(Solution Manual) Harrison Board Review

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Solution Manual

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Solution Manual for Harrison Board Review, The downloadable file consists of 639 pages, and the total size of the file is 25.93 MB. Purchase now only for highly discounted price.

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SECTION IGeneral Considerations in Clinical Medicine QUESTIONSDIRECTIONS: Choose the one best response to each question.I-1. All of the following statements regarding practice guidelines set forth by governing agencies andprofessional organizations are true EXCEPT:A. Clinical practice guidelines protect caregivers against inappropriate charges of malpractice, yetdo not provide protection for patients from receiving substandard care.B. Practice guidelines have largely reached a stage of nuance allowing them to address every uniqueillness and patient presented to the modern physician.C. Practice guidelines provide a legal constraint to physicians, and deviation from guideline-basedcare invariably leaves physicians vulnerable to legal action.D. Where different organizations disagree regarding practice guidelines, a third-party agency hasbeen appointed to mitigate these disagreements such that now all major organizations’ guidelinesare consistent.E. All of the above statements are not true.I-2. Regarding molecular medicine, which of the following statements represents an INACCURATEexample 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 duringthe cardiac cycle.C. Metagenomics: A biologist studies the genomic alterations in molds commonly found in humandwellings.D. Microbiomics: A microbiologist studies the genomic variation in thermophiles, bacteria that cansurvive extreme heat near deep ocean vents.E. Proteomics: A cardiologist studies desmosomal proteins and their posttranslational modificationsin studying arrhythmogenic right ventricular dysplasia.I-3. Which of the following is the best definition of evidence-based medicine?A. A summary of existing data from existing clinical trials with a critical methodologic review andstatistical analysis of summative dataB. A type of research that compares the results of one approach to treating disease with anotherapproach to treating the same diseaseC. Clinical decision-making support tools developed by professional organizations that includeexpert opinions and data from clinical trialsD. Clinical decision making supported by data, preferably randomized controlled clinical trialsE. One physician’s clinical experience in caring for multiple patients with a specific disorder overmany yearsI-4. Which of the following is the standard measure for determining the impact of a health condition ona population?A. Disability-adjusted life-yearsB. Infant mortalityC. Life expectancyD. Standardized mortality ratioE. Years of life lostI-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 totalglobal 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 perinatalconditions, and nutritional deficiencies has remained fairly stable, with the majority (76%) ofmortality 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, thesame relationship does not hold true when studying the link between national health indicatorsand gross domestic product per capita among nations.I-6. You are appointed to a governmental healthcare advisory subcommittee concerned with addressingproblems facing the global health community. Your task is to draw general conclusions from theglobal fight against tuberculosis (TB) and human immunodeficiency virus (HIV)/acquiredimmunodeficiency syndrome (AIDS) that may be applied in combatting other diseases, includingnoncommunicable diseases. Which of the following conclusions is reasonable when consideringHIV/AIDS and TB as chronic diseases?A. Barriers to adequate healthcare and patient adherence imposed by extreme poverty must beconcomitantly addressed to adequately treat and prevent chronic disease in developing nations.B. Charging small fees for health services (e.g., AIDS prevention and care) supplies the patient witha sense of the treatment’s value and increases compliance and overall public health.C. Despite adequate available tools to practice their trade locally in developing nations, manyphysicians and nurses emigrate to developed nations to practice their respective trades, aphenomenon called “brain drain.”D. In developed nations where physicians are abundant, community health worker supervision ofthe care of chronically ill patients is not effective.E. In the case of chronic infectious diseases, switching from one drug to another through aprolonged course of treatment provides the highest cure rate by obviating the infectious agent’sability to develop resistance to any single drug.I-7. Mrs. Jones, a 22-year-old African American woman, presents to Dr. Smith, an internal medicinespecialist, with a facial rash. Mrs. Jones states that the rash began after spending a day at the beachwith her family. She also notes that her metacarpophalangeal and proximal interphalangeal jointshave been painful and swollen for the preceding 2 weeks. On examination, the joints are swollen andtender. Laboratory analysis discloses reduced creatinine clearance, proteinuria, and hemolyticanemia. Antinuclear antibodies (a test with a high negative predictive value for systemic lupuserythematosus) are detected at significant titer, and ultimately, the diagnosis of systemic lupuserythematosus is made.Two weeks later, Mrs. Johnson, a 24-year-old African American woman, presents with a facial rashand elbow pain to Dr. Smith. After a cursory interview and brief physical exam, Dr. Smith sendsblood work only testing for antinuclear antibodies. When the test returns negative (no antibodiesdetected), Dr. Smith presumes this to be a false-negative result and starts Mrs. Johnson onhydroxychloroquine and prednisone for treatment of systemic lupus erythematosus. Whichheuristic(s) did Dr. Smith likely employ in diagnosing Mrs. Johnson with systemic lupuserythematosus?A. Availability heuristicB. Anchoring heuristicC. Bayes’ ruleD. Confirmation biasE. A and BI-8. You have invented a blood test, which you name “veritangin,” to determine if patients are having amyocardial infarction. You devise an experiment to determine the performance of your veritanginassay by testing it versus the troponin assay, the currently accepted gold standard for determiningmyocardial infarction, in 100 random emergency department patients with chest pain. You choose averitangin result >1 ng/dL as positive for myocardial infarction. Your results are listed in the tablebelow. Which of the following statements regarding the characteristics of the veritangin assay in this trial istrue?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 diseaseprevalence in that population.C. The sensitivity of the veritangin assay will decrease by 50% if you reduce the threshold for apositive 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 thetreatment of deep vein thrombosis. Which of the following statements regarding the design of thetrial is true?A. An optimal study design would assign many patients to clotbegone and compare their outcomesto the outcomes of prior (historical) patients not taking clotbegone. This would allow faster trialcompletion.B. If the trial returns a positive result (clotbegone is superior to placebo), that means that anypatient with a clot would benefit from clotbegone therapy.C. Observing the outcomes of patients already taking clotbegone versus patients who are not ispreferable to assigning patients to clotbegone or placebo in a blinded fashion. The observationalstrategy is more “real world,” applicable to the general population, and free of bias.D. Population selection for the trial enrollment is not important as long as careful attention torandomization and blinding is observed.E. The advantage of performing a randomized clinical trial of clotbegone over a prospectiveobservational 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 diagnosedisease 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 clinicalparameter 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 withthe 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 true-positive rate versus the false-positive rate.I-11. When considering a potential screening test, what end points should be considered to assess thepotential gain from a proposed intervention?A. Absolute and relative impact of screening on the disease outcomeB. Cost per life-year savedC. Increase in the average life expectancy for the entire populationD. Number of subjects screened to alter the outcome in one individualE. All of the aboveI-12. You are appointed to an advisory committee in the WHO tasked with making recommendationsregarding breast cancer screening and prevention. In regard to screening and preventing breastcancer in women, which of the following potential recommendations from your committee would bevalid?A. Any breast cancer detected by screening mammography and adequately treated represents areduction in breast cancer mortality.B. Screening is most effective when applied to relatively common diseases. Breast cancer, with alifetime risk of 10% in women, meets this criterion.C. The presence of a latent (asymptomatic) stage of breast cancer renders it a less ideal diseasecandidate for screening at the population level.D. When studying the effectiveness of breast cancer screening with mammography in a population,length of disease survival is the most important outcome to consider.E. Women in the general population should undergo just as rigorous screening and preventionmeasures 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 thefollowing statements regarding lung cancer screening can you truthfully make to Mr. Brown?A. “Recently, a large National Heart, Lung, and Blood Institute study demonstrated a significantreduction in mortality by employing low-dose chest computed tomography as a screening tool inpatients with a significant smoking history.”B. “Screening for lung cancer has a long history of successful implementation given the ease ofobtaining a chest x-ray and the fact that most lung cancers are curable at the time of screeningdetection.”C. “Screening for lung cancer is a ‘no-brainer’; there is really no harm in a false-positive test. Theonly real worry is always that you might have a cancer that we don’t know about.”D. “Because the sensitivity and specificity of any screening test do not depend on the populationstudied, your odds of having lung cancer after a positive chest x-ray do not depend on hissmoking history.”E. “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 targetpopulation?A. A regular exercise program for a 40-year-old manB. Getting a 35-year-old smoker to quit smokingC. Mammography in women age 50–70D. Pap smears in women age 18–65E. Prostate-specific antigen (PSA) and digital rectal examination for a man >50 years oldI-15. The U.S. Preventive Services Task Force (USPSTF) recommends which of the following screeningtests for the listed patients?A. 16-year-old male: immunoassay for HIV if not performed beforeB. 32-year-old sexually active woman: nucleic acid amplification on a cervical swab for chlamydiaC. 50-year-old woman with a smoking history: dual-energy x-ray absorptiometry (DEXA) scan forosteoporosisD. 58-year-old prior smoker: ultrasound for abdominal aortic aneurysmE. 80-year-old man: anti–hepatitis C virus (HCV) antibody for hepatitis CI-16. Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?A. AmoxicillinB. AspirinC. AtorvastatinD. PrevacidE. SildenafilI-17. A 26-year-old woman received an allogeneic bone marrow transplantation 9 months ago for acutemyelogenous leukemia. Her transplant course is complicated by graft-versus-host disease withdiarrhea, 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 andfevers to 101.5°F. She has a chest computed tomography (CT) showing nodular pneumonia, andfungal organisms are seen on a transbronchial lung biopsy. The culture demonstrates Aspergillusfumigatus, and a serum galactomannan level is elevated. She is initiated on therapy with voriconazole6 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 andtremors. 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/dLfrom 0.8 mg/dL on admission. What is the most likely cause of the patient’s current clinical picture?A. Aspergillus meningitisB. Congestive heart failureC. Recurrent graft-versus-host diseaseD. Tacrolimus toxicityE. Thrombotic thrombocytopenic purpura caused by voriconazoleI-18. A 43-year-old woman is diagnosed with pulmonary blastomycosis and is initiated on therapy withoral itraconazole therapy. All of the following could affect the bioavailability of this drug EXCEPT:A. Coadministration with a cola beverageB. Coadministration with oral contraceptive pillsC. Formulation of the drug (liquid vs. capsule)D. pH of the stomachE. Presence of food in the stomachI-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 todaycomplaining of a new rash on his chest and axilla, which you astutely diagnose as tinea corporis. Youwould like to prescribe a course of oral ketoconazole for therapy. You should consider doseadjustment for all of the following medicines that he is already taking EXCEPT:A. CarvedilolB. LovastatinC. MexiletineD. RitonavirE. SaquinavirI-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 plasmaconcentrations 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 ofalternative orders. For example, a first-order drug will have a higher affinity for the enzyme thana second-order drug.D. Steady state describes the situation during chronic drug dosing when the plasma concentration ofdrug is identical from minute to minute. One can only truly achieve steady state with continuousintravenous infusion.E. The only method by which a drug can be removed from the central compartment is byelimination.I-21. Mr. Brooks has been seeing you in the primary care clinic for over 20 years. Recently, he wasdiagnosed with amyotrophic lateral sclerosis (ALS), an almost universally fatal degenerativeneurologic condition. In consultation with his neurologist, you have started him on a high dose of anew medication, Drug X, to alleviate muscle spasms. However, although Mr. Brooks’s muscle spasmshave improved drastically, he is experiencing dry mouth and dry eyes, side effects that were notdescribed in very large clinical trials of Drug X. A recent postmarketing study of Drug X was releasedshowing that patients with ALS taking it live, on average, 14 days less than patients not taking it. Asyou discuss the plan regarding Drug X with Mr. Brooks, which statement would be valid?A. “A recent study shows that patients taking Drug X die sooner, on average, than those not takingit. I want to discuss your thoughts on continuing Drug X, perhaps at a lower dose, versus stoppingit.”B. “A recent study shows that patients taking Drug X die sooner, on average, than those not takingit. I recommend stopping it, and I anticipate the drug will be discontinued soon.”C. “If you’re having side effects at the high dose, it’s certain that you’ll have the same side effects ata lower dose.”D. No discussion is needed given the postmarketing data. You should stop Drug X and report thenew side effect to the U.S. Food and Drug Administration (FDA).E. “These side effects you describe were not described in clinical trials enrolling hundreds ofpatients with ALS. They cannot be from Drug X. Let’s figure out what other medication might becausing 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?FIGURE I-22AA. 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) likelyrepresents a saturation of the eliminating enzyme.D. Point B represents the time when drug is distributed both to and from a peripheral compartmentand 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 beconsidered given their concomitant listed comorbidity EXCEPT:A. A 57-year-old man with cirrhosis: reduced dose of sotalolB. A 35-year-old man with renal disease: reduced dose of meperidineC. A 97-year-old man with normal creatinine and bilirubin: reduced dose of diazepamD. A 42-year-old man with cirrhosis: reduced dose of meperidineE. A 35-year-old woman with a known loss-of-function allele in CYP2C9: reduced initial dose ofwarfarinI-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 CYP2C9B. Sotalol and furosemide: increased risk of QT prolongation and torsades de pointes; furosemide-induced inhibition of CYP3A4C. Sildenafil and sublingual nitroglycerin: increased risk of hypotension; sildenafil inhibition of thephosphodiesterase type 5 isoform that inactivates cyclic guanosine monophosphateD. Ritonavir and lovastatin: increased risk of myotoxicity; ritonavir inhibition of CYP2C19E. Allopurinol and azathioprine: increased risk of blood dyscrasias; allopurinol inhibition of P-glycoproteinI-25. Which of the following statements regarding coronary heart disease (CHD) in women whencompared 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 tomen.C. Physicians are less likely to consider CHD in women and are also less likely to recommend bothdiagnostic 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 commonlyhave cardiac arrest or cardiogenic shock.I-26. All of the following diseases are more common in women than men EXCEPT:A. DepressionB. HypertensionC. ObesityD. Rheumatoid arthritisE. Type 1 diabetes mellitusI-27. Which of the following statements regarding sex differences in the United States is true?A. Due to extensive public awareness campaigns, the majority of physicians are counseling theirfemale patients about their risk for cardiovascular disease.B. The leading causes of death are the same for women and men.C. Women’s bone density and their risk for cardiovascular disease decline after menopause.D. Women have a longer average life expectancy than men, and this difference has been unchangedfor decades.E. 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, treatedhypertension, and moderate obesity. She is recently menopausal. You note on her intake form thatshe has questions about hormone replacement therapy to reduce her risk of coronary heart diseaseand stroke. Which of the following statements to Mrs. Robin would be true?A. “Most studies suggest that combined continuous equine estrogen combined withmedroxyprogesterone acetate is superior to combined continuous equine estrogen alone in regardto risk for stroke or heart attack.”B. “Studies suggest that initiating hormone therapy can reduce the incidence of hot flashes, nightsweats, mood, sexual function, and bone density, but there is no change in risk for stroke,myocardial infarction, or venous thromboembolism.”C. “The largest trial done on hormone therapy demonstrated a benefit for hormone therapy inreducing the risk for heart attack and stroke.”D. “What is truly important for hormone therapy is the timing of initiation. Since you are recentlymenopausal, we know that starting hormone therapy now will reduce your risk of future heartattack.”E. “You should definitely take low-dose aspirin daily. It has been shown to reduce the risk ofcoronary heart disease in women more than men.”I-29. Which of the following statements is true regarding sex differences in disease?A. Most autoimmune diseases are more prevalent in women than men. This is attributed tostimulatory actions of estrogens and the inhibitory actions of androgens on the cellular mediatorsof immunity, and hormone therapy with oral contraceptives increases the risk of autoimmunedisease.B. Obesity decreases the risk of endometrial cancer in women.C. Testosterone administered to hypogonadal men will increase the incidence or severity ofobstructive sleep apnea. This does not occur with testosterone administered to hypogonadalwomen.D. Women are more sensitive to insulin than are men, and thus, women’s risk for type 2 diabetesmellitus is lower.E. Women have a longer QT interval on average than men and are at higher risk for drug-inducedtorsades 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 toask his doctor about “low T” (low testosterone). He is interested in getting tested. Which of thefollowing statements to this patient is valid?A. “If you are found to be testosterone deficient, therapy with exogenous testosterone may worsenyour sleep apnea.”B. “It is recommended that every man above the age of 60 be tested for low total and bioavailabletestosterone.”C. “Most studies show that testosterone concentration does not, on average, decline with advancingage. Instead, the endogenous testosterone made is less potent.”D. “Testosterone levels are associated with a risk for dementia in men.”E. “While exogenous testosterone therapy can increase lean muscle mass, it also increases visceralfat mass.”I-31. A 29-year-old former competitive power-lifter who stopped competing 6 months earlier due to adeltoid muscle tear confides that he and his wife have been unable to conceive despite over a year ofsexual intercourse without contraception. He wonders if there is a “shot or something that can, youknow, 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 cluessuggesting 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 asophisticated 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-haultrucker who enjoys fishing and traveling. During the spring and summer months, he takesdiphenhydramine daily for seasonal allergies. He has been generally feeling well, but has recentlynoticed some urinary urgency, straining to void, and even urinary incontinence. You perform acomplete physical examination including a digital prostate exam and confirm benign prostatichypertrophy. The International Prostate Symptom Score indicates that Mr. Brooks’s symptoms aremoderate. Which of the following statements to Mr. Brooks would be appropriate?A. “I recommend primary therapy with tolterodine, an anticholinergic agent targeted at treatedoveractive bladder symptoms.”B. “Therapy with finasteride can reduce progression to acute urinary retention and need for prostatesurgery.”C. “Urodynamic studies are warranted; I’ll refer you now.”D. “We should go straight to surgery. Given the severity of your symptoms, medical therapy isunlikely to help much.”E. “Your use of diphenhydramine is probably working to improve your lower urinary tractsymptoms 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 firstchild. To date, her pregnancy has been unremarkable and she has no family history of complicatedpregnancies. Her past medical history is unremarkable except for a history of mitral valve prolapse. Ablood pressure greater than which of the following would be considered potentially abnormallyelevated?A. 110/80 mmHg in the standing positionB. 120/80 mmHg in the standing position 2 minutes after rising from the supine positionC. 130/85 mmHg in the left lateral recumbent positionD. 130/85 mmHg in the seated positionE. 140/90 mmHg in the seated positionI-34. A 36-year-old nulliparous woman is found to have a blood pressure of 150/95 mmHg on a routineprenatal screening examination at 25 weeks’ gestation. Prior to this visit, her blood pressure wastypically 125/80 mmHg. She has a history of well-controlled diabetes and hyperlipidemia. Her examis 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 urineprotein/creatinine ratio of 0.4. Which of the following findings in this patient is necessary to confirmthe diagnosis of preeclampsia?A. DiabetesB. HyperlipidemiaC. ObesityD. Pedal edemaE. Protein/creatine ratioI-35. A 29-year-old woman who is 35 weeks pregnant has been managed with aspirin and labetalol forpreeclampsia after she was found to have elevated blood pressure and proteinuria. All of thefollowing findings characterize preeclampsia with severe features EXCEPT:A. AsthmaB. HemolysisC. Hepatocellular injuryD. SeizureE. ThrombocytopeniaI-36. A 33-year-old woman with diabetes mellitus, renal insufficiency, and hypertension presents to thehospital with seizures during week 38 of her pregnancy. Her blood pressure is 165/95 mmHg. Shehas 4+ proteinuria. Management should include all of the following EXCEPT:A. Emergent deliveryB. Intravenous labetalolC. Intravenous magnesium sulfateD. Intravenous phenytoinI-37. All of the following statements regarding a patient with type 1 diabetes who becomes pregnant aretrue EXCEPT:A. Early delivery should be avoided and undertaken only for obstetric or fetal indications.B. Fasting blood glucose should be maintained 140–180 mg/dL to avoid fetal hypoglycemia.C. Prenatal folate supplementation will decrease the risk of a fetal neural tube defect.D. She and her child are at higher perinatal mortality risk than a patient without diabetes.E. 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. Free T3B. Free T4C. Total T3D. Thyroid-stimulating hormone (TSH)I-39. Which of the following cardiovascular conditions is a contraindication to pregnancy?A. Atrial septal defect without Eisenmenger syndromeB. Idiopathic pulmonary arterial hypertensionC. Marfan syndromeD. Mitral regurgitationE. 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. Decreased blood pressureB. Increased cardiac outputC. Increased heart rateD. Increased plasma volumeE. Increased systemic vascular resistanceI-41. A 27-year-old woman develops left leg swelling during week 20 of her pregnancy. Left lowerextremity ultrasound reveals a left iliac vein deep vein thrombosis (DVT). Proper managementincludes:A. BedrestB. Catheter-directed thrombolysisC. EnoxaparinD. Inferior vena cava filter placementE. WarfarinI-42. In addition to a history and physical examination, which of the following should be performedpreoperatively to identify intermediate- or high-risk patients who may benefit from a more detailedclinical evaluation?A. Chest radiographB. ElectrocardiogramC. Liver function testsD. Serum creatinineE. Serum electrolytes (sodium, potassium, chloride, bicarbonate)I-43. Which of the following patients should receive a cardiac catheterization prior to the proposedsurgery?A. A 38-year-old man for elective bariatric surgery. He has a history of medically controlled familialhyperlipidemia but no history of chest pain and a normal electrocardiogram (ECG). He has anormal cardiac and pulmonary examination and can easily climb more than two flights of stairswithout stopping.B. A 45-year-old man with a history of coronary artery bypass graft surgery 8 years ago who hassustained a motor vehicle accident and has findings in the emergency department of abdominalvisceral bleeding.C. A 54-year-old woman for elective cholecystectomy. She was evaluated for chest pain in theemergency 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 patienthad an executive physical examination where the nodule was found on a chest CT; he also had anabnormal exercise stress test.E. A 68-year-old man for an elective radical prostatectomy. He had a coronary artery bypass graft 2years 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 isused to assess the risk of perioperative major cardiac events EXCEPT:A. Congestive heart failureB. High-risk surgeryC. Ischemic heart diseaseD. Renal dysfunctionE. ThrombocytopeniaI-45. A 74-year-old man is scheduled to undergo total colectomy for recurrent life-threateningdiverticular bleeding. He has a history of idiopathic cardiomyopathy, renal insufficiency,hypercholesterolemia, and chronic obstructive pulmonary disease (COPD). His current medicationsinclude metoprolol, atorvastatin, enalapril, metformin, and albuterol/ipratropium inhaler. Hissymptoms are well controlled, and he has had no emergency department visits in the past year forexacerbations of his cardiomyopathy or COPD. His blood pressure is 128/86 mmHg. His physicalexamination 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. Albuterol/ipratropium inhalerB. AtorvastatinC. EnalaprilD. MetoprololI-46. A 73-year-old man with a history of COPD and an forced expiratory volume in 1 second (FEV1) of1.3 L (40% predicted) is undergoing an elective cholecystectomy. In the postoperative period, whichof the following interventions has been shown to decrease the likelihood of pulmonarycomplications?A. Eliminating administration of narcoticsB. Incentive spirometryC. Pulmonary artery catheterizationD. Total enteral nutritionE. Total parenteral nutritionI-47. Which of the following surgeries would be considered to have the greatest risk for postsurgicalcomplications?A. Carotid endarterectomyB. Nonemergent repair of a thoracic aortic aneurysmC. Resection of a 5-cm lung cancerD. Total colectomy for colon cancerE. Total hip replacementI-48. All of the following are risk factors for postoperative pulmonary complications EXCEPT:A. Age >60 yearsB. Asthma with a peak expiratory flow rate of 220 L/minC. Chronic obstructive pulmonary diseaseD. Congestive heart failureE. FEV1 of 1.5 LI-49. You are caring for a 56-year-old woman who was admitted to the hospital with a change in mentalstatus. She underwent a right-sided mastectomy and axillary lymph node dissection 3 yearspreviously for stage IIIB ductal carcinoma. Serum calcium is elevated at 15.3 mg/dL. A chestradiograph demonstrates innumerable pulmonary nodules, and a head CT shows a brain mass in theright frontal lobe with surrounding edema. Despite correcting her calcium and treating cerebraledema, the patient remains confused. You approach the family to discuss the diagnosis of widelymetastatic disease and the patient’s poor prognosis. All of the following are components of the sevenelements for communicating bad news (P-SPIKES approach) EXCEPT:A. Assess the family’s perception of her current illness and the status of her underlying cancerdiagnosisB. Empathize with the family’s feelings and provide emotional supportC. Prepare mentally for the discussionD. Provide an appropriate setting for discussionE. Schedule a follow-up meeting in 1 day to reassess whether there are additional informational andemotional needsI-50. All of the following statements regarding end-of-life epidemiology in the United States are trueEXCEPT:A. More than 70% of deaths occur in people over 65 years old.B. Approximately 30% of patients die as hospital inpatients.C. Approximately 70% of deaths are preceded by a known illness.D. Cardiovascular disease and cancer are the most common causes of death.E. 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 certainconditionsB. Description of values that should guide discussions regarding terminal careC. Designation of a healthcare proxyD. General statements regarding whether the patient desires receipt of life-sustaining interventionssuch as mechanical ventilationI-52. A 72-year-old woman has stage IV ovarian cancer with diffuse peritoneal studding. She isdeveloping increasing pain in her abdomen and is admitted to the hospital for pain control. Shepreviously was treated with oxycodone 10 mg orally every 6 hours as needed. Upon admission, she isinitiated on morphine intravenously via patient-controlled analgesia. During the first 48 hours of herhospitalization, she received an average daily dose of morphine of 90 mg and reports adequate paincontrol unless she is walking. What is the most appropriate opioid regimen for transitioning thispatient to oral pain medication? I-53. You are asked to consult on 62-year-old man who was recently found to have newly metastaticdisease. He was originally diagnosed with cancer of the prostate 5 years previously and presented tothe hospital with back pain and weakness. Magnetic resonance imaging (MRI) demonstrated bonymetastases to his L2 and L5 vertebrae with cord compression at the L2 level only. On bone scanimages, there was evidence of widespread bony metastases. He has been started on radiation andhormonal therapy, and his disease has shown some response. However, he has become quitedepressed since the metastatic disease was found. His family reports that he is sleeping for 18 ormore hours daily and has stopped eating. His weight is down 12 lb over 4 weeks. He expressesprofound fatigue, hopelessness, and a feeling of sadness. He claims to have no interest in his usualactivities and no longer interacts with his grandchildren. What is the best approach to treating thispatient’s depression?A. Do not initiate pharmacologic therapy because the patient is experiencing an appropriatereaction to his newly diagnosed metastatic disease.B. Initiate therapy with doxepin 75 mg nightly.C. Initiate therapy with fluoxetine 10 mg daily.D. Initiate therapy with fluoxetine 10 mg daily and methylphenidate 2.5 mg twice daily in themorning and at noon.E. 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 unitfor aspiration pneumonia. After 7 days of mechanical ventilation, her family requests that care bewithdrawn. The patient is palliated with fentanyl intravenously at a rate of 25 μg/hr and midazolamintravenously at 2 mg/hr. You are urgently called to the bedside 15 minutes after the patient isextubated because the patient’s daughter is distraught. She states that you are “drowning” her motherand is upset because her mother appears to be struggling to breathe. When you enter the room, youhear a gurgling noise that is coming from accumulated secretions in the oropharynx. You suction thepatient for liberal amounts of thin salivary secretions and reassure the daughter that you will makeher mother as comfortable as possible. Which of the following interventions may help with thetreatment of the patient’s oral secretions?A. Increased infusion rate of fentanylB. N-Acetylcysteine nebulizedC. Pilocarpine dropsD. Placement of a nasal trumpet and oral airway to allow easier access for aggressive suctioningE. Scopolamine patchesI-55. You are caring for a 68-year-old man with end-stage idiopathic pulmonary fibrosis. Hisperformance status is currently 0; he is bed-bound and starting home hospice care. He is chronicallyon nasal oxygen at 4 L/min with SaO2 of 94%. The patient reports relentless and severe dyspnea thathas worsened over the last 1–2 months. It is now his most notable complaint. Physical examination isnotable for normal vital signs other than a respiratory rate of 25/min. There is no evidence ofongoing infection or other acute pulmonary process. Which of the following interventions would be areasonable first step to improve comfort for this patient?A. AlbuterolB. CodeineC. Increase nasal oxygen to 8 L/minD. LorazepamE. Nebulized morphineI-56. All of the following statements regarding euthanasia or physician-assisted suicide are true EXCEPT:A. Over 70% of patients with terminal disease consider euthanasia or physician-assisted suicide forthemselves.B. Over 75% of patients who seek physician-assisted suicide identify loss of autonomy or dignityand inability to engage in enjoyable activities as their main reason.C. Patients with cancer are the most common to consider euthanasia or physician-assisted suicidefor themselves.D. Physician-assisted suicide is legal in some states in the United States.E. Voluntary active euthanasia is not legal in the United States.I-57. Which continent has the highest median population age?A. AfricaB. AsiaC. AustraliaD. EuropeE. North AmericaI-58. The systemic effects of aging cluster into four domains: body composition, discrepancy betweenenergy demand and utilization, homeostatic dysregulation, and neurodegeneration. All of thefollowing statements regarding these effects are true EXCEPT:A. Lean muscle mass decreases after the third decade of life, whereas fat mass increasesprogressively after middle age.B. Most older individuals, even those who are healthy, develop mild increases in markers ofinflammation such as C-reactive protein and interleukin-6 when compared to youngerindividuals.C. Peak oxygen consumption declines progressively with age.D. The regions of the brain most likely to be atrophied with mild cognitive impairment are thelateral prefrontal cortex and hippocampus.I-59. Which of the following age groups is the fastest growing worldwide?A. 1–20 years oldB. 21–40 years oldC. 41–60 years oldD. 61–79 years oldE. >80 years oldI-60. Which of the following is the most common type of preventable adverse event in hospitalizedpatients?A. Adverse drug eventsB. Diagnostic failuresC. FallsD. Technical complications of proceduresE. Wound infectionsI-61. All of the following are steps in a cycle to rapidly improve a specific process EXCEPT:A. ActB. CheckC. DoD. PlanE. ReevaluateI-62. Which of the following is projected to cause the most deaths in low- and middle-income countriesin 2030?A. CancerB. Cardiovascular diseaseC. HIV/AIDS, TB, malaria, and other infectious diseasesD. Intentional injuriesE. Road traffic accidentsI-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 werehighlighted in the report, EXCEPT:A. Drug developmentB. LeadershipC. Public policyD. Service deliveryE. Universal health coverageI-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 andfunction 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 dietarysupplements.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 thehealth insurance context?A. A condition in which some individuals can be made better off without making anyone else worseoffB. A situation in which physicians are reimbursed a fixed amount per patient and will have afinancial incentive to avoid sick patientsC. The branch of economics that seeks to explain actual phenomena without making a judgmentabout the desirability of these phenomenaD. The incentives for better-insured individuals to use more medical servicesE. The system in which the price of a good or service is dictated by a governmental or othergoverning agency rather than by market forcesI-66. Independent of insurance status, income, age, and comorbid conditions, disparities exist betweenthe care received by black and white patients for which of the following scenarios?A. Prescription of analgesics for pain controlB. Referral to renal transplantationC. Surgical treatment for lung cancerD. Referral for cardiac catheterization and bypass graftingE. All of the aboveI-67. All of the following are legally relevant criteria for a physician establishing decision-makingcapacity in a patient EXCEPT:A. The ability to answer basic orientation questions such as name, year, and home addressB. The ability to appreciate the situation and its consequencesC. The ability to communicate a choiceD. The ability to reason about treatment optionsE. The ability to understand the relevant informationI-68. In which of the following conditions has stem cell therapy been shown to have in vivo benefit?A. CirrhosisB. Ischemic heart diseaseC. Parkinson diseaseD. Spinal cord injuryE. Type 1 diabetes mellitusI-69. The greatest source of nutrients and calories in an individual’s diet should come from whichsource?A. AlcoholB. CarbohydratesC. FatD. ProteinI-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 vitaminD has been measured previously as within normal limits. Which statement is true with regard to thisscenario?A. Dietary reference intakes (DRI) would have been a better tool to determine if her nutrient intakewas 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 andfrostbite in his distal extremities. He has a longstanding history of alcoholism, drinking about 1 L ofvodka on a daily basis. You are asked to consult due to concerns of bizarre behaviors exhibited by thepatient. He is expressing a belief that his wounds were the result of burns that were inflicted uponhim by “torturers” in the government because he “knows too much” about government surveillanceplans. The surgical team reports it is difficult to keep the patient in his bed, and he seems unsteadyon his feet at times. He has been medicated throughout his stay for prevention of alcohol withdrawalvia a symptom-triggered approach and last received lorazepam 2 mg orally about 2 hours ago. At thattime, the patient was noted to be tremulous, tachycardic, and hypertensive. The delusional thoughtsare not responsive to treatment of alcohol withdrawal symptoms. When you see the patient, he issleeping 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 extremitiesbelow the mid-tibia. His gait is wide based and ataxic. He no longer expresses his prior delusionalbeliefs, but he is disoriented and thinks he is in jail. He states he was brought to “this gulag” so thatthe government could experiment on him. He has 5% dextrose in half-normal saline infusing at 100mL/hr and is also receiving nafcillin 2 g IV every 4 hours for cellulitis. What do you suspect is thecause of the patient’s altered mental state?A. HypoglycemiaB. HyponatremiaC. Niacin deficiencyD. Thiamine deficiencyE. Undertreated alcohol withdrawalI-72. A 30-year-old woman expresses the desire to maintain a healthy lifestyle and has a focus onpreventative health. She believes that she can prevent illness and cancer through ingestingsupplements and antioxidants. When reviewing her current intake, you determine she is takingvitamin A 20,000 IU daily and has been for the past 12 months. What advice can you give herregarding this dose?A. Chronic ingestion of this dose could be associated with an increased risk of lung cancer even innonsmokers.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 anincreased risk of spontaneous abortions and congenital malformations, including craniofacialabnormalities 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 somemild diarrhea and also has mouth soreness. He remains fatigued with a loss of appetite andirritability. On examination, you notice his tongue is bright red and somewhat enlarged. It is tenderto touch. In addition, he has a pigmented and scaling rash that is most prominent around hisneckline. What is the most likely vitamin or mineral deficiency in this patient?A. CopperB. NiacinC. RiboflavinD. Vitamin CE. ZincI-74. Vitamin A deficiency is associated with an increased risk of which of the following:A. BlindnessB. Maternal infection and deathC. Mortality from dysenteryD. Mortality from malariaE. All of the aboveI-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 uppergastrointestinal (GI) bleed, but rather is having significant gingival bleeding. He is intoxicated andcomplains of fatigue. Reviewing his chart, you find that he had a hemarthrosis evacuated 6 monthsago and has been lost to follow-up since then. He takes no medications. Laboratory data showplatelets of 250,000 and international normalized ratio (INR) of 0.9. He has a diffuse hemorrhagiceruption on his legs that is centered around hair follicles. What is the recommended treatment forthis patient’s underlying disorder?A. FolateB. NiacinC. ThiamineD. Vitamin CE. Vitamin KI-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 pointesarrhythmia and was pulseless. She received cardiopulmonary resuscitation, defibrillation, andmagnesium en route to the hospital. Upon arrival, her initial potassium is 1.2 mEq/L. Her physicalexamination 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 nutritionalstate?A. Mortality in the disease is most commonly due to complications of malnutrition.B. Poor wound healing and frequent skin infections are common complications.C. Systemic inflammation is a predominant finding on laboratory examination.D. The serum albumin is typically less than 2.8 g/dL.E. Triceps skinfold <3 mm and mid-arm muscle circumference <15 cm are useful diagnosticcriteria.I-77. A 74-year-old woman is hospitalized in the surgical intensive care unit after undergoing anemergent colectomy for ischemic colitis related to vascular disease. At the time of surgery, she hadexperienced a bowel perforation. She is currently postoperative day 10 and remains intubated andsedated with evidence of ongoing multiorgan system failure. She requires norepinephrine infusioncontinuously at a rate of 10 μg/min. She has acute renal failure and is on continuous venovenoushemodialysis. Her blood cultures were positive for Escherichia coli, and she is being treated withcefepime 2 g IV every 8 hours and metronidazole 500 mg every 8 hours. She has a colostomy in herright lower quadrant, but the surgeons were unable to primarily close her abdomen due to the bowelperforation. She has returned to the operating room for reexploration and wash out of theperitoneum. Since admission, her fluid balance is positive more than 30 L. She has marked anasarcaand has not been fed since admission, although the team plans to initiate total parenteral nutritiontoday. 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 of19.1 kg/m2 admitted to the hospital with an asthma exacerbationB. A previously healthy 28-year-old man admitted to the intensive care unit with third-degree burnscovering 85% of his body surface areaC. A 32-year-old man with alcoholism admitted with acute pancreatitis who has been NPO for 6daysD. A 41-year-old woman with short gut syndrome following resection of small bowel for agastrointestinal stromal tumor admitted to the hospital with dehydrationE. A 55-year-old woman admitted to the hospital for right mastectomy for breast cancer who hasrecently lost 25 lb (from 200 to 175 lb) unintentionallyI-79. You are caring for a 54-year-old woman in the intensive care unit who was admitted for treatmentof severe sepsis and pneumonia. You would like to initiate enteral nutrition and plan to calculatebasal energy expenditure for the patient. All of the following factors are used to determine thepatient’s caloric needs EXCEPT:A. AgeB. AlbuminC. GenderD. HeightE. WeightI-80. A 65-year-old man is admitted for colectomy for stage III colon cancer. On the secondpostoperative day, he requires repeat exploratory laparotomy due to bleeding complications. It is nowpostoperative day 7 from his original resection, and the patient has had no nutrition since beforesurgery. 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 soundspresent, and ileostomy output is good. What would be recommended at the present time for thispatient?A. Continued NPO status because 5–7 days without nutritional support is acceptable for this patientB. Initiate a clear liquid diet and supplement with intravenous fluids with dextrose to maintainadequate intakeC. Placement of a central venous catheter and initiation of total parenteral nutritionD. Placement of a nasogastric tube and initiation of enteral nutritionE. Placement of a nasojejunal tube and initiation of enteral nutritionI-81. All of the following statements support the use of enteral feeding for critically ill patients EXCEPT:A. Enteral feeding increases splanchnic blood flow.B. Enteral feeding stimulates secretion of gastrointestinal hormones to promote trophic gut activity.C. Immunoglobulin (Ig) A antibody release is stimulated by enteral feeding.D. Neuronal activity to the gut is decreased by enteral feeding.E. Seventy percent of nutrients used by the gut are directly derived from food within the lumen ofthe gut.I-82. What body mass index is likely to be lethal in males?A. <10 kg/m2B. 11 kg/m2C. 13 kg/m2D. 16 kg/m2E. 18.5 kg/m2I-83. A 43-year-old woman develops hemorrhagic pancreatitis with severe systemic inflammationresponse syndrome. She is intubated and sedated in the medical intensive care unit with acuterespiratory distress syndrome, hypotension, and renal dysfunction. She has ongoing daily fevers to ashigh as 104.5°F (40.3°C). She is initiated on parenteral nutrition (PN) and develops hyperglycemia ashigh as 500 g/dL. She is also noted to have an increasingly positive fluid balance of more than 2 Ldaily. What is the most appropriate approach to management of PN in the context of herhyperglycemia and fluid retention?A. Addition of regular insulin to the total PN formulaB. Limiting sodium to less than 40 mEq/dC. Limiting glucose to less than 200 g/dD. Providing both glucose and fat to the total PN mixtureE. All of the aboveI-84. Microbial agents have been used as bioweapons since ancient times. All of the following are keyfeatures of microbial agents that are used as bioweapons EXCEPT:A. Environmental stabilityB. High morbidity and mortality ratesC. Lack of rapid diagnostic capabilityD. Lack of readily available antibiotic treatmentE. Lack of universally available and effective vaccineI-85. Ten individuals in Arizona are hospitalized over a 4-week period with fever and rapidly enlargingand painful lymph nodes. Seven of these individuals experience severe sepsis and three die. Whilereviewing the epidemiologic characteristics of these individuals, you note that they are all illegalimmigrants and have recently stayed in the same immigrant camp. Blood cultures are growing gram-negative rods that are identified as Yersinia pestis. You notify local public health officials and theCenters for Disease Control and Prevention. Which of the following factors indicates that this is NOTlikely 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-persontransmission.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. AerosolB. Contamination of the food supplyC. Contamination of the water supplyD. A and BE. All of the aboveI-87. Anthrax spores can remain dormant in the respiratory tract for how long?A. 1 weekB. 6 weeksC. 6 monthsD. 1 yearE. 3 yearsI-88. Twenty recent attendees at a National Football League game arrive at the emergency departmentcomplaining of shortness of breath, fever, and malaise. Chest roentgenograms show mediastinalwidening on several of these patients, prompting a concern for inhalational anthrax as a result of abioterror attack. Antibiotics are initiated and the Centers for Disease Control and Prevention isnotified. What form of isolation should be instituted for these patients in the hospital?A. AirborneB. ContactC. DropletD. NoneI-89. The Centers for Disease Control and Prevention has designated several biologic agents as categoryA in their ability to be used as bioweapons. Category A agents include agents that can be easilydisseminated or transmitted, result in high mortality, can cause public panic, and require specialaction for public health preparedness. All the following agents are considered category A EXCEPT:A. Bacillus anthracisB. Francisella tularensisC. Ricin toxin from Ricinus communisD. Smallpox virusE. Y pestisI-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-90Which of the following was the agent responsible for this event?A. B anthracisB. Botulinum toxinC. Ebola virusD. Variola majorE. Y pestisI-91. All of the following chemical agents of bioterrorism are correctly identified by their mechanism ofinjury EXCEPT:A. Arsine—asphyxiantB. Chlorine gas—pulmonary damageC. Cyanogen chloride—nerve agentD. Mustard gas—vesicantE. Sarin—nerve agentI-92. Over the course of 12 hours, 24 individuals present to a single emergency department complainingof a sunburn-like reaction with development of large blisters. Most of these individuals are alsoexperiencing irritation of the eyes, nose, and pharynx. Two individuals developed progressivedyspnea, severe cough, and stridor requiring endotracheal intubation. On physical examination, all ofthe patients exhibited conjunctivitis and nasal congestion. Erythema of the skin was greatest in theaxillae, neck, and antecubital fossae. Many of the affected individuals had large, thin-walled bullaeon the extremities that were filled with a clear or straw-colored fluid. On further questioning, all ofthe affected individuals had been shopping at a local mall within the past 24-hours and ate at thefood court. Many commented on a strong odor of burning garlic in the food court at that time. Yoususpect a bioterrorism act. Which of the following statements is true with regard to the likely agentcausing 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 andadult respiratory distress syndrome.D. The erythema that occurs can be delayed as long as 2 days following exposure and depends uponseveral factors including ambient temperature and humidity.E. The fluid within the bullae should be treated as a hazardous substance that can lead to localreactions and blistering with exposure.I-93. A 24-year-old man is evaluated immediately following exposure to chlorine gas as an act ofchemical terrorism. He currently denies dyspnea. His respiratory rate is 16/min, and oxygensaturation is 97% on room air. All of the following should be included in the immediate treatment ofthis individual EXCEPT:A. Aggressive bathing of all exposed skin areasB. Flushing of the eyes with water or normal salineC. Forced rest and fresh airD. Immediate removal of clothing if no frostbiteE. Maintenance of a semi-upright positionI-94. You are a physician working in an urban emergency department when several patients are broughtin after the release of an unknown gas at the performance of a symphony. You are evaluating a 52-year-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. Atpresent, she also has nausea, vomiting, diarrhea, and muscle twitching. On physical examination, thepatient has a blood pressure of 156/92 mmHg, a heart rate of 92, a respiratory rate of 30, and atemperature of 37.4°C (99.3°F). She has pinpoint pupils with profuse rhinorrhea and salivation. She isalso coughing profusely, with production of copious amounts of clear secretions. A lung examinationreveals wheezing on expiration in bilateral lung fields. The patient has a regular rate and rhythmwith normal heart sounds. Bowel sounds are hyperactive, but the abdomen is not tender. She ishaving diffuse fasciculations. At the end of your examination, the patient abruptly develops tonic-clonic seizures. Which of the following agents most likely caused this patient’s symptoms?A. ArsineB. Cyanogen chlorideC. Nitrogen mustardD. SarinE. VXI-95. All the following should be used in the treatment of the patient in the previous question EXCEPT:A. AtropineB. DecontaminationC. DiazepamD. PhenytoinE. 2-Pralidoxime chlorideI-96. All of the following statements regarding the results of detonation of a low-yield nuclear device bya terror group are true EXCEPT:A. After recovery of initial exposure symptoms, the patient remains at risk of systemic illness for upto 6 weeks.B. Appropriate medical therapy can change the median lethal dose from approximately 4 Gy to 8Gy.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 acuteradiation syndrome.I-97. A “dirty” bomb is detonated in downtown Boston. The bomb was composed of cesium-137 withtrinitrotoluene. In the immediate aftermath, an estimated 30 people were killed due to the power ofthe blast. The fallout area was about 0.5 mile, with radiation exposure of approximately 1.8 Gy. Anestimated 5000 people have been potentially exposed to beta and gamma radiation. Most of theseindividuals show no sign of any injury, but about 60 people have evidence of thermal injury. What isthe 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 foremergency care to prevent exposure of healthcare workers.D. Severely injured individuals should be transported to the hospital for emergency care afterremoving 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 onhis lower right leg by a snake that his hiking companion identified as a rattlesnake. The man waswearing shorts and hiking boots. There are two clear puncture wounds that are oozing blood justabove the sock line of his right boot, and the man is beginning to complain of increasing pain in theright leg. The man and his companion are about 15 minutes away from the trailhead and do not havea cell phone. What should be done immediately in the care of this patient?A. Apply a splint if available to support the limb and decrease pain and seek immediate medicalcareB. Apply a tourniquet superior to the bite to limit circulation of the venomC. Incise or apply suction to the site of the bite immediately to attempt to remove injected venomD. When possible, elevate the limb to heart levelE. A and D onlyF. All of the aboveI-99. The companion of the patient in Question I-98 assists him to the trailhead and activates emergencymedical services. Upon arrival to the emergency department, the patient is noted to have increasingswelling and pain in the right lower extremity. The vital signs are blood pressure 98/52 mmHg, heartrate 132 bpm, respiratory rate 24/min, SaO2 96% on room air, and temperature 37.0°C. The limb ispositioned at the level of the heart. The maximum level and progression of swelling is marked. Twolarge-bore IV’s are placed, and aggressive fluid resuscitation is begun. Which of the following is anindication for administration of antivenom?A. CoagulopathyB. Hypotension unresponsive to fluid administrationC. Swelling in the right lower leg that crosses the ankleD. Swelling in the right lower leg that involves more than half of the legE. All of the above would be indications for antivenom administrationI-100. Four individuals from the same family present to the emergency department with symptoms ofabdominal pain, nausea, vomiting, and diarrhea. Two of the family members are also reportingstrange tingling sensations around their lips, and one person says he feels like he is swallowingbubbles. The family is vacationing in Florida and have been deep sea fishing all day. For dinner, theyate some of the fish they had caught, including some small barracuda. Emergency departmentevaluation is unrevealing, and they are discharged with only symptomatic nausea treatment. Over thenext 24 hours, their GI symptoms peak and then resolve within 3 days. The two individuals with mildparesthesias also resolve over 3 days. However, one individual develops reversal of hot and coldperception after 3 days. This symptom continued to persist after 6 weeks. What was the likely causeof the patients’ illness?A. Ciguatera poisoningB. Diarrhetic shellfish poisoningC. Domoic acid intoxicationD. Scombroid poisoningE. Tetrodotoxin poisoningI-101. A 42-year-old woman and her 6-year-old daughter have each been treated for head lice with twoapplications of over-the-counter 1% permethrin separated by 10 days. Mechanical removal of lice andtheir eggs was performed after each application. Environmental measures have included washing allbedding in hot water and drying at >55°C. The father’s head is shaved. Despite this, the daughter isagain 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 pesticideB. Complete an additional treatment with 1% permethrinC. Perform a more thorough environmental investigation for possible fomite transmissionD. Refrain from all participation in school until the child is determined to be free of all nits (liceeggs)E. Treat with topical spinosad due to permethrin resistanceI-102. A 56-year-old man seeks evaluation due to a spider bite. He was dressing this morning and pulleda sweatshirt over his head. He felt a sharp sting on his upper arm and found a brown recluse spider inhis clothing. He has noticed some redness in this area. On examination, you see a 3 × 2 cm lesion onthe inner area of his upper arm. In the center, it is somewhat pale and indurated, but the surroundingarea is erythematous and painful to touch. What is the best treatment for this patient?A. Administer antivenomB. Advise the patient that most patients develop ischemic necrosis that requires prolonged healingC. Apply RICE (rest, ice, compression, and elevation) and observe closely for signs of ischemiaD. Prescribe clindamycin 600 mg qid for cellulitisE. Refer to the emergency department for further evaluation and possible debridementI-103. One of your patients is contemplating a trekking trip to Nepal at elevations between 2500 and3000 meters. Five years ago, while skiing at Telluride (altitude 2650 meters), she recalls havingheadache, nausea, and fatigue within a day of arriving that lasted about 2–3 days. All of thefollowing statements are true regarding the development of acute mountain sickness in this patientEXCEPT:A. Acetazolamide starting 1 day before ascent is effective in decreasing the risk.B. Ginkgo biloba is not effective in decreasing the risk.C. Gradual ascent is protective.D. Her prior episode increases her risk for this trip.E. 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 forhelicopter snowboarding in the Bugaboo mountain range in British Columbia (elevation 3000meters). 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 ofthe following statements are true regarding his illness EXCEPT:A. Descent and oxygen are most therapeutic.B. Exercise increased his risk.C. Fever and leukocytosis may occur.D. He should never risk return to high altitude after recovery.E. Pretreatment with nifedipine or tadalafil would have lowered his risk.