SELF-ASSESSMENT
AND BOARD REVIEW
HARRISON'S
INTERNAL
MEDICINE
Editorial Board
ANTHONY S. FAUCI, MD
Chief, Laboratory of Immunoregulation
Director, National Institute of Allergy and Infectious Diseases
National Institutes of Health
Bethesda
EUGENE BRAUNWALD,
MD
Distinguished Hersey Professor of Medicine
Harvard Medical School
Chairman, TIMI Study Group, Brigham and Women’s Hospital
Boston
DENNIS L. KASPER,
MD
William Ellery Channing Professor of Medicine
Professor of Microbiology and Molecular Genetics
Harvard Medical School
Director, Channing Laboratory
Department of Medicine
Brigham and Women’s Hospital
Boston
STEPHEN L. HAUSER,
MD
Robert A. Fishman Distinguished Professor and
Chairman, Department of Neurology

Vice Chair, Department of Medicine
Director, Osler Medical Training Program
The Johns Hopkins University School of Medicine
Baltimore
Contributing Editors
Gerald Bloomfield, MD, MPH
Cynthia D. Brown, MD
Joshua Schiffer, MD
Adam Spivak, MD
Department of Internal Medicine
The Johns Hopkins University School of Medicine
Baltimore
New York Chicago San Francisco Lisbon London Madrid Mexico City
New Delhi San Juan Seoul Singapore Sydney Toronto
HARRISON'S
INTERNAL
MEDICINE
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SECTION III ONCOLOGY AND HEMATOLOGY
Questions 55
Answers 71
SECTION IV INFECTIOUS DISEASES
Questions 103
Answers 130
SECTION V DISORDERS OF THE CARDIOVASCULAR SYSTEM
Questions 175
Answers 202
SECTION VI DISORDERS OF THE RESPIRATORY SYSTEM
Questions 237
Answers 254
SECTION VII DISORDERS OF THE URINARY AND KIDNEY TRACT
Questions 283
Answers 293
SECTION VIII DISORDERS OF THE GASTROINTESTINAL SYSTEM
Questions 307
Answers 321
SECTION IX RHEUMATOLOGY AND IMMUNOLOGY
Questions 345
Answers 358
For more information about this title, click here
vi C
ONTENTS
SECTION X ENDOCRINOLOGY AND METABOLISM
Questions 379
Answers 393
SECTION XI NEUROLOGIC DISORDERS
Questions 421
Answers 435

Medicine board examination.
We appreciate the confidence of the editors of Harri-
son’s,17th edition, to allow us to do this book. We thank our
families and loved ones who had to watch us pore over page
proofs to come up with original questions and answers. All
of the authors are (or were) affiliated with Osler Medical
Training Program at the The Johns Hopkins School of Medi-
cine. The dedicated physicians of the Osler Medical Service
inspire us daily to constantly learn and improve. We thank
them for their constant appreciation of high standards and
their dedication to outstanding patient care. Many of the
case presentations derive from actual patients we’ve cared
for, and we thank the patients of Johns Hopkins Hospital for
their nobility and their willingness to participate in our clin-
ical and educational missions.
Copyright © 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc.
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1
I. INTRODUCTION TO CLINICAL MEDICINE
QUESTIONS
DIRECTIONS: Choose the one best response to each question.
I-1. A physician is deciding whether to use a new test to
screen for disease X in his practice. The prevalence of dis-
ease X is 5%. The sensitivity of the test is 85%, and the
specificity is 75%. In a population of 1000, how many pa-
tients will have the diagnosis of disease X missed by this
test?
A. 50
B. 42

The physician’s pretest probability for coronary artery
disease causing these symptoms is low; however, the pa-
tient is referred for an exercise treadmill test, which shows
ST depression after moderate exercise. Using Bayes’ theo-
rem, how does one interpret these test results?
A. The pretest probability is low, and the sensitivity
and specificity of exercise treadmill testing in fe-
males are poor; therefore, the exercise treadmill
test is not helpful in clinical decision making in
this case.
B. Regardless of the pretest probability, the abnormal
result of this exercise treadmill testing requires fur-
ther evaluation.
C. Because the pretest probability for coronary artery
disease is low, the patient should be referred for fur-
ther testing to rule out this diagnosis.
D. Because the pretest probability was low in this case,
a diagnostic test with a low sensitivity and specificity
is sufficient to rule out the diagnosis of coronary ar-
tery disease.
E. The testing results suggest that the patient has a very
high likelihood of having coronary artery disease
and should undergo cardiac catheterization.
I-6. An effective way to measure the accuracy of a diag-
nostic test is a positive likelihood ratio [sensitivity/(1 –
specificity)], which is also defined as the ratio of the
probability of a positive test result in a patient with dis-
ease to the probability of a positive test result in a patient
without disease. What other piece of information is
needed along with a positive likelihood ratio to estimate

C. 12.5
D. 50
E. 93
I-9. A healthy 23-year-old female is referred to your clinic af-
ter being seen in the emergency department for intermittent
severe chest pain. During her visit, she is ruled out for car-
diac ischemia, with negative biomarkers for cardiac is-
chemia and unremarkable electrocardiograms. An exercise
single photon emission CT (SPECT) myocardial perfusion
test was performed, and a reversible exercise-induced perfu-
sion defect was noted. The test was read as positive. The pa-
tient was placed on aspirin. She is quite concerned that she
continues to have chest pain intermittently on a daily basis
without any consistency in regards to time or antecedent ac-
tivity. She is otherwise active and feeling well. She smokes
socially on weekends. She has no family history of early cor-
onary disease. What would be the best next course of action?
A. Cardiac catheterization
B. CT of her coronary arteries
C. Dobutamine stress echocardiogram
D. Evaluation for non-cardiac source of her chest pain
E. Repeat exercise SPECT test
I-10. Which of the following statements regarding gender
health is true?
A. Alzheimer’s disease affects men and women at equal
rates.
B. Alzheimer’s disease affects men two times more
commonly than women.
C. In a recent placebo-controlled trial, postmenopausal
hormone therapy did not show improvement in dis-

D. Women undergoing coronary artery bypass surgery
have lower 5- and 10-year survival rates than men.
E. Women undergoing coronary artery bypass surgery
have less relief of angina and less graft patency than
men.
I-13. Which of the following statements regarding cardio-
vascular risk is true?
A. Aspirin is effective as a means of primary prevention
in women for coronary heart disease.
B. Cholesterol-lowering drugs are less effective in
women than in men for primary and secondary pre-
vention of coronary heart disease.
C. Low high-density lipoprotein (HDL) and diabetes
mellitus are more important risk factors for men
than for women for coronary heart disease.
D. Total triglyceride levels are an independent risk factor
for coronary heart disease in women but not in men.
I-14. Which of the following alternative medicines has
shown proven benefit compared to placebo in a large ran-
domized clinical trial?
A. Echinacea root for respiratory infection
B. Ginkgo biloba for improving cognition in the elderly
C. Glucosamine/chondroitin sulfate for improving per-
formance and slowing narrowing of the joint space in
patients with moderate to severe osteoarthritis
D. Saw palmetto for men with symptomatic benign
prostatic hyperplasia (BPH)
E. St John’s-wort for major depression of moderate
severity
I-15. You prescribe an extended-release antihypertensive

since initiating diuretic therapy. Physical examination is
notable for a somnolent but conversant man with mild
jaundice, pinpoint pupils, palmar erythema, spider he-
mangiomas on his chest, a palpable nodular liver edge at
the costal margin, and bilateral 1+ lower extremity
edema. He does not have asterixis, abdominal tenderness,
or an abdominal fluid wave. Laboratory results compared
to 3 months previously reveal an increased INR, from 1.4
to 2.1; elevated total bilirubin, from 1.8 to 3.6 mg/dL; and
decreased albumin from 3.4 to 2.9 g/L; as well as baseline
elevations of his aspartate and alanine aminotransferases
(54 U/L and 78 U/L, respectively). Serum NH
4
is 16.
What would be a sensible next step for this patient?
A. Decrease his morphine dose by 50% and reevaluate
him in a few days
B. Initiate antibiotic therapy
C. Initiate haloperidol therapy
D. Initiate lactulose therapy
E. Perform a paracentesis
I-17. A homeless male is evaluated in the emergency depart-
ment. He has noted that after he slept outside during a par-
ticularly cold night his left foot has become clumsy and
feels “dead.” On examination, the foot has hemorrhagic
vesicles distributed throughout the foot distal to the ankle.
The foot is cool and has no sensation to pain or tempera-
ture. The right foot is hyperemic but does not have vesicles
and has normal sensation. The remainder of the physical
examination is normal. Which of the following statements

A. Falling albumin levels in the elderly lead to in-
creased free (active) levels of some medications, in-
cluding warfarin.
B. Fat-soluble drugs have a shorter half-life in geriatric
patients.
C. Hepatic clearance decreases with age.
D. The elderly have a decreased volume of distribution
for many medications because of a decrease in total
body water.
E. Older patients are two to three times more likely to
have an adverse drug reaction.
I-20. Which of the following class of medicines has been
linked to the occurrence of hip fractures in the elderly?
A. Benzodiazepines
B. Opiates
C. Angiotensin-converting enzyme inhibitors
D. Beta blockers
E. Atypical antipsychotics
I-21. 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-22. A recent 18-year-old immigrant from Kenya presents
to a university clinic with fever, nasal congestion, severe
I-17. (Continued)I-15. (Continued)
4 I. I
NTRODUCTION TO

examination reveals wheezing on expiration in bilateral lung
fields. The patient has a regular rate and rhythm with nor-
mal heart sounds. Bowel sounds are hyperactive, but the ab-
domen is not tender. She is having diffuse fasciculations. At
the end of your examination, the patient abruptly develops
tonic-clonic seizures. Which of the following agents is most
likely to cause this patient’s symptoms?
A. Arsine
B. Cyanogen chloride
C. Nitrogen mustard
D. Sarin
E. VX
I-24. All the following should be used in the treatment of
this patient except
A. atropine
B. decontamination
C. diazepam
D. phenytoin
E. 2-pralidoxime chloride
I-25. A 24-year-old male is brought to the emergency de-
partment after taking cyanide in a suicide attempt. He is
unconscious on presentation. What drug should be used
as an antidote?
A. Atropine
B. Methylene blue
C. 2-Pralidoxime
D. Sodium nitrite alone
E. Sodium nitrite with sodium thiosulfate
I-26. A 40-year-old female is exposed to mustard gas dur-
ing a terrorist bombing of her office building. She pre-

A. Atovaquone
B. Blood cultures and observation
C. Doxycycline
D. Rimantadine
E. Vancomycin, ceftriaxone, and ampicillin
I-28. A 23-year-old woman with a chronic lower extremity
ulcer related to prior trauma presents with rash, hypoten-
sion, and fever. She has had no recent travel or outdoor
exposure and is up to date on all of her vaccinations. She
does not use IV drugs. On examination, the ulcer looks
clean with a well-granulated base and no erythema,
warmth, or pustular discharge. However, the patient does
have diffuse erythema that is most prominent on her
palms, conjunctiva, and oral mucosa. Other than pro-
found hypotension and tachycardia, the remainder of the
examination is nonfocal. Laboratory results are notable
for a creatinine of 2.8 mg/dL, aspartate aminotransferase
of 250 U/L, alanine aminotransferase of 328 U/L, total
bilirubin of 3.2 mg/dL, direct bilirubin of 0.5 mg/dL, INR
of 1.5, activated partial thromboplastin time of 1.6 × con-
trol, and platelets at 94,000/µL. Ferritin is 1300 µg/mL.
The patient is started on broad-spectrum antibiotics after
I-22. (Continued)
I. I
NTRODUCTION TO
C
LINICAL
M
EDICINE
— Q

A. Escherichia coli sepsis
B. Hemolytic uremic syndrome
C. Meningococcemia
D. Staphylococcal toxic shock syndrome
E. Vibrio vulnificus infection
I-31. Hyperthermia is defined as
A. a core temperature >40.0°C
B. a core temperature >41.5°C
C. an uncontrolled increase in body temperature de-
spite a normal hypothalamic temperature setting
D. an elevated temperature that normalizes with anti-
pyretic therapy
E. temperature >40.0°C, rigidity, and autonomic dys-
regulation
I-32. A patient in the intensive care unit develops a temper-
ature of 40.8°C, profoundly rigid tone, and hemody-
namic shock 2 min after a succinylcholine infusion is
started. Immediate therapy should include
A. intravenous dantrolene sodium
B. acetaminophen
C. external cooling devices
D. A and C
E. A, B, and C
I-33. Which of the following conditions is associated with
increased susceptibility to heat stroke in the elderly?
A. A heat wave
B. Antiparkinsonian therapy
C. Bedridden status
D. Diuretic therapy
E. All of the above

A. Intravenous nitroglycerine
B. Oral nifedipine
C. Rapid rewarming
D. Surgical debridement
E. Topical nitroglycerine paste
I-37. Fecal occult blood testing (FOBT) was shown to de-
crease colon cancer–related mortality from 8.8/1000 per-
sons to 5.9/1000 persons over a 13-year period. What is
the approximate absolute risk reduction (ARR) of this in-
tervention in the studied population?
A. 50%
B. 30%
C. 3%
D. 0.3%
E. 0%
I-28. (Continued)
6 I. I
NTRODUCTION TO
C
LINICAL
M
EDICINE
— Q
UESTIONS
I-38. Which preventative intervention leads to the largest av-
erage 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 aged 50–70
D. Pap smears in women aged 18–65

later in life.
B. Over 80% of these patients will have concomitant
mood disorders such as major depression, dys-
thymia, or social phobia.
C. As in panic disorder, shortness of breath, tachycar-
dia, and palpitations are common.
D. Experimental work suggests that the pathophysiology
of generalized anxiety disorder involves impaired
binding of benzodiazepines at the γ-aminobutyric
acid (GABA) receptor.
E. The therapeutic approach to patients with general-
ized anxiety disorder should include both pharmaco-
logic agents and psychotherapy, although complete
relief of symptoms is rare.
I-41. For which of the following herbal remedies is there
the best evidence for efficacy in treating the symptoms of
benign prostatic hypertrophy?
A. Saint John’s wort
B. Gingko
C. Kava
D. Saw palmetto
E. No herbal therapy is effective
I-42. Which of the following personality traits is most likely
to describe a young female with anorexia nervosa?
A. Depressive
B. Borderline
C. Anxious
D. Perfectionist
E. Impulsive
I-43. Why is it necessary to coadminister vitamin B

A. Functional status
B. Life span of first-degree relatives
C. Marital status
D. Number of medical comorbidities
E. Socioeconomic status
I-47. Diagnostic criteria for delirium as a cause of a con-
fused state in a hospitalized patient include all of the fol-
lowing except
A. agitation
B. altered level of consciousness
C. disorganized thinking
I-41. (Continued)
I. I
NTRODUCTION TO
C
LINICAL
M
EDICINE
— Q
UESTIONS
7
D. fluctuating mental status
E. poor attention
I-48. Fall risks in the elderly include all of the following
except
A. creatinine clearance <65 mL/min
B. diabetes mellitus
C. fear of falling
D. history of falls
E. hypertension

tion in his right leg, decreased pain and temperature
sensation in his right arm and leg, and normal light
touch/pain and temperature sensation in his right leg.
Where is his causative lesion most likely to be?
A. Cervical nerve roots
B. High cervical spinal cord
C. Medulla
D. Pons
E. Right cortical hemisphere
I-52. A 32-year-old man with a history of HIV infection
presents to the hospital with nausea, abdominal disten-
tion and projectile vomiting that developed over the pre-
vious 8–12 h. He denies fevers, chills, diaphoresis,
melena, or diarrhea. Over the past 3 months, he has lost
30 lb in the context of advanced HIV infection. He has
never had abdominal surgery. On examination, his abdo-
men is distended, with high-pitched intermittent bowel
sounds and guarding but no rebound. A periumbilical
bruit is also detected. Abdominal x-ray reveals a small-
bowel obstruction with a probable cut-off point in the
mid duodenum. What is the diagnostic test of choice for
diagnosing the cause of the underlying obstruction?
A. Abdominal CT with abdominal angiogram
B. Enteroscopy
C. Laparoscopy
D. Serum carcinoembryonic antigen (CEA) level
E. Stool acid-fast bacillus culture
F. Upper gastrointestinal (GI) series with small bowel
follow through
I-53. A 64-year-old man with primary light chain amyloi-

D. Mycoplasma infection
E. Postnasal drip
I-47. (Continued)
I-52. (Continued)
8 I. I
NTRODUCTION TO
C
LINICAL
M
EDICINE
— Q
UESTIONS
I-56. A 64-year-old alcoholic presents to the emergency de-
partment with occasional hemoptysis, productive cough,
and low-grade fever over the past several weeks. His CT
scan shows an abnormality in the right lower lobe. He re-
ports several contacts with tuberculosis-infected patients
while in prison several years ago. Sputum examination
reveals putrid-smelling thick green sputum streaked with
blood. The Gram stain shows many polymorphonuclear
leukocytes and a mix of gram-positive and -negative or-
ganisms. What is the most likely diagnosis?
A. Bronchogenic carcinoma
B. Polymicrobial lung abscess
C. Pulmonary tuberculosis
D. Tricuspid valve endocarditis
E. Wegener’s granulomatosis
I-57. A 74-year-old man with known endobronchial carci-
noma of his left mainstem bronchus develops massive he-
moptysis (1 L of frank hemoptysis productive of bright

is notable for chest spider angiomas and palmar ery-
thema. His arterial oxygen saturations fall from 96% to
88% upon transition from lying to sitting. His lung
fields are clear and heart sounds are crisp. Abdominal
examination is notable for a palpable nodular liver edge
but no fluid wave or shifting dullness. He has 1+ lower
extremity edema. What is the most likely cause of his
dyspnea?
A. Chronic thromboembolic disease
B. Congestive heart failure
C. Pulmonary arteriovenous fistula
D. Portal hypertension
E. Ventricular septal defect
I-61. A 30-year-old woman complains of lower extremity
swelling and abdominal distention. It is particularly trou-
blesome after her daily shift as a toll booth operator and
is at its worst during hot weather. She denies shortness of
breath, orthopnea, dyspnea on exertion, jaundice, foamy
urine, or diarrhea. Her symptoms occur independently of
her menstrual cycle. Physical examination is notable for
2+ lower extremity edema, flat jugular venous pulsation,
no hepatojugular reflex, normal S
1
and S
2
with no extra
heart sounds, clear lung fields, a benign slightly distended
abdomen with no organomegaly, and normal skin. A
complete metabolic panel is within normal limits, and a
urinalysis shows no proteinuria. What is the most likely

B. Initiate an angiotensin-converting enzyme inhibitor
C. Initiate a beta blocker
D. Recheck her blood pressure in the seated position in
6 h
E. Recheck her blood pressure in the lateral recumbent
position in 6 h
I-64. A 33-year-old woman with diabetes mellitus and hy-
pertension presents to the hospital with seizures during
week 37 of her pregnancy. Her blood pressure is 156/92
mmHg. She has 4+ proteinuria. Management should in-
clude all of the following except
A. emergent delivery
B. intravenous labetalol
C. intravenous magnesium sulfate
D. intravenous phenytoin
I-65. Which cardiac valvular disorder is the most likely to
cause death during pregnancy?
A. Aortic regurgitation
B. Aortic stenosis
C. Mitral regurgitation
D. Mitral stenosis
E. Tricuspid regurgitation
I-66. A 27-year-old woman develops left leg swelling dur-
ing week 20 of her pregnancy. Left lower extremity ultra-
sonogram 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

I-70. A 72-year-old white man with New York Heart Associa-
tion II ischemic cardiomyopathy, diabetes mellitus, and
chronic renal insufficiency (creatinine clearance = 42 mL/
min) undergoes dobutamine echocardiography prior to ca-
rotid endarterectomy. He is found to have 7-mm ST de-
pressions in his lateral leads during the test and develops
dyspnea at 70% maximal expected dosage, requiring early
cessation of the stress test. His current medicines include an
angiotensin-converting enzyme inhibitor, a beta blocker,
and aspirin. What would be your advice to the patient?
A. Cancel the carotid endarterectomy
B. Proceed to cardiac catheterization
C. Maximize medical management
D. Proceed directly to carotid endarterectomy
E. Proceed directly to carotid endarterectomy and cor-
onary artery bypass surgery
I-71. Parkinson’s disease can often be differentiated from
the atypical Parkinsonian syndromes (multiple system at-
rophy, progressive supranuclear palsy) by the presence of
which of the following?
A. Axial stiffness
B. Pill-rolling tremor
C. Shuffling gait
D. Stooped posture
E. Turning en bloc
I-72. A wide-based gait with irregular lurching and erratic
foot placement but no subjective dizziness characterizes
which type of gait ataxia?
A. Cerebellar dysfunction
B. Frontal gait abnormality

Shining a flashlight into her right eye causes equal, strong
constriction in both of her eyes. When the light is flashed
into her left eye, both pupils dilate slightly though not to
their previous size prior to light confrontation. Where is
there most likely to be anatomic damage?
A. Left cornea
B. Left optic nerve or retina
C. Optic chiasm
D. Right cornea
E. Right optic nerve or retina
I-76. A patient complains of blurred vision in both eyes
particularly in the periphery with the right being worse
than the left. Visual field examination with finger con-
frontation reveals a decreased vision in the left periphery
in the left eye and right periphery in the right eye. Where
is there most likely to be a lesion?
A. Bilateral optic nerves
B. Left lateral geniculate body
C. Left occipital cortex
D. Post-chiasmic optic tract
E. Suprasellar space
I-77. Which of the following methods is most effective for
the diagnosis of corneal abrasions?
A. Fluorescein and cobalt-blue light examination
B. Intraocular pressure measurement
C. Lid eversion for foreign body examination
D. Oculoplegia and dilation
E. Viral culture of the cornea
I-78. Which of the following criteria best differentiates epi-
scleritis from conjunctivitis?

C. Erythrocyte sedimentation rate
D. No further evaluation unless symptoms recur
E. Temporal artery biopsy
I-82. A 69-year-old male dialysis patient with poorly con-
trolled diabetes, heart failure and chronic indwelling
catheters presents with fever and loss of vision in the left
eye developing over the past 6 h. Vital signs are notable
for a temperature of 101.3°F, heart rate of 105/min, and
blood pressure of 125/85. Which test is most likely to con-
firm the diagnosis?
A. Blood cultures
B. Blood smear
C. Brain MRI
D. Rheumatic panel
E. Rapid plasma reagin
I-83. Exposure to which of the following types of radiation
would result in thermal injury and burns but would not
cause damage to internal organs because the particle size
is too large to cause internal penetration?
I-73. (Continued)
I. INTRODUCTION TO CLINICAL MEDICINE — QUESTIONS 11
A. Alpha radiation
B. Beta radiation
C. Gamma radiation
D. Neutron particles
E. X-rays
I-84. A “dirty” bomb is detonated in downtown Boston.
The bomb was composed of cesium-137 with trinitro-
toluene. In the immediate aftermath, an estimated 30
people were killed due to the power of the blast. The

during the meeting and is concerned that his coffee may
have been contaminated. He otherwise is quite healthy
and takes no medications. On physical examination, he
appears ill. The vital signs are: blood pressure 98/60
mmHg, heart rate 112 beats/min, respiratory rate 24
breaths/min, Sa
O
2
94%, and temperature 37.4°C. Head,
ears, eyes, nose, and throat examination shows pale mu-
cous membranes. Cardiovascular examination is tachy-
cardic, but regular. His lungs are clear. The abdomen is
slightly distended with hyperactive bowel sounds. There is
no tenderness or rebound. Extremities show no edema,
but a few scattered petechiae are present. Neurologic ex-
amination is normal. A complete blood count is per-
formed. The results are: white blood cell (WBC) count
150/µL, red blood cell count 1.5/µL, hemoglobin 4.5 g/dL,
hematocrit 15%, platelet count 11,000/µL. The differential
on the WBC count is 98% PMNs, 2% monocytes, and 0%
lymphocytes. A blood sample is held for HLA testing. A
urine sample is positive for the presence of radioactive iso-
topes, which are determined to be polonium-210, a strong
emitter of alpha radiation. The mode of exposure is pre-
sumed to be ingestion. What is the best approach to the
treatment of this patient?
A. Bone marrow transplantation
B. Gastric lavage
C. Potassium iodide
D. Supportive care only

creased nasal secretions. A few individuals were dyspneic
with wheezing. The most severely affected victims fell un-
conscious and soon thereafter developed seizures. What
medication(s) should be administered immediately to the
survivors?
A. Atropine, 6 mg IM
B. 2-Pralidoxime chloride, 1800 mg IM
C. Diazepam, 5 mg IV
D. A and B
E. B and C
F. All of the above
I-85. (Continued)I-83. (Continued)
12 I. INTRODUCTION TO CLINICAL MEDICINE — QUESTIONS
I-88. A 7-month-old child is brought to clinic by his par-
ents. He was the product of a healthy pregnancy, and
there were no perinatal complications. The parents are
concerned that there is something wrong; he is very hy-
peractive and is noted to have a ‘mousy’ odor. On exami-
nation the child is found to have mild microcephaly,
hypopigmentation and eczema. Laboratory studies are
sent and a diagnosis is made. How could this clinical sce-
nario have been prevented?
A. Screening at 6 months of age for urine ketones
B. Screening at birth for phenylalanine in blood
C. Screening at birth for chromosomal abnormalities
D. Genetic screening of parents prior to delivery
E. Cord blood sampling at 2 months’ pregnancy for
glutamine synthase
I-89. A 35-year-old woman with a history of degenerative
joint disease comes to clinic complaining of dark urine

A. Fulminant liver failure
B. Myocarditis and subsequent heart failure
C. Progressive proximal muscle weakness
D. Rhabdomyolysis leading to renal failure
E. This is a benign disorder without major clinical risks
I-92. A 21-year-old woman comes to clinic to establish new
primary care. She has a history of type III glycogen storage
disease (debranching deficiency), for which she takes a
high-protein, high-carbohydrate diet. She has a normal
physical examination except for short stature, mild weak-
ness, and a slightly enlarged liver. She works as an adminis-
trative assistant and is planning to be married in the next 6
months. She is concerned about her long-term prognosis
and the chances of the disease developing in a child. All of
the following statements about her prognosis are true except
A. Cardiomyopathy is a possible complication.
B. Chronic liver disease is a possible complication.
C. Dementia is a possible complication.
D. Her child will not have the disease unless her fiancé
is a carrier.
E. Prenatal testing is available for the disease.
I-93. A 36-year-old man comes to your office asking for ge-
netic testing for Alzheimer’s disease. He has no cognitive
complaints but notes that all four of his grandparents have
had Alzheimer’s and his father has mild cognitive impair-
ment at the age of 62. His Mini-Mental Status Examination
is 29/30, losing one point on the serial-7’s examination. He
requests testing for the apolipoprotein E allele (ε4). This
request is an example of which of the following?
A. Early-onset dementia

A. 21-hydroxylase deficiency
B. androgen insensitivity syndrome
C. Klinefelter syndrome
D. mixed gonadal dysgenesis
E. testicular dysgenesis
I-97. An 18-year-old female is evaluated in an outpatient
clinic for a complaint of amenorrhea. She reports that she
feels as if she never developed normally compared with
other girls her age. She has never had a menstrual period
and complains that she has had only minimal breast
growth. Past medical history is significant for a diagnosis
of borderline hypertension. In childhood the patient fre-
quently had otitis media and varicella infections. She re-
ceived the standard vaccinations. She recently graduated
from high school and has no learning difficulties. She is
on no medications. On physical examination, the patient
is of short stature with a height of 56 in. Blood pressure is
142/88. The posterior hairline is low. The nipples appear
widely spaced, with only breast buds present. The patient
has minimal escutcheon consistent with Tanner stage 2
development. Her external genitalia appear normal. Bi-
manual vaginal examination reveals an anteverted, ante-
exed uterus. The ovaries are not palpable. What is the
most likely diagnosis?
A. Hypothyroidism
B. Hyperthyroidism
C. Malnutrition
D. Testicular feminization
E. Turner syndrome (gonadal dysgenesis)
I-98. A 30-year-old male is seen for a physical examination

ders are true except
A. The mitochondrial genome does not recombine.
B. Inheritance is maternal.
C. The proportion of wild-type and mutant mitochon-
dria in different tissues is identical.
D. Cardiomyopathy is a feature of many mitochondrial
disorders.
E. Acquired somatic mitochondrial mutations may
play a role in age-related degenerative disorders.
I-101. Prader-Willi syndrome (PWS) is a rare disorder that is
characterized by diminished fetal activity, obesity, mental
retardation, and short stature. A deletion on the paternal
copy of chromosome 15 is the cause. A deletion on the
same site on chromosome 15, but on the maternal copy, re-
sults in a different syndrome: Angelman’s syndrome. This
syndrome is characterized by mental retardation, seizures,
ataxia, and hypotonia. What is the name of the genetic
mechanism that results in this phenomenon?
A. Genetic anticipation
B. Genetic imprinting
C. Lyonization
D. Somatic mosaicism
E. Uniparental disomy
I-102. All the following are inherited disorders of connec-
tive tissue except
A. Alport syndrome
B. Ehlers-Danlos syndrome
C. Marfan syndrome
D. McArdle’s disease
E. osteogenesis imperfecta

fashion (i.e., not autosomal dominant, autosomal reces-
sive, or X-linked) and are seen more frequently in persons
bearing certain histocompatibility antigens include
A. gluten-sensitive enteropathy
B. neurofibromatosis
C. adult polycystic kidney disease
D. Wilson’s disease
E. cystic fibrosis
I-107. A 32-year-old man seeks evaluation for ongoing fevers
of uncertain cause. He first noted a feeling of malaise about
3 months ago, and for the past 6 weeks, he has been experi-
encing daily fevers to as high as 39.4°C (103°F). He awak-
ens with night sweats once weekly and has lost 4.5 kg. He
complains of nonspecific myalgias and arthralgias. He has
no rashes and reports no ill contacts. He has seen his pri-
mary care physician on three separate occasions during
this time and has had documented temperatures of 38.7°C
(101.7°F) while in the physician’s office. Multiple labora-
tory studies have been performed that have shown nonspe-
cific findings only. A complete blood count showed a white
blood cell count of 15,700/µL with 80% polymorphonu-
clear cells, 15% lymphocytes, 3% eosinophils, and 2%
monocytes. The peripheral smear is normal. The hemato-
crit is 34.7%. His erythrocyte sedimentation rate (ESR) is
elevated at 57 mm/h. Liver and kidney function are nor-
mal. HIV, Epstein-Barr virus (EBV), and cytomegalovirus
(CMV) testing are negative. Routine blood cultures for
bacteria, chest radiograph, and purified protein derivative
(PPD) testing are negative. In large groups of patients sim-
ilar to this one with fever of unknown origin, which of the

procedures
E. All of the above
I-110. Which of the following would be present in an indi-
vidual who has lost nondeclarative memory?
A. Inability to recall a spouse’s birthday
B. Inability to recall how to tie one’s shoe
C. Inability to recognize a photo that was taken at one’s
wedding
D. Inability to recognize a watch as an instrument for
keeping time
E. Inability to remember the events of one’s high
school graduation
I-111. A 24-year-old woman presents for a routine checkup
and complains only of small masses in her groin. She states
that they have been present for at least 3 years. On physical
FIGURE I-105
Solid figure
Open figure
Affected individual
Unaffected individuals
I-107. (Continued)
I. INTRODUCTION TO CLINICAL MEDICINE — QUESTIONS 15
examination, she is noted to have several palpable 1-cm in-
guinal lymph nodes that are mobile, nontender, and dis-
crete. There is no other lymphadenopathy on examination.
What should be the next step in management?
A. Bone marrow biopsy
B. CT scan of the chest, abdomen, and pelvis
C. Excisional biopsy
D. Fine-needle aspiration for culture and cytopathology

risk after elective splenectomy?
A. Patients are at no increased risk of viral infection af-
ter splenectomy.
B. Patients should be vaccinated 2 weeks after splenectomy.
C. Splenectomy patients over the age of 50 are at great-
est risk for postsplenectomy sepsis.
D. Staphylococcus aureus is the most commonly impli-
cated organism in postsplenectomy sepsis.
E. The risk of infection after splenectomy increases
with time.
I-116. A 64-year-old man comes to your office complaining
of erectile dysfunction. He is not able to generate an erec-
tion. His past medical history is significant for coronary
artery bypass grafting many years ago, status post-carotid
endarterectomy, and a mildly reduced left ventricular ejec-
tion fraction. His medications include aspirin, carvedilol,
simvastatin, lisinopril and furosemide. He does not take
nitrates. On physical examination, you note normal-sized
testes and a normal prostate. There are no fibrotic changes
along the penile corpora. His libido is intact. What is the
most likely cause of this patient’s erectile dysfunction?
A. Disturbance of blood flow
B. Low testosterone
C. Medication related
D. Psychogenic
I-117. You perform a nocturnal tumescence study on the
patient in the preceding scenario. He does not have any
erections during rapid-eye-movement sleep. Which treat-
ment modality do you offer at this time?
A. Couple sex therapy

ing. Your physical examination reveals no masses or other
pathology. A brief psychiatric examination shows no
signs of depression. You perform initial testing with a
complete blood count; electrolytes, renal function, liver
I-111. (Continued) I-116. (Continued)