TEST BANK Harrison's Principles of Internal Medicine Self-Assessment and Board Review

TEST BANK Harrison's Principles of Internal Medicine Self-Assessment and Board Review 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 truepositive rate versus the false-positive rate. I-11. When considering a potential screening test, what end points should be considered to assess the potential gain from a proposed intervention? A. 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; furosemideinduced inhibition of CYP3A4 C. Sildenafil and sublingual nitroglycerin: increased risk of hypotension; sildenafil inhibition of the phosphodiesterase type 5 isoform that inactivates cyclic guanosine monophosphate D. Ritonavir and lovastatin: increased risk of myotoxicity; ritonavir inhibition of CYP2C19 E. Allopurinol and azathioprine: increased risk of blood dyscrasias; allopurinol inhibition of Pglycoprotein I-25. Which of the following statements regarding coronary heart disease (CHD) in women when compared to men is true? A. Angina is a rare symptom in women with CHD. B. At the time of diagnosis of CHD, women typically have fewer comorbidities when compared to men. C. Physicians are less likely to consider CHD in women and are also less likely to recommend both diagnostic and therapeutic procedures in women. D. Women and men present with CHD at similar ages. E. Women are more likely to present with ventricular tachycardia, whereas men more commonly have cardiac arrest or cardiogenic shock. I-26. All of the following diseases are more common in women than men EXCEPT: A. 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 E. 140/90 mmHg in the seated position I-34. A 36-year-old nulliparous woman is found to have a blood pressure of 150/95 mmHg on a routine prenatal screening examination at 25 weeks’ gestation. Prior to this visit, her blood pressure was typically 125/80 mmHg. She has a history of well-controlled diabetes and hyperlipidemia. Her exam is notable for a body mass index (BMI) of 28, 2+ pretibial edema, and a 3/6 systolic flow murmur. Laboratories are notable for normal electrolytes, serum creatinine of 1.0 mg/dL, and a urine protein/creatinine ratio of 0.4. Which of the following findings in this patient is necessary to confirm the diagnosis of preeclampsia? A. Diabetes B. Hyperlipidemia C. Obesity D. Pedal edema E. Protein/creatine ratio I-35. A 29-year-old woman who is 35 weeks pregnant has been managed with aspirin and labetalol for preeclampsia after she was found to have elevated blood pressure and proteinuria. All of the following findings characterize preeclampsia with severe features EXCEPT: A. Asthma B. Hemolysis C. Hepatocellular injury D. Seizure E. Thrombocytopenia I-36. A 33-year-old woman with diabetes mellitus, renal insufficiency, and hypertension presents to the hospital with seizures during week 38 of her pregnancy. Her blood pressure is 165/95 mmHg. She has 4+ proteinuria. Management should include all of the following EXCEPT: A. Emergent delivery B. Intravenous labetalol C. Intravenous magnesium sulfate D. Intravenous phenytoin I-37. All of the following statements regarding a patient with type 1 diabetes who becomes pregnant are true 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 T3 B. Free T4 C. Total T3 D. Thyroid-stimulating hormone (TSH) I-39. Which of the following cardiovascular conditions is a contraindication to pregnancy? A. Atrial septal defect without Eisenmenger syndrome B. Idiopathic pulmonary arterial hypertension C. Marfan syndrome D. Mitral regurgitation E. 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 pressure B. Increased cardiac output C. Increased heart rate D. Increased plasma volume E. Increased systemic vascular resistance I-41. A 27-year-old woman develops left leg swelling during week 20 of her pregnancy. Left lower extremity ultrasound reveals a left iliac vein deep vein thrombosis (DVT). Proper management includes: A. Bedrest B. Catheter-directed thrombolysis C. Enoxaparin D. Inferior vena cava filter placement E. Warfarin I-42. In addition to a history and physical examination, which of the following should be performed preoperatively to identify intermediate- or high-risk patients who may benefit from a more detailed clinical evaluation? A. Chest radiograph B. Electrocardiogram C. Liver function tests D. Serum creatinine E. Serum electrolytes (sodium, potassium, chloride, bicarbonate) I-43. Which of the following patients should receive a cardiac catheterization prior to the proposed surgery? A. A 38-year-old man for elective bariatric surgery. He has a history of medically controlled familial hyperlipidemia but no history of chest pain and a normal electrocardiogram (ECG). He has a normal cardiac and pulmonary examination and can easily climb more than two flights of stairs without stopping. B. A 45-year-old man with a history of coronary artery bypass graft surgery 8 years ago who has sustained a motor vehicle accident and has findings in the emergency department of abdominal visceral bleeding. C. A 54-year-old woman for elective cholecystectomy. She was evaluated for chest pain in the emergency department and found to have no coronary artery calcifications on cardiac CT. D. A 58-year-old man for elective pulmonary lobectomy to resect a malignant nodule. The patient had an executive physical examination where the nodule was found on a chest CT; he also had an abnormal exercise stress test. E. A 68-year-old man for an elective radical prostatectomy. He had a coronary artery bypass graft 2 years ago and has no symptoms of heart failure or angina. I-44. All of the following risk factors are components of the Revised Cardiac Risk Index (RCRI) that is used to assess the risk of perioperative major cardiac events EXCEPT: A. Congestive heart failure B. High-risk surgery C. Ischemic heart disease D. Renal dysfunction E. Thrombocytopenia I-45. A 74-year-old man is scheduled to undergo total colectomy for recurrent life-threatening diverticular bleeding. He has a history of idiopathic cardiomyopathy, renal insufficiency, hypercholesterolemia, and chronic obstructive pulmonary disease (COPD). His current medications include metoprolol, atorvastatin, enalapril, metformin, and albuterol/ipratropium inhaler. His symptoms are well controlled, and he has had no emergency department visits in the past year for exacerbations of his cardiomyopathy or COPD. His blood pressure is 128/86 mmHg. His physical examination is normal. His most recent hemoglobin A1C was 6.3%, and his creatinine is 1.5 mg/dL. Which of his medications should be discontinued before surgery? A. Albuterol/ipratropium inhaler B. Atorvastatin C. Enalapril D. Metoprolol I-46. A 73-year-old man with a history of COPD and an forced expiratory volume in 1 second (FEV1) of 1.3 L (40% predicted) is undergoing an elective cholecystectomy. In the postoperative period, which of the following interventions has been shown to decrease the likelihood of pulmonary complications? A. Eliminating administration of narcotics B. Incentive spirometry C. Pulmonary artery catheterization D. Total enteral nutrition E. Total parenteral nutrition I-47. Which of the following surgeries would be considered to have the greatest risk for postsurgical complications? A. Carotid endarterectomy B. Nonemergent repair of a thoracic aortic aneurysm C. Resection of a 5-cm lung cancer D. Total colectomy for colon cancer E. Total hip replacement I-48. All of the following are risk factors for postoperative pulmonary complications EXCEPT: A. Age 60 years B. Asthma with a peak expiratory flow rate of 220 L/min C. Chronic obstructive pulmonary disease D. Congestive heart failure E. FEV1 of 1.5 L I-49. You are caring for a 56-year-old woman who was admitted to the hospital with a change in mental status. She underwent a right-sided mastectomy and axillary lymph node dissection 3 years previously for stage IIIB ductal carcinoma. Serum calcium is elevated at 15.3 mg/dL. A chest radiograph demonstrates innumerable pulmonary nodules, and a head CT shows a brain mass in the right frontal lobe with surrounding edema. Despite correcting her calcium and treating cerebral edema, the patient remains confused. You approach the family to discuss the diagnosis of widely metastatic disease and the patient’s poor prognosis. All of the following are components of the seven elements for communicating bad news (P-SPIKES approach) EXCEPT: A. Assess the family’s perception of her current illness and the status of her underlying cancer diagnosis B. Empathize with the family’s feelings and provide emotional support C. Prepare mentally for the discussion D. Provide an appropriate setting for discussion E. Schedule a follow-up meeting in 1 day to reassess whether there are additional informational and emotional needs I-50. All of the following statements regarding end-of-life epidemiology in the United States are true EXCEPT: A. 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 certain conditions B. Description of values that should guide discussions regarding terminal care C. Designation of a healthcare proxy D. General statements regarding whether the patient desires receipt of life-sustaining interventions such as mechanical ventilation I-52. A 72-year-old woman has stage IV ovarian cancer with diffuse peritoneal studding. She is developing increasing pain in her abdomen and is admitted to the hospital for pain control. She previously was treated with oxycodone 10 mg orally every 6 hours as needed. Upon admission, she is initiated on morphine intravenously via patient-controlled analgesia. During the first 48 hours of her hospitalization, she received an average daily dose of morphine of 90 mg and reports adequate pain control unless she is walking. What is the most appropriate opioid regimen for transitioning this patient to oral pain medication? I-53. You are asked to consult on 62-year-old man who was recently found to have newly metastatic disease. He was originally diagnosed with cancer of the prostate 5 years previously and presented to the hospital with back pain and weakness. Magnetic resonance imaging (MRI) demonstrated bony metastases to his L2 and L5 vertebrae with cord compression at the L2 level only. On bone scan images, there was evidence of widespread bony metastases. He has been started on radiation and hormonal therapy, and his disease has shown some response. However, he has become quite depressed since the metastatic disease was found. His family reports that he is sleeping for 18 or more hours daily and has stopped eating. His weight is down 12 lb over 4 weeks. He expresses profound fatigue, hopelessness, and a feeling of sadness. He claims to have no interest in his usual activities and no longer interacts with his grandchildren. What is the best approach to treating this patient’s depression? A. Do not initiate pharmacologic therapy because the patient is experiencing an appropriate reaction 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 the morning 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 unit for aspiration pneumonia. After 7 days of mechanical ventilation, her family requests that care be withdrawn. The patient is palliated with fentanyl intravenously at a rate of 25 μg/hr and midazolam intravenously at 2 mg/hr. You are urgently called to the bedside 15 minutes after the patient is extubated because the patient’s daughter is distraught. She states that you are “drowning” her mother and is upset because her mother appears to be struggling to breathe. When you enter the room, you hear a gurgling noise that is coming from accumulated secretions in the oropharynx. You suction the patient for liberal amounts of thin salivary secretions and reassure the daughter that you will make her mother as comfortable as possible. Which of the following interventions may help with the treatment of the patient’s oral secretions? A. Increased infusion rate of fentanyl B. N-Acetylcysteine nebulized C. Pilocarpine drops D. Placement of a nasal trumpet and oral airway to allow easier access for aggressive suctioning E. Scopolamine patches I-55. You are caring for a 68-year-old man with end-stage idiopathic pulmonary fibrosis. His performance status is currently 0; he is bed-bound and starting home hospice care. He is chronically on nasal oxygen at 4 L/min with SaO2 of 94%. The patient reports relentless and severe dyspnea that has worsened over the last 1–2 months. It is now his most notable complaint. Physical examination is notable for normal vital signs other than a respiratory rate of 25/min. There is no evidence of ongoing infection or other acute pulmonary process. Which of the following interventions would be a reasonable first step to improve comfort for this patient? A. Albuterol B. Codeine C. Increase nasal oxygen to 8 L/min D. Lorazepam E. Nebulized morphine I-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 for themselves. B. Over 75% of patients who seek physician-assisted suicide identify loss of autonomy or dignity and inability to engage in enjoyable activities as their main reason. C. Patients with cancer are the most common to consider euthanasia or physician-assisted suicide for 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. Africa B. Asia C. Australia D. Europe E. North America I-58. The systemic effects of aging cluster into four domains: body composition, discrepancy between energy demand and utilization, homeostatic dysregulation, and neurodegeneration. All of the following statements regarding these effects are true EXCEPT: A. Lean muscle mass decreases after the third decade of life, whereas fat mass increases progressively after middle age. B. Most older individuals, even those who are healthy, develop mild increases in markers of inflammation such as C-reactive protein and interleukin-6 when compared to younger individuals. C. Peak oxygen consumption declines progressively with age. D. The regions of the brain most likely to be atrophied with mild cognitive impairment are the lateral prefrontal cortex and hippocampus. I-59. Which of the following age groups is the fastest growing worldwide? A. 1–20 years old B. 21–40 years old C. 41–60 years old D. 61–79 years old E. 80 years old I-60. Which of the following is the most common type of preventable adverse event in hospitalized patients? A. Adverse drug events B. Diagnostic failures C. Falls D. Technical complications of procedures E. Wound infections I-61. All of the following are steps in a cycle to rapidly improve a specific process EXCEPT: A. Act B. Check C. Do D. Plan E. Reevaluate I-62. Which of the following is projected to cause the most deaths in low- and middle-income countries in 2030? A. Cancer B. Cardiovascular disease C. HIV/AIDS, TB, malaria, and other infectious diseases D. Intentional injuries E. Road traffic accidents I-63. The 2008 WHO World Health Report describes how a primary healthcare approach is necessary “now more than ever” to address global health priorities. All of the following areas of reform were highlighted in the report, EXCEPT: A. Drug development B. Leadership C. Public policy D. Service delivery E. Universal health coverage I-64. Which of the following statements regarding the Dietary Supplements Health and Education Act (DSHEA), passed in 1994, is true? A. Dietary supplement vendors can claim that dietary supplements maintain normal structure and function of body systems. B. Dietary supplement vendors can claim that dietary supplements prevent or treat diseases. C. The FDA is given the authority to regulate advertising and marketing claims related to dietary supplements. D. The FDA is given the authority to regulate homeopathic products. I-65. Which of the following descriptions best describes the term moral hazard as currently used in the health insurance context? A. A condition in which some individuals can be made better off without making anyone else worse off B. A situation in which physicians are reimbursed a fixed amount per patient and will have a financial incentive to avoid sick patients C. The branch of economics that seeks to explain actual phenomena without making a judgment about the desirability of these phenomena D. The incentives for better-insured individuals to use more medical services E. The system in which the price of a good or service is dictated by a governmental or other governing agency rather than by market forces I-66. Independent of insurance status, income, age, and comorbid conditions, disparities exist between the care received by black and white patients for which of the following scenarios? A. Prescription of analgesics for pain control B. Referral to renal transplantation C. Surgical treatment for lung cancer D. Referral for cardiac catheterization and bypass grafting E. All of the above I-67. All of the following are legally relevant criteria for a physician establishing decision-making capacity in a patient EXCEPT: A. The ability to answer basic orientation questions such as name, year, and home address B. The ability to appreciate the situation and its consequences C. The ability to communicate a choice D. The ability to reason about treatment options E. The ability to understand the relevant information I-68. In which of the following conditions has stem cell therapy been shown to have in vivo benefit? A. Cirrhosis B. Ischemic heart disease C. Parkinson disease D. Spinal cord injury E. Type 1 diabetes mellitus I-69. The greatest source of nutrients and calories in an individual’s diet should come from which source? A. Alcohol B. Carbohydrates C. Fat D. Protein I-70. You are evaluating the vitamin D intake for a 32-year-old woman who is not pregnant or lactating. It is found to be below the recommended dietary allowance (RDA), although a serum level of vitamin D has been measured previously as within normal limits. Which statement is true with regard to this scenario? A. Dietary reference intakes (DRI) would have been a better tool to determine if her nutrient intake was adequate. B. Given the normal serum level of vitamin D, there is no reason to increase her intake of vitamin D. C. RDA is not the best measure for evaluating the nutrient requirements of this individual. D. All of the above statements are true with regard to this scenario. I-71. A 56-year-old man was admitted to the surgical service for care due to exposure injury and frostbite in his distal extremities. He has a longstanding history of alcoholism, drinking about 1 L of vodka on a daily basis. You are asked to consult due to concerns of bizarre behaviors exhibited by the patient. He is expressing a belief that his wounds were the result of burns that were inflicted upon him by “torturers” in the government because he “knows too much” about government surveillance plans. The surgical team reports it is difficult to keep the patient in his bed, and he seems unsteady on his feet at times. He has been medicated throughout his stay for prevention of alcohol withdrawal via a symptom-triggered approach and last received lorazepam 2 mg orally about 2 hours ago. At that time, the patient was noted to be tremulous, tachycardic, and hypertensive. The delusional thoughts are not responsive to treatment of alcohol withdrawal symptoms. When you see the patient, he is sleeping quietly. Vital signs are blood pressure 110/82, heart rate 94, respiratory rate 16, temperature 37.1°C, and SaO2 97% on room air. He awakens easily and has a minimal resting tremor. On neurologic examination, he exhibits past pointing, difficulty with rapid alternating movements, horizontal nystagmus, and decreased sensation to light touch and pinprick in the lower extremities below the mid-tibia. His gait is wide based and ataxic. He no longer expresses his prior delusional beliefs, but he is disoriented and thinks he is in jail. He states he was brought to “this gulag” so that the government could experiment on him. He has 5% dextrose in half-normal saline infusing at 100 mL/hr and is also receiving nafcillin 2 g IV every 4 hours for cellulitis. What do you suspect is the cause of the patient’s altered mental state? A. Hypoglycemia B. Hyponatremia C. Niacin deficiency D. Thiamine deficiency E. Undertreated alcohol withdrawal I-72. A 30-year-old woman expresses the desire to maintain a healthy lifestyle and has a focus on preventative health. She believes that she can prevent illness and cancer through ingesting supplements and antioxidants. When reviewing her current intake, you determine she is taking vitamin A 20,000 IU daily and has been for the past 12 months. What advice can you give her regarding this dose? A. Chronic ingestion of this dose could be associated with an increased risk of lung cancer even in nonsmokers. B. Chronic ingestion of this dose is associated with yellowing of the skin but not the sclerae. C. She should discontinue this dose prior to attempting a pregnancy as this dose could lead to an increased risk of spontaneous abortions and congenital malformations, including craniofacial abnormalities and valvular heart disease. D. This dose is the highest daily recommended dose that is proven to be safe without toxicity. I-73. A 48-year-old man is diagnosed with carcinoid syndrome after presenting with diarrhea, flushing, and hypotension. With appropriate treatment, he experiences an appropriate response biochemically, and his flushing and blood pressure are markedly improved. However, he continues to have some mild diarrhea and also has mouth soreness. He remains fatigued with a loss of appetite and irritability. On examination, you notice his tongue is bright red and somewhat enlarged. It is tender to touch. In addition, he has a pigmented and scaling rash that is most prominent around his neckline. What is the most likely vitamin or mineral deficiency in this patient? A. Copper B. Niacin C. Riboflavin D. Vitamin C E. Zinc I-74. Vitamin A deficiency is associated with an increased risk of which of the following: A. Blindness B. Maternal infection and death C. Mortality from dysentery D. Mortality from malaria E. All of the above I-75. A 51-year-old alcoholic man presents to the emergency department complaining of vomiting blood. Upon further evaluation including gastric lavage, you determine that he is not experiencing an upper gastrointestinal (GI) bleed, but rather is having significant gingival bleeding. He is intoxicated and complains of fatigue. Reviewing his chart, you find that he had a hemarthrosis evacuated 6 months ago and has been lost to follow-up since then. He takes no medications. Laboratory data show platelets of 250,000 and international normalized ratio (INR) of 0.9. He has a diffuse hemorrhagic eruption on his legs that is centered around hair follicles. What is the recommended treatment for this patient’s underlying disorder? A. Folate B. Niacin C. Thiamine D. Vitamin C E. Vitamin K I-76. A 21-year-old woman is admitted to the cardiac care unit after collapsing in her college dormitory. When emergency personnel arrived at her home, she was found to be in a torsades de pointes arrhythmia and was pulseless. She received cardiopulmonary resuscitation, defibrillation, and magnesium en route to the hospital. Upon arrival, her initial potassium is 1.2 mEq/L. Her physical examination is remarkable for an excessively thin appearance with lanugo hair on arms and chest. Her BMI is 14.6 kg/m2. Which of the following statements is true regarding this patient’s nutritional state? A. 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 diagnostic criteria. I-77. A 74-year-old woman is hospitalized in the surgical intensive care unit after undergoing an emergent colectomy for ischemic colitis related to vascular disease. At the time of surgery, she had experienced a bowel perforation. She is currently postoperative day 10 and remains intubated and sedated with evidence of ongoing multiorgan system failure. She requires norepinephrine infusion continuously at a rate of 10 μg/min. She has acute renal failure and is on continuous venovenous hemodialysis. Her blood cultures were positive for Escherichia coli, and she is being treated with cefepime 2 g IV every 8 hours and metronidazole 500 mg every 8 hours. She has a colostomy in her right lower quadrant, but the surgeons were unable to primarily close her abdomen due to the bowel perforation. She has returned to the operating room for reexploration and wash out of the peritoneum. Since admission, her fluid balance is positive more than 30 L. She has marked anasarca and has not been fed since admission, although the team plans to initiate total parenteral nutrition today. Which statement is most likely true regarding her nutritional state? A. Aggressive nutritional support should be avoided. B. Immune function is not affected. C. The albumin is less than 2.8 g/dL. D. The body mass index will be less than 18.5 kg/m2. E. The nutritional state does not confer any increased mortality risk for this patient. I-78. Which of the following patients would be LEAST likely to be at high risk of nutritional depletion? A. A 21-year-old woman with a history of anorexia nervosa in remission for 2 months with a BMI of 19.1 kg/m2 admitted to the hospital with an asthma exacerbation B. A previously healthy 28-year-old man admitted to the intensive care unit with third-degree burns covering 85% of his body surface area C. A 32-year-old man with alcoholism admitted with acute pancreatitis who has been NPO for 6 days D. A 41-year-old woman with short gut syndrome following resection of small bowel for a gastrointestinal stromal tumor admitted to the hospital with dehydration E. A 55-year-old woman admitted to the hospital for right mastectomy for breast cancer who has recently lost 25 lb (from 200 to 175 lb) unintentionally I-79. You are caring for a 54-year-old woman in the intensive care unit who was admitted for treatment of severe sepsis and pneumonia. You would like to initiate enteral nutrition and plan to calculate basal energy expenditure for the patient. All of the following factors are used to determine the patient’s caloric needs EXCEPT: A. Age B. Albumin C. Gender D. Height E. Weight I-80. A 65-year-old man is admitted for colectomy for stage III colon cancer. On the second postoperative day, he requires repeat exploratory laparotomy due to bleeding complications. It is now postoperative day 7 from his original resection, and the patient has had no nutrition since before surgery. His BMI before surgery was 28.7 kg/m2, and he was felt to have normal nutritional status. He is currently clinically stable, but delirious and at high aspiration risk. He has bowel sounds present, and ileostomy output is good. What would be recommended at the present time for this patient? A. Continued NPO status because 5–7 days without nutritional support is acceptable for this patient B. Initiate a clear liquid diet and supplement with intravenous fluids with dextrose to maintain adequate intake C. Placement of a central venous catheter and initiation of total parenteral nutrition D. Placement of a nasogastric tube and initiation of enteral nutrition E. Placement of a nasojejunal tube and initiation of enteral nutrition I-81. All of the following statements support the use of enteral feeding for critically ill patients EXCEPT: A. 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 of the gut. I-82. What body mass index is likely to be lethal in males? A. 10 kg/m2 B. 11 kg/m2 C. 13 kg/m2 D. 16 kg/m2 E. 18.5 kg/m2 I-83. A 43-year-old woman develops hemorrhagic pancreatitis with severe systemic inflammation response syndrome. She is intubated and sedated in the medical intensive care unit with acute respiratory distress syndrome, hypotension, and renal dysfunction. She has ongoing daily fevers to as high as 104.5°F (40.3°C). She is initiated on parenteral nutrition (PN) and develops hyperglycemia as high as 500 g/dL. She is also noted to have an increasingly positive fluid balance of more than 2 L daily. What is the most appropriate approach to management of PN in the context of her hyperglycemia and fluid retention? A. Addition of regular insulin to the total PN formula B. Limiting sodium to less than 40 mEq/d C. Limiting glucose to less than 200 g/d D. Providing both glucose and fat to the total PN mixture E. All of the above I-84. Microbial agents have been used as bioweapons since ancient times. All of the following are key features of microbial agents that are used as bioweapons EXCEPT: A. Environmental stability B. High morbidity and mortality rates C. Lack of rapid diagnostic capability D. Lack of readily available antibiotic treatment E. Lack of universally available and effective vaccine I-85. Ten individuals in Arizona are hospitalized over a 4-week period with fever and rapidly enlarging and painful lymph nodes. Seven of these individuals experience severe sepsis and three die. While reviewing the epidemiologic characteristics of these individuals, you note that they are all illegal immigrants and have recently stayed in the same immigrant camp. Blood cultures are growing gramnegative rods that are identified as Yersinia pestis. You notify local public health officials and the Centers for Disease Control and Prevention. Which of the following factors indicates that this is NOT likely to be an act of bioterrorism? A. The area affected was limited to a small immigrant camp. B. The individuals presented with symptoms of bubonic plague rather than pneumonic plague. C. The individuals were in close contact with one another, suggesting possible person-to-person transmission. D. The mortality rate was less than 50%. E. Y pestis is not environmentally stable for longer than 1 hour. I-86. Which of the following routes of dispersal is/are likely for botulinum toxin used as a bioweapon? A. Aerosol B. Contamination of the food supply C. Contamination of the water supply D. A and B E. All of the above I-87. Anthrax spores can remain dormant in the respiratory tract for how long? A. 1 week B. 6 weeks C. 6 months D. 1 year E. 3 years I-88. Twenty recent attendees at a National Football League game arrive at the emergency department complaining of shortness of breath, fever, and malaise. Chest roentgenograms show mediastinal widening on several of these patients, prompting a concern for inhalational anthrax as a result of a bioterror attack. Antibiotics are initiated and the Centers for Disease Control and Prevention is notified. What form of isolation should be instituted for these patients in the hospital? A. Airborne B. Contact C. Droplet D. None I-89. The Centers for Disease Control and Prevention has designated several biologic agents as category A in their ability to be used as bioweapons. Category A agents include agents that can be easily disseminated or transmitted, result in high mortality, can cause public panic, and require special action for public health preparedness. All the following agents are considered category A EXCEPT: A. Bacillus anthracis B. Francisella tularensis C. Ricin toxin from Ricinus communis D. Smallpox virus E. Y pestis I-90. In September 2001, the U.S. public was exposed to a bioweapon agent delivered through the U.S. Postal Service. Characteristic lesions of this infectious agent are shown in Figure I-90, Parts A and B, below. FIGURE I-90 Which of the following was the agent responsible for this event? A. B anthracis B. Botulinum toxin C. Ebola virus D. Variola major E. Y pestis I-91. All of the following chemical agents of bioterrorism are correctly identified by their mechanism of injury EXCEPT: A. Arsine—asphyxiant B. Chlorine gas—pulmonary damage C. Cyanogen chloride—nerve agent D. Mustard gas—vesicant E. Sarin—nerve agent I-92. Over the course of 12 hours, 24 individuals present to a single emergency department complaining of a sunburn-like reaction with development of large blisters. Most of these individuals are also experiencing irritation of the eyes, nose, and pharynx. Two individuals developed progressive dyspnea, severe cough, and stridor requiring endotracheal intubation. On physical examination, all of the patients exhibited conjunctivitis and nasal congestion. Erythema of the skin was greatest in the axillae, neck, and antecubital fossae. Many of the affected individuals had large, thin-walled bullae on the extremities that were filled with a clear or straw-colored fluid. On further questioning, all of the affected individuals had been shopping at a local mall within the past 24-hours and ate at the food court. Many commented on a strong odor of burning garlic in the food court at that time. You suspect a bioterrorism act. Which of the following statements is true with regard to the likely agent causing the patients’ symptoms? A. 2-Pralidoxime should be administered to all affected individuals. B. The associated mortality of this agent is more than 50%. C. The cause of respiratory distress in affected individuals is related to direct alveolar injury and adult respiratory distress syndrome. D. The erythema that occurs can be delayed as long as 2 days following exposure and depends upon several factors including ambient temperature and humidity. E. The fluid within the bullae should be treated as a hazardous substance that can lead to local reactions and blistering with exposure. I-93. A 24-year-old man is evaluated immediately following exposure to chlorine gas as an act of chemical terrorism. He currently denies dyspnea. His respiratory rate is 16/min, and oxygen saturation is 97% on room air. All of the following should be included in the immediate treatment of this individual EXCEPT: A. Aggressive bathing of all exposed skin areas B. Flushing of the eyes with water or normal saline C. Forced rest and fresh air D. Immediate removal of clothing if no frostbite E. Maintenance of a semi-upright position I-94. You are a physician working in an urban emergency department when several patients are brought in after the release of an unknown gas at the performance of a symphony. You are evaluating a 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. At present, she also has nausea, vomiting, diarrhea, and muscle twitching. On physical examination, the patient has a blood pressure of 156/92 mmHg, a heart rate of 92, a respiratory rate of 30, and a temperature of 37.4°C (99.3°F). She has pinpoint pupils with profuse rhinorrhea and salivation. She is also coughing profusely, with production of copious amounts of clear secretions. A lung examination reveals wheezing on expiration in bilateral lung fields. The patient has a regular rate and rhythm with normal heart sounds. Bowel sounds are hyperactive, but the abdomen is not tender. She is having diffuse fasciculations. At the end of your examination, the patient abruptly develops tonicclonic seizures. Which of the following agents most likely caused this patient’s symptoms? A. Arsine B. Cyanogen chloride C. Nitrogen mustard D. Sarin E. VX I-95. All the followi