# Harrison

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Internal medicine

C. 8

C. 237

A. Capitation

### I-4. The curve that graphically represents the family of cutoff points for a positive vs. negative test is a receiver operating characteristic (ROC) curve. The area under this curve is a quantitative measure of the information content of a test. The ROC axes are

C. sensitivity vs. (1 - specificity)

### I-5. A patient is seen in the clinic for evaluation of chest pain. The patient is 35 years old and has no medical illnesses. She reports occasional intermittent chest pain that is unrelated to exercise but is related to eating spicy food. The physician's pretest probability for coronary artery disease causing these symptoms is low; however, the patient is referred for an exercise treadmill test, which shows ST depression after moderate exercise. Using Bayes' theorem, how does one interpret these test results?

A. The pretest probability is low, and the sensitivity
and specificity of exercise treadmill testing in females are poor; therefore, the exercise treadmill test is not helpful in clinical decision making in this case.

### I-6. An effective way to measure the accuracy of a diagnostic test is a positive likelihood ratio [sensitivity/(1 - specificity)], which is also defined as the ratio of the probability of a positive test result in a patient with disease to the probability of a positive test result in a patient without disease. What other piece of information is needed along with a positive likelihood ratio to estimate the possibility of a given disease in a certain patient with a positive test result?

D. Pretest probability of the disease in a patient

B. 8%

C. 12.5

### I-9. A healthy 23-year-old female is referred to your clinic after being seen in the emergency department for intermittent severe chest pain. During her visit, she is ruled out for cardiac ischemia, with negative biomarkers for cardiac ischemia and unremarkable electrocardiograms. An exercise single photon emission CT (SPECT) myocardial perfusion test was performed, and a reversible exercise-induced perfusion defect was noted. The test was read as positive. The patient was placed on aspirin. She is quite concerned that she continues to have chest pain intermittently on a daily basis without any consistency in regards to time or antecedent activity. She is otherwise active and feeling well. She smokes socially on weekends. She has no family history of early coronary disease. What would be the best next course of action?

D. Evaluation for non-cardiac source of her chest pain

### I-10. Which of the following statements regarding gender health is true?

C. In a recent placebo-controlled trial, postmenopausal
hormone therapy did not show improvement in disease
progression in women with Alzheimer's disease.

### I-11. All of the following statements regarding women's health are true except

D. Women with myocardial infarction (MI) are more
likely to present with ventricular tachycardia, whereas
men are more likely to present with cardiogenic
shock.

### I-12. When ordering an evaluation of coronary artery disease in a female patient, all of the following are true except

D. Women undergoing coronary artery bypass surgery
have lower 5- and 10-year survival rates than men.

### I-13. Which of the following statements regarding cardiovascular risk is true?

D. Total triglyceride levels are an independent risk factor
for coronary heart disease in women but not in men.

### I-14. Which of the following alternative medicines has shown proven benefit compared to placebo in a large randomized clinical trial?

C. Glucosamine/chondroitin sulfate for improving performance and slowing narrowing of the joint space in patients with moderate to severe osteoarthritis

### I-15. You prescribe an extended-release antihypertensive agent for your patient at a dosing interval of 24 h. The half-life of the agent is 48 h. Three days later the patient's blood pressure is not controlled. At this point you should

D. recheck the blood pressure in 1 week

### I-16. A 56-year-old patient arrives in your clinic with worsening somnolence, per his wife. You have followed him for several years for his long-standing liver disease related to heavy alcohol use in the past and hepatitis C infection, as well as chronic low back pain related to trauma. He has recently developed ascites but has had a good response to diuretic therapy. He has no history of gastrointestinal bleeding, he denies fever, chills, abdominal pain, tremor, or any recent change in his medicines, which include furosemide, 40 mg daily; spironolactone, 80 mg daily; and extended-release morphine, 30 mg twice a day. He is afebrile with normal vital signs. His weight is down 5 kg since initiating diuretic therapy. Physical examination is notable for a somnolent but conversant man with mild jaundice, pinpoint pupils, palmar erythema, spider hemangiomas on his chest, a palpable nodular liver edge at the costal margin, and bilateral 1+ lower extremity edema. He does not have asterixis, abdominal tenderness, or an abdominal fluid wave. Laboratory results compared to 3 months previously reveal an increased INR, from 1.4 to 2.1; elevated total bilirubin, from 1.8 to 3.6 mg/dL; and decreased albumin from 3.4 to 2.9 g/L; as well as baseline elevations of his aspartate and alanine aminotransferases (54 U/L and 78 U/L, respectively). Serum NH4 is 16. What would be a sensible next step for this patient?

A. Decrease his morphine dose by 50% and reevaluate
him in a few days

### I-17. 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?

B. During the period of rewarming, intense pain can
be anticipated.

### I-18. A 78-year-old female is seen in the clinic with complaints of urinary incontinence for several months. She finds that she is unable to hold her urine at random times throughout the day; this is not related to coughing or sneezing. The leakage is preceded by an intense need to empty the bladder. She has no pain associated with these episodes, though she finds them very distressing. The patient is otherwise independent in the activities of daily living, with continued ability to cook and clean for herself. Which of the following statements is true?

C. Indwelling catheters are rarely indicated for this disorder.

### I-19. All of the following statements regarding medications in the geriatric population are true except

B. Fat-soluble drugs have a shorter half-life in geriatric
patients.

### I-20. Which of the following class of medicines has been linked to the occurrence of hip fractures in the elderly?

A. Benzodiazepines

C. Atorvastatin

A. Encephalitis

D. Sarin

D. phenytoin

### I-25. A 24-year-old male is brought to the emergency department after taking cyanide in a suicide attempt. He is unconscious on presentation. What drug should be used as an antidote?

E. Sodium nitrite with sodium thiosulfate

### I-26. A 40-year-old female is exposed to mustard gas during a terrorist bombing of her office building. She presents to the emergency department immediately after exposure without complaint. The physical examination is normal. What is the next step?

A. Admit the patient for observation because symptoms
are delayed 2 h to 2 days after exposure and
treat supportively as needed.

C. Doxycycline

### I-28. A 23-year-old woman with a chronic lower extremity ulcer related to prior trauma presents with rash, hypotension, and fever. She has had no recent travel or outdoor exposure and is up to date on all of her vaccinations. She does not use IV drugs. On examination, the ulcer looks clean with a well-granulated base and no erythema, warmth, or pustular discharge. However, the patient does have diffuse erythema that is most prominent on her palms, conjunctiva, and oral mucosa. Other than profound hypotension and tachycardia, the remainder of the examination is nonfocal. Laboratory results are notable for a creatinine of 2.8 mg/dL, aspartate aminotransferase of 250 U/L, alanine aminotransferase of 328 U/L, total bilirubin of 3.2 mg/dL, direct bilirubin of 0.5 mg/dL, INR of 1.5, activated partial thromboplastin time of 1.6 × control, and platelets at 94,000/μL. Ferritin is 1300 μg/mL. The patient is started on broad-spectrum antibiotics after appropriate blood cultures are drawn and is resuscitated with IV fluid and vasopressors. Her blood cultures are negative at 72 h: at this point her fingertips start to desquamate. What is the most likely diagnosis?

C. Staphylococcal toxic shock syndrome

### I-29. The Centers for Disease Control and Prevention (CDC) 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

C. ricin toxin from Ricinus communis

### I-30. A 50-year-old alcoholic woman with well-controlled cirrhosis eats raw oysters from the Chesapeake Bay at a cookout. Twelve hours later she presents to the emergency department with fever, hypotension, and altered sensorium. Her extremity examination is notable for diffuse erythema with areas of hemorrhagic bullae on her shins. What is the most likely diagnosis?

E. Vibrio vulnificus infection

### I-31. Hyperthermia is defined as

C. an uncontrolled increase in body temperature despite
a normal hypothalamic temperature setting

### I-32. A patient in the intensive care unit develops a temperature of 40.8°C, profoundly rigid tone, and hemodynamic shock 2 min after a succinylcholine infusion is started. Immediate therapy should include

A. intravenous dantrolene sodium
C. external cooling devices
D. A and C

### I-33. Which of the following conditions is associated with increased susceptibility to heat stroke in the elderly?

A. A heat wave
B. Antiparkinsonian therapy
C. Bedridden status
D. Diuretic therapy
E. All of the above

### I-34. A 68-year-old alcoholic arrives in the emergency department after being found in the snow on a cold winter night in Chicago. His core temperature based on rectal and esophageal probe is 27°C. Pulse is 30 beats/min and blood pressure is 75/40 mmHg. He is immobile and lacks corneal, oculocephalic, and peripheral reflexes. He is immediately intubated and placed on a cardiac monitor. He then converts to ventricular fibrillation: a defibrillation attempt at 2 J/kg is not successful. What should be the next immediate step in management?

A. Active rewarming with forced-air heating blankets,
heated humidified oxygen, heated crystalloid infusion

B. Fibronectin

### I-36. A 45-year-old man is stranded overnight in the cold after an avalanche. He is airlifted to your medical center and found to have anesthesia and a clumsy sensation in the distal extent of the fingers on his left hand (see Color Atlas, Figure I-36). What is the best initial management of his hand?

C. Rapid rewarming

D. 0.3%

### I-38. Which preventative intervention leads to the largest average increase in life expectancy for a target population?

B. Getting a 35-year-old smoker to quit smoking

### I-39. All of the following patients should receive a lipid screening profile except

B. a 17-year-old female teen who recently began smoking

### I-40. A 46-year-old female presents to her primary care doctor complaining of a feeling of anxiety. She notes that she always had been what she describes as a "worrier," even in grade school. The patient has always avoided speaking in public and recently is becoming anxious to the extent where she is having difficulty functioning at work and in social situations. She has difficulty falling asleep at night and finds that she is always "fidgety" and has a compulsive urge to move. The patient owns a real estate company that has been in decline since a downturn in the local economy. She recently has been avoiding showing homes for sale. Instead, she defers to her partners because she finds that she is nervous to the point of being unable to speak to her clients. She has two children, ages 16 and 12, who are very active in sports. She feels overwhelmed with worry over the possibility of injury to her children and will not attend their sports events. You suspect that the patient has a generalized anxiety disorder. All of the following statements regarding this diagnosis are true except

C. As in panic disorder, shortness of breath, tachycardia,
and palpitations are common.

D. Saw palmetto

D. Perfectionist

### I-43. Why is it necessary to coadminister vitamin B6 (pyridoxine) with isoniazid?

C. Isoniazid interacts with pyridoxal phosphate.

C. 60-85%

### I-45. Diabetes is associated with all of the following in theelderly except

B. cognitive decline

### I-46. Which of the following is the best indicator of prognosis and longevity in a geriatric patient?

A. Functional status

A. agitation

E. hypertension

B. 1-2 days

E. Surgery

### I-51. A 38-year-old man with multiple sclerosis develops acute flaccid weakness in his left arm and left leg. Physical examination reveals normal sensorium, normal cranial nerve function, 1/5 strength in his left upper extremity, 0/5 strength in his left lower extremity, impaired proprioception in his left leg, intact proprioception in his right leg, decreased pain and temperature sensation in his right arm and leg, and normal light touch/pain and temperature sensation in his right leg. Where is his causative lesion most likely to be?

B. High cervical spinal cord

### I-52. A 32-year-old man with a history of HIV infection presents to the hospital with nausea, abdominal distention and projectile vomiting that developed over the previous 8-12 h. He denies fevers, chills, diaphoresis,melena, or diarrhea. Over the past 3 months, he has lost 30 lb in the context of advanced HIV infection. He has never had abdominal surgery. On examination, his abdomen is distended, with high-pitched intermittent bowel sounds and guarding but no rebound. A periumbilical bruit is also detected. Abdominal x-ray reveals a smallbowel obstruction with a probable cut-off point in the mid duodenum. What is the diagnostic test of choice for diagnosing the cause of the underlying obstruction?

A. Abdominal CT with abdominal angiogram

C. Gastroparesis

### I-54. A 42-year-old man with a history of end-stage renal disease is on hemodialysis and has been taking a medication chronically for nausea and vomiting. Over the past week he has developed new-onset involuntary lip smacking, grimacing, and tongue protrusion. This side effect is most likely due to which of the following antiemetics?

D. Prochlorperazine

### I-55. Which of the following is not a common cause of persistent cough lasting more than 3 months in a nonsmoker?

D. Mycoplasma infection

### I-56. A 64-year-old alcoholic presents to the emergency department with occasional hemoptysis, productive cough, and low-grade fever over the past several weeks. His CT scan shows an abnormality in the right lower lobe. He reports several contacts with tuberculosis-infected patients while in prison several years ago. Sputum examination reveals putrid-smelling thick green sputum streaked with blood. The Gram stain shows many polymorphonuclear leukocytes and a mix of gram-positive and -negative organisms. What is the most likely diagnosis?

B. Polymicrobial lung abscess

### I-57. A 74-year-old man with known endobronchial carcinoma of his left mainstem bronchus develops massive hemoptysis (1 L of frank hemoptysis productive of bright red blood) while hospitalized. All of the following should be considered in his initial management except

D. placing the patient in the lateral decubitus position
with his right side down

B. HIV infection

### I-59. A 35-year-old woman comes to your clinic complaining of shortness of breath. It is immediately apparent that she has a bluish tinge of her face, trunk, extremities, and mucusmembranes. Which of the following diagnoses is most likely?

A. Atrial septal defect

### I-60. A 43-year-old man with alcoholic liver disease complainsof dyspnea upon sitting up. Physical examination is notable for chest spider angiomas and palmar erythema. His arterial oxygen saturations fall from 96% to 88% upon transition from lying to sitting. His lung fields are clear and heart sounds are crisp. Abdominal examination is notable for a palpable nodular liver edge but no fluid wave or shifting dullness. He has 1+ lower extremity edema. What is the most likely cause of his dyspnea?

C. Pulmonary arteriovenous fistula

### I-61. A 30-year-old woman complains of lower extremity swelling and abdominal distention. It is particularly troublesome after her daily shift as a toll booth operator and is at its worst during hot weather. She denies shortness of breath, orthopnea, dyspnea on exertion, jaundice, foamyurine, or diarrhea. Her symptoms occur independently of her menstrual cycle. Physical examination is notable for 2+ lower extremity edema, flat jugular venous pulsation, no hepatojugular reflex, normal S1 and S2 with no extra heart sounds, clear lung fields, a benign slightly distended abdomen with no organomegaly, and normal skin. A complete metabolic panel is within normal limits, and a urinalysis shows no proteinuria. What is the most likely diagnosis?

D. Idiopathic edema

### I-62. All of the following factors are associated with a greater risk of ventricular arrhythmia versus anxiety/panic attack in a patient complaining of palpitations except

D. palpitations lasting >15 min

### I-63. A 25-year-old healthy woman visits your office during the fifth month of pregnancy. Her blood pressure is 142/86 mmHg. What should be your next step in management?

D. Recheck her blood pressure in the seated position in
6 h

### I-64. A 33-year-old woman with diabetes mellitus and hypertension presents to the hospital with seizures during week 37 of her pregnancy. Her blood pressure is 156/92 mmHg. She has 4+ proteinuria. Management should include all of the following except

D. intravenous phenytoin

### I-65. Which cardiac valvular disorder is the most likely to cause death during pregnancy?

D. Mitral stenosis

C. enoxaparin

### I-67. In which of the following categories should women undergo routine screening for gestational diabetes?

A. Age >25 years
B. Body mass index >25 kg/m2
C. Family history of diabetes mellitus in a first-degree relative
D. African American
E. All of the above

C. 3

### I-70. A 72-year-old white man with New York Heart Association II ischemic cardiomyopathy, diabetes mellitus, and chronic renal insufficiency (creatinine clearance = 42 mL/ min) undergoes dobutamine echocardiography prior to carotid endarterectomy. He is found to have 7-mm ST depressions in his lateral leads during the test and develops dyspnea at 70% maximal expected dosage, requiring early cessation of the stress test. His current medicines include an angiotensin converting enzyme inhibitor, a beta blocker, and aspirin. What would be your advice to the patient?

B. Proceed to cardiac catheterization

### I-71. Parkinson's disease can often be differentiated from the atypical Parkinsonian syndromes (multiple system atrophy, progressive supranuclear palsy) by the presence of which of the following?

B. Pill-rolling tremor

### I-72. A wide-based gait with irregular lurching and erratic foot placement but no subjective dizziness characterizes which type of gait ataxia?

A. Cerebellar dysfunction

### I-73. A patient with a narrow-based gait instability complains that he needs to look at his feet while he walks to prevent falling. He feels wobbly standing with his eyes closed and notes frequent falls. On examination, he has no difficulty initiating gait, his stride is regular, strength is normal, and there is no tremor. Review of routine blood work drawn 3 months prior reveals a hematocrit of 29% with an elevated mean corpuscular volume. Which of the following is the most likely diagnosis?

E. Pernicious anemia

### I-74. Which of the following is an effective method to evaluate for cortical sensory deficits?

A. Graphesthesia (the capacity to recognize letters drawn
by the examiner on the patient's hand)
B. Stereognosis (the ability to recognize common objects, such as coins, by palpation)
C. Touch localization
D. Two-point discrimination testing
E. All of the above

### I-75. A 23-year-old female patient complains of visual blurriness. On examination, her pupils are equally round. Shining a flashlight into her right eye causes equal, strong constriction in both of her eyes. When the light is flashed into her left eye, both pupils dilate slightly though not to their previous size prior to light confrontation. Where is there most likely to be anatomic damage?

B. Left optic nerve or retina

### I-76. A patient complains of blurred vision in both eyes particularly in the periphery with the right being worse than the left. Visual field examination with finger confrontation reveal a decreased vision in the left periphery in the left eye and right periphery in the right eye. Where is there most likely to be a lesion?

E. Suprasellar space

### I-77. Which of the following methods is most effective for the diagnosis of corneal abrasions?

A. Fluorescein and cobalt-blue light examination

### I-78. Which of the following criteria best differentiates episcleritis from conjunctivitis?

B. Lack of discharge

### I-79. Which diagnosis can be easily confused with adenoviral conjunctivitis and is a major cause of blindness in the United States?

B. Herpes simplex virus keratitis

E. toxoplasmosis

B. Brain MRI

### I-82. A 69-year-old male dialysis patient with poorly controlled diabetes, heart failure and chronic indwelling catheters presents with fever and loss of vision in the left eye developing over the past 6 h. Vital signs are notable for a temperature of 101.3°F, heart rate of 105/min, and blood pressure of 125/85. Which test is most likely to confirm the diagnosis?

A. Blood cultures

### I-84. 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 ~1.8 gray (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?

D. Severely injured individuals should be transported
to the hospital for emergency care after removing
the victims' clothes, as the risk of exposure to health
care workers is low.

### I-85. A 54-year-old man is admitted to the hospital with severe nausea, vomiting, and diarrhea. These symptoms began 36 h ago. He briefly improved for a few hours yesterday, but today has progressively worsened. He states he is concerned about possible poisoning because of his role in espionage and counterterrorism for the U.S. government. He met with an informant 2 days previously at a hotel bar, where he drank three cups of coffee but did not eat. He does state that he left the table to place a phone call during the meeting and is concerned that his coffee may have been contaminated. He otherwise is quite healthy and takes no medications. On physical examination, he appears ill. The vital signs are: blood pressure 98/60 mmHg, heart rate 112 beats/min, respiratory rate 24 breaths/min, SaO2 94%, and temperature 37.4°C. Head, ears, eyes, nose, and throat examination shows pale mucous membranes. Cardiovascular examination is tachycardic, but regular. His lungs are clear. The abdomen is slightly distended with hyperactive bowel sounds. There is no tenderness or rebound. Extremities show no edema, but a few scattered petechiae are present. Neurologic examination is normal. A complete blood count is performed. The results are: white blood cell (WBC) count 150/μL, red blood cell count 1.5/μL, hemoglobin 4.5 g/dL, hematocrit 15%, platelet count 11,000/μL. The differential on the WBC count is 98% PMNs, 2% monocytes, and 0% lymphocytes. A blood sample is held for HLA testing. A urine sample is positive for the presence of radioactive isotopes, which are determined to be polonium-210, a strong emitter of alpha radiation. The mode of exposure is presumed to be ingestion. What is the best approach to the

E. Supportive care and dimercaprol

C. Mustard gas

### I-87. An unknown chemical agent was released in a terrorist attack in the food court of a shopping mall. Several victims who were close to the site of the release of the gas died prior to arrival of the emergency medical teams. Upon arrival, the survivors were complaining of difficulty with vision and stated that they felt the world was "going black." The victims were also noted to be drooling and have increased nasal secretions. A few individuals were dyspneic with wheezing. The most severely affected victims fell unconscious and soon thereafter developed seizures. What medication(s) should be administered immediately to the survivors?

B. 2-Pralidoxime chloride, 1800 mg IM
C. Diazepam, 5 mg IV
E. B and C

### I-88. A 7-month-old child is brought to clinic by his parents. He was the product of a healthy pregnancy, and there were no perinatal complications. The parents are concerned that there is something wrong; he is very hyperactive and is noted to have a 'mousy' odor. On examination the child is found to have mild microcephaly, hypopigmentation and eczema. Laboratory studies are sent and a diagnosis is made. How could this clinical scenario have been prevented?

B. Screening at birth for phenylalanine in blood

A. Alkaptonuria

### I-90. A 22-year-old man presents to a local emergency room with severe muscle cramps and exercise intolerance. His symptoms have been worsening over a period of months. He has noticed that his urine is frequently dark. Examination reveals tenderness over all major muscle groups. A creatine phosphokinase (CK) is markedly elevated. He reports a normal childhood but since age 18 has noticed worsening exercise intolerance. He no longer plays basketball and recently noticed leg fatigue at two flights of stairs. After intense exercise, he occasionally has red-colored urine. Which of the following is the most likely diagnosis?

C. McArdle disease (type V glycogen storage disease)

### I-91. An enzymatic assay of muscle tissue is sent and a diagnosis is made. Which of the following represents a major source of morbidity in this disease which should be explained thoroughly to the patient?

D. Rhabdomyolysis leading to renal failure

### I-92. A 21-year-old woman comes to clinic to establish new primary care. She has a history of type III glycogen storage disease (debranching deficiency), for which she takes a high-protein, high-carbohydrate diet. She has a normal physical examination except for short stature, mild weakness, and a slightly enlarged liver. She works as an administrative assistant and is planning to be married in the next 6 months. She is concerned about her long-term prognosis and the chances of the disease developing in a child. All of the following statements about her prognosis are true except

C. Dementia is a possible complication.

### I-93. A 36-year-old man comes to your office asking for genetic testing for Alzheimer's disease. He has no cognitive complaints but notes that all four of his grandparents have had Alzheimer's and his father has mild cognitive impairment at the age of 62. His Mini-Mental Status Examination is 29/30, losing one point on the serial-7's examination. He requests testing for the apolipoprotein E allele (ε4). This request is an example of which of the following?

C. Predisposition testing

### I-94. A recently married couple comes to see you in clinic for prenatal counseling. They are both in their mid-thirties and have read extensively on the internet about pregnancy and increasing maternal age. They want to know the risk of miscarriage as well as the risk of having a child with Down syndrome. Which of the following is true regarding chromosome disorders and increasing maternal age?

E. Women over the age of 42 have a 33% chance of a
trisomic conception.

E. 10-25%

### I-96. All the following disorders can cause ambiguous sexual differentiation except

C. Klinefelter syndrome

### I-98. A 30-year-old male is seen for a physical examination when obtaining life insurance. The last time he saw a physician was 15 years ago. He has no complaints. Past medical history is notable for scoliosis that was surgically corrected when the patient was a teenager and a recent shoulder dislocation. He takes no medications and does not smoke, drink, or use illicit drugs. Family history is notable for a father and a brother with colon cancer at ages 45 and 50 years, respectively. Physical examination is notable for normal vital signs, a tall habitus with hypermobile joints, normal skin, and ectopia lentis. Rectal examination is normal, and stool is guaiac-negative. The remainder of the examination is normal. Appropriate recommendations for follow-up should include which of the following annual studies?

B. Echocardiography

### I-99. All the following diseases are caused by errors in DNA repair except

C. fragile X (FX) syndrome

### I-100. A 45-year-old male is evaluated for weakness and a progressive change in mental status. After extensive evaluation, he is diagnosed with a mitochondrial disorder. All of the following statements about mitochondrial disorders are true except

C. The proportion of wild-type and mutant mitochondria
in different tissues is identical.

### I-101. Prader-Willi syndrome (PWS) is a rare disorder that is characterized by diminished fetal activity, obesity, mental retardation, and short stature. A deletion on the paternal copy of chromosome 15 is the cause. A deletion on the same site on chromosome 15, but on the maternal copy, results in a different syndrome: Angelman's syndrome. This syndrome is characterized by mental retardation, seizures, ataxia, and hypotonia. What is the name of the genetic mechanism that results in this phenomenon?

B. Genetic imprinting

### I-102. All the following are inherited disorders of connective tissue except

D. McArdle's disease

### I-103. A 30-year-old male comes to your office for genetic counseling. His brother died at age 13 years with Tay- Sachs disease. His sister is unaffected. The patient and his wife wish to have children. Which of the following statements concerning Tay Sachs disease is true?

D. Death occurs as a result of progressive neurologic
decline.

### I-104. All of the following statements about Gaucher disease are true except

D. Splenomegaly is rare.

### I-106. Diseases that are inherited in a multifactorial genetic fashion (i.e., not autosomal dominant, autosomal recessive, or X-linked) and are seen more frequently in persons bearing certain histocompatibility antigens include

A. gluten-sensitive enteropathy

C. Infection

### I-108. Chronic hypoxia causes biochemical changes whereby oxygen delivery to tissues is not impaired. In comparison to someone living at sea level, which of the following changes would be expected in a healthy person acclimated to living at high altitude?

C. Increased red blood cell levels of 2,3-diphosphoglycerate

### I-109. Independent of insurance status, income, age, and comorbid conditions, African-American patients are less likely to receive equivalent levels of care when compared to white patients for the following scenarios:

A. Prescription of analgesic for pain control
B. Referral to renal transplantation
C. Surgical treatment for lung cancer
D. Utilization of cardiac diagnostic and therapeutic procedures
E. All of the above

### I-110. Which of the following would be present in an individual who has lost nondeclarative memory?

B. Inability to recall how to tie one's shoe

F. Reassurance

### I-112. Which of the following findings associated with lymphadenopathy is usually suggestive of metastatic cancer rather than a benign etiology?

A. Hard, matted texture of involved nodes
B. Splenomegaly
E. A and B

### I-113. All of the following diseases are associated with massive splenomegaly (spleen extends 8 cm below the costal margin or weighs >1000 g) except

C. cirrhosis with portal hypertension

### I-114. The presence of Howell-Jolly bodies, Heinz bodies,basophilic stippling, and nucleated red blood cells in a patient with hairy cell leukemia prior to any treatment intervention implies which of the following?

A. Diffuse splenic infiltration by tumor

### I-115. Which of the following is true regarding infection risk after elective splenectomy?

A. Patients are at no increased risk of viral infection after
splenectomy.

### I-116. A 64-year-old man comes to your office complaining of erectile dysfunction. He is not able to generate an erection. His past medical history is significant for coronar artery bypass grafting many years ago, status post-carotid endarterectomy, and a mildly reduced left ventricular ejection fraction. His medications include aspirin, carvedilol, simvastatin, lisinopril and furosemide. He does not take nitrates. On physical examination, you note normal-sized testes and a normal prostate. There are no fibrotic changes along the penile corpora. His libido is intact. What is the most likely cause of this patient's erectile dysfunction?

A. Disturbance of blood flow

D. Vardenafil

### I-118. The wife of the patient in the preceding scenario also reports to you that she has experienced a low sexual desire lately. She is not distressed by this and the couple reports no conflict as a result of her low desire. She is 61 years old and also has a history of a coronary artery bypass graft remotely. She experienced menopause at the age of 53. Her medications include an aspirin, metoprolol, simvastatin, verapamil, and a multivitamin. She asks whether an oral agent will assist with her sexual desire. What is the best answer for this patient?

C. PDE-5 inhibitors have no role in the treatment of female
sexual dysfunction

### I-119. A 54-year-old male patient of yours presents to your clinic complaining of unexplained weight loss. On review of his chart, you do notice that he has lost 8% of his total body weight in the past year. He has well-treated hypertension for which he takes a thiazide diuretic. Other than recently being widowed, he has no pertinent social history. He is a lifelong nonsmoker and worked as a hospital administrator. An extensive review of systems is unrevealing. Your physical examination reveals no masses or other pathology. A brief psychiatric examination shows no signs of depression. You perform initial testing with a complete blood count; electrolytes, renal function, liver function, urinalysis, thyroid-stimulating hormone, and a chest x-ray, which are unrevealing. He is up to date on his routine cancer screening. What is the next step in the workup of this patient?

B. Close follow-up

### I-120. You are conducting research on a novel nonsteroidal anti-inflammatory drug (NSAID). To ascertain the safety profile of the drug you recruit 100 volunteers who lack the ability to produce IgE. All subjects receive the drug. A minority of participants experience an anaphylactic reaction within minutes of ingesting the drug. IgE levels are undetectable in all 100 subjects. What is the most likely explanation for this phenomenon?

A. The drug itself directly triggered the immune system
in a minority of patients.

D. 6 weeks

A. Airborne
B. Contact
C. Droplet
D. None

### I-123. Typical Variola major (smallpox) infection can be distinguished from Varicella (chicken pox) infection based on which of the following clinical characteristics?

B. Lesions in the same stage of development at any location
D. Maculopapular rash that begins on the face and extremities and spreads to the trunk (centripetal spread)
F. B and D

### I-124. You are working in an urban-based intensive care unit and two cases of severe pneumonia are admitted. Francisella tularensis is cultured from both patients' sputum samples. Neither patient recalls contact with wild or domesticated animals in the past 2 weeks. You should do all of the following except

C. Institute droplet precaution for the involved patients.

### I-125. All of the following are well-documented physical effects of smoking marijuana except

C. delayed gastric emptying

### I-126. A young man is brought to the emergency department by his parents. For the past 12 h he has barricaded himself in his room out of fear of being taken away by "the guys in black." He fears he is losing control and fears that he is going to die. His parents found him trembling and sweating in his room with various pills and plant leaves in his possession. He feels like he is choking and that he is about to die at any minute. On examination, his pupils are dilated and he has a heart rate of 143 beats/min. What substance is most likely to have caused these symptoms?

B. Lysergic acid diethylamide (LSD)

### I-127. A 37-year-old woman arrives at the emergency department after experiencing a transient state of altered mental status on route to the United States as an immigrant from Nigeria. From the reports of the other passengers and flight attendants on the plane, she was normally interactive throughout most of the flight but was difficult to arouse from sleep upon landing. Upon trying to exit the plane, she fell over and became disarticulate. Her mental status immediately improved when she received naloxone, thiamine, and IV glucose via an emergency response team. Upon arrival at the emergency department 1 h later, she appears anxious but is alert, oriented, and appropriate. Temperature is 36.8°C, blood pressure is 162/84 mmHg, heart rate is 108 beats/min, respiratory rate is 22 breaths/min, and oxygen saturation is 99% on room air. Her pupils are equal and reactive. Cranial nerves are intact. Her oropharynx is slightly dry. There is no lymphadenopathy. Lungs are clear. She has a regular heart beat with normal S1, S2, and no extra heart sounds. Her abdomen has normal bowel sounds with slight epigastric tenderness. Her skin is normal without any track marks or rash. A complete metabolic panel and complete blood count are normal. A urine toxicology screen reveals heroin metabolites. Further evaluation should include:

E. orifice examination

### I-128. Which of the following is a distinguishing feature of amphetamine overdose versus other causes of sympathetic overstimulation due to drug overdose or withdrawal?

D. Markedly increased blood pressure, heart rate, and
end-organ damage in the absence of hallucination

### I-129. Which of the following findings suggests an opiate overdose?

E. Therapeutic response to naloxone

A. Lithium

### I-131. Which of the following is true regarding drug effects after an overdose in comparison to a reference dose?

B. Drug effects begin earlier, peak later, and last longer

E. phenytoin

### I-133. Which of the following statements regarding gastric decontamination for toxin ingestion is true?

A. Activated charcoal's most common side effect is aspiration.
B. Gastric lavage via nasogastric tube is preferred over
the use of activated charcoal in situations where therapeutic endoscopy may also be warranted.
C. Syrup of ipecac has no role in the hospital setting.
D. There are insufficient data to support or exclude a benefit when gastric decontamination is used more than 1 h after a toxic ingestion.
E. All of the above are true.

### I-134. What is the main contributor to the resting energyexpenditure of an individual?

C. Lean body mass

### II-1. A 19-year-old woman with anorexia nervosa undergoes surgery for acute appendicitis. The postoperative course is complicated by acute respiratory distress syndrome, and she remains intubated for 10 days. She develops wound dehiscence on postoperative day 10. Laboratory data show a white blood cell count of 4000/ μL, hematocrit 35%, albumin 2.1 g/dL, total protein 5.8 g/dL, transferrin 54 mg/dL, and iron-binding capacity 88 mg/dL. You are considering initiating nutritional therapy on hospital day 11. Which of the following is true regarding the etiology and treatment of malnutrition in this patient?

C. She has marasmic kwashiorkor, kwashiorkor predominant,and nutritional support should be aggressive.

### II-2. You are seeing a patient in follow-up 2 weeks after hospitalization. The patient is recovering from nosocomial pneumonia due to a resistant Pseudomonas spp. His hospital course was complicated by a deep venous thrombosis. The patient is currently on IV piperacillin/ tazobactam and tobramycin via a tunneled catheter, warfarin, lisinopril, hydrochlorothiazide, and metoprolol. Laboratory data this morning show an INR of 8.2. At hospital discharge his INR was stable at 2.5. He has no history of liver disease. What is the most likely cause of the elevated INR?

C. The patient is deficient in vitamin K and needs supplementation.

D. Vitamin C

### II-4. While working in the intensive care unit, you admit a 57-year-old woman with acute pancreatitis and oliguric renal failure. Respiratory rate is 26 breaths/min,heart rate is 125 beats/min, and temperature is 37.2°C. Physical examination shows marked abdominal tenderness with normoactive bowel sounds. A CT scan shows an inflamed pancreas without hemorrhage. You calculate her APACHE-I score to be 28. When deciding on when to initiate nutritional replacement in this patient, which of the following statements is true?

C. Enteral feeding supports gut function by secretion
of gastrointestinal hormones that stimulate gut
trophic activity.

### II-5. The resting energy expenditure is a rough estimate of total caloric needs in a state of energy balance. Of these two patients with stable weights, which person has the highest resting energy expenditure (REE): Patient A, a 40-year-old man who weighs 90 kg and is sedentary, or Patient B, a 40- year-old man who weighs 70 kg and is very active?

B. 40-year-old man who weighs 70 kg and is very active

### II-6. All of the following clinical features are common in patients with anorexia nervosa except

A. Avoid food-related occupations

### II-7. You diagnose anorexia nervosa in one of your newclinic patients. When coordinating a treatment program with the psychiatrist, what characteristics should prompt consideration for inpatient treatment instead of scheduling an outpatient assessment?

E. Weight <75% of expected body weight

B. Hemorrhage

D. dyslipidemia

### II-11. An 86-year-old woman with chronic obstructive pulmonary disease (COPD), congestive heart failure, and insulin- requiring type 2 diabetes mellitus is admitted to the intensive care unit with an exacerbation of her COPD.She is intubated and treated with glucocorticoids and nebulized albuterol. She is also continued on her glargine insulin, aspirin, pravastatin, furosemide, enalapril, and metoprolol. On hospital day 8, parenteral nutrition is begun via catheter in the subclavian vein. Her insulin requirements increase on hospital day 9 due to episodes of hyperglycemia. On hospital day 10, she develops rales and an increasing oxygen requirement. A chest radiograph shows bilateral pulmonary edema. Laboratory data show hypokalemia, hypomagnesemia, and hypophosphatemia and a normal creatinine. Her weight has increased by 3 kg since admission. Urine sodium is <10 meq/dL. All of the following changes in her nutritional regimen will improve her volume status except

C. increasing the protein content of the parenteral nutrition
mixture

### II-12. A new study has been published showing a benefit of 25 mg/day of vitamin X. The recommended estimated average requirement of vitamin X is 10 mg/day, 2 standard deviations below the amount published in the study. The tolerable upper limit of vitamin X is unknown. Your patient wants to know if it is safe to consume 25 mg/day of vitamin X. Which is the most appropriate answer?

C. 25 mg/day is statistically in a safe range of the estimated
average requirement.

A. Cortisol

### II-14. Which of the following statements regarding anorexia nervosa (AN) and bulimia nervosa (BN) is true?

D. The mortality of BN is lower than that of AN.

### II-15. You are seeing a pediatric patient from Djibouti in consultation who was admitted with a constellation of symptoms including diarrhea, alopecia, muscle wasting, depression, and a rash involving the face, extremities, and perineum. The child has hypogonadism and dwarfism. You astutely make the diagnosis of zinc deficiency, and laboratory test confirm this (zinc level <70 μL/dL). What other clinical findings is this patient likely to manifest?

D. Hypopigmented hair

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