he allegedly touched a fellow passenger inappropriately and was arrested by the federal aviation authorities. He pleaded guilty to a misdemeanor and was sentenced to a federal prison for 3 months. Prison health records show that he has had a tendency to explore objects by placing them in the mouth together with the indiscriminate eating or chewing of objects and all kinds of food. He reports that he has no other way to recognize objects as he cannot see them properly. His past medical history is significant for herpes simplex encephalitis and a head injury a year ago. In the physical examination, you notice a very passive individual with a flat affect and reduced response to your greetings,but he follows your commands well. He exhibits excessive attentiveness to visual stimuli with a tendency to touch every object. The MRI of his brain showed bilateral damage to the amygdala and the neighboring temporal cortex. Which of the following medications is found to be beneficial to reduce sexual behavioral abnormalities in patients with this disease?

A 46 yo male is brought to your office by his wife for the evaluation of his symptoms. She reports that for the last 8 months, the patient has lost all ‘norms of decency’. He is touching his private parts in public places. He is undressing and exposing his genitals to strangers. He has difficulty remembering things. A few months ago, on a flight from Los Angeles to New York, he allegedly touched a fellow passenger inappropriately and was arrested by the federal aviation authorities. He pleaded guilty to a misdemeanor and was sentenced to a federal prison for 3 months. Prison health records show that he has had a tendency to explore objects by placing them in the mouth together with the indiscriminate eating or chewing of objects and all kinds of food. He reports that he has no other way to recognize objects as he cannot see them properly. His past medical history is significant for herpes simplex encephalitis and a head injury a year ago. In the physical examination, you notice a very passive individual with a flat affect and reduced response to your greetings,but he follows your commands well. He exhibits excessive attentiveness to visual stimuli with a tendency to touch every object. The MRI of his brain showed bilateral damage to the amygdala and the neighboring temporal cortex. What is the most likely diagnosis in this patient?

A 68-year-old man of African heritage comes to your office complaining of progressive loss of vision over the last four months. First it started with loss of peripheral vision and later his central vision has also worsened. He gets headaches as he tries to see things more clearly than he can. His past medical history is significant for hypertension. He has a 30-pack-year smoking history. Family history is significant for MYOC gene carriers. On examination, his visual acuity is 20/400 both eyes. There does not appear to be a relative afferent pupillary defect (RAPD). Ophthalmoscopy shows symmetrically enlarged cup-to-disk ratio (0.8) and a highly asymmetric cupping in the right eye. Tonometry measures the intraocular pressure of 18 mm Hg in the left eye and 20 mm Hg in the right eye. Pachymetry reveals decreased thinning of the cornea in both eyes. You decide to use topical timolol to treat this patient’s disorder. Which of the following is NOT considered a systemic side effect of these medications?

A 22 year-old male comes to your office because he needs an urgent prescription for alprazolam. He shouts at your staff for keeping him too long in the waiting room even though he arrived late for his appointment. He called himself Jack Snyder even though his driver’s license shows a different name. Your office staff reports that he has a very ‘negative vibe around him’. Finally, when you meet him in the room, he states, ‘Doc, I respect you. But listen, if I don’t get some xanax today, I might seriously harm someone in this office or outside.I took buprenorphine from a friend. It’s crap. It’s not helping me to calm down’. As you explore his history, he informs you that during his school years, teachers warned him to respect the rights of other students, to control his impulsive behavior, and to take the safety of others seriously. He has a history of arrests for shoplifting and imprisonments for violent behavior and possession of drug paraphernalia. He has a family history of alcoholism, drug abuse, imprisonments and hysteria. During his school years, he was diagnosed with conduct disorder. When you inform him that he needs another follow up, he shouts, ‘I am in between jobs. I don’t have money to pay for these visits. I still owe a lot of money to a lot of people. My girlfriend left me last week’. In the physical and mental health examination, you notice an aggressive individual with a manipulative attitude, low frustration tolerance, high propensity for anger, poor impulse control and poor judgment. His orientation and cognition appear normal. He has no delusions or hallucinations. He has a tattoo on his right deltoid which indicates a gang affiliation. Which of the following has been used with reported success in treating individuals with this disorder?