Harrison's Principles of Internal Medicine Self-Assessment and Board Review, 19th Edition

804 Pages·2017·33.377 MB·English

by  Charles Wiener, Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo, Cynthia Brown, Brain Houston

19th Edition
‘HAISON’S
P L E 8
IN T 0E H N A0 L
M E D | C | N E
SELF-ASSESSMENT
AND BOARD REVIEW
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SECTION I
General Considerations in Clinical Medicine
QUESTIONS
DIRECTIONS: Choose the one best response to each question.
I-1. All of the following statements regarding practice guidelines set forth by governing agencies and
professional organizations are true EXCEPT:
A. Clinical practice guidelines protect caregivers against inappropriate charges of malpractice, yet
do not provide protection for patients from receiving substandard care.
B. Practice guidelines have largely reached a stage of nuance allowing them to address every unique
illness and patient presented to the modern physician.
C. Practice guidelines provide a legal constraint to physicians, and deviation from guideline-based
care invariably leaves physicians vulnerable to legal action.
D. Where different organizations disagree regarding practice guidelines, a third-party agency has
been appointed to mitigate these disagreements such that now all major organizations’ guidelines
are consistent.
E. All of the above statements are not true.
I-2. Regarding molecular medicine, which of the following statements represents an INACCURATE
example of the listed area of study:
A. Exposomics: An endocrinologist studies sunlight exposure and population risk of hip fracture.
B. Metabolomics: A biochemist studies the rate of flux through the creatine kinase pathway during
the cardiac cycle.
C. Metagenomics: A biologist studies the genomic alterations in molds commonly found in human
dwellings.
D. Microbiomics: A microbiologist studies the genomic variation in thermophiles, bacteria that can
survive extreme heat near deep ocean vents.
E. Proteomics: A cardiologist studies desmosomal proteins and their posttranslational modifications
in studying arrhythmogenic right ventricular dysplasia.
I-3. Which of the following is the best definition of evidence-based medicine?
A. A summary of existing data from existing clinical trials with a critical methodologic review and
statistical analysis of summative data
B. A type of research that compares the results of one approach to treating disease with another
approach to treating the same disease
C. Clinical decision-making support tools developed by professional organizations that include
expert opinions and data from clinical trials
D. Clinical decision making supported by data, preferably randomized controlled clinical trials
E. One physician’s clinical experience in caring for multiple patients with a specific disorder over
many years
I-4. Which of the following is the standard measure for determining the impact of a health condition on
a population?
A. Disability-adjusted life-years
B. Infant mortality
C. Life expectancy
D. Standardized mortality ratio
E. Years of life lost
I-5. Which of the following statements regarding disease patterns worldwide is true?
A. Childhood undernutrition is the leading risk factor for global disease burden.
B. In a 2006 publication, the World Health Organization (WHO) estimated that 10% of the total
global burden of disease was due to modifiable environmental risk factors.
C. In 2010, ischemic heart disease was the leading cause of death among adults.
D. In the last two decades, mortality attributed to communicable diseases, maternal and perinatal
conditions, and nutritional deficiencies has remained fairly stable, with the majority (76%) of
mortality from these causes occurring in sub-Saharan Africa and southern Asia.
E. While poverty status has been shown to be linked to health status on the individual level, the
same relationship does not hold true when studying the link between national health indicators
and gross domestic product per capita among nations.
I-6. You are appointed to a governmental healthcare advisory subcommittee concerned with addressing
problems facing the global health community. Your task is to draw general conclusions from the
global fight against tuberculosis (TB) and human immunodeficiency virus (HIV)/acquired
immunodeficiency syndrome (AIDS) that may be applied in combatting other diseases, including
noncommunicable diseases. Which of the following conclusions is reasonable when considering
HIV/AIDS and TB as chronic diseases?
A. Barriers to adequate healthcare and patient adherence imposed by extreme poverty must be
concomitantly addressed to adequately treat and prevent chronic disease in developing nations.
B. Charging small fees for health services (e.g., AIDS prevention and care) supplies the patient with
a sense of the treatment’s value and increases compliance and overall public health.
C. Despite adequate available tools to practice their trade locally in developing nations, many
physicians and nurses emigrate to developed nations to practice their respective trades, a
phenomenon called “brain drain.”
D. In developed nations where physicians are abundant, community health worker supervision of
the care of chronically ill patients is not effective.
E. In the case of chronic infectious diseases, switching from one drug to another through a
prolonged course of treatment provides the highest cure rate by obviating the infectious agent’s
ability to develop resistance to any single drug.
I-7. Mrs. Jones, a 22-year-old African American woman, presents to Dr. Smith, an internal medicine
specialist, with a facial rash. Mrs. Jones states that the rash began after spending a day at the beach
with her family. She also notes that her metacarpophalangeal and proximal interphalangeal joints
have been painful and swollen for the preceding 2 weeks. On examination, the joints are swollen and
tender. Laboratory analysis discloses reduced creatinine clearance, proteinuria, and hemolytic
anemia. Antinuclear antibodies (a test with a high negative predictive value for systemic lupus
erythematosus) are detected at significant titer, and ultimately, the diagnosis of systemic lupus
erythematosus is made.
Two weeks later, Mrs. Johnson, a 24-year-old African American woman, presents with a facial rash
and elbow pain to Dr. Smith. After a cursory interview and brief physical exam, Dr. Smith sends
blood work only testing for antinuclear antibodies. When the test returns negative (no antibodies
detected), Dr. Smith presumes this to be a false-negative result and starts Mrs. Johnson on
hydroxychloroquine and prednisone for treatment of systemic lupus erythematosus. Which
heuristic(s) did Dr. Smith likely employ in diagnosing Mrs. Johnson with systemic lupus
erythematosus?
A. Availability heuristic
B. Anchoring heuristic
C. Bayes’ rule
D. Confirmation bias
E. A and B
I-8. You have invented a blood test, which you name “veritangin,” to determine if patients are having a
myocardial infarction. You devise an experiment to determine the performance of your veritangin
assay by testing it versus the troponin assay, the currently accepted gold standard for determining
myocardial infarction, in 100 random emergency department patients with chest pain. You choose a
veritangin result >1 ng/dL as positive for myocardial infarction. Your results are listed in the table
below.
Which of the following statements regarding the characteristics of the veritangin assay in this trial is
true?
A. The posttest probability of the veritangin test does not depend on the population studied.
B. The sensitivity of the veritangin assay depends on the population studied and the disease
prevalence in that population.
C. The sensitivity of the veritangin assay will decrease by 50% if you reduce the threshold for a
positive result to >0.5 ng/dL.
D. The sensitivity of the veritangin test cannot be calculated based on the above data.
E. The specificity of the veritangin assay is 0.93 (70/75).
I-9. You are designing a clinical trial to test the use of a novel anticoagulant, clotbegone, in the
treatment of deep vein thrombosis. Which of the following statements regarding the design of the
trial is true?
A. An optimal study design would assign many patients to clotbegone and compare their outcomes
to the outcomes of prior (historical) patients not taking clotbegone. This would allow faster trial
completion.
B. If the trial returns a positive result (clotbegone is superior to placebo), that means that any
patient with a clot would benefit from clotbegone therapy.
C. Observing the outcomes of patients already taking clotbegone versus patients who are not is
preferable to assigning patients to clotbegone or placebo in a blinded fashion. The observational
strategy is more “real world,” applicable to the general population, and free of bias.
D. Population selection for the trial enrollment is not important as long as careful attention to
randomization and blinding is observed.
E. The advantage of performing a randomized clinical trial of clotbegone over a prospective
observational study of clotbegone is the avoidance of treatment selection bias.
I-10. A receiver operating characteristic (ROC) curve is constructed for a new test developed to diagnose
disease X. All of the following statements regarding the ROC curve are true EXCEPT:
A. One criticism of the ROC curve is that it is developed for testing only one test or clinical
parameter with exclusion of other potentially relevant data.
B. ROC curve allows the selection of a threshold value for a test that yields the best sensitivity with
the fewest false-positive tests.
C. The axes of the ROC curve are sensitivity versus 1 – specificity.
D. The ideal ROC curve will have a value of 0.5.
E. The value of the ROC curve is calculated as the area under the curve generated from the true-
positive rate versus the false-positive rate.
I-11. When considering a potential screening test, what end points should be considered to assess the
potential gain from a proposed intervention?
A. Absolute and relative impact of screening on the disease outcome
B. Cost per life-year saved
C. Increase in the average life expectancy for the entire population
D. Number of subjects screened to alter the outcome in one individual
E. All of the above
I-12. You are appointed to an advisory committee in the WHO tasked with making recommendations
regarding breast cancer screening and prevention. In regard to screening and preventing breast
cancer in women, which of the following potential recommendations from your committee would be
valid?
A. Any breast cancer detected by screening mammography and adequately treated represents a
reduction in breast cancer mortality.
B. Screening is most effective when applied to relatively common diseases. Breast cancer, with a
lifetime risk of 10% in women, meets this criterion.
C. The presence of a latent (asymptomatic) stage of breast cancer renders it a less ideal disease
candidate 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 prevention
measures for breast cancer as women with the BRCA1 or BRCA2 mutations.
I-13. You are seeing Mr. Brown today in the primary care clinic. He has a long history of tobacco abuse,
and you notice on his intake form that he wishes to discuss lung cancer screening today. Which of the
following statements regarding lung cancer screening can you truthfully make to Mr. Brown?
A. “Recently, a large National Heart, Lung, and Blood Institute study demonstrated a significant
reduction in mortality by employing low-dose chest computed tomography as a screening tool in
patients with a significant smoking history.”
B. “Screening for lung cancer has a long history of successful implementation given the ease of
obtaining a chest x-ray and the fact that most lung cancers are curable at the time of screening
detection.”
C. “Screening for lung cancer is a ‘no-brainer’; there is really no harm in a false-positive test. The
only real worry is always that you might have a cancer that we don’t know about.”
D. “Because the sensitivity and specificity of any screening test do not depend on the population
studied, your odds of having lung cancer after a positive chest x-ray do not depend on his
smoking history.”
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 target
population?
A. A regular exercise program for a 40-year-old man
B. Getting a 35-year-old smoker to quit smoking
C. Mammography in women age 50–70
D. Pap smears in women age 18–65
E. Prostate-specific antigen (PSA) and digital rectal examination for a man >50 years old
I-15. The U.S. Preventive Services Task Force (USPSTF) recommends which of the following screening
tests for the listed patients?
A. 16-year-old male: immunoassay for HIV if not performed before
B. 32-year-old sexually active woman: nucleic acid amplification on a cervical swab for chlamydia
C. 50-year-old woman with a smoking history: dual-energy x-ray absorptiometry (DEXA) scan for
osteoporosis
D. 58-year-old prior smoker: ultrasound for abdominal aortic aneurysm
E. 80-year-old man: anti–hepatitis C virus (HCV) antibody for hepatitis C
I-16. Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?
A. Amoxicillin
B. Aspirin
C. Atorvastatin
D. Prevacid
E. Sildenafil
I-17. A 26-year-old woman received an allogeneic bone marrow transplantation 9 months ago for acute
myelogenous leukemia. Her transplant course is complicated by graft-versus-host disease with
diarrhea, weight loss, and skin rash. She is immunosuppressed with tacrolimus 1 mg twice a day (bid)
and prednisone 7.5 mg daily. She recently was admitted to the hospital with shortness of breath and
fevers to 101.5°F. She has a chest computed tomography (CT) showing nodular pneumonia, and
fungal organisms are seen on a transbronchial lung biopsy. The culture demonstrates Aspergillus
fumigatus, and a serum galactomannan level is elevated. She is initiated on therapy with voriconazole
6 mg/kg IV every 12 hours for 1 day, decreasing to 4 mg/kg IV every 12 hours beginning on day 2.
Two days after starting voriconazole, she is no longer febrile but is complaining of headaches and
tremors. Her blood pressure is 150/92 mmHg, up from 108/60 mmHg on admission. On examination,
she has developed 1+ pitting edema in the lower extremities. Her creatinine has risen to 1.7 mg/dL
from 0.8 mg/dL on admission. What is the most likely cause of the patient’s current clinical picture?
A. Aspergillus meningitis
B. Congestive heart failure
C. Recurrent graft-versus-host disease
D. Tacrolimus toxicity
E. Thrombotic thrombocytopenic purpura caused by voriconazole
I-18. A 43-year-old woman is diagnosed with pulmonary blastomycosis and is initiated on therapy with
oral itraconazole therapy. All of the following could affect the bioavailability of this drug EXCEPT:
A. Coadministration with a cola beverage
B. Coadministration with oral contraceptive pills
C. Formulation of the drug (liquid vs. capsule)
D. pH of the stomach
E. Presence of food in the stomach
I-19. Mr. Jonas is a 47-year-old truck driver with a history of HIV, hypertension, coronary artery disease,
atrial fibrillation, and ischemic cardiomyopathy. He is on antiretroviral therapy. He presents today
complaining of a new rash on his chest and axilla, which you astutely diagnose as tinea corporis. You
would like to prescribe a course of oral ketoconazole for therapy. You should consider dose
adjustment for all of the following medicines that he is already taking EXCEPT:
A. Carvedilol
B. Lovastatin
C. Mexiletine
D. Ritonavir
E. Saquinavir
I-20. Which of the following pharmacokinetic concepts is accurate?
A. After four half-lives of a zero-order drug, 93.75% of drug elimination is achieved.
B. Elimination half-life is the sole determinant of the time required for steady-state plasma
concentrations to be achieved after any change in drug dosing.
C. First-order elimination refers to the priority a drug has for its elimination enzyme versus drugs of
alternative orders. For example, a first-order drug will have a higher affinity for the enzyme than
a second-order drug.
D. Steady state describes the situation during chronic drug dosing when the plasma concentration of
drug is identical from minute to minute. One can only truly achieve steady state with continuous
intravenous infusion.
E. The only method by which a drug can be removed from the central compartment is by
elimination.
I-21. Mr. Brooks has been seeing you in the primary care clinic for over 20 years. Recently, he was
diagnosed with amyotrophic lateral sclerosis (ALS), an almost universally fatal degenerative
neurologic condition. In consultation with his neurologist, you have started him on a high dose of a
new medication, Drug X, to alleviate muscle spasms. However, although Mr. Brooks’s muscle spasms
have improved drastically, he is experiencing dry mouth and dry eyes, side effects that were not
described in very large clinical trials of Drug X. A recent postmarketing study of Drug X was released
showing that patients with ALS taking it live, on average, 14 days less than patients not taking it. As
you discuss the plan regarding Drug X with Mr. Brooks, which statement would be valid?
A. “A recent study shows that patients taking Drug X die sooner, on average, than those not taking
it. I want to discuss your thoughts on continuing Drug X, perhaps at a lower dose, versus stopping
it.”
B. “A recent study shows that patients taking Drug X die sooner, on average, than those not taking
it. I recommend stopping it, and I anticipate the drug will be discontinued soon.”
C. “If you’re having side effects at the high dose, it’s certain that you’ll have the same side effects at
a lower dose.”
D. No discussion is needed given the postmarketing data. You should stop Drug X and report the
new side effect to the U.S. Food and Drug Administration (FDA).
E. “These side effects you describe were not described in clinical trials enrolling hundreds of
patients with ALS. They cannot be from Drug X. Let’s figure out what other medication might be
causing them.”
I-22. The graph below represents a plasma time-concentration curve after a single dose of Drug A.
Which of the following statements regarding Figure I-22A is true?
FIGURE I-22A
A. This drug was likely administered orally.
B. This drug demonstrates zero-order kinetics.
C. The shift in rapid reduction in plasma concentration to a more gradual reduction (point B) likely
represents a saturation of the eliminating enzyme.
D. Point B represents the time when drug is distributed both to and from a peripheral compartment
and eliminated from the central compartment.
E. This drug does not have a half-life given the curvilinear shape of its elimination curve.
I-23. All of the following patients are correctly matched to the drug and dose adjustment that should be
considered given their concomitant listed comorbidity EXCEPT:
A. A 57-year-old man with cirrhosis: reduced dose of sotalol
B. A 35-year-old man with renal disease: reduced dose of meperidine
C. A 97-year-old man with normal creatinine and bilirubin: reduced dose of diazepam
D. A 42-year-old man with cirrhosis: reduced dose of meperidine
E. A 35-year-old woman with a known loss-of-function allele in CYP2C9: reduced initial dose of
warfarin
I-24. Which of the following sets of drug–drug interaction and mechanism is accurately described?
A. Ibuprofen and warfarin: increased risk of GI bleeding; ibuprofen inhibition of CYP2C9
B. Sotalol and furosemide: increased risk of QT prolongation and torsades de pointes; furosemide-
induced inhibition of CYP3A4
C. Sildenafil and sublingual nitroglycerin: increased risk of hypotension; sildenafil inhibition of the
phosphodiesterase type 5 isoform that inactivates cyclic guanosine monophosphate
D. Ritonavir and lovastatin: increased risk of myotoxicity; ritonavir inhibition of CYP2C19
E. Allopurinol and azathioprine: increased risk of blood dyscrasias; allopurinol inhibition of P-
glycoprotein
I-25. Which of the following statements regarding coronary heart disease (CHD) in women when
compared to men is true?
A. Angina is a rare symptom in women with CHD.
B. At the time of diagnosis of CHD, women typically have fewer comorbidities when compared to
men.
C. Physicians are less likely to consider CHD in women and are also less likely to recommend both
diagnostic and therapeutic procedures in women.
D. Women and men present with CHD at similar ages.
E. Women are more likely to present with ventricular tachycardia, whereas men more commonly
have cardiac arrest or cardiogenic shock.
I-26. All of the following diseases are more common in women than men EXCEPT:
A. Depression
B. Hypertension
C. Obesity
D. Rheumatoid arthritis
E. Type 1 diabetes mellitus
I-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 their
female 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 unchanged
for 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, treated
hypertension, and moderate obesity. She is recently menopausal. You note on her intake form that
she has questions about hormone replacement therapy to reduce her risk of coronary heart disease
and stroke. Which of the following statements to Mrs. Robin would be true?
A. “Most studies suggest that combined continuous equine estrogen combined with
medroxyprogesterone acetate is superior to combined continuous equine estrogen alone in regard
to risk for stroke or heart attack.”
B. “Studies suggest that initiating hormone therapy can reduce the incidence of hot flashes, night
sweats, mood, sexual function, and bone density, but there is no change in risk for stroke,
myocardial infarction, or venous thromboembolism.”
C. “The largest trial done on hormone therapy demonstrated a benefit for hormone therapy in
reducing the risk for heart attack and stroke.”
D. “What is truly important for hormone therapy is the timing of initiation. Since you are recently
menopausal, we know that starting hormone therapy now will reduce your risk of future heart
attack.”
E. “You should definitely take low-dose aspirin daily. It has been shown to reduce the risk of
coronary heart disease in women more than men.”
I-29. Which of the following statements is true regarding sex differences in disease?
A. Most autoimmune diseases are more prevalent in women than men. This is attributed to
stimulatory actions of estrogens and the inhibitory actions of androgens on the cellular mediators
of immunity, and hormone therapy with oral contraceptives increases the risk of autoimmune
disease.
B. Obesity decreases the risk of endometrial cancer in women.
C. Testosterone administered to hypogonadal men will increase the incidence or severity of
obstructive sleep apnea. This does not occur with testosterone administered to hypogonadal
women.
D. Women are more sensitive to insulin than are men, and thus, women’s risk for type 2 diabetes
mellitus is lower.
E. Women have a longer QT interval on average than men and are at higher risk for drug-induced
torsades de pointes.
I-30. A 67-year-old man with hypertension and sleep apnea presents to your clinic for routine follow-up.
As you open your discussion with him, he says that he has seen some commercials advising him to
ask his doctor about “low T” (low testosterone). He is interested in getting tested. Which of the
following statements to this patient is valid?
A. “If you are found to be testosterone deficient, therapy with exogenous testosterone may worsen
your sleep apnea.”
B. “It is recommended that every man above the age of 60 be tested for low total and bioavailable
testosterone.”
C. “Most studies show that testosterone concentration does not, on average, decline with advancing
age. 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 visceral
fat mass.”
I-31. A 29-year-old former competitive power-lifter who stopped competing 6 months earlier due to a
deltoid muscle tear confides that he and his wife have been unable to conceive despite over a year of
sexual intercourse without contraception. He wonders if there is a “shot or something that can, you
know, help me out.” You suspect that the patient may be using anabolic-androgenic steroids (AAS).
Which of the following statements is true regarding AAS use?
A. AAS users have the same mortality as the general population.
B. An elevated hematocrit should increase suspicion for AAS abuse.
C. Elevated luteinizing hormone levels and suppressed follicle-stimulating hormone levels are clues
suggesting AAS abuse.
D. Increased testicular volume is a clue for AAS abuse.
E. Several prolonged clinical trials of AAS abuse have provided the medical community with a
sophisticated understanding of the adverse effects of AAS abuse.
I-32. Mr. Brooks returns to clinic in August for his yearly follow-up. He is a 78-year-old former long-haul
trucker who enjoys fishing and traveling. During the spring and summer months, he takes
diphenhydramine daily for seasonal allergies. He has been generally feeling well, but has recently
noticed some urinary urgency, straining to void, and even urinary incontinence. You perform a
complete physical examination including a digital prostate exam and confirm benign prostatic
hypertrophy. The International Prostate Symptom Score indicates that Mr. Brooks’s symptoms are
moderate. Which of the following statements to Mr. Brooks would be appropriate?
A. “I recommend primary therapy with tolterodine, an anticholinergic agent targeted at treated
overactive bladder symptoms.”
B. “Therapy with finasteride can reduce progression to acute urinary retention and need for prostate
surgery.”
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 is
unlikely to help much.”
E. “Your use of diphenhydramine is probably working to improve your lower urinary tract
symptoms given its anticholinergic properties.”
I-33. A 24-year-old woman comes to clinic for a routine visit. She is 28 weeks pregnant with her first
child. To date, her pregnancy has been unremarkable and she has no family history of complicated
pregnancies. Her past medical history is unremarkable except for a history of mitral valve prolapse. A
blood pressure greater than which of the following would be considered potentially abnormally
elevated?
A. 110/80 mmHg in the standing position
B. 120/80 mmHg in the standing position 2 minutes after rising from the supine position
C. 130/85 mmHg in the left lateral recumbent position
D. 130/85 mmHg in the seated position