Section 11: Selected Topics in General and Internal Medicine

CHAPTER 64: SELECTED TOPICS IN GERIATRIC MEDICINE

Q.1. A healthy 65-year-old woman comes to the office complaining of urinary

incontinence. She has the urge to void but cannot reach the toilet before leaking a
moderate amount of urine. She lives alone and takes no medications. Her physical
examination is normal except for a blood pressure of 148/88. Which of the
following would not be appropriate in the initial evaluation?
A. Urinalysis
B. Postvoid residual volume
C. Bladder record
D. Urodynamic testing
Answer: D. The primary care physician should carry out the initial evaluation
of urinary incontinence with an emphasis on the history and physical examination.
A urinalysis should be performed to evaluate for evidence of inflammation or
infection. A postvoid residual volume should be measured to exclude overflow
incontinence because the history and physical are often insensitive. Bladder
records can be helpful in understanding the timing and frequency of incontinence
episodes, as well as behavioral factors that may be contributing to incontinence.
Urodynamic testing should be reserved for instances when the diagnosis remains
unclear after initial evaluation, when treatment fails, or when there is
consideration for surgery.

Q.2. An 85-year-old man returns from the hospital following repair of a right hip
fracture. Upon inspection of his skin he is found to have a 5- by 5-cm stage IV
sacral pressure ulcer. The wound is foul-smelling with copious drainage and a
large area of soft necrotic tissue at the base. The skin surrounding the wound is
slightly erythematous. The patient is afebrile. His leukocyte count is normal. All of
the following are appropriate except
A. Provide pressure relief
B. Sharply debride the necrotic tissue
C. Perform swab cultures and administer systemic antibiotics
D. Apply wet-to-dry dressings
Answer: C. A critical part of the treatment of any pressure ulcer is pressure
relief. Pressure relief is accomplished by turning and repositioning the patient
every two hours. Specialized beds that reduce skin pressure have become
standard of care for deep wounds, but their efficacy has not been rigorously
established. For wounds to begin healing, necrotic tissue must be removed.
Debridement can be accomplished by mechanical means with wet-to-dry
 dressings, or with enzymatic or autolytic agents, but can also be achieved with
sharp debridement. Ulcers with a large amount of drainage tend to heal more
slowly. Because all stage II to IV wounds are colonized with bacteria, swab
cultures provide no clinical utility. Without evidence of sepsis, cellulitis, or
osteomyelitis, systemic antibiotics are unwarranted.

Q.3. The prevalence of dementia in the general population at age 60 is

A. 1%
B. 10%
C. 20%
D. 33%
Answer: A. Only about 1% at age 60 has dementia. After age 60, the
prevalence of dementia doubles every five years.

Q.4. What is the most common cause of falls in the elderly?

A. Cardiogenic syncope
B. Slipping on ice
C. Dehydration
D. Multifactorial
Answer: D. While environmental hazards are involved in nearly half of all
falls, the majority of falls occur within the home, rather than outside on ice. Falls
are generally distinguished from syncope. While dehydration may contribute to
falls in some patients, particularly those on diuretics, falls are usually multifactorial
in etiology, attributed to the combination of individual host factors that make them
susceptible, environmental factors, and often an acute precipitant.

Q.5. An elderly man complains that for the past week he has leaked small amounts
of urine without any warning that he has to void. This is unrelated to any position
or activity. He does not have a fever. Of the potential causes of incontinence
listed, which is the most likely in this case?
A. Urinary tract infection
B. Prostatic hypertrophy
C. Stroke
D. Pudendal nerve injury
Answer: B. He has symptoms that would suggest he has overflow
incontinence. Stress incontinence, which results from a weakened pelvic floor such
as with pudendal nerve injury, is characterized by leakage of small or large
amounts of urine with maneuvers that increase intra-abdominal pressure. Stroke
and urinary tract infections usually cause incontinence by precipitating
 uncontrolled detrussor muscle contraction. He has neither dysuria described nor
fever, and does not get any sensation of “urge” to void to suggest this diagnosis.
His symptoms are most consistent with dribbling from overflow incontinence. This
commonly occurs in men with prostatic hypertrophy, and that would be the most
likely diagnosis in this case.

Q.6. A 71-year-old woman presents with a complaint of incontinence. She describes

daily episodes of incontinence that come on suddenly and are associated with a
strong desire to urinate. Urine loss occurs so quickly that she is unable to reach
the bathroom in time. Which of the following medicines is most likely to improve
her incontinence?
A. Pseudoephedrine
B. Doxazosin
C. Carbamazepine
D. Imipramine
E. Estrogen
Answer: D. This woman presents with urge incontinence. Urge incontinence
results from detrusor overactivity, instability, or hyperreflexia. Urge incontinence
may result from neurologic disease (e.g. stroke, cervical stenosis, CNS masses,
multiple sclerosis, Parkinson’s disease and others), or from bladder infection or
other genitourinary irritants. Nonpharmacologic treatment includes pelvic muscle
exercises and bladder retraining. Medications with anticholinergic activity (i.e.,
imipramine, answer choice D, as well as oxybutinin and tolterodine) are also used
in the management of urge incontinence. Pseudoephedrine may be used in the
management of stress incontinence, but is not used in urge incontinence.
Doxazosin has no role in the management of incontinence, and in fact may
exacerbate it. Carbamazepine also has no role in the management of incontinence.
Estrogen may be used (in combination with alpha-adrenergics) for the
management of stress incontinence, but is not used for urge incontinence.

Q.7. You are evaluating a 67-year-old woman for incontinence. Past medical history
is notable for diabetes and hypertension. Current medications include lisinopril,
glipizide, and metformin. Laboratory examination shows the following:
Na: 135
K: 3.9
Cl: 103
CO2: 21
BUN: 19
Cr: 1.6
 Glucose: 132
Calcium 9.1
Glycosylated hemoglobin is 7.8. Urinalysis shows no protein or glucose, occasional
RBCs, 1–3 WBC, 1–3 epithelial cells. The patient is asked to fully empty her bladder;
then catheterization of her bladder is performed. 175 cc of fluid is drained. The most
likely cause of incontinence in this patient is
A. Overflow incontinence
B. Stress incontinence
C. Osmotic diuresis
D. Renal insufficiency
E. Medication side effects
Answer: A. This patient with complaints of incontinence has an elevated
postvoid residual of urine in her bladder, suggesting the diagnosis of overflow
incontinence. There is insufficient information provided to diagnose this woman
with stress incontinence, which usually occurs with coughing, laughing, sneezing,
and exercising. While her overall glycemic control is suboptimal (glycosylated
hemoglobin is 7.8), the glucose must typically be above 200 to cause an osmotic
diuresis. Renal insufficiency is not a cause of incontinence, and the medications
that she takes are not common causes of incontinence.

Q.8. The general surgery service asks you to assist in choosing an antibiotic to
manage a stage III pressure ulcer in a 72-year-old woman admitted to their
service with small bowel obstruction. Upon admission, the patient was noted to
have a nondraining stage III pressure ulcer on her sacrum. A swab of the ulcer
grew methicillin-resistant Staphylococcus aureus. The patient is afebrile and
otherwise clinically stable; her small bowel obstruction has improved with
nasogastric suction. An appropriate antibiotic choice would be
A. Vancomycin
B. Imipenem
C. Tetracycline
D. Gatifloxacin
E. No antibiotic treatment is indicated
Answer: E. This patient has a stage III sacral decubitus ulcer that apparently
is colonized with methicillin-resistant Staphylococcus aureus. She is afebrile, there
is no wound drainage, and she is clinically without evidence of systemic infection.
In the absence of evidence of infection, skin ulcers should not be treated with
systemic antibiotics. Topical antibiotics are used by some, but if used, should be
discontinued after 48 hours of treatment.
Q.9. Pharmacotherapeutic options for dementia include treatment with donepezil,
tacrine, rivastigmine, and galantamine. These medications share which of the
following characteristics?
A. Cholinergic augmentation
B. Mild sedation
C. Anxiolytic properties
D. Nephrotoxic effects
E. Hyperglycemic effects
Answer: A. All of these medications share cholinergic augmentation. None of
the other options are shared by the medications mentioned.

CHAPTER 65: SELECTED TOPICS IN WOMEN’S HEALTH FOR THE

INTERNIST

Q.1. A 23-year-old woman, pregnant for the first time, is admitted at 32 weeks
gestation after an office visit where her blood pressure is 170/110. She has had
epigastric pain and vomiting since last night. Examination reveals significant
edema. On admission, her platelet count is 45,000 and her AST is 2300 IU/L.
Which of the following would you not expect?
A. Hematocrit of 24%
B. Urine protein of 4 (3 grams/24 hours)
C. No increase in risk of seizure
D. Peripheral blood smear consistent with thrombotic thrombocytopenic purpura
(TTP)
E. Possible recurrence with subsequent pregnancies
Answer: C. This patient has severe preeclampsia and probable associated
HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. It would not
be surprising to find a low hematocrit secondary to hemolysis. The peripheral
blood smear in HELLP is nondiagnostic and is also consistent with TTP or hemolytic
uremic syndrome. The elevated urine protein is expected with preeclampsia.
Severe preeclampsia puts this patient at high risk of seizure, and intravenous
magnesium sulfate should be started. She is also at risk of recurrence of the
preeclampsia with subsequent pregnancies.

Q.2. A 27-year-old women who has had diabetes since age 8 years and chronic
hypertension since age 22 years, and who has had no previous pregnancies,
comes to you for prepregnancy consultation. Her current medications include
 ramipril and glipizide. Which of the following advice would be incorrect to give your
patient?
A. Continue the ramipril through the pregnancy to protect renal function from
diabetes
B. Tight glycemic control should be in place before conception
C. Optimal blood sugars before and during pregnancy are 60 to 80 mg/dL fasting
and 60 to 120 mg/dL two hours postprandial
D. Oral hypoglycemic agents are not well evaluated for safety in pregnancy, and
insulin is preferred
E. Her diabetes, if not controlled, could lead to either fetal macrosomia or growth
retardation
Answer: A. Angiotensin-converting enzyme inhibitors (e.g., ramipril) are
contraindicated in pregnancy; it should be discontinued before attempting
conception. Uncontrolled diabetes can lead to fetal macrosomia or growth
retardation, as well as other fetal abnormalities, including death. Tight control to
prevent such complications is crucial, and the goals outlined in choice C are
appropriate. Insulin is the preferred drug for diabetes in pregnancy.

Q.3. A 19-year-old college student presents to your office for a routine health
checkup. She has no significant medical history. She lives in a dormitory room
with several friends and drinks alcohol on the weekends. She is sexually active
with her boyfriend and uses condoms for birth control. Her physical examination,
including pelvic exam, is normal. The Pap smear results return in one week as
“low-grade squamous intraepithelial lesion” (LGSIL). Which of the following is true
regarding her condition?
A. She will most likely require a surgical procedure, such as a laser conization, but
cure is likely
B. HPV testing will be helpful in decision-making regarding colposcopy referral
C. If a repeat Pap smear in six months shows HGSIL, she will need colposcopy
D. Her risk for cervical cancer is low; repeat Pap testing in 12 months is
appropriate
E. The finding of LGSIL has a high likelihood of regressing to normal
Answer: E. This patient’s Pap smear result, LGSIL, confers a 15% to 30%
risk of having a high-grade lesion on colposcopy. In the majority of instances,
LGSIL actually regresses to normal and has a benign prognosis. The need for
eventual laser conization is unlikely. Nevertheless, the result does require further
evaluation with colposcopy. Simply repeating the Pap smear in 6 to 12 months or
using HPV testing to help triage the need for colposcopy (as with ASCUS) would
not be aggressive enough or appropriate in this situation.
Q.4. A 38-year-old woman is currently on an oral contraceptive for birth control. She
is married and monogamous with her husband. Her sons are 10 and 7 years old,
respectively, and she is not interested in having any more children. Lately, she has
become concerned about how the oral contraceptive makes her feel and is worried
that it might cause breast or ovarian cancer. Her family history is notable for an
older sister who died of ovarian cancer at age 50. The patient does not drink or
smoke. Her physical examination is unremarkable. What do you tell her about her
contraceptive options?
A. The oral contracaptive agent will not increase her risk of ovarian cancer; in fact,
it may be protective
B. She should discontinue the oral contraceptive as it is contraindicated in women
over the age of 35 years
C. Injectable long-acting progesterone may be a better option as it will help
protect against bone mineral density loss
D. An IUD would not be a good option given the increased risk of ectopic
pregnancy at her age
E. Administering the contraceptive as a patch rather than a pill will avoid the
increased risk of breast cancer
Answer: A. This woman has many options for contraception. Certainly,
continuing her current oral contraceptive would be acceptable—as long as her
anxiety with it is alleviated. Oral combination contraceptives are contraindicated
only in women over 35 years who smoke. They are not associated with ovarian
cancer and, in fact, may be protective. The association of oral contraceptive with
breast cancer is less clear, but probably not significant. Using a patch rather than
a pill will do nothing to attenuate this risk. Long-acting (depot) progesterone has
been linked to reversible bone mineral density loss and thus may not be the best
first-line choice for this older woman. Finally, an IUD is a very reasonable option
for her and is not associated with an increased risk of ectopic pregnancy in any
age group.

Q.5. A 20-year-old young woman presents to your office for an urgent appointment.
She is distraught as she recently discovered her boyfriend, with whom she is
sexually active, has genital warts. She is worried that she may contract these and
that she might develop cervical cancer. She has been in a monogamous
relationship with her boyfriend for about nine months. She is otherwise healthy.
What do you recommend for cervical cancer screening?
A. After three annual Pap smears that are normal, she can increase the screening
interval to Pap smears every three years
B. The HPV strains that cause cervical cancer do not cause genital warts;
therefore, she can defer screening for another year
C. She should undergo a Pap smear with HPV testing
 D. A finding of squamous metaplasia on Pap smear should prompt HPV testing
E. She does not require cervical cancer screening as she has not reached 21 years
of age
Answer: C. This patient should undergo cervical cancer screening now as she
is sexually active and has probable exposure to HPV. Guidelines suggest screening
at age 21 or upon initiation of sexual activity, whichever is first. HPV testing in
women less than 30 years of age is more controversial, given that many women
will spontaneously clear the infection with no sequelae. This patient, however, has
a known exposure, and HPV testing (with serotyping of low- vs. high-risk
serotypes) will add in prognosticating her future risk of cervical cancer. It is true
that the HPV strains that cause genital warts are usually low-risk strains, but that
alone would not be sufficient to defer screening in this patient. Most guidelines do
not recommend lengthening the screening interval to three years until a woman
reaches 30 years of age, regardless of HPV status. A finding of squamous
metaplasia is normal and does not require further testing of any kind.

Q.6. A 50-year-old woman presents to your office with moderate hot flashes that
began about six months ago. They are worsening in severity and wake her up
many times throughout the night. She is becoming increasingly sleep-deprived
and describes inability to concentrate at work. Her last menses was 10 months
ago. She is on a small dose of a thiazide diuretic for mild hypertension but is
otherwise healthy. Which of the following is true about the treatment of her hot
flashes?
A. Alpha-adrenergic agents are the best-tolerated option and would be a good
choice for her
B. Venlafaxine is the most effective alternative to estrogen
C. Coping mechanisms alone may not be enough for her; estrogen is reasonable to
try
D. Gabapentin provides the quickest onset and the fewest side effects; it should
be prescribed for her
E. Estrogen will work for her, but its use should be limited to under a year
Answer: C. This woman has moderate hot flashes associated with
menopause that are now affecting her quality of life and ability to work. She
deserves treatment. There is no “right or wrong” choice for therapy, although
estrogen has the quickest onset and best efficacy. It is very reasonable to try it in
this patient, given her moderate to severe symptoms. Coping mechanisms will
probably not be adequate. Estrogen use should be limited to five years, not one
year. The other prescription alternatives are reasonable, but reduce hot flash
frequency and severity by roughly 50%. It is not true that alpha-adrenergic agents
are the best tolerated (they are the least well tolerated). Likewise, venlafaxine is
not necessarily the most effective and gabapentin does not have the quickest
 onset or fewest side effects. Head-to-head trials for most estrogen alternatives are
lacking.

Q.7. As a practicing internist, you see many pregnant women as patients. While they
often call their obstetrician for advice regarding their pregnancy, you still receive
many phone calls about common problems, such as allergic rhinitis, urinary tract
infections, and reflux disease. Which of the following is not appropriate advice for
a pregnant woman?
A. For a urinary tract infection, nitrofurantoin is a good choice
B. For allergic rhinitis, chlorpheniramine is appropriate to try
C. For gastroesophageal reflux, omeprazole is recommended
D. For a severe headache, acetaminophen is an acceptable option
E. For acne, topical clindamycin is a reasonable strategy
Answer: C. As an internist, it is important to know how to treat commonly
occurring medical conditions in pregnant women. All of the above choices are
reasonable and correct except choice C. Proton pump inhibitors, such as
omeprazole, are pregnancy class C and should be avoided if possible. H2 blockers
(e.g., famotidine, ranitidine) are pregnancy class B and are preferred for the
treatment of gastroesophageal reflux.

Q.8. Which of the following is true regarding cervical cancer screening with a
Papanicolaou (Pap) smear?
A. A finding of atypical squamous cells of undetermined significance (ASCUS) on
Pap smear with a negative DNA test for human papilloma virus (HPV) test can be
followed with a repeat Pap smear in one year
B. A finding of atypical glandular cells of undetermined significance (AGUS) is less
serious that ASCUS and can be followed with a repeat Pap smear in four to six
months
C. Cervical cancer screening with a Pap smear is recommended beginning at age
21 years, regardless of sexual activity
D. Trichomonas found on a routine Pap smear should be confirmed with a normal
saline prep before initiating treatment
E. If a Pap smear shows ASCUS, but colposcopy reveals cervical intraepithelial
neoplasia grade II, there was probably a sampling error and a repeat colposcopy
should be performed
Answer: A. HPV testing can be useful in triaging patients with a finding of
ASCUS on Pap smear. If negative, repeating the Pap at one year is an appropriate
course of management. If positive, the patient should be referred for colposcopy.
AGUS is often related to more serious disease than ASCUS (usually endometrial
rather than cervical cancer) and should be followed more aggressively. Colposcopy
 and biopsy are more appropriate that repeat Pap testing. Recommendations are to
begin cervical cancer screening at age 18 years or when sexually active, whichever
comes first. Any infection, including trichomonas, found on a routine Pap smear,
should be treated. A normal saline prep is not necessary for confirmation. Finally,
if there is a discrepancy between a Pap smear reading and a histological finding by
colposcopy, treatment should be initiated if the histological diagnosis is more
serious (as in this case). The patient should have definitive therapy with cold knife
or laser conization or a loop electrosurgical excision procedure (LEEP). If the
histological diagnosis is less severe, a sampling error may have occurred and a
larger biopsy should be taken.

Q.9. A 25-year-old woman is 12 weeks pregnant with her second child. She
presents to the emergency department with an acute onset of shortness of breath
and wheezing. She has a history of mild, intermittent asthma for which she uses
an albuterol metered dose inhaler on an as-needed basis. On examination, her
blood pressure is 130/85 mm Hg and her heart rate is 110 bpm. She is tachypneic
and has diffuse, polyphonic wheezes throughout her lung fields. Her oxygen
saturation is 94% on room air. What is appropriate management?
A. Administer O2 by nasal cannula, prednisone, and -agonist nebulizer
treatments
B. Administer O2 by nasal cannula and theophylline, as it is pregnancy class B
C. Administer O2 by nasal cannula and -agonist nebulizer treatments; avoid
prednisone because of pregnancy and risk to the fetus
D. Administer O2 by nasal cannula and intravenous magnesium sulfate, as it is
safe in pregnancy
E. Administer O2 by nasal cannula and prednisone; avoid -agonist nebulizer
treatments because she is in the first trimester
Answer: A. This pregnant woman is having a severe asthma flare. The risk of
hypoxemia from the asthma far outweighs any risk of treatment. She should be
given oxygen by nasal cannula treated aggressively, no matter what her trimester.
Prednisone and -agonist nebulizer treatments are both appropriate therapies.
Theophylline is pregnancy class C and should be avoided unless absolutely
required. Magnesium sulfate has not been proven to be efficacious in asthma and
alone would not be enough to treat the flare.

Q.10. Which of the following women would not be a good candidate for the use of
combination oral contraceptive pills?
A. A 40-year-old woman with no smoking history
B. A 30-year-old woman with a strong family history of ovarian cancer
 C. A 29-year-old woman with mild hypertension that is well controlled with a
thiazide diuretic
D. A 32-year-old woman with a history of autoimmune hepatitis that is under
reasonable control
E. A 34-year-old woman with heavy menses secondary to uterine fibroids
Answer: D. Combination oral contraceptives are a safe and effective method
of birth control. There are, however, certain relative contraindications regarding
their use. Women with a history of liver disease should be advised not to use them
(choice D). Other contraindications include a history of thromboembolic disease, a
history of breast or endometrial cancer, and smokers over age 35 years. In choice
A, the woman does not smoke and would still be a candidate. For choice B, oral
contraceptives may actually decrease the risk of ovarian cancer. In choice C, the
hypertension is well controlled. Only uncontrolled hypertension is a
contraindication. Finally, use of an oral contraceptive may actually decrease
menstrual bleeding in a woman with uterine fibroids.

Q.14. A 19-year-old woman comes to your office for counseling regarding birth
control. She has been using condoms, but does not like “depending on someone
else for protection.” She also has horrible migraines that only occur
premenstrually (once a month) but force her to stay in bed for a day. She is
interested in trying a combination oral contraceptive. She is healthy with no
chronic medical conditions. When initiating oral contraceptives, which of the
following statements would be appropriate advice for the patient?
A. Explain that if she misses a couple days of her oral contraceptive she should
take one immediately, and then one twice a day until all the missed tablets have
been taken. If she does so, she will not need an additional form of contraception
for that cycle
B. Inform her that the mini-pill may be a good option for her; because it contains
estrogen only, it tends to have fewer side effects
C. She should start the oral contraceptive midcycle, roughly 14 days before her
expected menstruation
D. Oral contraceptives are not necessarily contraindicated for premenstrual
migraines; in fact, she may opt to have a withdrawal bleed only every three
months on the pill to decrease the frequency of her migrainesE. Symptoms of
premenstrual syndrome (nausea, irritability, headache, bloating) usually worsen
after starting an oral contraceptive
Answer: D. Oral contraceptives are a reasonable choice for this healthy,
young woman with no contraindications. While oral contraceptives may worsen
migraines in general, they may actually alleviate premenstrual headaches and
migraines. An added bonus is the ability to take the inert pills only every three
months (perfectly safe to do), thus decreasing the frequency of premenstrual
 migraines. If she misses more than one dose, she should take the missed tablets
as directed in choice A, but she should also use an additional form of contraception
that cycle. The mini-pill contains progestin only (not estrogen) and is associated
with a higher incidence of breakthrough bleeding. It is used predominantly in
breastfeeding women or women who cannot tolerate estrogen. Oral contraceptives
should be started on the first day of menses, not mid-cycle. Finally, symptoms
associated with premenstrual syndrome tend to improve on oral contraceptives,
not worsen.

CHAPTER 66: DERMATOLOGY FOR THE INTERNIST

Q.1. A 36-year-old man with a history of asthma presents with a rash on his leg that
has been present for the past six weeks. His current medications include
fluticasone and salmeterol inhalers. The lesion is a well-circumscribed, 2-cm
diameter plaque just above the right medial malleolus. No surrounding erythema,
papules, or vesicles are noted. A potassium hydroxide preparation is done and fails
to reveal hyphae, pseudohyphae, or spores. What is the most appropriate therapy
for this patient?
A. Topical corticosteroids and emollients
B. Oral griseofulvin
C. Topical antifungal agents
D. Oral antistaphylococcal antibiotics
E. Either B or C
Answer: A. This man presents with a well-circumscribed lesion on his
extremity. He has a history of asthma, which suggests atopy. The most common
lesions presenting in this fashion are nummular eczema and tinea infections. His
potassium hydroxide preparation is not consistent with tinea, so he should be
treated for eczema with topical corticosteroids and emollients. Because there are
no signs of superimposed bacterial infection, oral antibiotics are unnecessary.

Q.2. A 55-year-old man presents for follow-up of his chronic plaque psoriasis. You
instituted therapy with emollients and topical corticosteroids two months ago, but
this has led to only minimal improvement. Which of the following is not an
appropriate next step in his management?
A. A trial of oral prednisone with a taper over six to eight weeks
B. Methotrexate
C. Referral for psoralen and phototherapy with ultraviolet A light (PUVA)
D. Topical vitamin D derivatives (calcipotriene)
E. Topical vitamin A derivatives (tazarotene)
 Answer: A. This patient has plaque psoriasis unresponsive to initial therapy.
All of the choices would be appropriate (depending on the extent of disease)
except for oral prednisone. Systemic corticosteroids should be avoided in these
patients because tapering will predispose them to erythrodermic or pustular
psoriasis.

Q.3. A 40-year-old woman comes to the office with fever and arthralgias. On
examination, you note tender red nodules on her legs. Medical history includes
hypertension, deep venous thrombosis, and endometriosis. Her medications are
hydrochlorothiazide (HCTZ), warfarin, and ortho-tricyclen. Which medication is
most likely the cause of her condition?
A. HCTZ
B. Warfarin
C. Ortho-tricyclen
D. None of the above
Answer: C. This women has erythema nodosum. A septal panniculitis related
to infection, autoimmune disorders and medications including oral contraception.
Treatment includes stopping the offending agent, and if necessary oral NSAIDs,
potassium iodide, or corticosteroids.

Q.4. A 70-year-old man presents with painful vesicles on his nose and left forehead,
and no lesions elsewhere. His mental status is intact. What specialist must be
consulted?
A. Neurologist
B. Opthalmologist
C. Audiologist
D. Cardiologist
E. None, just start acyclovir
Answer: B. This patient has herpes zoster in the V1 distribution. When
lesions involve the nose, there is a concern for involvement of the opthalmic nerve
(Hutchinson’s sign). Herpes zoster opthalmicus can cause viral keratitis and
blindness. Opthalmology must be consulted for a full examination.

Q.5. A 70-year-old man presents for evaluation of multiple scaly macules on the
dorsum of his hands and scalp. You diagnose actinic keratosis. Which of the
following statements regarding this condition is correct?
A. These lesions can transform into melanoma
B. These lesions can transform into basal cell carcinoma
C. These lesions can transform into squamous cell carcinoma
 D. The malignant potential of these lesions can be predicted by the presence or
absence of scaling
E. Both B and D are correct
Answer: C. Actinic keratosis is a premalignant condition seen on sun-
exposed skin in patients over the age of 40. Although their presence may suggest
a susceptibility to all types of ultraviolet light–related skin cancers, the lesions
themselves carry a low risk of transformation into squamous cell carcinoma only.
Unfortunately, there is no way to determine which lesions will progress to
squamous cell carcinoma.

Q.6. A 26-year-old man presents complaining of a pruritic rash that has been
present for about four weeks. On review of systems, he notes that he has been
having intermittent episodes of diarrhea and abdominal cramping for the last year.
He was told by another physician that he has irritable bowel syndrome so he has
been increasing the fiber in his diet. His physical examination is notable for
clusters of grouped vesicles on his elbows and buttocks. There is no involvement
of the palms, soles, or mucous membranes. A skin biopsy is done and reveals a
subepidermal vesicle with neutrophils and eosinophils in the dermal papillae.
Direct immunofluorescence reveals IgA deposition at the basement membrane
zone. Which of the following is most appropriate for the treatment of this patient?
A. Oral acyclovir
B. Oral corticosteroids
C. Topical corticosteroids
D. A gluten-free diet
E. Bother B and D are correct
Answer: D. This patient has a pruritic, vesicular rash and abdominal
symptoms that are suggestive of gluten-sensitive enteropathy. The biopsy and
clinical findings are typical for dermatitis herpetiformis. Dermatitis herpetiformis is
associated with gluten-sensitive enteropathy and other autoimmune diseases. The
best treatment is a gluten-free diet. Dapsone can be used if dietary restrictions are
not sufficient. Steroids and antiviral agents are not helpful for this condition.

Q.7. A 36-year-old woman presents complaining of a painful erythematous rash on

her lower extremities. She reports that they have been present for the last week
and are causing her significant discomfort. She denies any other complaints at this
time. Her examination reveals subcutaneous, painful, erythematous nodules. All of
the following are appropriate as part of an initial evaluation of this patient except
A. Epstein-Barr virus serology
B. Throat culture
C. Tuberculin skin test
 D. Chest x-ray
E. Antistreptolysin O titer
Answer: A. This woman presents with erythema nodosum (EN) with no other
localizing symptoms. Most cases are associated with streptococcal pharyngitis or
are idiopathic. Given that sarocoidosis, tuberculosis, histoplasmosis, and Hodgkin’s
disease can also cause EN, a basic evaluation should include a throat culture, ASO
titer, PPD, and a chest x-ray. Epstein-Barr virus infection has not been shown to
be associated with EN. Other associated conditions include inflammatory bowel
disease, chlamydia infection, medications, and Behcet’s disease.

CHAPTER 67: OPHTHALMOLOGY FOR THE INTERNIST

Q.1. A 36-year-old woman is referred back to you by her ophthalmologist, who

states that she has evidence of uveitis. She was begun on topical corticosteriods
with some improvement. She says that her ophthalmologist wanted you to do a
systemic evaluation. She has no complaints and no abnormalities on physical
examination. Which of the following tests is an appropriate component of her
evaluation?
A. Chest x-ray
B. MRI of the head
C. Purified protein derivative (PPD) test
D. Herpes simplex virus (HSV) serology
Answer: A. This woman was referred for an evaluation after being diagnosed
with uveitis. Although she may have primary disease not related to an underlying
disorder, it is necessary to exclude certain diseases before reaching that
conclusion. The most common disorders associated with uveitis include juvenile
chronic (rheumatoid) arthritis, seronegative spondyloarthropathies, Behcet’s
syndrome, and sarcoidosis. Therefore, a chest x-ray to assess for
lymphadenopathy from sarcoidosis would be the best answer. A PPD skin test is
not recommended in patients with no risk factors for TB. HSV serology has a poor
positive predictive value, and cranial MRI is rarely indicated as part of a workup
for uveitis, especially if more common causes have yet to be ruled out.

Q.2. A 55-year-old man with a history of type 2 diabetes diagnosed 7 years ago
presents to your office for a checkup. He reports that he had an eye examination
about eight months ago that showed no evidence of retinopathy. Which of the
following statements regarding screening for diabetic retinopathy is correct?
A. He should be screened again immediately because he is overdue for his every-
six-month ophthalmologic examination
 B. He should be screened yearly, so he should make an appointment in four
months
C. Because he does not have existing retinopathy, he should be screened every
two to three years
D. Because he does not have existing retinopathy, he should be screened very five
years
E. Screening is not recommended for this patient
Answer: B. Current recommendations suggest that diabetics (both type 1
and type 2) be screened yearly when there is no evidence of retinopathy. In type
1 diabetics, screening may begin about five years after diagnosis, but in type 2
diabetics screening should begin at the time of diagnosis. If the patient previously
had been diagnosed with retinopathy, he would need more frequent examinations.

Q.3. Which of the following statements regarding diabetic retinopathy is correct?

A. Glycemic control does not play a role in progression of disease
B. Diabetic patients who become pregnant will typically see some improvement in
their retinopathy over the course of their pregnancy
C. Women who have gestational diabetes are not at increased risk to develop
diabetic retinopathy
D. Diabetic retinopathy is the leading cause of blindness in elderly white
Americans
Answer: C. Although patients with diabetic retinopathy who become
pregnant can expect worsening of their eye disease, patients with gestational
diabetes are not at increased risk for developing the disease. Diabetic retinopathy
is the leading cause of blindness in patients aged 20 to 60 years. In older patients,
however, macular degeneration is more common. Tight glycemic control is the
best method to prevent disease onset and progression.

Q.4. A 65-year-old woman presents with severe pain in one eye associated with
redness and light sensitivity. She describes decreased vision and “halos.” She has
no previous history of eye problems except for needing glasses and has never had
eye surgery or trauma. Her general health is good except for a recent upper
respiratory infection for which she takes an over-the-counter “cold medication.”
The most likely diagnosis is:
A. Scleritis
B. Anterior uveitis
C. Angle-closure glaucoma
D. Endophthalmitis
 Answer: C. Angle-closure glaucoma is more common in older patients and
can be triggered in anatomically susceptible eyes by certain medications, including
decongestants found in many cold remedies. Her symptoms of unilateral pain and
redness could be caused by any of the conditions listed, but she has no risk factors
for endophthalmitis, and a first episode of scleritis or uveitis would be extremely
unlikely at her age; furthermore, scleritis would be unlikely to cause halos (which
are due to the corneal edema from the rapid elevation in intraocular pressure in
angle-closure glaucoma).

Q.5. Which of the following medications increases the risk of open-angle glaucoma?
A. Anticholinergics
B. α-adrenergic agents
C. β-blockers
D. Corticosteroids
Answer: D. Corticosteroids in any form (especially eyedrops and oral
formulations, and probably only rarely with dermatologic creams) can cause
elevations in intraocular pressure without any visible anatomic changes (i.e., eyes
with steroid-induced glaucoma look morphologically identical to those with primary
open-angle glaucoma). Patients with open-angle glaucoma or with first-degree
relatives with open-angle glaucoma are at increased risk for developing steroid-
induced glaucoma. Anticholinergics and alpha-adrenergic agents can precipitate
angle-closure glaucoma. Topical beta-blockers are one of the most commonly used
and effective treatments for open-angle glaucoma and oral beta-blockers do not
cause increases in intraocular pressure.

Q.6. Which of the following statements about cataracts is correct?

A. They usually cause pain
B. They are the leading cause of acute-onset “red eye” in patients over the age of
50
C. Cataracts are usually present bilaterally, although the severity of impairment
may vary between eyes
D. A cataract should be operated on if the visual acuity in the affected eye is
worse than 20/50
Answer: C. Cataracts occur when the lens of the eyes become opacified.
They are usually bilateral and occur with advancing age. They typically do not
cause pain or redness. The decision to operate should be based on functional
impairment, rather than on visual acuity.
Q.7. Which of the following treatments has been shown in randomized, controlled
clinical studies to reduce the likelihood of progression of moderate nonexudative
(dry) age-related macular degeneration?
A. Photodynamic therapy (verteporfin)
B. Antioxidants
C. Vascular endothelial growth factors antagonists
D. Laser photocoagulation
Answer: B. The Age-related Eye Disease Study (AREDS) showed that a
combination of vitamins A (e.g., beta-carotene), C, and E, along with zinc,
reduced the risk of progression of moderate nonexudative macular degeneration
(AMD). It did not show a benefit in reducing the risk of progression of mild AMD.
The other treatments listed have been shown effective in the treatment of
exudative (wet) AMD, in which choroidal neovascularization occurs beneath the
retina, but are not effective for nonexudative AMD.

Q.8. A 65-year-old Asian woman with a history of hypertension presents with a

painful red left eye, nausea, headache, and vomiting. She notes that she was
doing well until this morning when she developed the symptoms. Her only
medications are hydrochlorothiazide and oxybutinin (which was just started by her
gynecologist for urinary incontinence). Her physical examination reveals decreased
visual acuity on the left. Which of the following is most appropriate regarding her
management?
A. Refer her urgently to an ophthalmologist
B. Discontinue the oxybutinin and have her follow up in three days
C. Prescribe oral acetazolamide
D. Prescribe topical tobramycin eydrops
E. Prescribe a topical beta-blocker
Answer: A. This woman presents with acute narrow-angle glaucoma
precipitated by the anticholinergic agent oxybutinin. Narrow-angle glaucoma is
much less common than open-angle glaucoma. It presents with acute pain,
redness, and decreased visual acuity. Headache, nausea, and vomiting are
frequently seen. The constellation of these symptoms requires urgent referral to
an ophthalmologist for laser iridotomy. Even though the oxybutinin should be
discontinued, it is not sufficient at this time. Carbonic anhydrase inhibitors can be
given to try to reduce the eye pressure but its use is an adjunct to prompt
referral. Tobramycin is inappropriate since there is no evidence of infection.
Topical beta-blockers are useful for open-angle glaucoma but do not play a
significant role in the acute management of narrow-angle glaucoma.
Q.9. A 66-year-old woman with a history of asthma presents complaining of
increased wheezing and dyspnea. She notes that her asthma had been under good
control until about four weeks ago when she noted that she needed to use her
inhalers more often. Her past medical history is notable for hypertension,
diabetes, and asthma. Her current medications include glyburide,
hydrocholorthiazide, lisinopril, and an eyedrop started by her ophthalmologist for
open-angle glaucoma about six weeks ago. Her physical examination is notable for
diffuse wheezing, fair air entry, and prolonged expiration. What is the most likely
medication that was started by the ophthalmologist?
A. Topical corticosteroid
B. Topical β-blocker
C. Topical α-agonist
D. Topical carbonic anhydrase inhibitor
E. Topical prostaglandin analog
Answer: B. All of the medications listed, except for the topical
corticosteroids, are used in the treatment of primary open-angle glaucoma. Ocular
medications can cause systemic side effects and must be considered when
evaluating complaints. Corticosteroids can cause cataracts and can lead to
glaucoma. Topical β-blockers can cause bronchospasm, bradycardia, and
hypotension similar to systemic β-blockers. Care must be taken in asthmatics and
in patients with congestive heart failure. α-agonists cause dry mouth, dizziness,
and hypotension. Nausea, fatigue, hypokalemia, and depression are usually seen
with oral carbonic anhydrase inhibitors but can occasionally be associated with
topical administration. Prostaglandin agonists can cause myalgias and arthralgias.

Q.10. Which of the following statements regarding age-related macular degeneration

is correct?
A. It is the leading cause of blindness in patients aged 20 to 60 years in the United
States
B. Central vision is typically lost while peripheral vision remains intact
C. Patients typically present with redness in one or both eyes without pain
D. Antioxidant vitamins have been shown to be effective in prevention and
treatment of disease
E. A dendritic pattern is seen when the cornea is stained with fluoroscein
Answer: B. Age-related macular degeneration (AMD) is the leading cause of
blindness in white elderly patients. An estimated 30% of people between age 75
and 85 have evidence of AMD. In younger patients (aged 20–60), diabetes is the
leading cause of blindness. Patients with AMD typically have loss of central vision
and retention of peripheral vision. The eyes are usually not painful or red.
Antioxidant vitamins that include a combination of zinc, vitamins C and E, and
 beta carotene may reduce the risk of progression from moderate to severe AMD,
but has not been shown to reduce the risk of progression from mild to moderate
AMD or to prevent disease. The dendritic pattern on fluoroscein staining is seen in
patients with HSV keratitis. Patients with non-neovascular AMD typically have
bright, yellow macular deposits (drusen) on ophthalmoscopy.

Q.11. A 28-year-old woman presents complaining of red right eye of three days’
duration. She denies any fever, nausea, vomiting, or trauma to the eye. There is
no pain in the eye but some itching and discharge. On examination, the eye is
diffusely injected. There is crusting and copious amounts of mucopurulent
discharge. Visual acuity is normal. There is no lymphadenopathy. Fluoroscein
examination reveals no abnormalities. Which of the following statements regarding
her management is most appropriate?
A. She should be prescribed topical tobramycin to treat her infection
B. She should be prescribed a topical corticosteroid to reduce her inflammation
C. She should be prescribed a topical antiviral agent
D. She should be treated with a topical antihistamine
E. She should be told to stay home from work for about 14 days to prevent
person-to-person spread of the infection
Answer: A. This woman has evidence of bacterial conjunctivitis. She has
unilateral mucopurulent discharge and redness of the eye. There is no
lymphadenopathy. These findings are highly suggestive of a bacterial process for
which tobramycin eyedrops would be appropriate. Topical corticosteroids should
not be prescribed unless a specific diagnosis such as uveitis has been made. Viral
infections and allergic conjunctivitis will typically be associated with a clear
discharge. Antihistamines and antiviral agents are not appropriate in this case.
Patients with viral conjunctivitis are highly infectious and should avoid close
contact with others for 7 to 14 days.

CHAPTER 68: PSYCHIATRY FOR THE INTERNIST

Q.1. A 44-year-old man with a history of long-standing HIV presents to your office
complaining of depression and fatigue. He reports that he has been going through
an emotionally rough time recently because of a breakup with his significant other.
His review of symptoms reveals anhedonia, insomnia, decreased appetite, and
some feelings of guilt. He has had undetectable HIV RNA levels for two years, ever
since starting on zidovudine (AZT), lamivudine (3TC), and indinavir. His only other
medications include TMP/SMZ. He also takes a multivitamin and saw palmetto and
recently began self-treating his depression with St. John’s wort. You obtain some
blood work, which reveals no significant changes except that his HIV RNA level is
now 10,000 copies/mL. What is the most appropriate next step?
 A. Tell him that his depression and fatigue are caused by a worsening of his HIV,
so a change in his protease inhibitor will be necessary
B. Tell him that his depression and fatigue are caused by a worsening of his HIV,
so his AZT should be changed to didanosine (DDI)
C. Discontinue his saw palmetto
D. Discontinue his St. John’s wort
E. Add an SSRI to his current medical regimen
Answer: D. This patient has a history of HIV and began treating some
depressive symptoms with St. John’s wort, an herbal supplement with probable
efficacy for patients with mild depressive symptoms. St. John’s wort, however, has
been found to lower levels of some protease inhibitors (including indinavir),
rendering them less effective. The rise in this patient’s HIV RNA level could
therefore be caused by the herbal supplement. Discontinuation and monitoring of
symptoms and RNA levels would be the initial approach given a patient with a
highly active antiretroviral therapy (HAART) regimen that had previously been
effective. Saw palmetto, often used for prostatic symptoms, has not been shown
to have significant drug interactions. Even though an SSRI may ultimately be
useful for treatment of depression in this patient, it should not be added in a
patient taking St. John’s wort because it can increase the risk for serotonin
syndrome.

Q.2. A 56-year-old man whom you have been treating for depression returns eight
weeks after you initiated therapy with paroxetine (an SSRI). He reports that his
symptoms have improved tremendously and wishes to discontinue his
antidepressant at this time because he does not like taking medications. He has a
history of three episodes of depression in the past, all requiring treatment. Which
of the following is correct?
A. It is fine to discontinue his antidepressant at this time, but it will need to be
tapered
B. The medication should be continued for two more months; then it can be
discontinued without taper
C. The medication should be continued indefinitely at this time
D. He should be changed to a tricyclic antidepressant that can be slowly tapered
over six weeks
Answer: C. This patient has now had four episodes of major depression. It is
wise to consider chronic treatment in such cases. Even in patients presenting with
their first episode, antidepressants should be continued for four to six months
before tapering. Discontinuation before this may result in a recurrence of
depressive symptoms. Medications should not be stopped abruptly because of the
risk of withdrawal symptoms.
Q.3. A 32-year-old male presents to you with worsening complaints of depression.
He gives a several-month history of decreasing mood, insomnia, decreased
appetite, and lethargy. He also reported feeling as though he is a “worthless”
person and feels that his coworkers are upset because his job performance has
suffered recently. Additional stressors include recent separation from his wife of
three years. He reported a similar episode in his mid-20s that responded to an
unknown antidepressant. He is not currently on any medications and his medical
history is significant only for seasonal rhinitis. What is the next step for this
patient?
A. Given his insomnia and decreased appetite, he should be prescribed a month’s
supply of nortriptyline 75 mg, taken at night, and scheduled to return in 30 days
for follow-up
B. Refer patient for psychological counseling as he is experiencing significant
stress at work, which could be affecting his self-image
C. The patient should not be started on any treatment until his suicide risk is
assessed
D. Given that this most likely represents a recurrence of major depressive
disorder, he should be placed on two different agents from the start to
aggressively treat this episode
Answer: C. The patient gives a history consistent with an episode of major
depression, which may represent a recurrence of a previous illness. His symptoms
include a decrease in self-esteem and are occurring in the setting of real and
perceived stressors. Before deciding the next step in treatment, the patient should
be assessed for the presence of suicidal ideation/intent. Nortriptyline is an
effective antidepressant, but carries the risk of lethal overdose given its effect on
the myocardium and should not be given to patients until their risk of suicide is
known. Psychotherapy could be an adjunctive therapy, but in cases of severe
depression is not as effective as combination pharmaco- and psychotherapy.
Despite its recurrence, the patient will not necessarily need two antidepressants to
treat this episode effectively.

Q.4. A 72-year-old male patient is seen in your office for evaluation and treatment of
complaints of bilateral knee pain. The patient’s past history is remarkable for mild
hypertension and bipolar disorder. Current medications include
hydorchlorothiazide 25 mg and lithium carbonate 300 mg orally twice a day. You
diagnose osteoarthritis and prescribe naproxen sodium. The patient calls in a week
and states that his pain has improved significantly. Two weeks later, his wife calls
and states that the patient appears confused and disoriented, has not recognized
her at times, has fallen, and has become incontinent of urine. What is the most
likely cause of the patient’s new symptoms?
 A. A recurrence of the patient’s mixed- or manic-state bipolar disorder
B. Normal pressure hydrocephalus
C. Lithium intoxication
D. Catatonic depression
Answer: C. The patient’s fairly acute onset of disorientation and confusion
suggests a delirium. While further workup is necessary, the most likely cause of
his delirium and associated symptoms is lithium intoxication. The presentation is
not consistent with a recurrence of his affective illness. Normal pressure
hydrocephalus is associated more with dementia than delirium and has a more
insidious course. Lithium intoxication causes altered mental status, ataxia,
polyuria as well as nausea, vomiting, and a gradually coarsening tremor. Both
thiazide diuretics and nonsteroidals affect lithium clearance through the kidney
and can be associated with increased lithium levels. Their use is not
contraindicated in patients taking lithium, but should be used with caution and
close collaboration with the physician prescribing the lithium, especially in older
patients who may have some baseline renal insufficiency.

Q.5. A 23-year-old woman with no significant past medical history presents

complaining of burning in her chest. She notes that the problem was intermittent
but is now fairly constant. She is working at a local news station, hoping to
ultimately become a reporter. She describes her job as stressful due to the intense
competition for work. She denies any cigarette or alcohol use. She has had four
sexual partners over the last two years and notes regular condom use. She notes
irregular menstrual periods, but she notes it has been that way for a few years.
Her last period was two months ago. She says that she exercises one to two hours
per day and is on the “Zone” diet in an effort to control her weight. Her review of
systems is notable for some generalized hair loss. Her physical examination
reveals a temperature of 98.6º F, pulse 80/min, blood pressure 98/70, weight 110
pounds, height 5'5", and her BMI equals 18.3 kg/m2. Her oral cavity is notable for
dental erosions. There is generalized thinning of the hair but no patches of
alopecia. Her chest is clear. Her heart is regular S1, S2 without murmurs. Her
abdomen is soft, scaphoid, and nontender. Her extremity examination reveals
calluses over the knuckles of the 2nd, 3rd, and 4th digits of the right hand. Her
labs reveal a sodium of 138 mEq/L, a potassium of 3.2 mEq/L, an HCT of 35%,
and an MCV of 92. Urinalysis is HCG negative and HIV negative. Which of the
following is most appropriate for long-term management of this woman?
A. Send off an anti-nuclear antibody (ANA)
B. Start omeprazole 20 mg twice per day
C. Refer her to a gastroenterologist
D. Refer her for psychotherapy
 E. Prescribe lifestyle changes (e.g., elevation of the head of the bed, cessation of
caffeine, avoidance of eating late at night) and see her back in two to three weeks
Answer: D. This woman presents with symptoms of esophagitis but the
underlying etiology is bulimia nervosa. She is concerned over her weight despite
being underweight. She has intermittent irregular menses, hair loss, dental
erosions, calluses on the knuckles (Russell’s sign), hypokalemia, and a mild
anemia. This suggests an eating disorder, specifically bulimia. Although treatment
of her esophageal symptoms may be appropriate, they are unlikely to be
successful unless her purging behavior is stopped. Psychotherapy (e.g., cognitive
behavioral therapy) is the most effective mode of therapy. Antidepressants may
be helpful as an adjunct.

Q.6. A 29-year-old man with a history of asthma presents to your office complaining
of chest pain. The pain is reportedly substernal, without radiation, and associated
with dyspnea, diaphoresis, nausea, and a sense of doom. The discomfort seems to
come on during stressful situations and usually resolves within 30 minutes. He
notes that the symptoms are not typical for his asthma attacks and do not seem to
be helped by use of albuterol. The symptoms are not worse at night or with
exertion. He denies any past medical problems. He denies cigarette use. He drinks
about two beers per week. He is employed as an accountant and has been under
significant stress recently with his job and with a personal relationship. He
exercises three days per week by jogging up to five miles at a time. He has never
experienced chest pain with exercise. He is concerned because he knows his
grandfather died of a heart attack a few years ago, shortly after turning 80. His
physical examination reveals pulse of 68, and blood pressure of 120/75. His heart
is regular and without murmurs. His abdomen is soft and nontender. His EKG
reveals no abnormalities. His total cholesterol is 180 mg/dL, LDL 105 mg/dL, HDL
50 mg/dL, and triglycerides 125 mg/dL. Which of the following is the most
appropriate next step?
A. Obtain a stress echocardiogram
B. Begin a two-week steroid taper
C. Begin paroxetine
D. Begin a two-week trial of omeprazole
E. Begin a two-week trial of celocoxib
Answer: C. This man has symptoms highly suggestive of panic attacks. He
has no risk factors for coronary heart disease and has no exertional symptoms.
The symptoms are not typical for asthma so steroids should not be given.
Although gastroesophageal reflux could be responsible for atypical chest pain, the
association of the other symptoms in addition to the trigger of stress makes panic
disorder most likely. Tricyclic antidepressants, SSRIs, MAO inhibitors, and
 cognitive behavioral therapy have all been shown to be effective for treatment of
panic attack, although there is a high relapse rate after discontinuation of therapy.

CHAPTER 69: ALLERGYAND IMMUNOLOGY FOR THE INTERNIST

Q.1. A 26-year-old woman carries the diagnosis of hereditary angioedema. She is

anxious about the risk of recurrence of her angioedema during an upcoming
wisdom tooth extraction. What agents are most likely to be useful in prevention of
such a recurrence?
A. Danazol
B. Prednisone
C. Antihistamine
D. Leukotriene antagonist
Answer: A. The use of androgen derivatives has been shown to reduce the
frequency of attacks of angioedema in individuals who have hereditary
angioedema. The apparent mechanism seems to involve induction of synthesis of
C1 and rise in C4 levels. None of the other agents has been shown to be of benefit
in this disorder.

Q.2. A 25-year-old pregnant female has a five-year history of nasal congestion,

sneezing, and rhinorrhea on a year-round basis, with peaks in April and late
summer. She resides in a 100-year-old home with a water-damaged basement
along with her husband, two dogs, and a cat. The patient admits to the daily use
of an over-the-counter nasal spray for the last several months. What is the most
likely diagnosis in this patient?
A. Perennial allergic rhinitis secondary to animal danders or indoor mold
B. Seasonal allergies caused by oak tree pollen and ragweed sensitivities
C. Rhinitis of pregnancy
D. Rhinitis medicamentosa
Answer: A. Given that this woman lives in an old house and has pets, she is
most likely suffering from perennial allergic rhinitis, secondary to animal danders
or indoor mold. Answer B does not explain year-round symptoms in this patient; it
may, however, explain seasonal peaks in April and late summer. Answer C would
only explain recent symptoms occurring during the pregnancy and does not fit the
duration and character of the symptoms. Choice D may be a complication in this
patient, but only during the last year and still does not adequately explain
symptoms for five years.

Q.3. Which diagnostic test would be most helpful for a patient with possible indoor
mold allergy?
 A. Nasal smear for eosinophils
B. Puncture skin tests
C. RAST testing
D. Total IgE levels
E. Patch testing
Answer: B. Identification of specific allergen sensitivity by skin testing is
more rapid (20 minutes) and of greater sensitivity than RAST testing. A nasal
smear positive for eosinophils would support the diagnosis of allergic rhinitis, but
without the additional information offered by skin testing (e.g., allergen
identification followed by specific treatment). A total serum IgE may be elevated
above the normal range and support the presence of an atopic disease, but does
not offer specific information. Lastly, patch testing is best used for contact-
mediated sensitivities (e.g., nickel allergy) and does not involve an IgE-mediated
allergic mechanism.

Q.4. Which of the following is considered appropriate management for a patient with
a history of bee-sting anaphylaxis?
A. Prescription of auto-injectable epinephrine upon discharge
B. Referral to an allergist for specific bee venom skin testing
C. Serum β-tryptase measurement
D. All of the above
E. None of the above
Answer: D. A prescription for self-injectable epinephrine would be
appropriate in this case given the high (50% to 60%) risk that the patient may
suffer a similar severe reaction with a future sting. The need for referral for skin
testing is based on the experience that specific venom immunotherapy provides
98% protection against a future severe venom reaction. The demonstration of an
elevated serum β-tryptase level (i.e., mast cell activation) within a few hours of a
presumed anaphylactic event supports the diagnosis of anaphylaxis.

Q.5. A 34-year-old man who currently uses injection drugs (cocaine and heroin) is
admitted to the hospital with bacterial endocarditis which requires penicillin and
aminoglycoside treatment. The patient, however, has a history of a penicillin
allergy. How would you proceed?
A. Major and minor penicillin skin tests
B. Infectious disease consultation for alternative agent
C. Desensitization to penicillin
D. Obtain specific details of previous penicillin reactions
 Answer: D. A careful review of the drug allergy history is the most logical
next step. Often the term drug “allergy” is applied to any untoward drug reaction
including known medication side effects. If the history supports a classic, IgE-
mediated process, then skin testing with the major and minor determinants is
indicated. If the patient is positive to either determinant, a penicillin-based
antibiotic is the drug of choice, and if no other alternative class of antibiotic is
effective, drug desensitization should be performed.

Q.6. A 50-year-old male is at a party and eats fresh shrimp.Within minutes, he feels
nauseated, flushed, and reports a tightening in his throat. Ten minutes later he
describes difficulty in breathing and a 911 call is made. What blood test would
assist the diagnosis in this case?
A. Total IgE
B. Serum histamine
C. Specific IgE to shrimp
D. None of the above
Answer: C. A total IgE level does not readily discriminate allergic and
nonallergic persons. Serum histamine may be elevated acutely in anaphylaxis but
is rapidly metabolized and therefore is not helpful, whereas a serum tryptase is
elevated in many but not all food-based anaphylaxis. The detection of an elevated
specific IgE level to shrimp would support the diagnosis of food allergy.

Q.7. A college freshman presents with a well-demarcated erythematous rash on her

right wrist. She reports wearing a new wristwatch for the last week on her right
wrist. What is the most likely diagnosis?
A. Atopic dermatitis
B. Allergic contact dermatitis
C. Urticaria
D. None of the above
Answer: B. The well-demarcated nature of the lesions argues for an
exposure-related skin eruption such as seen with acute contact dermatitis.
Urticaria is a transient lesion, whereas the distribution of a rash to a single wrist is
not typical for atopic dermatitis. In allergic contact dermatitis, the eruptions tend
to have a sharp margin, which reflects the causative agent, such as possibly nickel
in the watch case.

Q.8. A 50-year-old female presents to the office for a possible sinus infection. A
review of the chart reveals this is the sixth visit in the past year for sinusitis. After
finishing a course of antibiotics, the patient had a recent sinus CT scan that was
unremarkable. She typically responds to prolonged courses of antibiotics. The
 patient also was hospitalized last year for pneumonia. What diagnosis is most
likely in this patient?
A. Nasal polyps with chronic sinusitis
B. Allergic rhinitis
C. Common variable immunodeficiency
D. None of the above
Answer: C. In the case of nasal polyposis, one would expect to see
opacification, which is persistent of sinus imaging. Allergic rhinitis would not
typically respond to repeated antibiotic courses. In common variable
immunodeficiency, patients often experience an increased number of sino-
pulmonary infections that require repeated courses of antibiotics.

Q.9. A 22-year-old male presents for a new patient physical examination. His past
history is notable only for aspirin allergy; exposure to aspirin results in dyspnea
and hives. He has been to the emergency department for this allergy only once,
three years ago. He was told at that time never to take aspirin or related products
again. The immune response that resulted in this patient’s clinical presentation
three years ago was due to which of the following?
A. IgE-mediated basophil stimulation
B. IgE-mediated mast cell stimulation
C. Both
D. Neither
Answer: D. Aspirin and other NSAIDs do not result in an IgE-mediated
immune response. Although the clinical presentation of a patient with an aspirin-
or NSAID-mediated immune reaction may be similar to that of a patient with an
anaphylactic response, IgE does not trigger the immune reaction. Therefore, the
immune response is termed an “anaphylactoid” response. Aspirin, NSAIDs, and
radiocontrast agents can stimulate an anaphylactoid response in certain
individuals.

Q.10. A 40-year-old woman presents with “hives.” She was in her usual state of
health until six weeks ago, when she developed a pruritic rash over her
extremities. She otherwise felt well, and had no febrile illness with the rash, no
recent travel, and no sick contacts. She went to an emergency room, and was
diagnosed with urticaria, and told to follow up with you. She has been taking
diphenhydramine around the clock, with moderate relief of symptoms. She
otherwise has no past medical history, and takes no medications or over-the-
counter substances. She eats a consistent diet, and recalls no unusual or novel
foods. Physical exam confirms urticaria. Management at this point includes all of
the following except
 A. Hepatitis B and C serologies
B. Cryoglobulin assay
C. Bacterial throat culture
D. Antinuclear antibodies
E. Skin biopsy
Answer: C. This patient has urticaria. Urticaria may result from medications,
certain foods, physical triggers (heat, cold, pressure), or underlying disease. Chronic
urticaria is defined as urticaria present for greater than six weeks. Autoimmune
thyroid disease is associated with urticaria, as are infections with certain viruses
(e.g., hepatitis B or C, as noted in choice A). Autoimmune disease, such as systemic
lupus erythematosus or other forms of vasculitis, may result in urticaria; any patient
with urticaria lasting over 72 hours should have a skin biopsy performed, and ANA
testing is recommended (answers D and E). Cryoglobulinemia, either essential or
secondary to other causes (e.g., hepatitis C) may result in chronic urticaria, as noted
in choice B. Bacterial throat culture has no role in the evaluation of the patient with
chronic urticaria as bacterial throat infections are not associated with the
development of urticaria.

Q.11. A 37-year-old woman presents for follow-up. On her last visit, she had
streptococcal pharyngitis, and was treated with penicillin. Three days into therapy,
she developed urticaria, so penicillin was discontinued, and erythromycin was
used. She completed her course of antibiotics, but had nausea with erythromycin.
You arrange skin testing for penicillin allergy, which comes back negative. Which
one of the following statements is true?
A. If penicillin is administered in the future, she is likely to develop urticaria
B. First-generation cephalosporins should be used as a substitute for penicillin
C. Imipenem can safely be used in patients that are allergic to penicillin
D. Patients allergic to penicillin should not be administered sulfonamides
E. Aztreonam should be avoided in patients with penicillin allergy
Answer: A. Allergic reaction to penicillin is among the most common adverse
drug reactions. Skin testing is often used to evaluate the patient with an adverse
drug reaction. Skin testing detects the presence of specific IgE, and does not
predict non-IgE-dependent reactions. Only 10% to 20% of penicillin “allergic”
patients will have an IgE-mediated response. Therefore, skin testing will be normal
(i.e., negative) in the majority of patients who develop an “allergic” reaction to
penicillin. Considering these statistics, this patient is more likely to have a
recurrent reaction to penicillin than to be among the 10% to 20% of penicillin-
allergic patients who have positive skin testing. Cross-reactivity of cephalosporins
and penicillins ranges from 6% to 30%, but is less common with second- and
third-generation cephalosporins. First-generation cephalosporins should not be
 used in penicillin-allergic patients. Imipenem also cross-reacts with penicillin, and
should be avoided in patients allergic to penicillin. Aztreonam and sulfonamides do
not cross-react with penicillin.

CHAPTER 70: GENETICS FOR THE INTERNIST

Q.1. A 52-year-old man presents with fatigue, arthralgia, vague abdominal pain, and
decreased libido. He has mild dyspnea on climbing two flights of stairs.
Testosterone is mildly low, transaminases are normal, serum ferritin is 512, and
transferrin saturation is 72%. Echocardiogram shows an ejection fraction of 40%.
DNA testing confirms homozygosity for the C282Y mutation of the HFE gene.
Which of the following is most likely to occur or persist with therapeutic
phlebotomy?
A. Anemia
B. Arthralgia
C. Cardiomyopathy
D. Diabetes
E. Hepatic cirrhosis
Answer: B. Most patients with hereditary hemochromatosis have substantial
iron stores and tolerate several months of weekly phlebotomy without developing
anemia. Cardiomyopathy, transaminase elevations, fatigue, and general nonspecific
symptoms usually improve as iron stores are depleted. However, arthralgia (correct
Answer B) and endocrine insufficiencies often continue despite adequate phlebotomy.
Additional organ failure (such as diabetes and cirrhosis), if not present at the time of
initial diagnosis, is prevented by iron depletion therapy.

Q.2. A 39-year-old man is diagnosed with hereditary hemochromatosis due to

mutation in the HFE gene. His unrelated wife of Northern European descent asks
about the chance that their son is genetically affected. Which of the following is
the best estimate of the likelihood that both of their son’s HFE alleles are mutated?
A. Nearly 0%, but he is a carrier
B. Approximately 5%
C. Approximately 10%
D. 25%
E. 50%
Answer: B. Hereditary hemochromatosis is inherited in an autosomal
recessive pattern. The affected man must be homozygous and can only pass along
a mutated copy of the gene to his children, so all must at least be carriers.
However, because the condition is so common among those of Northern European
 descent, there is a 10% chance that his wife is a carrier. If so, then 50% of their
children will inherit a mutated copy of the gene from her as well, and will therefore
be genetically affected (regardless of their current iron levels or clinical status).
The correct answer of 5% (choice B) is calculated by multiplying the 10% chance
that his wife is a carrier by the 50% chance that a carrier parent (i.e., the wife)
passes the mutated gene to her child.

Q.3. A 33-year-old woman in good health has the following family history (Fig. 70Q-
1). Which of the following is the best assessment of her family colon cancer
history?
A. Attenuated familial adenomatous polyposis
B. Familial adenomatous polyposis
C. Familial colon cancer
D. Hereditary nonpolyposis colon cancer
E. Late-onset sporadic (random) colon cancer
Answer: C. Familial adenomatous polyposis and attenuated familial
adenomatous polyposis present with dozens or hundreds of polyps, with cancer
onset much earlier than the 60s or 70s. This family history is suggestive of
hereditary non-polyposis colon cancer, but does not meet clinical diagnostic
criteria. However, the clustering of her mother’s adenoma under age 50 with her
grandfather’s and great-aunt’s colon cancer is statistically unlikely to be a random
association. This most likely represents multifactorial familial colon cancer (correct
choice C).

Q.4. A 45-year-old woman has type 1 neurofibromatosis with multiple café au lait
macules and dermal neurofibromas. She does not have any plexiform
neurofibromas. To allay her anxiety, another physician ordered a cerebral MRI two
years ago, which revealed several unidentified bright objects and some thickening
of the right optic nerve. Her vision and neurologic examination have been normal,
and she does not have proptosis. She is otherwise in good health, but has recently
developed hypertension. Which of the following is the most likely cause of her
hypertension?
A. Coarctation of the aorta
B. Enlarging intracranial lesion
C. Essential hypertension
D. Pheochromocytoma
E. Renal artery stenosis
Answer: C. Hypertension occurs at increased frequency in patients with
neurofibromatosis type 1 (NF1), but is usually essential (correct choice C). Aortic
coarctation, pheochromocytoma, and renovascular hypertension must be
 considered and ruled out, but are less common than essential hypertension. The
findings on cerebral MRI are common in NF1 and usually have no clinical
consequence.

Q.5. An otherwise healthy 45-year-old woman has not been sleeping well due to
anxiety about developing breast cancer. Her paternal aunt died of metastatic
breast cancer at age 50, and her 42-year-old first cousin (the aunt’s daughter)
was recently diagnosed with the disease through screening mammography. She
desires genetic testing to see if she is at risk. Which of the following statements
regarding genetic (DNA) testing is most correct?
A. Genetic testing is unnecessary because the breast cancer is on the paternal side
and does not increase her risk
B. A negative genetic test would be reassuring that her chance of developing
breast cancer is less than 5%
C. Finding an abnormality in her BRCA1 gene implies up to an 80% chance that
she will develop breast cancer
D. Her cousin should be tested first
E. Her father should be tested first
Answer: D. For genetic testing in an unaffected person, the closest available
affected relative should be tested first (in this case, the cousin). This establishes
what, if any, detectable genetic mutation is present in the family. Testing her
father is inappropriate, since it is not known whether he is carrying the same
genetic predisposition as the aunt and cousin. However, familial breast cancer is
equally likely to be transmitted through the mother or the father. Genetic testing
is subject to both false positives (some DNA changes do not cause disease) and
false negatives (some DNA changes cannot currently be detected). Even a true
negative test does not give complete reassurance, as the lifetime prevalence for
sporadic breast cancer is roughly 12%. Certainly, genetic testing may increase her
anxiety, but the benefits may outweigh the risks. For this reason, genetic
counseling by a fully informed professional should precede genetic testing.

Q.6. Which of the following is a true statement regarding inheritance of genetic

disorders?
A. A 30-year-old man with polycystic kidney disease may have sons affected with
the disorder, but his daughters will be spared
B. A 35-year-old man with Marfan’s syndrome has a 50% chance of having an
affected son
C. A 23-year-old woman with cystic fibrosis has a 100% chance of passing the
disease to her daughter
 D. A 28-year-old man with hemophilia A has a 50% chance of having an affected
son
E. A 28-year-old woman with sickle cell anemia has a 25% chance that her
daughter will also have sickle cell anemia
Answer: B. To answer this question one must be familiar with the inheritance
patterns of common, single-gene genetic disorders. Both polycystic kidney disease
and Marfan’s syndrome are autosomal dominant disorders, and each patient has a
50% chance of having an affected child (son or daughter). Cystic fibrosis and
sickle cell anemia are autosomal recessive disorders. All children of affected
patients must inherit one mutant allele (thus being carriers), but will not be
affected unless the other parent is also a carrier. The 25% risk for autosomal
recessive conditions applies when both parents are carriers; it increases to 50% if
one parent is affected and the other is a carrier. Hemophilia A is an X-linked
disorder; male-to-male transmission does not occur.

Q.7. A healthy 31-year-old man is concerned about the chance of having a child with
cystic fibrosis. His brother died from cystic fibrosis, and both of his parents are
known to be carriers. Which of the following represents the chance that he is also
a carrier of cystic fibrosis?
A. 67%
B. 50%
C. 33%
D. 25%
E. 5%
Answer: A. Cystic fibrosis is an autosomal recessive condition. If both
parents are carriers, each child has a 1 out of 4 chance of being affected, a 2 out
of 4 chance of being a carrier, and a 1 out of 4 chance of being a noncarrier.
However, since the patient is known not to be affected with cystic fibrosis, there
are only three possible choices, two of which result in him being a carrier (2 out of
3, or 67%). In a Punnet square, the calculation looks like this (Fig. 70Q-2):

CHAPTER 71: COMPLEMENTARY AND ALTERNATIVE MEDICINE

Q.1. A 54-year-old woman with a history of recently diagnosed breast cancer comes
to see you before her second round of chemotherapy. She reports that she had
terrible nausea, vomiting, and fatigue with the first round and was wondering what
you thought about acupuncture. Which of the following is correct regarding this
modality?
 A. Given the risk of transmission of hepatitis B, hepatitis C, and HIV with
acupuncture needling, it should be avoided
B. Given the risk of cellulitis with acupuncture needling, it should be avoided
C. The most common side effect from acupuncture therapy is organ puncture
D. It may add to the fatigue that she experiences, especially within the first few
hours after each treatment
E. It could be useful in this setting, but it carries a risk of significant bleeding
and/or hemorrhage
Answer: D. Acupuncture has been proven to be quite safe in the hands of
experienced practitioners. In the United States transmission of infection through
needling is rare because disposable needles are routinely used. Organ puncture
and bleeding are also quite rare and have usually been linked to improper training
of the practitioner. Acupuncture is thought to be useful for postoperative nausea
and vomiting but may cause localized pain, minor bleeding at the insertion site,
fatigue, and occasionally vasovagal syncope.

Q.2. A 34-year-old woman presents to your office to discuss her weight. She is
obese and has tried a number of fad diets with varying success. She continues to
walk three to four days per week for an hour at a time. On her request, you
discussed the prescription weight loss medication Orlistat with her during her last
visit, but she realized that she could not afford it and did not want to deal with
potential side effects. She returns today with a printout for a nonprescription
weight loss remedy called Blubberwacker 2000, which consists of a combination of
various herbs. The advertisement states that it is “100% natural” and “clinically
proven to be safe and effective.” You decide that you want to discuss supplement
and drug regulation with her so that she can make an informed choice. Which of
the following statements is correct?
A. Blubberwacker 2000 has not been evaluated by the Food and Drug
Administration (FDA) prior to being marketed while Orlistat has
B. Blubberwacker 2000 has been evaluated by the FDA prior to being marketed
but the efficacy and safety data required was much less than for Orlistat
C. The efficacy and safety data required by the FDA prior to marketing of
Blubberwacker 2000 is equivalent to Orlistat
D. The efficacy and safety data required by the FDA prior to marketing of
Blubberwacker 2000 is not equivalent to Orlistat but the safety data required is
equivalent to nonprescription medications such as diphenhydramine
Answer: A. After the passage of the Dietary Supplement Health and
Education Act (DSHEA) of 1994, botanicals, vitamins, and other biologics no longer
required efficacy and safety data prior to marketing. This is in stark contrast to
 drugs (both prescription and nonprescription), which require extensive efficacy
and safety trials prior to reaching the shelves.

Q.2. A 58-year-old woman with a history of hypertension and atrial fibrillation

presents for a physical. On questioning, she reports a number of complaints
including neck pain, menopausal symptoms, depression, and arthritis of the knees.
Her current medications include lisinopril, hydrochlorothiazide, and warfarin. The
patient does not like taking medications and is looking for natural ways to improve
her symptoms. Which of the following CAM modalities should be avoided in
patients taking warfarin?
A. Biofeedback
B. Chiropractic
C. Glucosamine sulfate
D. Black cohosh
E. Both B and D should be avoided
Answer: B. Given that chiropractic therapy involves vigorous thrusting of
spinal axis, it should be avoided in patients with coagulopathies of any kind.
Biofeedback is a mind-body modality that uses monitoring (e.g.,
electroencephalograms, electrocardiograms, blood pressure) to assist in voluntary
control of physiologic processes. It is not contraindicated in patients on warfarin.
Although a number of supplements including St. John’s Wort, gingko biloba, and
garlic may interfere with INR, glucosamine and black cohosh have not been shown
to affect warfarin metabolism.

Q.3. Consumption of high-dose (>2 grams/day) fish oil has been shown to have
which of the following effects on the lipid profile?
A. Lowers HDL
B. Lowers LDL
C. Lowers triglycerides
D. Both B and C are correct
E. Both A and C are correct
Answer: C. Doses of fish oil greater than 2 grams per day have been shown
to decrease triglyceride levels in a dose-dependent manner while having little
effect on HDL and LDL. At higher doses, a 5% to 10% increase in LDL levels can
be seen.
CHAPTER 72: SUBSTANCE ABUSE

Q.1. A 43-year-old man presents to your primary care office for his routine annual
physical. During the visit, he reports having decreased libido and fatigue that he
feels is related to stress at work. He also describes increased tension. He asks
your opinion regarding a trial of sildenafil. His past history is unremarkable other
than one episode of palpitations that resolved on its own a few months ago.
Physical examination is notable for an elevated blood pressure of 148/98. He has
an ecchymosis on his left flank that he attributes to a fall on a slippery surface a
few weeks ago. Otherwise his examination is unremarkable. Based on this
presentation, what condition(s) would you like to rule out with more information?
A. Essential hypertension
B. Depression with an anxiety component
C. Drug/alcohol abuse
D. A and C
E. All of the above
Answer: E. Patients with an active substance abuse disorder can present
with symptoms that both mimic and are associated with many different physical
and mental health conditions. Alcohol abuse and dependence are associated with
hypertension. Many with alcohol dependence also have comorbid depression and
anxiety disorders. Finally, alcohol and drug abuse are commonly associated with
some of the findings in this presentation, such as impotence and sexual
dysfunction and non-sports-related adult traumas. Because hypertension and
depression can coexist with substance abuse, as well as contribute to or be the
result of drinking and drug use, all the conditions listed should be considered.

Q.2. To rule out substance abuse in the patient in the previous question, what is the
most important additional information you would need to obtain?
A. Blood alcohol and urine toxicology screen
B. CAGE questionnaire
C. Both
D. Neither
Answer: B. Alcohol abuse and dependence are diagnosed both by the
absolute quantity of weekly intake and the effect that intake has on normal
functioning and interpersonal relations. More than 14 drinks a week for men and 7
drinks a week for women are warnings that the patient may be a hazardous
drinker. The CAGE questionnaire is a useful screening instrument that is easy to
administer in a primary care setting. It assesses the effect alcohol or drugs may
have on a patient’s day-to-day functioning. The more positive answers a person
gives, the more likely he or she has a substance use disorder. Blood alcohol and
 urine toxicology screens are not helpful because of the limited window for when
someone will test positive. They are also nonspecific and time-dependent in terms
of chronicity of use or quantity ingested.

Q.3. You diagnose a 45-year-old male patient with alcoholism. He takes your advice,
completes a 28-day program, and begins attending Alcoholics Anonymous
meetings. He returns to see you six weeks after the initial visit. He is appreciative
of your help but is struggling to maintain sobriety while balancing the stresses of
home and work life. He also reports continued cravings for alcohol, particularly
when his office plans Friday happy hour social functions. What is your advice to
him?
A. “Twenty-eight days was not enough. Return to an inpatient treatment program
for at least another month and possibly six months.”
B. “The stresses you are experiencing are normal and relapses are a part of
recovery. Hang in there and keep attending meetings.” You also prescribe
naltrexone 50 mg daily to help with the cravings
C. “I’m glad we got through this problem. Now let’s get back to focusing on your
medical issues”
D. “The stresses you are experiencing are real and interfering with your normal
functioning.” You prescribe a short course of low-dose benzodiazepines to help
with the anxiety and encourage him to keep up the good work
Answer: B. Relapse is extremely common in recovery and poses unique
challenges for the primary care provider. It is important to be supportive and
encouraging and to acknowledge and offer help with these issues. Naltrexone has
been reported to be useful in patients with a history of alcohol abuse in reducing
subsequent cravings. If it is prescribed, you will need to first check for liver
dysfunction. It should also be avoided in pregnant women.

Q.4. A 57-year-old man is found wandering on the street and is brought to the
emergency room. He is disoriented, confused, and apathetic. On physical
examination, he is disheveled and smells of alcohol. Blood pressure is 145/90,
pulse is 94, and respirations are 16. His skin is notable for several telangectasias,
and he is mildly ataxic. Which of the following is not an appropriate initial step in
his evaluation?
A. Lumbar puncture
B. Head CT
C. Administration of dextrose followed by thiamine
D. Complete blood count
Answer: C. The patient may have Wernicke’s encephalopathy, which consists
of the triad of confusion, ataxia, and ophthalmoplegia in chronic alcohol users. The
 initial management is the administration of thiamine; this is followed by dextrose.
Administration in the reverse order may worsen Wernicke’s through altered
glucose metabolic pathways. Certainly, performing a lumbar puncture, head CT,
and a complete blood count are other reasonable options in any patient who
presents with confusion.

Q.5. A 34-year-old female presents to your primary care office for a new patient
visit. She has a history of hepatitis C, systemic lupus erythematosis, fibromyalgia,
and depression. After a detailed history, she reveals to you that she still uses
cocaine a couple of times a week with her boyfriend but is interested in quitting
because it causes her asthma to flare. She has previously participated in several
outpatient treatment programs but has relapsed shortly after completing them.
What would your next step be?
A. Begin fluoxetine
B. Provide feedback on the risks to her of continued cocaine use
C. Refer her to an inpatient substance abuse treatment program
D. Explore a menu of treatment options and alternatives with her
Answer: D. The patient is likely in the determination phase of readiness to
change her drug use behavior but has not yet taken action to quit. Starting an
antidepressant might treat an underlying depression but would not address the
cocaine use. A referral to an inpatient substance abuse treatment program might
be appropriate but the patient may not follow through with this recommendation
unless she has achieved enough self-efficacy to make her own decision regarding
this type of treatment. A FRAMES approach to addressing her interest in quitting is
an appropriate intervention for this encounter, but she already sees the health
risks of continued cocaine use. Exploring a menu of treatment options and
alternatives, that could include an inpatient program, would be the best next step
at this point to help the patient move to quit.

Q.6. A 55-year-old man is brought to the emergency department by his niece who
found him down on the floor of his kitchen. He is somnolent and barely arousable,
with shallow respirations at 7/min, blood pressure of 90/60, and a heart rate of 58
bpm. After establishing an airway, what is the most appropriate next step?
A. Administer naloxone 0.4 mg IM
B. Send off a urine sample for toxicology screening
C. Obtain an EKG
D. Obtain blood sample for serum chemistry testing
Answer: A. Although the differential diagnosis for severe respiratory
depression is broad, one of the early goals of management is to reverse any
potential toxic ingestions. An opioid overdose, whether from heroin or prescription
 opioids, is easily reversed with naloxone. An initial dose of 0.4 mg can be followed
by subsequent doses if an incomplete response was achieved. Patients require
frequent assessments with possible repeat naloxone doses until their sensorium
remains clear. Sending off a urine sample for toxicology screening, obtaining an
EKG, and testing serum chemistries are all appropriate after establishment of an
airway and the initial dose of naloxone has been administered.

Q.7. The patient in the previous question has recovered from the opioid overdose
and is now seeing his primary care doctor for a follow-up visit. Further history
reveals that he recently came home from an inpatient detoxification program
where he had weaned off large amounts of daily heroin. He was still fatigued,
irritable, and was having a difficult time sleeping so he took a handful of old
oxycodone pills he found to fall asleep. He has no other medical problems, is
divorced with no children, but his niece lives next door and looks in on him from
time to time. What would the most appropriate next step?
A. Prescribe a sleeping agent such as Ambien
B. Refer him to a methadone maintenance treatment program
C. Discuss relapse triggers and ways of coping with cravings
D. Refer him to psychiatry for evaluation of depression
Answer: C. Although the patient recently completed an opioid detoxification
program, he was discharged with symptoms suggestive of physiologic withdrawal
that may become protracted and last for 6 to 12 months. As self-medication for
this, the patient relapsed by taking an unknown amount of oxycodone and
overdosed. Prescribing a sleeping medication at this point might provide the
patient with some short-term relief but it does not address the underlying opioid
dependence, which is at the root of his difficulties. In addition, although he may
have an underlying mood disorder, at this point the focus should be on preventing
any further relapses and then consider referring him to psychiatry or screening for
depression. The patient might benefit from methadone or sublingual
buprenorphine to help maintain abstinence from heroin but those are treatment
options that may not be immediately available. Discussing relapse triggers and
ways of coping with cravings, such as attending Narcotics Anonymous groups or
calling his niece, are relapse prevention interventions that can be provided
immediately in the office.

Q.10. A 62-year-old female presents to your primary care office complaining of falls
over the last two years. She recently was hospitalized for a severely sprained right
wrist after a fall she sustained while walking down her front steps. On physical
examination her blood pressure is 145/96, heart rate 87 bpm, and she weighs 132
lbs. She ambulates with a cane. Her neurologic exam is notable for an abnormal
 heel-knee-shin test but intact finger-to-nose testing. What is the most likely
diagnosis?
A. Alcoholic cerebellar degeneration
B. Benzodiazepine intoxication
C. Paraneoplastic cerebellar degeneration
D. Cobalamin deficiency
Answer: A. The patient exhibits typical signs of alcoholic cerebellar
degeneration; gait abnormalities causing falls, slightly elevated blood pressure
from chronic alcohol use, abnormal lower extremity cerebellar involvement but
more intact upper extremity findings. Cognitive function is often spared in
alcoholic cerebellar degeneration. Benzodiazepine intoxication may mimic this
diagnosis but cognition may be more affected and symptoms are typically
reversible with cessation of the hypnotic drugs. Paraneoplastic cerebellar
degeneration can be associated with small cell lung, breast, and ovarian cancer,
Hodgkin’s lymphoma, or Lambert-Eaton myasthenic syndrome. Patients with this
disorder typically have the acute onset of dizziness, nausea, and vomiting,
followed by gait abnormalities.

Q.11. A 42-year-old woman presents to your office for evaluation of chronic

insomnia. She has recently sustained a fracture to her left wrist while falling down
the stairs. Several months ago, she sprained her ankle in a separate fall. She
denies any difficulty with mood or appetite and describes her energy as fair. She
does experience frequent colds each winter. Her examination is unrevealing. She
is married and denies any difficulty with her spouse. She describes herself as a
social drinker and denies illicit drug use. She is taking no medications. The most
appropriate initial evaluation is
A. Detailed questions regarding possible cerebellar disorders
B. CAGE questionnaire
C. Prescription of diphenhydramine for sleep
D. Serum and urine toxicology screens
E. Prescription of zolpidem for sleep
Answer: B. The patient has several warning signs in her history that she may
have an alcohol abuse problem. She has insomnia, possible evidence of immune
dysfunction manifested as frequent colds, and a history of falls. Further
questioning revealed that her definition of social drinking was two to three mixed
drinks per evening and even more on weekends. There is nothing in her history or
physical to suggest a cerebellar disorder. It would not be appropriate to start a
medication for insomnia without attempting to determine the underlying etiology.
Serum and urine toxicology screens are not useful due to the narrow window in
 which they are positive. One could easily miss the diagnosis of substance abuse
using these alone.

Q.12. A 19-year-old college student presents to the emergency department on

Monday morning with symptoms of persistent palpitations and lightheadedness for
the last two hours. She is on no medications and has no prior medical problems. It
was homecoming weekend, and she admits to drinking beer all day Saturday and
Sunday. Her blood pressure is stable at 120/85. Her heart rate is 145 bpm. What
is the best initial treatment of her underlying disorder?
A. Intravenous procainamide
B. Heparin followed by warfarin
C. Aspirin
D. Intravenous diltiazem
E. Intravenous lidocaine
Answer: D. This patient presents with an episode of binge drinking and
probably is in atrial fibrillation (“holiday heart”). Her vital signs are stable. The first
step would be to slow her heart rate by using intravenous diltiazem. This will
alleviate her symptoms of palpitations. Atrial fibrillation related to heavy alcohol
ingestion is usually self-limited. Intravenous anti-arrhythmics, such as
procainamide and lidocaine, are not needed. Likewise, as long as the patient
avoids future episodes of binge drinking and atrial fibrillation, she will not need
chronic antiplatelet or anticoagulation therapy to prevent stroke.

Q.13. A long-time patient of yours returns to the office for a physical. He is quite
irritable that you are running 15 minutes late and has been somewhat disruptive
in the waiting room. On examination, he has a new elevation in his blood pressure
to 150/90. His breath smells of alcohol. On questioning, he reports often needing
an “eye-opener” morning drink to get the day going and is really getting tired of
people telling him he needs to cut back on his alcohol consumption. Based on this
information, your advice to the patient should be
A. “You have a drinking problem that is at the root of your other problems. Go see
a psychiatrist and get some help. You are welcome back into my practice once this
problem is treated appropriately”
B. You have a drinking problem, along with hypertension and probably an anxiety
disorder. I’m going to start you on nifedipine XL 30 mg daily and sertraline. I’ll see
you back in one month”
C. “You have a drinking problem. Here is a prescription of disulfiram 50 mg to be
taken orally each day. This will help you stop drinking. If you drink while taking
this medicine you will get violently ill”
 D. “You have a drinking problem that may be contributing to the other problems
we have identified on this visit. You need some professional help. I am going to
make a referral, but I also want to see you back here in two weeks”
Answer: D. When discussing a substance abuse disorder with a patient, it is
best to try to follow the principles behind motivational interviewing and brief
interventions as much as possible. Be direct with the patient in identifying that
they have a problem and be clear in the advice that you give to him or her.
Similarly, it is important that you impress to your patient the self-responsibility
that they have for addressing this problem while being empathic and encouraging.
Finally, it is important to make sure that early follow-up is included so that you
can monitor progress and be supportive, particularly in early stages of recovery
when relapse is so common. (Answer A is not supportive; B treats only the
obvious medical problems and not the underlying alcoholism; C does not provide
the patient with a sense of self-responsibility, nor does it provide the patient with
professional help.)

Q.14. A 26-year-old man presents to the emergency room with symptoms of diffuse
myalgias and tea-colored urine. He has a fever of 39.2° C. His blood pressure is
140/95 and heart rate is 105 bpm. His muscles are diffusely tender. EKG reveals
sinus tachycardia and urinalysis shows large hemoglobin but no RBCs. His urine
toxicology is most likely to show which of the following substances?
A. Heroin
B. LSD
C. Benzodiazepines
D. Alcohol
E. Cocaine
Answer: E. Given the muscle pains, tea-colored urine, and fever this patient
most likely has rhabdomyolysis. Of the substance listed, cocaine is the most
common cause. Heroin and alcohol can also cause rhabdomyolysis, but usually in
patients who have been found unconscious for a prolonged period of time. LSD
and marijuana do not cause it.

Q.15. Which withdrawal syndrome is potentially life-threatening?

A. Alcohol
B. Cocaine
C. Heroin
D. Marijuana
E. LSD
 Answer: A. Only alcohol and benzodiazepine withdrawal syndromes are
potentially life threatening, typically related to the delirium tremens (DTs) and
complications from withdrawal seizures. Patients who have had DTs or seizures in
the past are more prone to having them in the future and need to be monitored
more closely. Heroin withdrawal, while extremely uncomfortable, is not life-
threatening. There is no withdrawal syndrome with marijuana or LSD.

CHAPTER 73: PREOPERATIVE EVALUATION

Q.1. Which one of the following statements concerning cardiovascular risk is true?
A. Patients with Wenckebach (Mobitz I) second-degree heart block should have an
intraoperative pacing wire placed because complete heart block perioperatively is
common in this population
B. A patient who has a myocardial infarction should have elective surgery
postponed for at least six weeks
C. Aortic insufficiency, even if severe, is well tolerated during surgery
D. The risk of perioperative myocardial infarction (MI) in patients who have had an
MI remains elevated for up to three months post-MI
E. All antihypertensives should be held on the day of surgery
Answer: B. Patients with a prior history of MI have an increased risk of
perioperative MI for at least six weeks, and all elective surgeries should be
postponed until at least six weeks following myocardial infarction. Elective surgery
is also postponed six weeks following coronary stent placement. Patients with first-
degree and Mobitz I heart block do not need special operative interventions, but
patients with Mobitz II or complete heart block require intraoperative pacing.
Aortic valve disorders (particularly stenosis, but also insufficiency) are tolerated
poorly during surgery. All antihypertensives (except diuretics) should be given on
the day of surgery.

Q.2. Which one of the following statements concerning perioperative -blockers is

true?
A. They should be discontinued in all patients for one week following surgery
B. They should be discontinued in all patients who are on them for one week
leading up to surgery
C. They should be given to all patients for one week following surgery
D. They should be considered for patients with known or suspected CAD for
administration perioperatively
E. They are poor agents for control of preoperative hypertension
Answer: D. β-blockers have been shown to reduce the risk of perioperative
myocardial infarction in selected patients undergoing noncardiac surgery,
 especially when undergoing intermediate- or high-risk surgery. This benefit has
been shown to persist for at least two years postoperatively and should be
considered for patients with known or suspected coronary artery disease. All
antihypertensives should be continued on the day of surgery, with the exception of
diuretics, which are held on the morning of surgery. β-blockers are the agent of
choice for control of perioperative hypertension. Patients with known or suspected
(i.e., two or more cardiovascular risk factors) should be treated with β-blockers
perioperatively when undergoing intermediate- or high-risk surgery.

Q.2. The following are series of operative procedures. In which series are the
operative procedures correctly listed from one with the lowest risk to one with the
highest risk?
A. Cataract surgery < total hip replacement < mastectomy
B. Mastectomy < prostatectomy < femoral/popliteal bypass
C. Laparoscopy < aortic valve replacement < carotid endarterectomy
D. Arthroscopy < emergency colectomy < hysterectomy
E. Mastectomy < pulmonary lobectomy <cataract surgery
Answer: B. Surgical procedures are divided into low risk (<1% risk of
death), intermediate risk (1%–5% risk of death), and high risk (>5% risk of
death). Low-risk procedures include superficial surgeries, breast surgery,
endoscopic procedures, and cataract surgery. Intermediate-risk procedures include
prostatectomy, orthopedic surgery, intra-abdominal and intrathoracic surgery,
carotid endarterectomy, and head and neck surgery. Vascular surgery, including
aortic or major vascular surgery (but excluding carotid endarterectomy),
emergency surgery, and prolonged surgery are all high-risk surgeries. Only choice
B lists surgeries from low risk to high risk.

Q.3. Which of the following statements about noninvasive cardiac testing (e.g.,
dobutamine echocardiogram) is true?
A. A patient with minor clinical risk (such as advanced age) may proceed directly
to surgery without cardiac testing, even if functional status is poor
B. Low-risk surgical procedures (such as endoscopic surgery) do not need
noninvasive cardiac testing, even if functional status is poor
C. High-risk surgical procedures always require noninvasive cardiac testing before
surgery
D. A patient with high clinical risk (e.g., decompensated CHF) can proceed with
low-risk surgery without noninvasive cardiac testing
E. Noninvasive cardiac testing is required for all intermediate- and high-risk
surgical patients, regardless of clinical or functional status
 Answer: B. The majority of patients being evaluated for elective surgery will
have risk assessment completed by reviewing their clinical risk predictors, their
functional status, and the procedure planned. In some clinical scenarios, risk
assessment will require noninvasive cardiac testing. The most common reason for
wanting this testing is poor functional status (defined as the inability to perform at
least 4 METs of activity without symptoms). Low-risk surgical procedures,
however, present such a low level of cardiovascular stress that noninvasive cardiac
testing is of no clinical use, even when functional status is poor. A patient with
minor clinical risk (choice A) typically does not require noninvasive cardiac testing,
unless the patient is undergoing high-risk surgery; in that instance, patients with
minor clinical risk and poor functional status should undergo noninvasive cardiac
testing. High-risk surgical procedures do not require noninvasive cardiac testing in
a patient with minor clinical risk and good functional status (therefore choice C is
incorrect). A patient with high clinical risk should not undergo elective surgery; it
should be postponed until risk has been lowered (therefore answer D is incorrect).
Intermediate-risk surgical procedures require noninvasive cardiac testing only if
clinical risk is intermediate and functional status is poor.

Q.4. A 64-year-old woman with diabetes, hypertension, and depression presents for
preoperative evaluation. She is to undergo excision of a lung mass. Current
medications are glyburide 10 mg daily, lisinopril 30 mg daily, hydrochlorothiazide
25 mg daily, and sertraline 100 mg daily. When instructing the patient about what
to do with these medications on the morning of surgery, she should be told the
following:
A. Hold all medications on the morning of surgery
B. Take only the hydrochlorothiazide on the morning of surgery
C. Take all of your medications, but take only half of the glyburide dose
D. Take all of your medications except the hydrochlorothiazide, which should be
held
E. Take only the lisinopril on the morning of surgery
Answer: E. There are general principles used in managing medications
perioperatively. All antihypertensives are given on the morning of surgery, with
the exception of diuretics (which are held on the morning of surgery). Oral
hypoglycemics are held on the morning of surgery (and metformin is held two
days preoperatively). CNS active medications, including antidepressants, are
typically held on the day of surgery. For this patient, the only medication she
should take on the morning of surgery is lisinopril.

Q.5. Which of the following types of valvular heart disease is associated with the
highest intraoperative risk?
A. Mitral stenosis
 B. Mitral regurgitation
C. Aortic stenosis
D. Aortic regurgitation
E. Tricuspid stenosis
Answer: C. Aortic stenosis is poorly tolerated during surgery, due to pressure
changes and volume shifts. Moderate and severe mitral stenosis is also poorly
tolerated during surgery, albeit slightly better than aortic stenosis.

CHAPTER 74: IMMUNIZATION AND PREVENTION

Q.1. Which of the following is not an indication for the pneumococcal vaccine?
A. Asplenia
B. Native American heritage
C. Age 50 years and older
D. Diabetes
E. Congestive heart failure
Answer: C. Currently, the influenza vaccine is recommended for all adults 50
years and older. The pneumococcal vaccine is recommended for adults 65 and
older. All other items listed are indications for the pneumococcal vaccine.

Q.2. Which of the following is true regarding live attenuated vaccines?

A. They confer lifelong immunity
B. They can be safely given to immunocompromised hosts
C. Tetanus, hepatitis B, and influenza are all examples
D. They should not be given concurrently with other vaccines
Answer: A. Live attenuated vaccines are felt to confer lifelong immunity.
They should not be given to immunocompromised hosts, and they can be given
with other vaccines, just at different sites. Tetanus and hepatitis B are fractional
protein-based vaccines, and the influenza vaccine is a killed whole pathogen.

Q.3. For which one of the following diseases can passive immunization with an
immunoglobulin infusion not be given simultaneously with the vaccine for the
disease?
A. Varicella
B. Hepatitis A
C. Hepatitis B
 D. Tetanus
Answer: A. The immunoglobulin preparation can be given with the vaccine
for most diseases except when the vaccine is a live attenuated preparation. Of
those listed, only varicella is a live attenuated vaccine.

Q.4. A 53-year-old man of Native-American heritage is seeing you for a routine

physical. He is in good health and has no concerns. His family history is significant
for his mother developing adult onset diabetes at age 47 years. He does not
smoke or drink. His physical examination is normal. Which of the following should
be used to screen for diabetes in this patient, based on screening guidelines?
A. Glucose tolerance test
B. Random glucose
C. Fasting glucose
D. Hemoglobin A1C
E. No diabetes screening should be performed
Answer: C. Although screening for diabetes is controversial, most current
guidelines recommend serious consideration in high-risk patients such as this one.
A random glucose may be helpful if markedly elevated (i.e., over 200), but a
fasting glucose is more useful based on current ADA guidelines for diagnosing
diabetes. Hemoglobin A1C testing has too much lab-to-lab variability to be a good
screening test.

Q.5. A 38-year-old recent immigrant from Vietnam comes into the emergency room
after cutting his foot on a nail. He does not recall receiving any vaccines as a child.
Which regimen does he need?
A. Tetanus toxoid alone
B. One tetanus (dT) vaccine now
C. Two-shot dT vaccine series plus tetanus toxoid now, with first dT shot now
D. Three-shot dT vaccine series plus tetanus toxoid now, with first dT shot now
Answer: D. This patient has no history of prior immunization. He needs to be
vaccinated with the primary three-shot series. However, at the time of this
exposure he has no immunity and needs passive immunization with tetanus toxoid
as well.

Q.6. A 67-year-old man presents for a routine physical. He has no complaints. He

has no family history of heart disease. He is physically active and exercises
extensively every day. He smoked briefly in college over 40 years ago. His
physical exam is completely normal with a blood pressure of 108/70 and a normal
 cardiac examination. Which of the following cardiac screening tests are indicated
by USPSTF recommendations?
A. Total cholesterol and HDL measurement
B. Exercise stress testing
C. Ultrasound for abdominal aortic aneurysm
D. A and C
E. All of the above
Answer: D. This patient has no significant cardiac risk factors and at this
time there is no indication for exercise stress testing. The USPSTF does
recommend routine cholesterol measurement in men over 35. This patient
smoked, and current USPSTF recommendations are to screen men between 65
and 70 who have ever smoked for abdominal aortic aneurysm.

Q.7. A 76-year-old woman presents to your office in October for a routine physical.
She is a recent immigrant from Russia and is unsure about vaccines she has had,
but believes that she has never been vaccinated for anything, not even in
childhood. She is in good health. Which of the following would be the most
appropriate vaccine regimen to give her?
A. MMR, tetanus series, pneumococcus, influenza
B. Varicella, Hepatitis B, oral polio, MMR
C. Enhanced inactivated polio vaccine (eIPV), tetanus series, pneumococcus,
influenza
D. MMR, eIPV, pneumococcus, influenza
E. MMR, oral polio, pneumococcus, influenza
Answer: C. This patient has to receive routine primary vaccination series.
She does not need MMR because she was born prior to 1957. Oral polio is not
used, although she does need the eIPV vaccine. No risk factors for hepatitis B
were given, so this is not indicated based on the information. She is over 65 so
she should receive the pneumovax. She is over 50 and it is October so she should
receive the flu vaccine. She should receive the tetanus primary series.

Q.8. A 19-year-old man presents to your office for a routine physical. He is a junior
in college getting excellent grades. He admits to occasional alcohol use, but denies
drug use or cigarette smoking. He is sexually active with a single partner for the
last year and reports using condoms. His physical examination is normal. Which of
the following interventions is statistically the most likely to yield benefit in terms
of morbidity and mortality in this patient’s near future?
A. Counseling regarding safe sex
B. Counseling regarding alcohol abuse
 C. Counseling regarding injury prevention
D. Meningococcal vaccine
E. Cholesterol and HDL measurement
Answer: C. In this age group, the intervention that is most likely to have an
impact on the patient’s morbidity and mortality in the near future is the prevention
of injury (seatbelts, firearm use, smoke detectors, etc.). The meningococcal
vaccine can be considered, but will not be likely to impact the patient as much as
injury prevention. Cholesterol measurement may be important for the future, but
in the patient’s near future, it is not as important as injury prevention. Safe sex
and alcohol counseling are important, but no red flags are listed for risky behavior
with respect to these. Injury prevention is not mentioned in the information given
(and is often neglected in encounters in this age group), but is statistically the
most likely event to cause harm to the patient.

Q.9. A 45-year-old man presents to your office in July of this year for a routine
physical. He is currently drinking two six-packs of beer a day, but has no other
medical problems. He believes he received all of his routine childhood
vaccinations, but doesn’t recall getting any other shots since then. Which vaccine
combination makes the most sense for him?
A. Hepatitis A, hepatitis B
B. Pneumococcus, meningococcus, hemophilus influenzae
C. Pneumoccus, tetanus
D. Tetanus, influenza
E. Hepatitis A, hepatitis B, tetanus
Answer: C. This patient is likely alcohol dependent which is an indication for
the pneumococcal vaccine. In addition, he should receive the tetanus vaccine
because he hasn’t had it since childhood. July is not the appropriate time of year
to give the influenza vaccine. There are no indications for the meningococcal or H.
flu vaccines. If he has significant hepatic impairment it may be reasonable to give
him the hepatitis A and B vaccines, but there is nothing in the case history that
would suggest that other than his alcohol consumption.

Q.10. Which of the following is true of the MMR vaccine?

A. It should not be given if a patient has a prior history of measles as a child
B. Egg allergy is a contraindication
C. It should not be given during pregnancy, or within three months of the
anticipated start of a pregnancy
D. Patients born prior to 1968 do not need to be vaccinated as they are considered
immune
 Answer: C. Because it is a live attenuated vaccine there is potential risk of
vertical transmission to a fetus during pregnancy. A prior history of one disease
does not contraindicate vaccination with MMR to confer protection against the
other two organisms in the vaccine. Egg allergy is currently not felt to be a
contraindication. Patients born prior to 1957 are considered immune. Patients born
between 1957 and 1968 who received the first (ineffective) vaccine are not
considered immune and need to be revaccinated.

Q.11. Which of the following is true regarding cervical cancer screening?

A. It is acceptable to perform Pap smears every three years if a woman is not at
high risk
B. It is not necessary to screen women over the age of 65 by Pap smear
C. HIV-infected patients have the same screening recommendations for Pap
smears as the general population
D. All women should begin having Pap smears at age 16
Answer: A. While not all guidelines agree, the USPSTF and ACP-ASIM agree
that low-risk women can be screened every three years via a Pap smear. If a
woman over 65 has no risk factors and has been regularly screened up to that
point with no abnormal Pap smears then screening can stop. However, it is
important to remember to perform Pap smears in women over 65 who have not
had previous Pap smears done. HIV-infected patients need Pap smears every six
months. Current recommendations are to start performing Pap smears at age 18
in sexually active women with a cervix.

Q.12. A 29-year-old man presents for a routine physical examination. He has no

complaints and no significant past medical history. His family history is significant
for his father having had a myocardial infarction at age 54. His mother developed
lung cancer at age 52. He has a sister with hypothyroidism. The patient has been
a smoker for the last seven years. His physical exam is completely normal. Which
of the following screening tests would be supported by most guidelines and
evidence?
A. Chest x-ray
B. Total cholesterol and HDL measurement
C. EKG
D. Exercise stress test
E. Thyroid stimulating hormone (TSH) measurement
Answer: B. Current recommendations are to begin screening for cholesterol
in patients who have multiple risk factors at age 20. Screening chest x-rays are
not recommended even in smokers. Screening EKGs and stress tests in
 asymptomatic patients are not recommended. Routine TSH measurement in men
is not recommended by any guideline.

CHAPTER 75: CLINICAL EPIDEMIOLOGY

Q.1. Match the following study description with the study design employed:
“To assess the benefits of sigmoidoscopy, we assessed the prior history of
sigmoidoscopy in 352 adults with biopsy-confirmed colon cancer and in 704
individuals without cancer, all of whom were enrolled in our HMO from 1990 to
1995.”
A. Cross-sectional study
B. Case-control study
C. Prospective cohort study
D. Randomized clinical trial
E. Case series
Answer: B: This is a description of a case-control study. Cases of patients
with biopsy-confirmed colon cancer were compared with controls (704 individuals
without cancer); the history of prior sigmoidoscopy was compared in both.

Q.2. A study examines the relationship between self-report of a history of

hypertension compared with a medical record review (the gold standard). The
following data are collected:
What is the sensitivity of self-report in identifying a history of hypertension?
A. 37/43
B. 37/73
C. 36/73
D. 36/181
E. Cannot be ascertained from the data provided
F. None of the above
Answer: A. The first step is to identify the table’s yes/no structure. The gold
standard “positive” is the top row, indicating all true positives. Sensitivity is
“positive in disease.” To calculate sensitivity, one would ask, “Of all those with the
disease identified by medical record review (n = 43), how many were called
‘positive’ by self-report (n = 37)?” The sensitivity is 37/43.

Q.3. In a randomized, controlled trial of intravenous IgG to treat chronic fatigue

syndrome, 200 adults are assigned to IV IgG and 198 are assigned to IV saline.
 The preparations appear similar, but the IgG causes a sensation of “arm burning”
in 75% of recipients. A physician-conducted interview within 48 hours of the
intervention reveals a 15% improvement in self-perceived fatigue in the IgG group
compared with 7% in the placebo group (p = 0.02). The results are reported as a
“significant and clinically important benefit of IgG in treating chronic fatigue
syndrome.” In this study, which source of error represents the greatest threat to
internal validity?
A. Bias
B. Chance
C. Decreased precision
D. Confounding
E. None of the above
F. Cannot be determined from the information given
Answer: A. The outcome is a subjective sense of decreased fatigue. The
participants who received IgG felt a burning sensation and may be more likely to
report a beneficial effect, thus biasing the observed outcome.

Q.4. A study investigates the performance of a new dipstick in diagnosing

microalbuminuria (determined by the gold standard of timed overnight albumin
excretion rate). The following data were obtained (trace is considered negative;
more than a trace is considered positive
Based on this study, what is true about the positive predictive value (PPV) of the
dipstick in diagnosing microalbuminuria?
A. It is greater than the negative predictive value (NPV) of the dipstick
B. It is greater than the specificity of the dipstick
C. It decreases with increasing prevalence
D. It is equal to 250/700 = 0.36
E. It cannot be calculated because the gold standard of overnight albumin
excretion rate is not a perfect test
F. None of the above
Answer: A. The first step is to identify the table’s positive/negative structure.
The PPV is true positives/(true positives false positives) = 320/470 = 68%. The
NPV is true negatives/(true negatives false negatives) = 450/700 = 64%. The
specificity is 450/600 = 75%. Therefore choice A is correct. The PPV of a test
always increases with increasing prevalence. Regarding the gold standard not
being a perfect test: Any new test needs to be compared to a gold standard
(which is usually more invasive or expensive and as accurate as possible) but all
tests, including gold standard tests, have some rate of false positives and false
negatives, even if those errors cannot be measured.
Q.5. A new urine dipstick test can be used to detect microalbuminuria in the office
for patients with diabetes. This test has a sensitivity of 95% and a specificity of
95%. Your nurse mistakenly has performed this test on one of your first patients
of the day, a 30-year-old woman. The test reads positive. This patient has no
diabetes, but she has hypertension and a family history of type 2 diabetes. You
estimate the prevalence of microalbuminuria in a group of persons like her would
be approximately 5%. What is the negative predictive value of the test for this
patient?
A. 5%
B. 35%
C. 50%
D. 95%
E. 99%
F. Cannot be calculated from the information above
Answer: E. The first step is to identify the table’s 2 × 2 structure. You
estimate the prevalence of disease in this population to be 5%. By setting up the
population prevalence first, you can determine the contents of the remainder of
the cells.
Disease
Present Absent
Positive 4.75 4.75 9.5
Test

Negative 0.25 90.25 90.5

Totals 5 95 100

Prevalence: 5/(5+95) = 5%
Sensitivity: 4.75/(4.75+0.25) = 95%
Specificity: 90.25/(90.25+5.75) = 95%
Positive predictive value: 4.75/(4.75+4.75) = 50%
Negative predictive value: 90.25/(90.25+0.25) = 99%

Q.6. In a randomized controlled trial of patients with hypertension and coronary

artery disease, 500 patients are treated with a beta-blocker to prevent recurrent
myocardial infarction (treatment A), and 500 are treated with a new combination
beta-blocker and diuretic antihypertensive agent (treatment B). All patients are
followed for five years to assess their rates of recurrent myocardial infarction. Of
patients receiving treatment A, 50 develop recurrent myocardial infarction over
the five-year follow-up, compared with 40 patients receiving treatment B. What
are the absolute and relative risk reductions for treatment B compared to
treatment A?
 A. 5% and 25%
B. 2% and 50%
C. 50% and 2%
D. 2% and 20%
E. 10% and 80%
F. None of the above
Answer: D. The absolute risk reduction is (50/500)−(40/500)=2%. The
relative risk reduction is: ([50/500] − [40/500])/(50/500) = 20%.

Q.7. The ability of a negative test to correctly identify persons without the disease is
a measure of
A. Sensitivity
B. Specificity
C. Positive predictive value
D. Negative predictive value
E. None of the above
Answer: B. Specificity is a measure of how well a test correctly identifies
persons without disease. Sensitivity is the ability of a test to correctly identify
persons with disease. Positive predictive value is the likelihood that a positive test
result in a person signifies disease, while negative predictive value is the likelihood
that a negative test result in a person signifies health (or the absence of disease).

Q.8. To determine the effect of a new over-the-counter analgesic on the incidence of

proteinuria in pregnant women, a group of researchers recruited 100 women from
5 local OB-GYN practices. The researchers asked all study participants to complete
a questionnaire, which asked participants whether they were taking the new
analgesic. Researchers then collected urine from study participants monthly for
eight months. Of 20 women reporting they took the analgesic, the incidence of
proteinuria was 20%. Of 480 women reporting they did not take the analgesic, the
incidence of proteinuria during study follow-up was 5%. What is the study design
of the preceding study?
A. Randomized controlled trial
B. Case-control study
C. Nonrandomized controlled trial
D. Longitudinal cohort study
E. Ecological study
F. None of the above
 Answer D. The participants were not randomized to receive (vs. not receive)
the analgesic. Therefore, this study is not a randomized controlled trial. Because
researchers observed (via questionnaire) whether patients reported taking the
analgesic (exposure), this is an observational study. Because the researchers
collected information about study participants’ exposures to the analgesic at the
beginning of the study and then followed them over time for the incidence of
proteinuria, this is a longitudinal cohort study. In a case-control study, researchers
would have identified persons with proteinuria versus no proteinuria first, and then
looked to see if participants were exposed to the analgesic in the past (e.g., using
chart review).

Q.8. You are evaluating a new screening test. Two hundred individuals undergo the
test. After comparing the new screening test with the gold standard test it is to
replace, the following results are gathered:
Patients with disease and positive test result: 60
Patients with disease and negative test result: 40
Patients without disease and positive test result: 30
Patients without disease and negative test result: 70
Which one of the following is true?
A. The sensitivity of this test is the sum of those with a positive test result (60 +
30) divided by all patients tested (200), or 45%
B. The specificity of this test is those without disease who have a negative test
result (70) divided by all patients tested without disease (70 + 30), or 70%
C. The positive predictive value of this test is those with disease who have a
positive test result (60) divided by all those with disease (60 + 40), or 60%
D. The negative predictive value of this test cannot be determined without
knowing the prevalence of disease in the population
Answer: B. Test sensitivity refers to the ability of a test to detect those with
disease (sensitivity = PID, or positive in disease). Sensitivity is calculated by
looking at the entire tested population who have disease, and seeing how many
have a positive test result. In the sample above, the total with disease and a
positive test result is 60, but the entire population of diseased individuals is 100
(60 + 40). Therefore, sensitivity is 60%, not 45% as mentioned in choice A.
Specificity refers to the ability of a test to be negative in those without disease
(specificity = NIH, or negative in health). In the population tested, it is the
proportion of those without disease who have a negative test result. There are 100
individuals without disease (70 + 30), of which 70 have a negative test result.
Specificity is therefore 70/100, or 70% (as shown correctly in choice B). Positive
predictive value refers to the likelihood that a positive test result represents a true
positive (i.e., those with disease). It is the proportion of positive test results in
 those with disease out of all positive test results. Above, there are 60 individuals
with a positive test result and real disease, but 90 individuals (60 + 30) with a
positive test result. The positive predictive value is therefore 60/90, or 66.7%. The
negative predictive value refers to the likelihood that a negative test result
represents a true negative (i.e., those without disease). It is the proportion of
negative test results in those without disease out of all negative test results. There
are 70 individuals with a negative test result who do not have disease, but a total
of 110 individuals (70+40) with negative test results. The negative predictive
value is therefore 70/110, or 64%.

Q.9. You are evaluating a new imaging test to screen for a fatal neurologic disease.
The gold standard test for this disease is brain biopsy, an invasive and expensive
procedure. The new imaging test is less expensive and noninvasive, and you are
on the committee asked to evaluate it. Two hundred patients were evaluated with
the new imaging test and also with brain biopsy. The following results were
obtained:
Seventy patients with disease had a positive imaging test
Thirty patients with disease had a negative imaging test
Ten patients without disease had a positive imaging test
Ninety patients without disease had a negative imaging test
Which one of the following statements is true?
A. The sensitivity of this test is 30%
B. The specificity of this test is 70%
C. The positive predictive value of this test is 87.5%
D. The negative predictive value of this test is 90%
Answer: C. Test sensitivity refers to the ability of a test to detect those with
disease (sensitivity = PID, or positive in disease). Sensitivity is calculated by
looking at the entire tested population who have disease, and seeing how many
have a positive test result. In the sample above, the total with disease and a
positive imaging result is 70, but the entire population of diseased individuals is
100 (70 + 30). Therefore, sensitivity is 70%, not 30% as mentioned in choice A.
Specificity refers to the ability of a test to be negative in those without disease
(specificity = NIH, or negative in health). In the population tested, it is the
proportion of those without disease who have a negative test result. Above, there
are 100 individuals without disease (10 + 90), of which 90 have a negative
imaging result. Specificity is therefore 90/100, or 90% (not the 70% shown in
choice B). Positive predictive value refers to the likelihood that a positive test
result represents a true positive (i.e., those with disease). It is the proportion of
positive test results in those with disease out of all positive test results. Above,
there are 70 individuals with a positive test result and real disease, but 80
 individuals (70 + 10) with a positive test result. The positive predictive value is
therefore 70/80, or 87.5%, as shown correctly in answer choice C. The negative
predictive value refers to the likelihood that a negative test result represents a
true negative (i.e., those without disease). It is the proportion of negative test
results in those without disease out of all negative test results. Above, there are
90 individuals with a negative test result who do not have disease, but a total of
120 individuals (90 + 30) with negative test results. The negative predictive value
is therefore 90/120, or 75%.

Q.10. You are performing a study of 1000 students who attend Baltimore College,
and follow them over one year. On your initial evaluation 10 students have disease
X. Over the year of study five more students contract disease X. Which of the
following statements about the study population is true?
A. The prevalence of disease X at the beginning of the study is 10%
B. The prevalence of disease X cannot be determined without knowing the
prevalence of disease X in Baltimore City
C. The incidence of disease X is 5/1000, or 0.5%
D. The incidence of disease X is 15/1000, or 1.5%
Answer: C. When investigating the impact of a disease on a community,
common measures of assessment include prevalence and incidence. Prevalence is
the number of existing cases of a disease at a specific point in time, divided by the
number in the population studied. In the case above, 10 individuals at Baltimore
College have disease X at the beginning of the study. We know there are 1000
individuals at Baltimore College, thus the prevalence of disease X at the beginning
of the study is 10/1000, or 0.1%. At the completion of the study, the prevalence
has increased to 15/1000, or 0.15%. Incidence looks at the number of new cases
over a defined time period in a specific population studied. Baltimore College was
studied over one year, during which time five new cases of disease X were noted.
The incidence is thus 5/1000, or 0.5%. Recall that incidence refers only to new
cases; choice D includes preexisting cases of disease X, and is therefore incorrect.

Q.11. You are beginning a study of the impact of a new drug on disease X. You start
with 100 patients with disease X, and randomize 50 patients to get treatment and
50 patients to get placebo. Four patients in the treatment group decide against
completing the study, and two patients in the placebo group decide against
completing the study. The analysis of the data when the study is completed,
including the six patients who did not complete the study, is referred to as
A. Intention-to-treat analysis
B. Validity analysis
C. Crossover-bias analysis
 D. On-treatment analysis
Answer: A. When performing research, researchers attempt to minimize bias
(bias is defined as systematic error, resulting in decreased accuracy of results).
Proper randomization, avoidance of confounding factors, and inclusion of a placebo
control are often used to minimize bias. Intention to treat analysis refers to the
inclusion of all individuals initially randomized in a clinical trial, regardless of
whether that individual actually received treatment. Intention to treat will tend to
minimize the impact of an intervention, since not all individuals included in the
analysis will have received treatment. Intention to treat therefore presents a
conservative assessment of the impact of an intervention, avoiding overstatement
of results.

Q.12. While studying a small community in Oklahoma you note that as the number
of churches increase, the number of bingo parlors increase. The conclusion that
churches cause bingo parlors to increase is likely to be limited by
A. Internal validity
B. External validity
C. Generalizability
D. Confounding
Answer: D. Confounding describes the impact of a different cause of a result
rather than the one studied. In the example above, it is likely that increasing
population led to both the increase in churches and bingo parlors, and that the
increase in bingo parlors was not a result of the impact of churches. Internal
validity refers to whether the results accurately reflect the connection between a
proposed cause and its result. External validity, also known as generalizability,
refers to whether the results from a studied population can be applied to another
target population.

Q.13. You are studying cancer X. There is no screening test for cancer X, and you
are evaluating a new test that can screen for cancer X. Previously, once cancer X
was diagnosed, death resulted six months later. With the new screening test, the
average individual diagnosed with cancer X died nine months later. The inventors
of the screening test therefore claimed that their test increased life expectancy by
three months, or 50%. A more likely explanation of the increased length of
survival would be
A. Length-time bias
B. Lead-time bias
C. Over-diagnosis bias
D. Selection bias
 Answer: B. The above screening test appears to identify disease at an earlier
stage, rather than improving prognosis. The bias introduced by a screening test
that identifies disease at an earlier stage and seemingly increasing survival time
while not actually impacting prognosis is referred to as lead-time bias. Length-
time bias (or simply length bias) refers to screening tests that are more likely to
detect individuals with longer survival and less severe disease, than those
individuals with shorter survival due to more severe disease. In the screened
population, survival will appear to be longer than in an unscreened population,
when the reality is the screen is detecting mostly those with less severe disease.
Selection bias refers to a situation in which those chosen for a study systematically
differ from those not chosen (with respect to characteristics important to the study
question). Over-diagnosis bias is not a descriptive term used in medical literature
on bias.

Q.14. You are studying the impact of a new screening test on mortality. You are
screening for cancer X, which has an indolent version (survival is usually 10 years
or more), and an aggressive version (survival is usually less than 1 year following
diagnosis). Two populations are studied, one that is screened with the new test
every three years, and one that is not screened at all. Average survival of those
patients in the screened group who have cancer X is 7.8 years; while in the
unscreened group average survival is 2.1 years. The most likely explanation for
the improved survival in the screened group is
A. The screening test detects cancer X at an early, treatable stage
B. The screening test introduces length-time bias into the screened population
C. The screening test is likely to be followed by better medical care in the screened
group
D. The unscreened group was subject to selection bias
Answer: B. Length-time bias refers to the impact of a screening test program
that preferentially detects more indolent disease than in the comparison group. It
is likely that patients with cancer X are dying between screening intervals, and
that more patients with indolent disease are detected in the screened group as
compared to the unscreened group. This will give the appearance that survival is
longer in the screened group rather than the unscreened group (where most
patients diagnosed with cancer X have the aggressive version). The other types of
bias mentioned are legitimate concerns, but the scenario described is most
suggestive of length-time bias.
CHAPTER 76: ETHICS

Q.1. A 70-year-old Chinese-speaking woman originally from China is brought by her

family to the emergency department with hemoptysis, shortness of breath,
weakness, and weight loss. Initial workup suggests the possibility of advanced
lung cancer. Wanting to be culturally competent, how should the physician initially
handle the news of a tumor seen on chest x-ray?
A. Out of respect for autonomy, the physician should disclose the results directly
to the patient with the aid of an interpreter
B. Wanting to show respect for the family unit, the physician should disclose the
results only to the patient’s family, not wanting to burden her with the news
C. The physician should inquire of the patient whether results should be disclosed
to her or to her family or to both
D. The physician should call an ethics consult to make a decision about disclosure
Answer: C. Ethical issues: Respect for persons, respect for autonomy,
cultural competence, informed consent, surrogate decision-making. While
autonomy is highly valued in American culture, it may not be the guiding paradigm
in other cultures. Involvement by the family in medical decisions may be more of
the norm in certain cultures, such as those from Asian descent. Because the
patient is receiving care in a setting that values respect for autonomy, it is still
important to inquire of the patient how she wants decisions to be made. This
includes how information should be shared. It is within the rights of the patient as
an autonomous agent to decline to receive information about her diagnosis, and
thus insisting the information be “forced” on her, as in option A, is incorrect. It is
also incorrect to assume that because the patient comes from a certain cultural
background that she favors one form of information-sharing over another. Answer
B is incorrect, because it unnecessarily assumes that the patient agrees that the
family unit is the arbiter of decisions for her. As a matter of preventive ethics, it
would be prudent for the physician when ordering the chest x-ray to ask the
patient how test results should be handled (i.e., whether she should be told or
whether her family should be told). It would also be prudent to involve a medically
trained interpreter to discuss the situation with the patient, as family members
who serve as interpreters may filter information in both directions, thus hindering
the acquisition of a complete picture. At the early stage of preliminary findings, it
would be premature to involve an ethics consultant, since the clinician should be
able to navigate the situation alone and only involve an ethics committee if a
dispute or dilemma arose.

Q.2. You have been caring for a 54-year-old unemployed male for the past year. He
complains of joint pains and objective evidence suggests mild arthritis. He has
been on welfare for several years, but because of a change in federal programs,
 he has been told he has to find work. You know that he has three young children
at home, he is widowed, and he cares for his elderly mother. He asks you to
complete a medical disability form, citing his arthritis as making him permanently
disabled for any employment. What is your most appropriate next step?
A. Complete the forms as he requests
B. Complete the forms but state on them that he is not disabled
C. Suggest he see another physician who is known to put everyone on disability
D. Suggest that he consult with a social worker to look into other options, such as
the Family Medical Leave Act
Answer: D. Ethical issue: Professionalism. After obtaining a license to
practice medicine, a physician obtains certain authority in society—such things as
writing prescriptions and determining disability. The society that grants this
authority expects that certain standards will be maintained, so that the process is
fair. It expects that the physician will practice medicine honestly and forthrightly.
In this case, the physician does not have objective evidence that the patient would
qualify for medical disability, so options A and C would be inappropriate. Since the
physician has an ongoing relationship with this patient and wants to look after the
patient’s best interests, the physician should pursue options that will benefit the
patient while still fulfilling his obligations to society. Social work referral would be
helpful to see if there are means to help the patient with financial problems. If
these avenues are exhausted and the patient still insists on applying for disability,
then the physician may have no choice but to state that objective medical
evidence does not support the determination of disability (choice B); however, this
would not be the immediate next step after the initial evaluation.

Q.3. A new patient on a fixed income comes to your practice on a statin that she has
been on for many years. She was just assigned to a Medicare D prescription drug
plan and discovers that all of her medications except her statin are on the
formulary list. The statin on formulary is less expensive and presumed as effective
at a higher dose as the patient’s, but it has not been studied as extensively. The
patient is aware of the study data on her medication and is concerned that other
statins at higher doses may increase her risks of myositis. She wants to stay on
her medication. What should you do next?
A. Write a prescription for the drug on formulary without any explanation
B. Petition the administrator or medical director of the Medicare D prescription
drug plan to make an exception in this case
C. Write a prescription for the patient’s statin and tell her to buy it out of pocket
D. Lobby the drug formulary committee to expand the number of statins on its list
Answer: B. Ethical issues: Professionalism, medical economics, dual
obligations, beneficence. The physician has a professional duty to society to keep
 health care costs down, but not at the expense of the patient’s best interests,
which should be the physician’s primary obligation. In this case, there is
justification for use of one statin over another, and it therefore may be in the
patient’s best interest to stay on the same medication. Since she is on a fixed
income, it is unreasonable to expect her to pay for the medication on her own. The
physician should attempt to get authorization from the prescription plan for her to
receive her medication off formulary as the first step. It could turn out that the
request is denied and the physician will have to go back to the patient to discuss
options, such as going on the formulary statin with closer monitoring of beneficial
action and side effects; but the first step should be to try to serve her best
interests. Because the physician practices in a health care world of cost-
containment, it is not necessarily his or her obligation to advocate for expanded
drug formularies if they ultimately prove counter to society’s expressed desire to
allocate scarce resources. Nevertheless, the physician does have the option of
presenting evidence to the formulary of why certain medications should be on the
formulary instead of others.

Q.4. Dr. X is an infectious disease specialist who serves on her hospital’s drug
formulary committee. She did some pilot studies on a new antibiotic that has since
proven to be more effective than standard therapy but is more expensive. A
pharmaceutical representative with whom she is friendly encourages her to get it
on the formulary. He also reminds her that he was instrumental in getting her
funding for the pilot study, that he sponsored her presentation at a national
meeting, and that he’s been able to provide free samples of other drugs for
indigent patients in her practice. What should she do at the upcoming drug
formulary meeting, which is open to the public since it is a city hospital?
A. Do not suggest the new drug, even though it is more beneficial
B. Suggest the drug based on its merits, without mentioning her relationship with
the drug rep because it is not germane
C. Suggest the drug but abstain from the voting, citing the conflict
D. Suggest the drug, mentioning the conflict, but vote for the drug
Answer: C. Ethical issues: Conflict of interests, dual obligations. Often as
important as actual conflicts of interest is the appearance of a conflict of interest.
One step in avoiding the appearance of a conflict of interest is public disclosure of
a potential conflict, which then allows others to judge whether personal interests
factor into what is said. Dr. X is under obligation to the hospital as a member of
the drug formulary committee to report potentially advantageous new drugs to the
committee for review. It would be up to the hospital to decide if the medication
were cost-effective and served the interests of the patient population. Because the
vote by Dr. X could be challenged as being biased by her relationship with the
pharmaceutical representative and company, disclosure of the relationship may
 not be sufficient in this case. Option C allows Dr. X to fulfill her obligation of
reporting new drugs to the committee, allows others to hear about the potential
conflict of interest, and permits the voting to be based upon the merits of the drug
by members of the committee who do not have a financial interest in the outcome.

Q.5. A 78-year-old male with metastatic lung cancer is transported by ambulance to

the hospital obtunded and in respiratory distress. He has a health care proxy who
is unavailable. He has not completed a living will or a DNR order. The emergency
room physician determines that he needs to be placed on mechanical ventilation.
Which statement is true?
A. The patient should not be intubated because he is not capable of giving
informed consent
B. The patient should not be intubated because his surrogate is unavailable to give
informed consent on his behalf
C. The patient should not be intubated because he has metastatic lung cancer and
his prognosis is poor
D. The patient should not be intubated because once he is on a ventilator he
cannot be extubated until he recovers
E. None of the above
Answer: E. Ethical issues: Decision-making capacity, surrogate decision-
making, withholding and withdrawal of treatment, emergency situations. In
emergency situations that require life or death decisions, the physician should act
to preserve the life of an incompetent patient if a surrogate is not available. Thus,
without compelling evidence against mechanical ventilation (e.g., an outpatient
DNR order), the patient should be intubated. His poor prognosis may factor into
his or his surrogate’s decision about limitations in care, but the emergency room
physician does not have knowledge of whether he may want to live for a while
longer to help resolve “unfinished business.” Ethicists maintain that there is no
moral distinction between withholding and withdrawal of life-sustaining treatment,
because the patient can refuse treatment at any time. There may be emotional
factors that create a feeling about not starting and stopping a treatment, but these
do not change the moral permissibility of withdrawing the ventilator later if it is
judged to be extraordinary care by either the patient or his surrogate.

Q.6. Your 39-year-old patient who is known to use injection drugs is admitted to the
hospital with fulminant hepatitis. He has been trying to turn his life around—he
married in the last six months and his wife just found out she is pregnant. He
subsequently goes into a coma and dies on the transplant waiting list. Lab work
reveals that he had hepatitis B. His wife asks what he died of. What do you do?
A. Inform her that you cannot disclose the diagnosis because it is confidential
information
 B. Inform her that he died of liver failure and leave it at that
C. Inform her that he had hepatitis B and recommend that she be tested for this
D. Contact the local health department of the newly diagnosed case of hepatitis B
and leave the responsibility of contact tracing to them
E. Anonymously send a copy of the death certificate to his wife
Answer: C. Ethical issue: Confidentiality, ethic of care. The physician has an
obligation to protect a patient’s confidentiality; information learned in confidence can
only be disclosed with the patient’s permission or when an identifiable third party is
at risk of a significant harm and the harm is likely to occur without the intervention.
In this case, the patient’s wife was placed at risk of contracting hepatitis B; while this
potential harm cannot be avoided now, she might be a candidate for treatment if she
has developed chronic, active hepatitis. In addition, her fetus is at risk of contracting
hepatitis, and measures can be taken to reduce the chances of peripartum
transmission if the patient’s wife has in fact been infected. Thus, an argument can be
made for disclosure of the information. There may also be the need to disclose the
information to the health department for public health reasons, depending on the
diseases that the health department tracks. Finally, once a patient dies, the
information about cause of death becomes public knowledge, freeing the physician
somewhat from the bounds of confidentiality.

Q.7. A patient is intubated and determined to have a lobar pneumonia for which he
is placed on IV cefuroxime. His daughter and his lady friend arrive. His friend has
been named his durable power of attorney for health care (DPAHC). She requests
that the antibiotics and ventilator be discontinued and the patient be given
comfort measures only. Which statement is true?
A. The friend cannot make the decisions because the patient’s daughter has
priority as a surrogate since she’s family
B. She can make the decision about the ventilator because it is extraordinary care,
but not the antibiotic because it is ordinary care
C. The friend’s request to discontinue both the ventilator and the antibiotics is
within her capacity to act as DPAHC
D. The friend cannot make the decisions because the patient did not spell out
these wishes in a living will
Answer: C. Ethical issue: Surrogate decision-making, standards for surrogate
decision-making, advance directives, ordinary and extraordinary care. The legal
hierarchy for surrogates starts with the durable power of attorney for health care.
The designated health care agent can be anyone chosen by the patient and takes
precedence over any family member who would be lower on the list of potential
surrogates. The healthy care agent has authority to make decisions about all
medical treatments, although some states require “clear and convincing” evidence
of the patient’s prior wishes for such things as artificial nutrition and hydration.
 Mechanical ventilation and antibiotics would be within the scope of the health care
agent’s decisional authority. The surrogate can use a “best interest” standard to
make this decision, even if the patient has not spelled out the wishes previously.
When there is some knowledge of the patient’s wishes and values, then
“substituted judgment” can be used. Whether a treatment is ordinary or
extraordinary does not have to do with its technological complexity, but rather a
determination of the burden to benefit ratio. If the surrogate determines within
the context of the whole clinical picture that the harms of antibiotic administration
outweigh the benefits, then the antibiotics can be considered extraordinary care.

Q.8. A patient is just removed from the ventilator. He is dyspneic and in his
obtunded state, he says, “Just put me out of my misery.” Which statement is
ethically and legally justifiable?
A. You should not give him narcotics because that would be complying with his
wish for active euthanasia
B. You should give him a large dose of a narcotic with the intention of ending his
life and complying with his wish
C. You should give him a sufficient dose of a narcotic to ease his dyspnea even if it
has the foreseen consequence of hastening his death
D. You should not give him anything potentially sedating or affecting his mental
state because he may become more alert and be able to give a competent decision
about being on the ventilator
Answer: C. Ethical issues: Rule of double effect, euthanasia, and palliative
care. Administration of a narcotic such as morphine to ease respiratory distress in
the setting of a terminal condition constitutes appropriate palliative care. Since the
patient is currently obtunded, his utterance does not constitute an informed,
competent decision. The physician does not need to follow the patient’s demand
but he needs to respond to it, since the patient appears to be suffering. The
patient may never regain decision-making capacity, so it would be inappropriate to
withhold a palliative measure on the possibility that it might affect his mental
state. The intentionality of the physician may determine whether the act is morally
licit. The rule of double effect has four principal conditions: (1) The act itself must
be good or morally neutral; (2) while a bad effect from the act may be foreseen,
the agent intends only the good effect; (3) the bad effect must not be the means
to achieve the good effect; and (4) the good effect must outweigh the bad effect.
In option B, the intention of the physician is to end the patient’s life; this would
entail active euthanasia and therefore the rule of double effect does not apply.
Option C is the correct answer, because, even though the physician anticipates
that the narcotic may speed the dying process, the reason for administering it is to
ease the dyspnea.