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Nothing prepares you for exam success like Harrison’s!

Vibrant full-color presentation includes color atlas — 500 all-new questions!

Now you can add the unmatched authority of Harrison’s to your board review or test preparation. Based on the content of Harrison’s Principles of Internal Medicine, Nineteenth Edition, this rigorous study aid is essential for Internal Medicine Board certification or recertification/maintenance of certification, or as a refresher for any internal medicine examination.
Reflecting the accuracy, currency, and wide scope of Harrison’s, this complete review of internal medicine delivers more than 1,000 extremely challenging review questions, many of which utilize realistic patient scenarios, including radiographic and pathologic images. Each question is accompanied by explanations for correct and incorrect answers. These explanations — which are derived from and cross-referenced to Harrison’s Principles of Internal Medicine, Nineteenth Edition — are one of the most effective ways to learn and teach internal medicine. They are designed to bolster your understanding of pathophysiology, epidemiology, differential diagnosis, clinical decision making, and therapeutics.
The format of the book has also been enhanced, allowing for a more effective use of color images throughout. Readers will appreciate the convenience of having color images next to their citations in the text.

A great way to learn internal medicine:
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ক্যাটাগোরিগুলো:
সাল:
2016
সংস্করণ:
19
প্রকাশক:
McGraw-Hill
ভাষা:
english
পৃষ্ঠা:
672 / 804
ISBN 10:
1259642895
ISBN 13:
9781259642890
বইয়ের সিরিজ:
Internal medicine
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19th Edition

‘HAISON’S
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IN T 0E H N A0L
M E D | C | N E
SELF-ASSESSMENT
AND BOARD REVIEW
WIENER
KASPER

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Graw
Hill
. Education

by
Dr. Nigam Rashmi Dhar
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join free whatsapp medical grp
LOSCALZO
009779804202884

SECTION I

General Considerations in Clinical Medicine

QUESTIONS
DIRECTIONS: Choose the one best response to each question.
I-1. All of the following statements regarding practice guidelines set forth by governing agencies and
professional organizations are true EXCEPT:
A.
B.
C.
D.
E.

Clinical practice guidelines protect caregivers against inappropriate charges of malpractice, yet
do not provide protection for patients from receiving substandard care.
Practice guidelines have largely reached a stage of nuance allowing them to address every unique
illness and patient presented to the modern physician.
Practice guidelines provide a legal constraint to physicians, and deviation from guideline-based
care invariably leaves physicians vulnerable to legal action.
Where different organizations disagree regarding practice guidelines, a third-party agency has
been appointed to mitigate these disagreements such that now all major organizations’ guidelines
are consistent.
All of the above statements are not true.

I-2. Regarding molecular medicine, which of the following statements represents an INACCURATE
example of the listed area of study:
A. Exposomics: An endocrinologist studies sunlight exposure and population risk of hip fracture.
B. Metabolomics: A biochemist studies the rate of flux through the creatine kinase pathway during
the cardiac cycle.
C. Metagenomics: A biologist studies the genomic alterations in molds commonly found in human
dwellings.
D. Microbiomics: A microbiologist studies the genomic variation in thermophiles, bacteria that can
survive extreme heat near deep ocean vents.
E. Proteomics: A cardiologist studies desmosomal proteins and their posttranslational modifications
in studying arrhythmogenic right ventricular dysplasia.
I-3. ; Which of the following is the best definition of evidence-based medicine?
A.
B.
C.
D.
E.

A summary of existing data from existing clinical trials with a critical methodologic review and
statistical analysis of summative data
A type of research that compares the results of one approach to treating disease with another
approach to treating the same disease
Clinical decision-making support tools developed by professional organizations that include
expert opinions and data from clinical trials
Clinical decision making supported by data, preferably randomized controlled clinical trials
One physician’s clinical experience in caring for multiple patients with a specific disorder over
many years

I-4. Which of the following is the standard measure for determining the impact of a health condition on
a population?
A.
B.
C.
D.
E.

Disability-adjusted life-years
Infant mortality
Life expectancy
Standardized mortality ratio
Years of life lost

I-5. Which of the following statements regarding disease patterns worldwide is true?
A. Childhood undernutrition is the leading risk factor for global disease burden.
B. In a 2006 publication, the World Health Organization (WHO) estimated that 10% of the total
global burden of disease was due to modifiable environmental risk factors.
C. In 2010, ischemic heart disease was the leading cause of death among adults.
D. In the last two decades, mortality attributed to communicable diseases, maternal and perinatal
conditions, and nutritional deficiencies has remained fairly stable, with the majority (76%) of
mortality from these causes occurring in sub-Saharan Africa and southern Asia.
E. While poverty status has been shown to be linked to health status on the individual level, the
same relationship does not hold true when studying the link between national health indicators
and gross domestic product per capita among nations.
I-6. You are appointed to a governmental healthcare advisory subcommittee concerned with addressing
problems facing the global health community. Your task is to draw general conclusions from the
global fight against tuberculosis (TB) and human immunodeficiency virus (HIV)/acquired
immunodeficiency syndrome (AIDS) that may be applied in combatting other diseases, including
noncommunicable diseases. Which of the following conclusions is reasonable when considering
HIV/AIDS and TB as chronic diseases?
A.
B.
C.
D.
E.

Barriers to adequate healthcare and patient adherence imposed by extreme poverty must be
concomitantly addressed to adequately treat and prevent chronic disease in developing nations.
Charging small fees for health services (e.g., AIDS prevention and care) supplies the patient with
a sense of the treatment’s value and increases compliance and overall public health.
Despite adequate available tools to practice their trade locally in developing nations, many
physicians and nurses emigrate to developed nations to practice their respective trades, a
phenomenon called “brain drain.”
In developed nations where physicians are abundant, community health worker supervision of
the care of chronically ill patients is not effective.
In the case of chronic infectious diseases, switching from one drug to another through a
prolonged course of treatment provides the highest cure rate by obviating the infectious agent’s
ability to develop resistance to any single drug.

I-7. Mrs. Jones, a 22-year-old African American woman, presents to Dr. Smith, an internal medicine
specialist, with a facial rash. Mrs. Jones states that the rash began after spending a day at the beach
with her family. She also notes that her metacarpophalangeal and proximal interphalangeal joints
have been painful and swollen for the preceding 2 weeks. On examination, the joints are swollen and
tender. Laboratory analysis discloses reduced creatinine clearance, proteinuria, and hemolytic
anemia. Antinuclear antibodies (a test with a high negative predictive value for systemic lupus
erythematosus) are detected at significant titer, and ultimately, the diagnosis of systemic lupus
erythematosus is made.
Two weeks later, Mrs. Johnson, a 24-year-old African American woman, presents with a facial rash
and elbow pain to Dr. Smith. After a cursory interview and brief physical exam, Dr. Smith sends
blood work only testing for antinuclear antibodies. When the test returns negative (no antibodies
detected), Dr. Smith presumes this to be a false-negative result and starts Mrs. Johnson on
hydroxychloroquine and prednisone for treatment of systemic lupus erythematosus. Which
heuristic(s) did Dr. Smith likely employ in diagnosing Mrs. Johnson with systemic lupus
erythematosus?

A.
B.
C.
D.
E.

Availability heuristic
Anchoring heuristic
Bayes’ rule
Confirmation bias
A and B

I-8. You have invented a blood test, which you name “veritangin,” to determine if patients are having a
myocardial infarction. You devise an experiment to determine the performance of your veritangin
assay by testing it versus the troponin assay, the currently accepted gold standard for determining
myocardial infarction, in 100 random emergency department patients with chest pain. You choose a
veritangin result >1 ng/dL as positive for myocardial infarction. Your results are listed in the table
below.

Which of the following statements regarding the characteristics of the veritangin assay in this trial is
true?
A. The posttest probability of the veritangin test does not depend on the population studied.
B.
The sensitivity of the veritangin assay depends on the population studied and the disease
prevalence in that population.
C. The sensitivity of the veritangin assay will decrease by 50% if you reduce the threshold for a
positive result to >0.5 ng/dL.
D. The sensitivity of the veritangin test cannot be calculated based on the above data.
E. The specificity of the veritangin assay is 0.93 (70/75).
I-9. You are designing a clinical trial to test the use of a novel anticoagulant, clotbegone, in the
treatment of deep vein thrombosis. Which of the following statements regarding the design of the
trial is true?
A.
B.
C.
D.
E.

An optimal study design would assign many patients to clotbegone and compare their outcomes
to the outcomes of prior (historical) patients not taking clotbegone. This would allow faster trial
completion.
If the trial returns a positive result (clotbegone is superior to placebo), that means that any
patient with a clot would benefit from clotbegone therapy.
Observing the outcomes of patients already taking clotbegone versus patients who are not is
preferable to assigning patients to clotbegone or placebo in a blinded fashion. The observational
strategy is more “real world,” applicable to the general population, and free of bias.
Population selection for the trial enrollment is not important as long as careful attention to
randomization and blinding is observed.
The advantage of performing a randomized clinical trial of clotbegone over a prospective
observational study of clotbegone is the avoidance of treatment selection bias.

I-10. A receiver operating characteristic (ROC) curve is constructed for a new test developed to diagnose
disease X. All of the following statements regarding the ROC curve are true EXCEPT:
A.

One criticism of the ROC curve is that it is developed for testing only one test or clinical
parameter with exclusion of other potentially relevant data.
B. ROC curve allows the selection of a threshold value for a test that yields the best sensitivity with
the fewest false-positive tests.

C. The axes of the ROC curve are sensitivity versus 1 – specificity.
D. The ideal ROC curve will have a value of 0.5.
E. The value of the ROC curve is calculated as the area under the curve generated from the truepositive rate versus the false-positive rate.
I-11. When considering a potential screening test, what end points should be considered to assess the
potential gain from a proposed intervention?
A.
B.
C.
D.
E.

Absolute and relative impact of screening on the disease outcome
Cost per life-year saved
Increase in the average life expectancy for the entire population
Number of subjects screened to alter the outcome in one individual
All of the above

I-12. You are appointed to an advisory committee in the WHO tasked with making recommendations
regarding breast cancer screening and prevention. In regard to screening and preventing breast
cancer in women, which of the following potential recommendations from your committee would be
valid?
A.
B.
C.
D.
E.

Any breast cancer detected by screening mammography and adequately treated represents a
reduction in breast cancer mortality.
Screening is most effective when applied to relatively common diseases. Breast cancer, with a
lifetime risk of 10% in women, meets this criterion.
The presence of a latent (asymptomatic) stage of breast cancer renders it a less ideal disease
candidate for screening at the population level.
When studying the effectiveness of breast cancer screening with mammography in a population,
length of disease survival is the most important outcome to consider.
Women in the general population should undergo just as rigorous screening and prevention
measures for breast cancer as women with the BRCA1 or BRCA2 mutations.

I-13. You are seeing Mr. Brown today in the primary care clinic. He has a long history of tobacco abuse,
and you notice on his intake form that he wishes to discuss lung cancer screening today. Which of the
following statements regarding lung cancer screening can you truthfully make to Mr. Brown?
A.
B.
C.
D.
E.

“Recently, a large National Heart, Lung, and Blood Institute study demonstrated a significant
reduction in mortality by employing low-dose chest computed tomography as a screening tool in
patients with a significant smoking history.”
“Screening for lung cancer has a long history of successful implementation given the ease of
obtaining a chest x-ray and the fact that most lung cancers are curable at the time of screening
detection.”
“Screening for lung cancer is a ‘no-brainer’; there is really no harm in a false-positive test. The
only real worry is always that you might have a cancer that we don’t know about.”
“Because the sensitivity and specificity of any screening test do not depend on the population
studied, your odds of having lung cancer after a positive chest x-ray do not depend on his
smoking history.”
“There is really no evidence of benefit for lung cancer screening by any modality.”

I-14. Which preventative intervention leads to the largest average increase in life expectancy for a target
population?
A.
B.
C.
D.
E.

A regular exercise program for a 40-year-old man
Getting a 35-year-old smoker to quit smoking
Mammography in women age 50–70
Pap smears in women age 18–65
Prostate-specific antigen (PSA) and digital rectal examination for a man >50 years old

I-15. The U.S. Preventive Services Task Force (USPSTF) recommends which of the following screening

tests for the listed patients?
A. 16-year-old male: immunoassay for HIV if not performed before
B. 32-year-old sexually active woman: nucleic acid amplification on a cervical swab for chlamydia
C. 50-year-old woman with a smoking history: dual-energy x-ray absorptiometry (DEXA) scan for
osteoporosis
D. 58-year-old prior smoker: ultrasound for abdominal aortic aneurysm
E. 80-year-old man: anti–hepatitis C virus (HCV) antibody for hepatitis C
I-16. Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?
A.
B.
C.
D.
E.

Amoxicillin
Aspirin
Atorvastatin
Prevacid
Sildenafil

I-17. A 26-year-old woman received an allogeneic bone marrow transplantation 9 months ago for acute
myelogenous leukemia. Her transplant course is complicated by graft-versus-host disease with
diarrhea, weight loss, and skin rash. She is immunosuppressed with tacrolimus 1 mg twice a day (bid)
and prednisone 7.5 mg daily. She recently was admitted to the hospital with shortness of breath and
fevers to 101.5°F. She has a chest computed tomography (CT) showing nodular pneumonia, and
fungal organisms are seen on a transbronchial lung biopsy. The culture demonstrates Aspergillus
fumigatus, and a serum galactomannan level is elevated. She is initiated on therapy with voriconazole
6 mg/kg IV every 12 hours for 1 day, decreasing to 4 mg/kg IV every 12 hours beginning on day 2.
Two days after starting voriconazole, she is no longer febrile but is complaining of headaches and
tremors. Her blood pressure is 150/92 mmHg, up from 108/60 mmHg on admission. On examination,
she has developed 1+ pitting edema in the lower extremities. Her creatinine has risen to 1.7 mg/dL
from 0.8 mg/dL on admission. What is the most likely cause of the patient’s current clinical picture?
A.
B.
C.
D.
E.

Aspergillus meningitis
Congestive heart failure
Recurrent graft-versus-host disease
Tacrolimus toxicity
Thrombotic thrombocytopenic purpura caused by voriconazole

I-18. A 43-year-old woman is diagnosed with pulmonary blastomycosis and is initiated on therapy with
oral itraconazole therapy. All of the following could affect the bioavailability of this drug EXCEPT:
A.
B.
C.
D.
E.

Coadministration with a cola beverage
Coadministration with oral contraceptive pills
Formulation of the drug (liquid vs. capsule)
pH of the stomach
Presence of food in the stomach

I-19. Mr. Jonas is a 47-year-old truck driver with a history of HIV, hypertension, coronary artery disease,
atrial fibrillation, and ischemic cardiomyopathy. He is on antiretroviral therapy. He presents today
complaining of a new rash on his chest and axilla, which you astutely diagnose as tinea corporis. You
would like to prescribe a course of oral ketoconazole for therapy. You should consider dose
adjustment for all of the following medicines that he is already taking EXCEPT:
A.
B.
C.
D.
E.

Carvedilol
Lovastatin
Mexiletine
Ritonavir
Saquinavir

I-20. Which of the following pharmacokinetic concepts is accurate?

A. After four half-lives of a zero-order drug, 93.75% of drug elimination is achieved.
B.
Elimination half-life is the sole determinant of the time required for steady-state plasma
concentrations to be achieved after any change in drug dosing.
C. First-order elimination refers to the priority a drug has for its elimination enzyme versus drugs of
alternative orders. For example, a first-order drug will have a higher affinity for the enzyme than
a second-order drug.
D. Steady state describes the situation during chronic drug dosing when the plasma concentration of
drug is identical from minute to minute. One can only truly achieve steady state with continuous
intravenous infusion.
E.
The only method by which a drug can be removed from the central compartment is by
elimination.
I-21. Mr. Brooks has been seeing you in the primary care clinic for over 20 years. Recently, he was
diagnosed with amyotrophic lateral sclerosis (ALS), an almost universally fatal degenerative
neurologic condition. In consultation with his neurologist, you have started him on a high dose of a
new medication, Drug X, to alleviate muscle spasms. However, although Mr. Brooks’s muscle spasms
have improved drastically, he is experiencing dry mouth and dry eyes, side effects that were not
described in very large clinical trials of Drug X. A recent postmarketing study of Drug X was released
showing that patients with ALS taking it live, on average, 14 days less than patients not taking it. As
you discuss the plan regarding Drug X with Mr. Brooks, which statement would be valid?
A.
B.
C.
D.
E.

“A recent study shows that patients taking Drug X die sooner, on average, than those not taking
it. I want to discuss your thoughts on continuing Drug X, perhaps at a lower dose, versus stopping
it.”
“A recent study shows that patients taking Drug X die sooner, on average, than those not taking
it. I recommend stopping it, and I anticipate the drug will be discontinued soon.”
“If you’re having side effects at the high dose, it’s certain that you’ll have the same side effects at
a lower dose.”
No discussion is needed given the postmarketing data. You should stop Drug X and report the
new side effect to the U.S. Food and Drug Administration (FDA).
“These side effects you describe were not described in clinical trials enrolling hundreds of
patients with ALS. They cannot be from Drug X. Let’s figure out what other medication might be
causing them.”

I-22. The graph below represents a plasma time-concentration curve after a single dose of Drug A.
Which of the following statements regarding Figure I-22A is true?

by
Dr. Nigam Rashmi Dhar
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FIGURE I-22A
A. This drug was likely administered orally.
B. This drug demonstrates zero-order kinetics.
C. The shift in rapid reduction in plasma concentration to a more gradual reduction (point B) likely
represents a saturation of the eliminating enzyme.
D. Point B represents the time when drug is distributed both to and from a peripheral compartment
and eliminated from the central compartment.
E. This drug does not have a half-life given the curvilinear shape of its elimination curve.
I-23. All of the following patients are correctly matched to the drug and dose adjustment that should be
considered given their concomitant listed comorbidity EXCEPT:
A.
B.
C.
D.
E.

A 57-year-old man with cirrhosis: reduced dose of sotalol
A 35-year-old man with renal disease: reduced dose of meperidine
A 97-year-old man with normal creatinine and bilirubin: reduced dose of diazepam
A 42-year-old man with cirrhosis: reduced dose of meperidine
A 35-year-old woman with a known loss-of-function allele in CYP2C9: reduced initial dose of
warfarin

I-24. Which of the following sets of drug–drug interaction and mechanism is accurately described?
A. Ibuprofen and warfarin: increased risk of GI bleeding; ibuprofen inhibition of CYP2C9
B. Sotalol and furosemide: increased risk of QT prolongation and torsades de pointes; furosemideinduced inhibition of CYP3A4
C. Sildenafil and sublingual nitroglycerin: increased risk of hypotension; sildenafil inhibition of the
phosphodiesterase type 5 isoform that inactivates cyclic guanosine monophosphate
D. Ritonavir and lovastatin: increased risk of myotoxicity; ritonavir inhibition of CYP2C19
E. Allopurinol and azathioprine: increased risk of blood dyscrasias; allopurinol inhibition of Pglycoprotein
I-25. Which of the following statements regarding coronary heart disease (CHD) in women when
compared to men is true?
A. Angina is a rare symptom in women with CHD.
B. At the time of diagnosis of CHD, women typically have fewer comorbidities when compared to
men.

C.

Physicians are less likely to consider CHD in women and are also less likely to recommend both
diagnostic and therapeutic procedures in women.
D. Women and men present with CHD at similar ages.
E. Women are more likely to present with ventricular tachycardia, whereas men more commonly
have cardiac arrest or cardiogenic shock.
I-26. All of the following diseases are more common in women than men EXCEPT:
A.
B.
C.
D.
E.

Depression
Hypertension
Obesity
Rheumatoid arthritis
Type 1 diabetes mellitus

I-27. Which of the following statements regarding sex differences in the United States is true?
A.
B.
C.
D.
E.

Due to extensive public awareness campaigns, the majority of physicians are counseling their
female patients about their risk for cardiovascular disease.
The leading causes of death are the same for women and men.
Women’s bone density and their risk for cardiovascular disease decline after menopause.
Women have a longer average life expectancy than men, and this difference has been unchanged
for decades.
Women younger than age 65 correctly believe that breast cancer is their leading health risk.

I-28. You are seeing Mrs. Robin today, a 58-year-old woman with a history of tobacco use, treated
hypertension, and moderate obesity. She is recently menopausal. You note on her intake form that
she has questions about hormone replacement therapy to reduce her risk of coronary heart disease
and stroke. Which of the following statements to Mrs. Robin would be true?
A.
B.
C.
D.
E.

“Most studies suggest that combined continuous equine estrogen combined with
medroxyprogesterone acetate is superior to combined continuous equine estrogen alone in regard
to risk for stroke or heart attack.”
“Studies suggest that initiating hormone therapy can reduce the incidence of hot flashes, night
sweats, mood, sexual function, and bone density, but there is no change in risk for stroke,
myocardial infarction, or venous thromboembolism.”
“The largest trial done on hormone therapy demonstrated a benefit for hormone therapy in
reducing the risk for heart attack and stroke.”
“What is truly important for hormone therapy is the timing of initiation. Since you are recently
menopausal, we know that starting hormone therapy now will reduce your risk of future heart
attack.”
“You should definitely take low-dose aspirin daily. It has been shown to reduce the risk of
coronary heart disease in women more than men.”

I-29. Which of the following statements is true regarding sex differences in disease?
A.

B.
C.
D.
E.

Most autoimmune diseases are more prevalent in women than men. This is attributed to
stimulatory actions of estrogens and the inhibitory actions of androgens on the cellular mediators
of immunity, and hormone therapy with oral contraceptives increases the risk of autoimmune
disease.
Obesity decreases the risk of endometrial cancer in women.
Testosterone administered to hypogonadal men will increase the incidence or severity of
obstructive sleep apnea. This does not occur with testosterone administered to hypogonadal
women.
Women are more sensitive to insulin than are men, and thus, women’s risk for type 2 diabetes
mellitus is lower.
Women have a longer QT interval on average than men and are at higher risk for drug-induced
torsades de pointes.

I-30. A 67-year-old man with hypertension and sleep apnea presents to your clinic for routine follow-up.
As you open your discussion with him, he says that he has seen some commercials advising him to
ask his doctor about “low T” (low testosterone). He is interested in getting tested. Which of the
following statements to this patient is valid?
A.
B.
C.
D.
E.

“If you are found to be testosterone deficient, therapy with exogenous testosterone may worsen
your sleep apnea.”
“It is recommended that every man above the age of 60 be tested for low total and bioavailable
testosterone.”
“Most studies show that testosterone concentration does not, on average, decline with advancing
age. Instead, the endogenous testosterone made is less potent.”
“Testosterone levels are associated with a risk for dementia in men.”
“While exogenous testosterone therapy can increase lean muscle mass, it also increases visceral
fat mass.”

I-31. A 29-year-old former competitive power-lifter who stopped competing 6 months earlier due to a
deltoid muscle tear confides that he and his wife have been unable to conceive despite over a year of
sexual intercourse without contraception. He wonders if there is a “shot or something that can, you
know, help me out.” You suspect that the patient may be using anabolic-androgenic steroids (AAS).
Which of the following statements is true regarding AAS use?
A. AAS users have the same mortality as the general population.
B. An elevated hematocrit should increase suspicion for AAS abuse.
C. Elevated luteinizing hormone levels and suppressed follicle-stimulating hormone levels are clues
suggesting AAS abuse.
D. Increased testicular volume is a clue for AAS abuse.
E. Several prolonged clinical trials of AAS abuse have provided the medical community with a
sophisticated understanding of the adverse effects of AAS abuse.
I-32. Mr. Brooks returns to clinic in August for his yearly follow-up. He is a 78-year-old former long-haul
trucker who enjoys fishing and traveling. During the spring and summer months, he takes
diphenhydramine daily for seasonal allergies. He has been generally feeling well, but has recently
noticed some urinary urgency, straining to void, and even urinary incontinence. You perform a
complete physical examination including a digital prostate exam and confirm benign prostatic
hypertrophy. The International Prostate Symptom Score indicates that Mr. Brooks’s symptoms are
moderate. Which of the following statements to Mr. Brooks would be appropriate?
A.
B.
C.
D.
E.

“I recommend primary therapy with tolterodine, an anticholinergic agent targeted at treated
overactive bladder symptoms.”
“Therapy with finasteride can reduce progression to acute urinary retention and need for prostate
surgery.”
“Urodynamic studies are warranted; I’ll refer you now.”
“We should go straight to surgery. Given the severity of your symptoms, medical therapy is
unlikely to help much.”
“Your use of diphenhydramine is probably working to improve your lower urinary tract
symptoms given its anticholinergic properties.”

I-33. A 24-year-old woman comes to clinic for a routine visit. She is 28 weeks pregnant with her first
child. To date, her pregnancy has been unremarkable and she has no family history of complicated
pregnancies. Her past medical history is unremarkable except for a history of mitral valve prolapse. A
blood pressure greater than which of the following would be considered potentially abnormally
elevated?
A.
B.
C.
D.

110/80 mmHg in the standing position
120/80 mmHg in the standing position 2 minutes after rising from the supine position
130/85 mmHg in the left lateral recumbent position
130/85 mmHg in the seated position

E. 140/90 mmHg in the seated position
I-34. A 36-year-old nulliparous woman is found to have a blood pressure of 150/95 mmHg on a routine
prenatal screening examination at 25 weeks’ gestation. Prior to this visit, her blood pressure was
typically 125/80 mmHg. She has a history of well-controlled diabetes and hyperlipidemia. Her exam
is notable for a body mass index (BMI) of 28, 2+ pretibial edema, and a 3/6 systolic flow murmur.
Laboratories are notable for normal electrolytes, serum creatinine of 1.0 mg/dL, and a urine
protein/creatinine ratio of 0.4. Which of the following findings in this patient is necessary to confirm
the diagnosis of preeclampsia?
A.
B.
C.
D.
E.

Diabetes
Hyperlipidemia
Obesity
Pedal edema
Protein/creatine ratio

I-35. A 29-year-old woman who is 35 weeks pregnant has been managed with aspirin and labetalol for
preeclampsia after she was found to have elevated blood pressure and proteinuria. All of the
following findings characterize preeclampsia with severe features EXCEPT:
A.
B.
C.
D.
E.

Asthma
Hemolysis
Hepatocellular injury
Seizure
Thrombocytopenia

I-36. A 33-year-old woman with diabetes mellitus, renal insufficiency, and hypertension presents to the
hospital with seizures during week 38 of her pregnancy. Her blood pressure is 165/95 mmHg. She
has 4+ proteinuria. Management should include all of the following EXCEPT:
A.
B.
C.
D.

Emergent delivery
Intravenous labetalol
Intravenous magnesium sulfate
Intravenous phenytoin

I-37. All of the following statements regarding a patient with type 1 diabetes who becomes pregnant are
true EXCEPT:
A.
B.
C.
D.
E.

Early delivery should be avoided and undertaken only for obstetric or fetal indications.
Fasting blood glucose should be maintained 140–180 mg/dL to avoid fetal hypoglycemia.
Prenatal folate supplementation will decrease the risk of a fetal neural tube defect.
She and her child are at higher perinatal mortality risk than a patient without diabetes.
The child is at higher risk of macrosomia than a child from a mother without diabetes.

I-38. Which of the following thyroid function tests will likely be altered due to pregnancy?
A.
B.
C.
D.

Free T3
Free T4
Total T3
Thyroid-stimulating hormone (TSH)

I-39. Which of the following cardiovascular conditions is a contraindication to pregnancy?
A.
B.
C.
D.
E.

Atrial septal defect without Eisenmenger syndrome
Idiopathic pulmonary arterial hypertension
Marfan syndrome
Mitral regurgitation
Prior peripartum cardiomyopathy with a current ejection fraction of 65%

I-40. All of the following are changes in the cardiovascular system seen in pregnancy EXCEPT:
A.
B.
C.
D.
E.

Decreased blood pressure
Increased cardiac output
Increased heart rate
Increased plasma volume
Increased systemic vascular resistance

I-41. A 27-year-old woman develops left leg swelling during week 20 of her pregnancy. Left lower
extremity ultrasound reveals a left iliac vein deep vein thrombosis (DVT). Proper management
includes:
A.
B.
C.
D.
E.

Bedrest
Catheter-directed thrombolysis
Enoxaparin
Inferior vena cava filter placement
Warfarin

I-42. In addition to a history and physical examination, which of the following should be performed
preoperatively to identify intermediate- or high-risk patients who may benefit from a more detailed
clinical evaluation?
A.
B.
C.
D.
E.

Chest radiograph
Electrocardiogram
Liver function tests
Serum creatinine
Serum electrolytes (sodium, potassium, chloride, bicarbonate)

I-43. Which of the following patients should receive a cardiac catheterization prior to the proposed
surgery?
A. A 38-year-old man for elective bariatric surgery. He has a history of medically controlled familial
hyperlipidemia but no history of chest pain and a normal electrocardiogram (ECG). He has a
normal cardiac and pulmonary examination and can easily climb more than two flights of stairs
without stopping.
B. A 45-year-old man with a history of coronary artery bypass graft surgery 8 years ago who has
sustained a motor vehicle accident and has findings in the emergency department of abdominal
visceral bleeding.
C. A 54-year-old woman for elective cholecystectomy. She was evaluated for chest pain in the
emergency department and found to have no coronary artery calcifications on cardiac CT.
D. A 58-year-old man for elective pulmonary lobectomy to resect a malignant nodule. The patient
had an executive physical examination where the nodule was found on a chest CT; he also had an
abnormal exercise stress test.
E. A 68-year-old man for an elective radical prostatectomy. He had a coronary artery bypass graft 2
years ago and has no symptoms of heart failure or angina.
I-44. All of the following risk factors are components of the Revised Cardiac Risk Index (RCRI) that is
used to assess the risk of perioperative major cardiac events EXCEPT:
A.
B.
C.
D.
E.

Congestive heart failure
High-risk surgery
Ischemic heart disease
Renal dysfunction
Thrombocytopenia

I-45. A 74-year-old man is scheduled to undergo total colectomy for recurrent life-threatening
diverticular bleeding. He has a history of idiopathic cardiomyopathy, renal insufficiency,
hypercholesterolemia, and chronic obstructive pulmonary disease (COPD). His current medications

include metoprolol, atorvastatin, enalapril, metformin, and albuterol/ipratropium inhaler. His
symptoms are well controlled, and he has had no emergency department visits in the past year for
exacerbations of his cardiomyopathy or COPD. His blood pressure is 128/86 mmHg. His physical
examination is normal. His most recent hemoglobin A1C was 6.3%, and his creatinine is 1.5 mg/dL.
Which of his medications should be discontinued before surgery?
A.
B.
C.
D.

Albuterol/ipratropium inhaler
Atorvastatin
Enalapril
Metoprolol

I-46. A 73-year-old man with a history of COPD and an forced expiratory volume in 1 second (FEV1) of
1.3 L (40% predicted) is undergoing an elective cholecystectomy. In the postoperative period, which
of the following interventions has been shown to decrease the likelihood of pulmonary
complications?
A.
B.
C.
D.
E.

Eliminating administration of narcotics
Incentive spirometry
Pulmonary artery catheterization
Total enteral nutrition
Total parenteral nutrition

I-47. Which of the following surgeries would be considered to have the greatest risk for postsurgical
complications?
A.
B.
C.
D.
E.

Carotid endarterectomy
Nonemergent repair of a thoracic aortic aneurysm
Resection of a 5-cm lung cancer
Total colectomy for colon cancer
Total hip replacement

I-48. All of the following are risk factors for postoperative pulmonary complications EXCEPT:
A.
B.
C.
D.
E.

Age >60 years
Asthma with a peak expiratory flow rate of 220 L/min
Chronic obstructive pulmonary disease
Congestive heart failure
FEV1 of 1.5 L

I-49. You are caring for a 56-year-old woman who was admitted to the hospital with a change in mental
status. She underwent a right-sided mastectomy and axillary lymph node dissection 3 years
previously for stage IIIB ductal carcinoma. Serum calcium is elevated at 15.3 mg/dL. A chest
radiograph demonstrates innumerable pulmonary nodules, and a head CT shows a brain mass in the
right frontal lobe with surrounding edema. Despite correcting her calcium and treating cerebral
edema, the patient remains confused. You approach the family to discuss the diagnosis of widely
metastatic disease and the patient’s poor prognosis. All of the following are components of the seven
elements for communicating bad news (P-SPIKES approach) EXCEPT:
A.
B.
C.
D.
E.

Assess the family’s perception of her current illness and the status of her underlying cancer
diagnosis
Empathize with the family’s feelings and provide emotional support
Prepare mentally for the discussion
Provide an appropriate setting for discussion
Schedule a follow-up meeting in 1 day to reassess whether there are additional informational and
emotional needs

I-50. All of the following statements regarding end-of-life epidemiology in the United States are true
EXCEPT:

A.
B.
C.
D.
E.

More than 70% of deaths occur in people over 65 years old.
Approximately 30% of patients die as hospital inpatients.
Approximately 70% of deaths are preceded by a known illness.
Cardiovascular disease and cancer are the most common causes of death.
HIV/AIDS is one of the top 10 causes of death.

I-51. All of the following are components of a living will EXCEPT:
A.

Delineation of specific interventions that would be acceptable to the patient under certain
conditions
B. Description of values that should guide discussions regarding terminal care
C. Designation of a healthcare proxy
D. General statements regarding whether the patient desires receipt of life-sustaining interventions
such as mechanical ventilation
I-52. A 72-year-old woman has stage IV ovarian cancer with diffuse peritoneal studding. She is
developing increasing pain in her abdomen and is admitted to the hospital for pain control. She
previously was treated with oxycodone 10 mg orally every 6 hours as needed. Upon admission, she is
initiated on morphine intravenously via patient-controlled analgesia. During the first 48 hours of her
hospitalization, she received an average daily dose of morphine of 90 mg and reports adequate pain
control unless she is walking. What is the most appropriate opioid regimen for transitioning this
patient to oral pain medication?

I-53. You are asked to consult on 62-year-old man who was recently found to have newly metastatic
disease. He was originally diagnosed with cancer of the prostate 5 years previously and presented to
the hospital with back pain and weakness. Magnetic resonance imaging (MRI) demonstrated bony
metastases to his L2 and L5 vertebrae with cord compression at the L2 level only. On bone scan
images, there was evidence of widespread bony metastases. He has been started on radiation and
hormonal therapy, and his disease has shown some response. However, he has become quite
depressed since the metastatic disease was found. His family reports that he is sleeping for 18 or
more hours daily and has stopped eating. His weight is down 12 lb over 4 weeks. He expresses
profound fatigue, hopelessness, and a feeling of sadness. He claims to have no interest in his usual
activities and no longer interacts with his grandchildren. What is the best approach to treating this
patient’s depression?
A.
B.
C.
D.
E.

Do not initiate pharmacologic therapy because the patient is experiencing an appropriate
reaction to his newly diagnosed metastatic disease.
Initiate therapy with doxepin 75 mg nightly.
Initiate therapy with fluoxetine 10 mg daily.
Initiate therapy with fluoxetine 10 mg daily and methylphenidate 2.5 mg twice daily in the
morning and at noon.
Initiate therapy with methylphenidate 2.5 mg twice daily in the morning and at noon.

I-54. You are treating a 76-year-old woman with Alzheimer disease admitted to the intensive care unit
for aspiration pneumonia. After 7 days of mechanical ventilation, her family requests that care be
withdrawn. The patient is palliated with fentanyl intravenously at a rate of 25 μg/hr and midazolam
intravenously at 2 mg/hr. You are urgently called to the bedside 15 minutes after the patient is
extubated because the patient’s daughter is distraught. She states that you are “drowning” her mother
and is upset because her mother appears to be struggling to breathe. When you enter the room, you
hear a gurgling noise that is coming from accumulated secretions in the oropharynx. You suction the
patient for liberal amounts of thin salivary secretions and reassure the daughter that you will make
her mother as comfortable as possible. Which of the following interventions may help with the
treatment of the patient’s oral secretions?
A.
B.
C.
D.
E.

Increased infusion rate of fentanyl
N-Acetylcysteine nebulized
Pilocarpine drops
Placement of a nasal trumpet and oral airway to allow easier access for aggressive suctioning
Scopolamine patches

I-55. You are caring for a 68-year-old man with end-stage idiopathic pulmonary fibrosis. His
performance status is currently 0; he is bed-bound and starting home hospice care. He is chronically
on nasal oxygen at 4 L/min with SaO2 of 94%. The patient reports relentless and severe dyspnea that
has worsened over the last 1–2 months. It is now his most notable complaint. Physical examination is
notable for normal vital signs other than a respiratory rate of 25/min. There is no evidence of
ongoing infection or other acute pulmonary process. Which of the following interventions would be a
reasonable first step to improve comfort for this patient?
A.
B.
C.
D.
E.

Albuterol
Codeine
Increase nasal oxygen to 8 L/min
Lorazepam
Nebulized morphine

I-56. All of the following statements regarding euthanasia or physician-assisted suicide are true EXCEPT:
A.
B.
C.
D.
E.

Over 70% of patients with terminal disease consider euthanasia or physician-assisted suicide for
themselves.
Over 75% of patients who seek physician-assisted suicide identify loss of autonomy or dignity
and inability to engage in enjoyable activities as their main reason.
Patients with cancer are the most common to consider euthanasia or physician-assisted suicide
for themselves.
Physician-assisted suicide is legal in some states in the United States.
Voluntary active euthanasia is not legal in the United States.

I-57. Which continent has the highest median population age?
A.
B.
C.
D.
E.

Africa
Asia
Australia
Europe
North America

I-58. The systemic effects of aging cluster into four domains: body composition, discrepancy between
energy demand and utilization, homeostatic dysregulation, and neurodegeneration. All of the
following statements regarding these effects are true EXCEPT:
A.

Lean muscle mass decreases after the third decade of life, whereas fat mass increases
progressively after middle age.
B.
Most older individuals, even those who are healthy, develop mild increases in markers of
inflammation such as C-reactive protein and interleukin-6 when compared to younger

individuals.
C. Peak oxygen consumption declines progressively with age.
D. The regions of the brain most likely to be atrophied with mild cognitive impairment are the
lateral prefrontal cortex and hippocampus.
I-59. Which of the following age groups is the fastest growing worldwide?
A.
B.
C.
D.
E.

1–20 years old
21–40 years old
41–60 years old
61–79 years old
>80 years old

I-60. Which of the following is the most common type of preventable adverse event in hospitalized
patients?
A.
B.
C.
D.
E.

Adverse drug events
Diagnostic failures
Falls
Technical complications of procedures
Wound infections

I-61. All of the following are steps in a cycle to rapidly improve a specific process EXCEPT:
A.
B.
C.
D.
E.

Act
Check
Do
Plan
Reevaluate

I-62. Which of the following is projected to cause the most deaths in low- and middle-income countries
in 2030?
A.
B.
C.
D.
E.

Cancer
Cardiovascular disease
HIV/AIDS, TB, malaria, and other infectious diseases
Intentional injuries
Road traffic accidents

I-63. The 2008 WHO World Health Report describes how a primary healthcare approach is necessary
“now more than ever” to address global health priorities. All of the following areas of reform were
highlighted in the report, EXCEPT:
A.
B.
C.
D.
E.

Drug development
Leadership
Public policy
Service delivery
Universal health coverage

I-64. Which of the following statements regarding the Dietary Supplements Health and Education Act
(DSHEA), passed in 1994, is true?
A.

Dietary supplement vendors can claim that dietary supplements maintain normal structure and
function of body systems.
B. Dietary supplement vendors can claim that dietary supplements prevent or treat diseases.
C. The FDA is given the authority to regulate advertising and marketing claims related to dietary
supplements.
D. The FDA is given the authority to regulate homeopathic products.

I-65. Which of the following descriptions best describes the term moral hazard as currently used in the
health insurance context?
A. A condition in which some individuals can be made better off without making anyone else worse
off
B. A situation in which physicians are reimbursed a fixed amount per patient and will have a
financial incentive to avoid sick patients
C. The branch of economics that seeks to explain actual phenomena without making a judgment
about the desirability of these phenomena
D. The incentives for better-insured individuals to use more medical services
E. The system in which the price of a good or service is dictated by a governmental or other
governing agency rather than by market forces
I-66. Independent of insurance status, income, age, and comorbid conditions, disparities exist between
the care received by black and white patients for which of the following scenarios?
A.
B.
C.
D.
E.

Prescription of analgesics for pain control
Referral to renal transplantation
Surgical treatment for lung cancer
Referral for cardiac catheterization and bypass grafting
All of the above

I-67. All of the following are legally relevant criteria for a physician establishing decision-making
capacity in a patient EXCEPT:
A.
B.
C.
D.
E.

The ability to answer basic orientation questions such as name, year, and home address
The ability to appreciate the situation and its consequences
The ability to communicate a choice
The ability to reason about treatment options
The ability to understand the relevant information

I-68. In which of the following conditions has stem cell therapy been shown to have in vivo benefit?
A.
B.
C.
D.
E.

Cirrhosis
Ischemic heart disease
Parkinson disease
Spinal cord injury
Type 1 diabetes mellitus

I-69. The greatest source of nutrients and calories in an individual’s diet should come from which
source?
A.
B.
C.
D.

Alcohol
Carbohydrates
Fat
Protein

I-70. You are evaluating the vitamin D intake for a 32-year-old woman who is not pregnant or lactating.
It is found to be below the recommended dietary allowance (RDA), although a serum level of vitamin
D has been measured previously as within normal limits. Which statement is true with regard to this
scenario?
A. Dietary reference intakes (DRI) would have been a better tool to determine if her nutrient intake
was adequate.
B. Given the normal serum level of vitamin D, there is no reason to increase her intake of vitamin D.
C. RDA is not the best measure for evaluating the nutrient requirements of this individual.
D. All of the above statements are true with regard to this scenario.

I-71. A 56-year-old man was admitted to the surgical service for care due to exposure injury and
frostbite in his distal extremities. He has a longstanding history of alcoholism, drinking about 1 L of
vodka on a daily basis. You are asked to consult due to concerns of bizarre behaviors exhibited by the
patient. He is expressing a belief that his wounds were the result of burns that were inflicted upon
him by “torturers” in the government because he “knows too much” about government surveillance
plans. The surgical team reports it is difficult to keep the patient in his bed, and he seems unsteady
on his feet at times. He has been medicated throughout his stay for prevention of alcohol withdrawal
via a symptom-triggered approach and last received lorazepam 2 mg orally about 2 hours ago. At that
time, the patient was noted to be tremulous, tachycardic, and hypertensive. The delusional thoughts
are not responsive to treatment of alcohol withdrawal symptoms. When you see the patient, he is
sleeping quietly. Vital signs are blood pressure 110/82, heart rate 94, respiratory rate 16,
temperature 37.1°C, and SaO2 97% on room air. He awakens easily and has a minimal resting tremor.
On neurologic examination, he exhibits past pointing, difficulty with rapid alternating movements,
horizontal nystagmus, and decreased sensation to light touch and pinprick in the lower extremities
below the mid-tibia. His gait is wide based and ataxic. He no longer expresses his prior delusional
beliefs, but he is disoriented and thinks he is in jail. He states he was brought to “this gulag” so that
the government could experiment on him. He has 5% dextrose in half-normal saline infusing at 100
mL/hr and is also receiving nafcillin 2 g IV every 4 hours for cellulitis. What do you suspect is the
cause of the patient’s altered mental state?
A.
B.
C.
D.
E.

Hypoglycemia
Hyponatremia
Niacin deficiency
Thiamine deficiency
Undertreated alcohol withdrawal

I-72. A 30-year-old woman expresses the desire to maintain a healthy lifestyle and has a focus on
preventative health. She believes that she can prevent illness and cancer through ingesting
supplements and antioxidants. When reviewing her current intake, you determine she is taking
vitamin A 20,000 IU daily and has been for the past 12 months. What advice can you give her
regarding this dose?
A.

Chronic ingestion of this dose could be associated with an increased risk of lung cancer even in
nonsmokers.
B. Chronic ingestion of this dose is associated with yellowing of the skin but not the sclerae.
C. She should discontinue this dose prior to attempting a pregnancy as this dose could lead to an
increased risk of spontaneous abortions and congenital malformations, including craniofacial
abnormalities and valvular heart disease.
D. This dose is the highest daily recommended dose that is proven to be safe without toxicity.
I-73. A 48-year-old man is diagnosed with carcinoid syndrome after presenting with diarrhea, flushing,
and hypotension. With appropriate treatment, he experiences an appropriate response biochemically,
and his flushing and blood pressure are markedly improved. However, he continues to have some
mild diarrhea and also has mouth soreness. He remains fatigued with a loss of appetite and
irritability. On examination, you notice his tongue is bright red and somewhat enlarged. It is tender
to touch. In addition, he has a pigmented and scaling rash that is most prominent around his
neckline. What is the most likely vitamin or mineral deficiency in this patient?
A.
B.
C.
D.
E.

Copper
Niacin
Riboflavin
Vitamin C
Zinc

I-74. Vitamin A deficiency is associated with an increased risk of which of the following:
A. Blindness

B.
C.
D.
E.

Maternal infection and death
Mortality from dysentery
Mortality from malaria
All of the above

I-75. A 51-year-old alcoholic man presents to the emergency department complaining of vomiting blood.
Upon further evaluation including gastric lavage, you determine that he is not experiencing an upper
gastrointestinal (GI) bleed, but rather is having significant gingival bleeding. He is intoxicated and
complains of fatigue. Reviewing his chart, you find 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 and international normalized ratio (INR) of 0.9. He has a diffuse hemorrhagic
eruption on his legs that is centered around hair follicles. What is the recommended treatment for
this patient’s underlying disorder?
A.
B.
C.
D.
E.

Folate
Niacin
Thiamine
Vitamin C
Vitamin K

I-76. A 21-year-old woman is admitted to the cardiac care unit after collapsing in her college dormitory.
When emergency personnel arrived at her home, she was found to be in a torsades de pointes
arrhythmia and was pulseless. She received cardiopulmonary resuscitation, defibrillation, and
magnesium en route to the hospital. Upon arrival, her initial potassium is 1.2 mEq/L. Her physical
examination is remarkable for an excessively thin appearance with lanugo hair on arms and chest.
Her BMI is 14.6 kg/m2. Which of the following statements is true regarding this patient’s nutritional
state?
A.
B.
C.
D.
E.

Mortality in the disease is most commonly due to complications of malnutrition.
Poor wound healing and frequent skin infections are common complications.
Systemic inflammation is a predominant finding on laboratory examination.
The serum albumin is typically less than 2.8 g/dL.
Triceps skinfold <3 mm and mid-arm muscle circumference <15 cm are useful diagnostic
criteria.

I-77. A 74-year-old woman is hospitalized in the surgical intensive care unit after undergoing an
emergent colectomy for ischemic colitis related to vascular disease. At the time of surgery, she had
experienced a bowel perforation. She is currently postoperative day 10 and remains intubated and
sedated with evidence of ongoing multiorgan system failure. She requires norepinephrine infusion
continuously at a rate of 10 μg/min. She has acute renal failure and is on continuous venovenous
hemodialysis. Her blood cultures were positive for Escherichia coli, and she is being treated with
cefepime 2 g IV every 8 hours and metronidazole 500 mg every 8 hours. She has a colostomy in her
right lower quadrant, but the surgeons were unable to primarily close her abdomen due to the bowel
perforation. She has returned to the operating room for reexploration and wash out of the
peritoneum. Since admission, her fluid balance is positive more than 30 L. She has marked anasarca
and has not been fed since admission, although the team plans to initiate total parenteral nutrition
today. Which statement is most likely true regarding her nutritional state?
A. Aggressive nutritional support should be avoided.
B. Immune function is not affected.
C. The albumin is less than 2.8 g/dL.

D. The body mass index will be less than 18.5 kg/m2.
E. The nutritional state does not confer any increased mortality risk for this patient.
I-78. Which of the following patients would be LEAST likely to be at high risk of nutritional depletion?
A. A 21-year-old woman with a history of anorexia nervosa in remission for 2 months with a BMI of

B.
C.
D.
E.

19.1 kg/m2 admitted to the hospital with an asthma exacerbation
A previously healthy 28-year-old man admitted to the intensive care unit with third-degree burns
covering 85% of his body surface area
A 32-year-old man with alcoholism admitted with acute pancreatitis who has been NPO for 6
days
A 41-year-old woman with short gut syndrome following resection of small bowel for a
gastrointestinal stromal tumor admitted to the hospital with dehydration
A 55-year-old woman admitted to the hospital for right mastectomy for breast cancer who has
recently lost 25 lb (from 200 to 175 lb) unintentionally

I-79. You are caring for a 54-year-old woman in the intensive care unit who was admitted for treatment
of severe sepsis and pneumonia. You would like to initiate enteral nutrition and plan to calculate
basal energy expenditure for the patient. All of the following factors are used to determine the
patient’s caloric needs EXCEPT:
A.
B.
C.
D.
E.

Age
Albumin
Gender
Height
Weight

I-80. A 65-year-old man is admitted for colectomy for stage III colon cancer. On the second
postoperative day, he requires repeat exploratory laparotomy due to bleeding complications. It is now
postoperative day 7 from his original resection, and the patient has had no nutrition since before

surgery. His BMI before surgery was 28.7 kg/m2, and he was felt to have normal nutritional status.
He is currently clinically stable, but delirious and at high aspiration risk. He has bowel sounds
present, and ileostomy output is good. What would be recommended at the present time for this
patient?
A. Continued NPO status because 5–7 days without nutritional support is acceptable for this patient
B. Initiate a clear liquid diet and supplement with intravenous fluids with dextrose to maintain
adequate intake
C. Placement of a central venous catheter and initiation of total parenteral nutrition
D. Placement of a nasogastric tube and initiation of enteral nutrition
E. Placement of a nasojejunal tube and initiation of enteral nutrition

I-81. All of the following statements support the use of enteral feeding for critically ill patients EXCEPT:
A.
B.
C.
D.
E.

Enteral feeding increases splanchnic blood flow.
Enteral feeding stimulates secretion of gastrointestinal hormones to promote trophic gut activity.
Immunoglobulin (Ig) A antibody release is stimulated by enteral feeding.
Neuronal activity to the gut is decreased by enteral feeding.
Seventy percent of nutrients used by the gut are directly derived from food within the lumen of
the gut.

I-82. What body mass index is likely to be lethal in males?
A. <10 kg/m2
B. 11 kg/m2

C. 13 kg/m2

D. 16 kg/m2

E. 18.5 kg/m2
I-83. A 43-year-old woman develops hemorrhagic pancreatitis with severe systemic inflammation
response syndrome. She is intubated and sedated in the medical intensive care unit with acute
respiratory distress syndrome, hypotension, and renal dysfunction. She has ongoing daily fevers to as

high as 104.5°F (40.3°C). She is initiated on parenteral nutrition (PN) and develops hyperglycemia as
high as 500 g/dL. She is also noted to have an increasingly positive fluid balance of more than 2 L
daily. What is the most appropriate approach to management of PN in the context of her
hyperglycemia and fluid retention?
A.
B.
C.
D.
E.

Addition of regular insulin to the total PN formula
Limiting sodium to less than 40 mEq/d
Limiting glucose to less than 200 g/d
Providing both glucose and fat to the total PN mixture
All of the above

I-84. Microbial agents have been used as bioweapons since ancient times. All of the following are key
features of microbial agents that are used as bioweapons EXCEPT:
A.
B.
C.
D.
E.

Environmental stability
High morbidity and mortality rates
Lack of rapid diagnostic capability
Lack of readily available antibiotic treatment
Lack of universally available and effective vaccine

I-85. Ten individuals in Arizona are hospitalized over a 4-week period with fever and rapidly enlarging
and painful lymph nodes. Seven of these individuals experience severe sepsis and three die. While
reviewing the epidemiologic characteristics of these individuals, you note that they are all illegal
immigrants and have recently stayed in the same immigrant camp. Blood cultures are growing gramnegative rods that are identified as Yersinia pestis. You notify local public health officials and the
Centers for Disease Control and Prevention. Which of the following factors indicates that this is NOT
likely to be an act of bioterrorism?
A. The area affected was limited to a small immigrant camp.
B. The individuals presented with symptoms of bubonic plague rather than pneumonic plague.
C. The individuals were in close contact with one another, suggesting possible person-to-person
transmission.
D. The mortality rate was less than 50%.
E. Y pestis is not environmentally stable for longer than 1 hour.
I-86. Which of the following routes of dispersal is/are likely for botulinum toxin used as a bioweapon?
A.
B.
C.
D.
E.

Aerosol
Contamination of the food supply
Contamination of the water supply
A and B
All of the above

I-87. Anthrax spores can remain dormant in the respiratory tract for how long?
A.
B.
C.
D.
E.

1 week
6 weeks
6 months
1 year
3 years

I-88. Twenty recent attendees at a National Football League game arrive at the emergency department
complaining of shortness of breath, fever, and malaise. Chest roentgenograms show mediastinal
widening on several of these patients, prompting a concern for inhalational anthrax as a result of a
bioterror attack. Antibiotics are initiated and the Centers for Disease Control and Prevention is
notified. What form of isolation should be instituted for these patients in the hospital?
A. Airborne

B. Contact
C. Droplet
D. None
I-89. The Centers for Disease Control and Prevention has designated several biologic agents as category
A in their ability to be used as bioweapons. Category A agents include agents that can be easily
disseminated or transmitted, result in high mortality, can cause public panic, and require special
action for public health preparedness. All the following agents are considered category A EXCEPT:
A.
B.
C.
D.
E.

Bacillus anthracis
Francisella tularensis
Ricin toxin from Ricinus communis
Smallpox virus
Y pestis

I-90. In September 2001, the U.S. public was exposed to a bioweapon agent delivered through the U.S.
Postal Service. Characteristic lesions of this infectious agent are shown in Figure I-90, Parts A and B,
below.

FIGURE I-90
Which of the following was the agent responsible for this event?
A.
B.
C.
D.
E.

B anthracis
Botulinum toxin
Ebola virus
Variola major
Y pestis

I-91. All of the following chemical agents of bioterrorism are correctly identified by their mechanism of
injury EXCEPT:
A.
B.
C.
D.
E.

Arsine—asphyxiant
Chlorine gas—pulmonary damage
Cyanogen chloride—nerve agent
Mustard gas—vesicant
Sarin—nerve agent

I-92. Over the course of 12 hours, 24 individuals present to a single emergency department complaining
of a sunburn-like reaction with development of large blisters. Most of these individuals are also
experiencing irritation of the eyes, nose, and pharynx. Two individuals developed progressive
dyspnea, severe cough, and stridor requiring endotracheal intubation. On physical examination, all of
the patients exhibited conjunctivitis and nasal congestion. Erythema of the skin was greatest in the
axillae, neck, and antecubital fossae. Many of the affected individuals had large, thin-walled bullae
on the extremities that were filled with a clear or straw-colored fluid. On further questioning, all of
the affected individuals had been shopping at a local mall within the past 24-hours and ate at the

food court. Many commented on a strong odor of burning garlic in the food court at that time. You
suspect a bioterrorism act. Which of the following statements is true with regard to the likely agent
causing the patients’ symptoms?
A. 2-Pralidoxime should be administered to all affected individuals.
B. The associated mortality of this agent is more than 50%.
C. The cause of respiratory distress in affected individuals is related to direct alveolar injury and
adult respiratory distress syndrome.
D. The erythema that occurs can be delayed as long as 2 days following exposure and depends upon
several factors including ambient temperature and humidity.
E. The fluid within the bullae should be treated as a hazardous substance that can lead to local
reactions and blistering with exposure.
I-93. A 24-year-old man is evaluated immediately following exposure to chlorine gas as an act of
chemical terrorism. He currently denies dyspnea. His respiratory rate is 16/min, and oxygen
saturation is 97% on room air. All of the following should be included in the immediate treatment of
this individual EXCEPT:
A.
B.
C.
D.
E.

Aggressive bathing of all exposed skin areas
Flushing of the eyes with water or normal saline
Forced rest and fresh air
Immediate removal of clothing if no frostbite
Maintenance of a semi-upright position

I-94. You are a physician working in an urban emergency department when several patients are brought
in after the release of an unknown gas at the performance of a symphony. You are evaluating a 52year-old female who is not able to talk clearly because of excessive salivation and rhinorrhea,
although she is able to tell you that she feels as if she lost her sight immediately upon exposure. At
present, she also has nausea, vomiting, diarrhea, and muscle twitching. On physical examination, the
patient has a blood pressure of 156/92 mmHg, a heart rate of 92, a respiratory rate of 30, and a
temperature of 37.4°C (99.3°F). She has pinpoint pupils with profuse rhinorrhea and salivation. She is
also coughing profusely, with production of copious amounts of clear secretions. A lung examination
reveals wheezing on expiration in bilateral lung fields. The patient has a regular rate and rhythm
with normal heart sounds. Bowel sounds are hyperactive, but the abdomen is not tender. She is
having diffuse fasciculations. At the end of your examination, the patient abruptly develops tonicclonic seizures. Which of the following agents most likely caused this patient’s symptoms?
A.
B.
C.
D.
E.

Arsine
Cyanogen chloride
Nitrogen mustard
Sarin
VX

I-95. All the following should be used in the treatment of the patient in the previous question EXCEPT:
A.
B.
C.
D.
E.

Atropine
Decontamination
Diazepam
Phenytoin
2-Pralidoxime chloride

I-96. All of the following statements regarding the results of detonation of a low-yield nuclear device by
a terror group are true EXCEPT:
A. After recovery of initial exposure symptoms, the patient remains at risk of systemic illness for up
to 6 weeks.
B. Appropriate medical therapy can change the median lethal dose from approximately 4 Gy to 8
Gy.

C. Initial mortality is mostly due to shock blast and thermal damage.
D. Most of the total mortality is related to release of alpha and beta particles.
E. The hematopoietic, gastrointestinal, and neurologic systems are most likely involved in acute
radiation syndrome.
I-97. A “dirty” bomb is detonated in downtown Boston. The bomb was composed of cesium-137 with
trinitrotoluene. In the immediate aftermath, an estimated 30 people were killed due to the power of
the blast. The fallout area was about 0.5 mile, with radiation exposure of approximately 1.8 Gy. An
estimated 5000 people have been potentially exposed to beta and gamma radiation. Most of these
individuals show no sign of any injury, but about 60 people have evidence of thermal injury. What is
the most appropriate approach to treating the injured victims?
A. All individuals who have been exposed should be treated with potassium iodide.
B. All individuals who have been exposed should be treated with Prussian blue.
C. All individuals should be decontaminated prior to transportation to the nearest medical center for
emergency care to prevent exposure of healthcare workers.
D.
Severely injured individuals should be transported to the hospital for emergency care after
removing the victims’ clothes, because the risk of exposure to healthcare workers is low.
E. With this degree of radiation exposure, no further testing and treatment are needed.
I-98. A 38-year-old man was hiking in a national forest near Tallahassee, Florida, when he was bitten on
his lower right leg by a snake that his hiking companion identified as a rattlesnake. The man was
wearing shorts and hiking boots. There are two clear puncture wounds that are oozing blood just
above the sock line of his right boot, and the man is beginning to complain of increasing pain in the
right leg. The man and his companion are about 15 minutes away from the trailhead and do not have
a cell phone. What should be done immediately in the care of this patient?
A.
B.
C.
D.
E.
F.

Apply a splint if available to support the limb and decrease pain and seek immediate medical
care
Apply a tourniquet superior to the bite to limit circulation of the venom
Incise or apply suction to the site of the bite immediately to attempt to remove injected venom
When possible, elevate the limb to heart level
A and D only
All of the above

I-99. The companion of the patient in Question I-98 assists him to the trailhead and activates emergency
medical services. Upon arrival to the emergency department, the patient is noted to have increasing
swelling and pain in the right lower extremity. The vital signs are blood pressure 98/52 mmHg, heart
rate 132 bpm, respiratory rate 24/min, SaO2 96% on room air, and temperature 37.0°C. The limb is
positioned at the level of the heart. The maximum level and progression of swelling is marked. Two
large-bore IV’s are placed, and aggressive fluid resuscitation is begun. Which of the following is an
indication for administration of antivenom?
A.
B.
C.
D.
E.

Coagulopathy
Hypotension unresponsive to fluid administration
Swelling in the right lower leg that crosses the ankle
Swelling in the right lower leg that involves more than half of the leg
All of the above would be indications for antivenom administration

I-100. Four individuals from the same family present to the emergency department with symptoms of
abdominal pain, nausea, vomiting, and diarrhea. Two of the family members are also reporting
strange tingling sensations around their lips, and one person says he feels like he is swallowing
bubbles. The family is vacationing in Florida and have been deep sea fishing all day. For dinner, they
ate some of the fish they had caught, including some small barracuda. Emergency department
evaluation is unrevealing, and they are discharged with only symptomatic nausea treatment. Over the
next 24 hours, their GI symptoms peak and then resolve within 3 days. The two individuals with mild
paresthesias also resolve over 3 days. However, one individual develops reversal of hot and cold

perception after 3 days. This symptom continued to persist after 6 weeks. What was the likely cause
of the patients’ illness?
A.
B.
C.
D.
E.

Ciguatera poisoning
Diarrhetic shellfish poisoning
Domoic acid intoxication
Scombroid poisoning
Tetrodotoxin poisoning

I-101. A 42-year-old woman and her 6-year-old daughter have each been treated for head lice with two
applications of over-the-counter 1% permethrin separated by 10 days. Mechanical removal of lice and
their eggs was performed after each application. Environmental measures have included washing all
bedding in hot water and drying at >55°C. The father’s head is shaved. Despite this, the daughter is
again found to have live lice on her scalp. What measures would you recommend at this time?
A. Apply topical treatments such as petrolatum to avoid further exposure to pesticide
B. Complete an additional treatment with 1% permethrin
C. Perform a more thorough environmental investigation for possible fomite transmission
D. Refrain from all participation in school until the child is determined to be free of all nits (lice
eggs)
E. Treat with topical spinosad due to permethrin resistance
I-102. A 56-year-old man seeks evaluation due to a spider bite. He was dressing this morning and pulled
a sweatshirt over his head. He felt a sharp sting on his upper arm and found a brown recluse spider in
his clothing. He has noticed some redness in this area. On examination, you see a 3 × 2 cm lesion on
the inner area of his upper arm. In the center, it is somewhat pale and indurated, but the surrounding
area is erythematous and painful to touch. What is the best treatment for this patient?
A.
B.
C.
D.
E.

Administer antivenom
Advise the patient that most patients develop ischemic necrosis that requires prolonged healing
Apply RICE (rest, ice, compression, and elevation) and observe closely for signs of ischemia
Prescribe clindamycin 600 mg qid for cellulitis
Refer to the emergency department for further evaluation and possible debridement

I-103. One of your patients is contemplating a trekking trip to Nepal at elevations between 2500 and
3000 meters. Five years ago, while skiing at Telluride (altitude 2650 meters), she recalls having
headache, nausea, and fatigue within a day of arriving that lasted about 2–3 days. All of the
following statements are true regarding the development of acute mountain sickness in this patient
EXCEPT:
A.
B.
C.
D.
E.

Acetazolamide starting 1 day before ascent is effective in decreasing the risk.
Ginkgo biloba is not effective in decreasing the risk.
Gradual ascent is protective.
Her prior episode increases her risk for this trip.
Improved physical conditioning before the trip decreases the risk.

I-104. A 36-year-old man develops shortness of breath, dyspnea, and dry cough 3 days after arriving for
helicopter snowboarding in the Bugaboo mountain range in British Columbia (elevation 3000
meters). Over the next 12 hours, he becomes more short of breath and produces pink frothy sputum.
An emergency medical technician (EMT)–trained guide hears crackles on chest examination. All of
the following statements are true regarding his illness EXCEPT:
A.
B.
C.
D.
E.

Descent and oxygen are most therapeutic.
Exercise increased his risk.
Fever and leukocytosis may occur.
He should never risk return to high altitude after recovery.
Pretreatment with nifedipine or tadalafil would have lowered his risk.

I-105. Which of the following is considered an absolute contraindication to hyperbaric oxygen therapy?
A.
B.
C.
D.
E.

Carbon monoxide poisoning
History of COPD
History of high-altitude pulmonary edema
Radiation proctitis
Untreated pneumothorax

I-106. A 35-year-old woman is scuba diving while vacationing in Malaysia. During her last dive of the
day, her regulator malfunctioned, requiring her to ascend from 20 meters to the surface rapidly.
Upon returning to the boat she felt well. However, about 6 hours after returning to shore, she
develops diffuse itching and muscle aches, leg pain, blurred vision, slurred speech, and nausea.
Which of the following statements regarding her condition is true?
A.
B.
C.
D.
E.

Decompression illness is unlikely at 20-meter water depth.
Inhalation of 100% oxygen is contraindicated.
She can never again scuba dive to a depth greater than 6 meters.
She should receive recompression and hyperbaric oxygen therapy.
She should remain upright as much as possible.

I-107. A 48-year-old man is brought to the emergency department in January after being found
unresponsive in a city park. He suffers from alcoholism and was last seen by his daughter about 12
hours before being brought to the emergency department. At that time, he left their home intoxicated
and agitated. He left seeking additional alcohol as his daughter had poured out his last bottle of
vodka hoping that he would seek treatment. On presentation, he has a core body temperature of
88.5°F (31.4°C), heart rate of 48 bpm, respiratory rate of 28/min, and blood pressure of 88/44
mmHg; oxygen saturation is unable to be obtained. The arterial blood gas demonstrates a pH of 7.05,
PaCO2 of 32 mmHg, and PaO2 of 56 mmHg. Initial blood chemistries demonstrate a sodium of 132
mEq/L, potassium of 5.2 mEq/L, chloride of 94 mEq/L, bicarbonate of 10 mEq/L, blood urea
nitrogen (BUN) of 56 mg/dL, and creatinine of 1.8 mg/dL. Serum glucose is 63 mg/dL. The serum
ethanol level is 65 mg/dL. The measured osmolality is 328 mOsm/kg. ECG demonstrates sinus
bradycardia with a long first-degree atrioventricular block and J waves. In addition to initiating a
rewarming protocol, what additional tests should be performed in this patient?
A. Endotracheal intubation with hyperventilation to a goal PaCO2 of less than 20 mmHg
B. Intravenous hydration with a 1- to 2-L bolus of warmed lactated Ringer’s solution
C. No other measures necessary because interpretation of the acid-base status is unreliable with this
degree of hypothermia
D. Measure levels of ethylene glycol and methanol
E. Placement of a transvenous cardiac pacemaker
I-108. A homeless male is evaluated in the emergency department. He has noted that after he slept
outside during a particularly cold night his left foot has become clumsy and feels “dead.” On
examination, the foot has hemorrhagic vesicles distributed throughout the foot distal to the ankle.
The foot is cool and has no sensation to pain or temperature. The right foot is hyperemic but does not
have vesicles and has normal sensation. The remainder of the physical examination is normal. Which
of the following statements regarding the management of this disorder is true?
A.
B.
C.
D.
E.

Active foot rewarming should not be attempted.
During the period of rewarming, intense pain can be anticipated.
Heparin has been shown to improve outcomes in this disorder.
Immediate amputation is indicated.
Normal sensation is likely to return with rewarming.

I-109. Which of the following is the major source of heat loss in normal adults?
A. Kidney/urine
B. Skin

C. Stomach/bowel
D. Upper/lower respiratory system
I-110. A 74-year-old man is brought to the emergency department by ambulance after being found in his
yard confused and somnolent. He was outside trimming hedges with an electric cutter during a hot
summer day for about 2–3 hours prior to being found by his wife. He has a history of mild-moderate
systolic heart failure, and his medications include atorvastatin, metoprolol, and losartan. He lives
with his wife and works as a TSA officer in the airport. On examination, he is difficult to arouse and
confused, with a heart rate of 120 bpm, blood pressure of 100/50 mmHg, respiratory rate of 26
breaths/min, oxygen saturation of 97% on room air, and temperature of 41°C. His skin is dry and
warm with the rest of the physical examination unremarkable. His laboratory studies are notable for
a sodium of 146 mEq/L, potassium of 3.8 mEq/L, creatine kinase of 250 U/L (reference 25–200 U/L),
glucose of 120 mg/dL, BUN of 35 mg/dL, and creatinine of 1.2 mg/dL. Which of the following is the
most likely diagnosis?
A.
B.
C.
D.
E.

Cerebral hemorrhage
Classic heat stroke
Exertional heat stroke
Neuroleptic malignant syndrome
Statin-induced rhabdomyolysis

I-111. In the patient described in Question I-110, which is the most appropriate therapy?
A.
B.
C.
D.
E.

Cold water bladder irrigation
Cooling blankets
Evaporative cooling
Immersion cooling
Phenylephrine

ANSWERS
I-1.

The answer is E. (Chap. 1) Practice guidelines have been developed by many professional
organizations and agencies as a decision-making aid to caregivers. Most organizations attempt to
incorporate the most recent available evidence and concerns of cost-effectiveness into their
guideline formulations. Despite increasing levels of nuance in current guidelines, they cannot be
expected to account for the uniqueness of each individual and his or her illness. Furthermore,
many discrepancies exist in guidelines from major organizations. By setting a standard of
reasonable care in most cases, clinical guidelines provide protection to both clinicians (from
inappropriate charges of malpractice) and to patients, particularly those with inadequate
healthcare resources. Even though guidelines do provide this protection, they do not provide a
rigid legal constraint for the conscientious physician. The physician’s challenge is to incorporate
the useful recommendations provided by the experts in guidelines and incorporate them into the
care of each individual patient.

I-2.

The answer is D. (Chap. 1) The field of molecular medicine is seeing rapid progress in fields
other than genetics, bringing a new era of “-omics.” Metagenomics is the genomic study of
environmental species that have the potential to influence human biology directly or indirectly.
Metabolomics is the study of the range of metabolites in cells or organs and ways in which they are
altered in disease states. Microbiomics is the study of the resident microbes in humans and other
mammals. Thermophiles do not reside in humans or other mammals by definition, and thus, their
study would not be included in the field of microbiomics. This field has proven particularly rich;
the microbes residing on and in the human body comprise over 3–4 million genes (vs. the 20,000
genes in the human haploid genome). Proteomics is the study of the library of proteins made in a
cell or organ (including posttranslational modifications) and its complex relationship to disease.
Exposomics is the study cataloguing environmental exposures and their impact on health and

disease.
I-3.

The answer is D. (Chap. 1) Evidence-based medicine (EBM) is an important cornerstone to the
effective and efficient practice of medicine. EBM refers to the concept that clinical decisions
should be supported by data with the strongest evidence gleaned from randomized controlled
clinical trials. In many situations, data from observational studies such as cohort or case-control
studies supply important information and contribute to the evidence used in clinical decisions in
EBM. EBM is used by professional organizations and other agencies to formulate clinical practice
guidelines, which are support tools to aid clinical decision making (option C). Systematic reviews
summarize the accumulated data from all existing clinical trials (option A). Comparative
effectiveness research (option B) compares different approaches to treating disease to determine
effectiveness from a clinical and cost-effectiveness standpoint. Anecdotal evidence (option E) is
the weakest type of evidence, represents one individual’s clinical experience, and is subject to the
bias inherent in one practitioner’s personal experience.

I-4.

The answer is A. (Chap. 2) The disability-adjusted life-year (DALY) is the standard measure for
determining global burden of disease by the World Health Organization. This measure takes into
account both absolute years of life lost due to disease (premature death) as well as productive
years lost due to disability. DALY is felt to more accurately reflect the true effects of disease
within a population because individuals who become disabled cannot contribute fully to society.
Life expectancy, years of life lost due to disease, standardized mortality ratios, and infant
mortality do provide important information about the general health of a population but do not
capture the true burden of disease.

I-5.

The answer is C. (Chap. 2) Although 24.6% of deaths worldwide were due to communicable
diseases, maternal and perinatal conditions, and nutritional deficiencies in 2010, this represented
a striking decrease with figures from 1990, when these conditions accounted for 34% of
worldwide mortality (option A). The majority of mortality from these causes occurs in subSaharan Africa or southern Asia (76%). Poverty status and health are strongly linked both at the
individual and national levels (option C). In 1990, childhood undernutrition was the leading risk
factor for global disease burden. However, in 2010, the three leading risk factors for global
disease burden were high blood pressure, tobacco smoking (including secondhand smoke), and
alcohol use (option D). Childhood undernutrition ranked eighth in 2010, which remains vexing
given the rise of obesity as a global risk factor for disease. The WHO in 2006 estimated that a full
25% of total global burden of disease was due to modifiable risk factors. This includes remarkable
estimates that 80% of cardiovascular disease and type 2 diabetes and 40% of all cancers can be
prevented through healthier diets, increased physical activity, and avoidance of tobacco.

I-6.

The answer is A. (Chap. 2) Examining AIDS and TB as chronic diseases—instead of simply
communicable diseases—makes it possible to draw a number of conclusions, many of them
pertinent to global health in general. One of the most striking lessons is that these chronic
infections are best treated with multidrug regimens to which the infecting strains are susceptible.
This involves the concomitant administration of several drugs, instead of a switching from one
drug to another throughout the course of treatment (option E), a strategy more likely to lead to
multidrug resistance in chronic infections. For people living in poverty, even small fees (option A)
for health services often pose insurmountable problems and obviates these people’s ability to
obtain important healthcare. Such services might best be seen as a public good promoting public
health. Many physicians and nurses do indeed emigrate from their homes in resource-poor
settings to practice their trades elsewhere (option C). However, a lack of tools necessary for their
practice in their home nations is the primary reason cited for their emigration. Even in areas
where physicians are abundant, community-based supervision represents the highest standard of
care for chronic disease (option D). Option B is correct;– barriers to adequate healthcare and
adherence imposed by extreme poverty (e.g., food supplements for the hungry, child care,
housing) must be addressed when treating and preventing chronic diseases in developing nations.

I-7.

The answer is E. (Chap. 3) Dr. Smith likely employed both the availability heuristic and
anchoring heuristic in diagnosing Mrs. Johnson with systemic lupus erythematosus (SLE).

Heuristics are decision-making “shortcuts” or “rules of thumb” that clinicians employ to simplify
decision strategies. The availability heuristic involves judgments based on how easily the current
case brings to mind prior cases. Mrs. Johnson likely reminded Dr. Smith of Mrs. Jones, a recent
young African American woman with facial rash and joint pain who turned out to have SLE. After
the negative test for antinuclear antibodies, Dr. Smith failed to adjust her posttest probability
appropriately, settling on the diagnosis of SLE regardless of the negative test result. This
represents the anchoring heuristic, whereby a clinician insufficiently adjusts the probability up or
down based on a test result; –in effect, they are stuck or “anchored” to their pretest diagnosis. The
anchoring heuristic often represents a failure of the clinician to properly employ Bayes’ rule. This
rule states that a posttest probability of diagnosis depends on three parameters: the pretest
probability of disease, the test sensitivity, and the test specificity. Mathematically, it is expressed
as follows for a positive test:
Posttest probability = (Pretest probability × Sensitivity)/[Pretest probability × Sensitivity + (1 –
Pretest probability) × False-positive rate]
Confirmation bias is defined as the tendency to look for confirming evidence to support a
diagnosis rather than look for discomfirming evidence to refute it (despite the latter often being
more persuasive and definitive). In this case, the antinuclear antibody test has a high specificity
and high negative predictive value for SLE. Thus, despite Dr. Smith’s high pretest probability, a
negative test for antinuclear antibodies provides a very low posttest probability that Mrs. Johnson
has SLE. Dr. Smith fails to take this into account, “anchoring” instead on the diagnosis of SLE to
the point of starting treatment.
I-8. The answer is E. (Chap. 3) Specificity is the number of true negatives of the test studied divided
by the number of subjects in the population without the disease (true negatives + false positives).
In this case, 70 subjects with a negative troponin assay had a negative veritangin assay, and 5
patients with a negative troponin assay has a positive veritangin assay (false positive). Thus, the
specificity of veritangin is 0.93 (70/75). Sensitivity and specificity of a test do not depend on the
disease prevalence in a population (option B). However, posttest probability depends heavily on
pretest probability by Bayes’ rule (option A). For example, if you chose a population where every
patient had a positive troponin (the gold standard blood test for myocardial infarction), your preand posttest probability for myocardial infarction would be 1.0 regardless of any other test
performed. By decreasing the cut point of the studied assay, the sensitivity will increase by
reducing the number of false-negative tests (option C). Without other data, it is unknown by how
much the sensitivity would increase. The sensitivity of a test is calculated by the number of true
positives divided by the total number of patients with the disease by gold standard testing (true
positives + false negatives). In this case, 25 patients had myocardial infarctions by troponin
assay, 10 of whom had a positive veritangin assay (true positive). Thus, the sensitivity is 10/25,
or 0.4 (option D).
I-9. The answer is E. (Chap. 3) In prospective observational studies, the investigator does not control
patient care. Thus, any intervention studied is subject to treatment selection bias (–i.e., clinical
practice in selecting patients in the population for the treatment may not be random). Although
certain statistical models may be employed to attempt to adjust for treatment selection bias in
observational studies, randomized controlled trials obviate treatment selection bias by their
prospective random assignment of patients to treatment or placebo arms of the trial. While
observational trials can be very useful and provide immense insight, randomized controlled trials
are generally deemed superior if feasible (option A). Likewise, the use of concurrent controls is
superior to historical controls (option C). The use of historical controls can be misleading because
it may not account for advances in clinical medicine that have occurred between the treatment of
the control and intervention arms of the trial. Population selection of any randomized trial is
crucial to determining the external validity (generalizability) of the results to practicing clinicians
(option D). The savvy physician will read randomized controlled trials published in high-impact
journals to determine if their patients fit the population studied. A “positive” trial does not mean
that any patient with clotbegone would benefit from therapy. For example, if the trial did not

enroll women, the results could not be generalized to that population (option B).
I-10.

The answer is D. (Chap. 3) A receiver operating characteristic (ROC) curve plots sensitivity (or
true-positive rate) on the y-axis and 1 – specificity (or false-positive rate) on the x-axis. Each point
on the curve represents a cutoff point of sensitivity and 1 – specificity, and these cutoff points are
used to select the threshold value for a diagnostic test that yields the best trade-off between truepositive and false-positive tests. The area under the curve can be used as a quantitative measure
of the information content of a test. Values range from 0.5 (a 45 degree line), representing no
diagnostic information, to 1.0 for an ideal test. In the medical literature, ROC curves are often
used to compare alternative diagnostic tests, but the interpretation of a specific test and ROC
curve is not as simple in clinical practice. One criticism of the ROC curve is that it evaluates only
one test parameter with exclusion of other potentially relevant clinical data. Also, one must
consider the underlying population in which the ROC curve was validated and how generalizable
this is to the entire population with disease.

I-11. The answer is E. (Chap. 4) Within a population, it is certainly impractical to perform all possible
screening procedures for the variety of diseases that exist in that population. This approach would
be overwhelming to the medical community and would not be cost-effective. Indeed, the amount
of monetary and psychological stress that would occur from pursuing false-positive test results
would add an additional burden on the population. When determining which procedures should
be considered as screening tests, a variety of end points can be used. One of these is to determine
how many individuals would need to be screened in the population to prevent or alter the
outcome in one individual with disease. While this can be statistically determined, there are no
recommendations for what the threshold value should be, and may change based on the
invasiveness or cost of the test and the potential outcome avoided. Additionally, one should
consider both the absolute and relative impact of screening on disease outcome. Another measure
used in considering the utility of screening tests is the cost per life-year saved. Most measures are
considered cost-effective if they cost <$30,000–$50,000 per year of life saved. This measure is
also sometimes adjusted for the quality of life as well and presented as quality-adjusted life-years
saved. A final measure that is used in determining the effectiveness of a screening test is the effect
of the screening test on life expectancy of the entire population. When applying the test across the
entire population, this number is surprisingly small, and a goal of about 1 month is desirable for a
population-based screening strategy.
I-12. The answer is B. (Chap. 4) Screening is indeed most effective when applied to relatively common
diseases within the population. Because no test is perfect and posttest probability depends heavily
on the disease prevalence within the population studied (pretest probability) by Bayes’ rule, any
screening test will perform poorly if employed in the wrong population. To use an extreme
example, screening for prostate cancer in women with prostate-specific antigen testing can only
lead to an unacceptable level of false-positive results. On the other hand, populations with very
high risk of the disease should undergo more rigorous screening and prevention measures.
Patients with the BRCA1 or BRCA2 mutations have a very high lifetime risk of breast cancer.
Thus, their chance of experiencing a false-negative result with traditional screening methods is
unacceptable. It is recommended that these patients undergo breast magnetic resonance imaging
for screening (option E). This is not necessary in the general population, as their baseline risk of
breast cancer is lower. In general, the presence of a latent period (asymptomatic presence of the
disease) is a necessity for successful screening. If a disease has no latent period, screening
becomes less effective as early treatment and prevention are obviated (option C). When
considering the effectiveness of any screening method, disease incidence and overall mortality are
the most important outcomes (option D). Comparing length of disease survival will be susceptible
to lead and length time biases. Lead time bias occurs because screening identifies a case before it
would have presented clinically, thereby creating the perception that a patient lived longer after
diagnosis simply by moving the date of diagnosis earlier rather than the date of death later.
Length time bias occurs because screening is more likely to identify slowly progressive disease
than rapidly progressive disease. Thus, within a fixed period of time, a screened population will
have a greater proportion of these slowly progressive cases and will appear to have better disease

survival than an unscreened population. It is also important to remember that every detected and
treated disease by any screening mechanism does not necessarily represent a reduction in
mortality (option A). Certain diseases have a long enough latent period that many patients die
with the disease and not from the disease. In fact, recent estimates suggest that as many as 15%–
25% of breast cancers identified by mammography screening would never have presented
clinically.
I-13.

The answer is A. (Chap. 4) Recently, the National Heart, Lung, and Blood Institute found that
low-dose chest CT scanning can detect tumors earlier, and CT was recently demonstrated to
reduce lung cancer mortality by 20% in individuals who had at least a 30-pack-year history of
smoking (option E). This represented somewhat of a paradigm shift in how lung cancer screening
was viewed. Historically, lung cancer screening in even high-risk populations had proven largely
unsuccessful as many detected cancers were incurable at the time of detection by screening
(option B). A screening test is hardly ever a “no-brainer.” In the case of lung cancer screening,
several risks need to be discussed with the patient prior to referral for low-dose CT scanning. First,
there is the risk of detection of an incurable cancer as discussed above. Second, even low-dose CT
scanning exposes the patient to radiation and may increase their risk for subsequent neoplasm.
Finally, every screening test carries a risk of a false positive. In the case of lung cancer screening,
false-positive results may lead to invasive biopsies and even drastic surgeries such as
pneumonectomy (option C). Finally, although the sensitivity and specificity of a test do not
depend on the population risk (a patient’s pretest probability), the posttest probability of disease
provided by a positive or negative test does strongly depend on the pretest probability (option D).
This is the reason why carefully choosing the appropriate risk patient for each screening test is
important.

I-14. The answer is B. (Chap. 4) Predicted increases in life expectancy are average numbers that apply
to populations, not individuals. Because we often do not understand the true nature of risk of
disease, screening and lifestyle interventions usually benefit a small proportion of the total
population. For screening tests, false positives may also increase the risk of diagnostic tests. While
Pap smears increase life expectancy overall by only 2–3 months, for the individual at risk of
cervical cancer, Pap smear screening may add many years to life. The average life expectancy
increases resulting from mammography (1 month), PSA (2 weeks), or exercise (1–2 years) are less
than from quitting smoking (3–5 years).
I-15.

The answer is C. (Chap. 4) The U.S. Preventive Services Task Force (USPSTF) is an independent
panel of experts selected by the federal government to provide evidence-based guidelines for
prevention and screening for disease. The panel typically consists of primary care providers from
internal medicine, family medicine, pediatrics, and obstetrics and gynecology. The USPSTF
recommends screening all patients age 15–65 once for HIV. Ultrasound for abdominal aortic
aneurysm should be performed in men age 65–75 who have smoked (option D). Screening for
chlamydia and gonorrhea should be performed in sexually active women <25 years old (option
B). Hepatitis C screening is recommended for adults born between 1945 and 1965 (option E).
DEXA scanning for osteoporosis screening is recommended for woman >65 or >60 years old
with risk factors (option C).

I-16.

The answer is C. (Chap. 5) Grapefruit juice inhibits CYP3A4 in the liver, particularly at high
doses. This can cause decreased drug elimination via hepatic metabolism and can increase
potential drug toxicities. Atorvastatin is metabolized via this pathway. Drugs that may enhance
atorvastatin toxicity via this mechanism include phenytoin, ritonavir, clarithromycin, and azole
antifungals. Aspirin is cleared via renal mechanisms. Prevacid can cause impaired absorption of
other drugs via its effect on gastric pH. Sildenafil is a phosphodiesterase inhibitor that may
enhance the effect of nitrate medications and cause hypotension.

I-17.

The answer is D. (Chap. 5) Calcineurin inhibitors such as tacrolimus and cyclosporine are
immunosuppressive agents that are used following solid organ transplantations as well as for
treatment of graft-versus-host disease in bone marrow transplant patients. These drugs are
primarily metabolized via the cytochrome P450 pathway and excreted into bile. Many drugs and

foods can be inhibitors or inducers of this pathway, and thoughtful consideration of possible drug
interactions must be considered when starting any patient on a new medication while on
tacrolimus or cyclosporine. In this case, voriconazole inhibits metabolism of tacrolimus, leading to
increased serum concentrations of the drug. The clinical signs and symptoms of tacrolimus
toxicity include hypertension, edema, headaches, insomnia, and tremor. In addition, elevated
levels of tacrolimus can lead to worsening renal function and electrolyte abnormalities including
hyperkalemia, hypomagnesemia, hypophosphatemia, and hyperglycemia. It is recommended that
the tacrolimus dose be decreased to one-third of the original dose when it is necessary to
coadminister tacrolimus and voriconazole. Aspergillus meningitis is a rare infection that typically
results from direct invasion from a rhinosinusitis. Congestive heart failure is unlikely in the
clinical scenario as this is a young woman with no known heart disease and the neurologic
symptoms are not consistent with that diagnosis. Graft-versus-host disease (GVHD) occurs when
transplanted immune cells recognize the host cells as foreign and initiate an immune response.
GVHD occurs following allogeneic hematopoietic stem cell transplantations, and there is increased
risk of GVHD in those with a greater disparity of human leukocyte antigens (HLAs) between the
graft and the host. GVHD presents acutely with a diffuse maculopapular rash, fever, elevations in
bilirubin and alkaline phosphatase, and diarrhea with abdominal cramping. There are case reports
of nephritic syndrome related to GVHD, but renal involvement is not common. Also unlikely are
neurologic symptoms, headache, hypertension, and tremor. Thrombotic thrombocytopenic
purpura (TTP) could be considered in an individual with renal disease, altered mental status, and
hypertension if there was concurrent evidence of an intravascular hemolytic process. However,
TTP has not been associated with administration of voriconazole.
I-18. The answer is B. (Chap. 5) Bioavailability refers to the amount of the drug that is available to the
systemic circulation when administered by routes other than the intravenous route. In this setting,
bioavailability may be much less than 100%. The primary factors affecting bioavailability are the
amount of drug that is absorbed and metabolism of the drug prior to entering the systemic
circulation (the first-pass effect). Oral itraconazole is the recommended treatment for mild
blastomycosis, but a problem with use of this drug is its bioavailability which is estimated at
about 55%. While oral itraconazole does not experience a significant first-pass effect, its
absorption from the stomach can be quite variable under different conditions. A first important
consideration is the drug preparation. The liquid formulation should be taken on an empty
stomach, whereas the capsule should be taken after a meal. Furthermore, having an acid pH
improves bioavailability, and use of gastric acid suppressors such as H2 blockers or proton pump
inhibitors should be avoided with itraconazole use. When acid suppressors cannot be withheld, it
is recommended to co-administer itraconazole with a cola beverage, which has been shown to
enhance absorption in some clinical trials. Oral contraceptive pills will not affect the
bioavailability of itraconazole; however, azole antifungals (including itraconazole) inhibit CYP450
3A4 and may increase the serum levels of estrogens and progestins.
I-19.

The answer is A. (Chap. 5) Mexiletine, lovastatin, ritonavir, and saquinavir are all substrates of
the cytochrome P450 enzyme CYP3A4. As one of the most ubiquitous drug clearance enzymes,
CYP3A4 metabolism is often a culprit in adverse drug–drug interactions, and the savvy clinician
will be wary of co-prescribing drugs metabolized by this enzyme. Ketoconazole is a powerful
inhibitor of CYP3A4, and co-administration of ketoconazole with lovastatin, mexiletine, ritonavir,
and saquinavir may lead to impressive increases in the plasma level of these medications,
resulting in potential toxicity. In fact, the CYP3A4-inhibition qualities of ketoconazole are
sometimes leveraged to increase drug levels of medications like tacrolimus in the posttransplant
patient when stable and elevated tacr