Questions

1. Which of the following statements about the normal microbial flora is false?

a. The microorganisms on the epithelial surfaces of the body remain in place chiefly through adherence.

b. When mechanical defenses of the epithelial layers are breached so as to expose normally sterile areas, severe infections can result from the normal microbial flora.

c. There is little benefit of these microorganisms to humans.

d. If antimicrobial agents eliminate normal flora, the host’s susceptibility to normally excluded pathogenic microorganisms is increased.

2. Which of the following statements about Staphylococcus aureus is false?

a. 25% of tertiary care isolates are resistant to beta-lactam antibiotics.

b. Transmission of organisms is by direct contact.

c. Resistance of organisms to antimicrobials is usually plasmid determined and varies by institution.

d. First-generation cephalosporins are the treatment of choice for life-threatening infections.

3. Which of the following is true of Staphylococcus epidermidis?

a. Staphylococcus epidermidis is present in up to 90% of skin cultures and cannot produce local infections.

b. Its characteristic adherence to prosthetic devices makes it the most common cause of prosthetic heart infections and is a common infectious organism of intravenous catheters and cerebrospinal fluid shunts.

c. Most isolates are not resistant to methicillin or cephalosporins; therefore, the drugs of choice are first-generation cephalosporins.

d. Management of an infected prosthetic device or vascular catheter only requires appropriate antibiotic administration.

4. Which of the following associations regarding Streptococcus is incorrectly paired?

a. Streptococcus pneumoniae: Lancet-shaped diplococci that cause alpha-hemolysis on blood agar.

b. Group A beta-hemolytic streptococci: Acute suppurative infections transmitted through droplets mediated by an opsonizing antibody.

c. Streptococcus pyogenes: Highly sensitive to Penicillin G.

d. Streptococcus pneumoniae: Can lead to pneumococcal pneumonia that is highly sensitive to penicillin and has a low mortality rate in the elderly.

5. Which of the following patients would not require endocarditis prophylaxis during invasive surgery?

a. a patient with a history of severe coronary artery disease.

b. a patient with a prosthetic heart valve.

c. a patient with a previous history of bacterial endocarditis.

d. a patient with acquired valvular dysfunction such as rheumatic heart disease.

6. What type of ocular surgery would require endocarditis prophylaxis?

a. cataract surgery.

b. vitrectomy.

c. tear duct reconstruction.

d. corneal transplant.

7. Which of the following is a false statement regarding pseudomembranous enterocolitis?

a. It is most commonly caused by Clostridium difficile.

b. Clostridium difficile is an anaerobic gramnegative bacterium.

c. Typically occurs within 1 to 14 days of starting antibiotic therapy in which patients develop fever and diarrhea.

d. Treatment includes discontinuing the causative antibiotic and administering metronidazole for 10 days.

8. Which of the following is true regarding Haemophilus influenzae?

a. Long-term immunity follows with the development of bactericidal antibodies to the type B capsule in the presence of complement.

b. Haemophilus influenzae is uncommonly found in the respiratory tracts of children.

c. Macrolides, such as erythromycin, are the treatment of choice.

d. Immunized patients are no longer susceptible to all strains of Haemophilus influenza.

9. Which of the following statements regarding Neisseria gonorrhoeae is false?

a. Gonococci are not part of the normal microbial flora.

b. 50% of women and 95% of men infected with gonococci are symptomatic.

c. Chlamydia trachomatis is found in as many as half of all women and one-third of all men infected with gonococci.

d. Macrolides and quinolones are generally not good agents to treat gonococcal infections.

10. Which of the following is true regarding Neisseria meningitidis?

a. Infection with Neisseria meningitidis is limited to meningitis.

b. Meningitis with a petechial or puerperal exanthema is the classic presentation.

c. The routine administration of meningococcal vaccine is recommended.

d. The treatment of choice for meningococcal meningitis is vancomycin.

11. Which of the following statements about syphilis is false?

a. The treatment of choice for patients with neurosyphilis is Penicillin G 2.4 million units intramuscularly weekly for 3 weeks.

b. Transplacental transmission from an untreated pregnant female to her fetus before 16 weeks’ gestation can result in congenital syphilis.

c. Serum FTA-ABS titers do not decrease with successful treatment.

d. Serum VDRL becomes negative after successful therapy.

12. Which of the following spirochetes causes Lyme disease?

a. Treponema pallidum.

b. Ixodes scapularis.

c. Borrelia burgdorferi.

d. Leptospira interrogans.

13. Which statement is true regarding Chlamydia trachomatis?

a. Chlamydia trachomatis is the most common sexually transmitted infection.

b. Chlamydial infections are treated with third-generation cephalosporins.

c. Chlamydia is a small extracellular parasite.

d. Chlamydia trachomatis can survive long periods outside the body and it is essential to avoid contact with patients that are infected.

14. Which of the following regarding tuberculosis is false?

a. Infection usually occurs through inhalation of infective droplets and rarely by way of the skin or gastrointestinal tract.

b. Treatment of active infection often involves use of two or three drugs because of the emergence of resistance.

c. Laboratory diagnosis involves culture of infective material on Lowenstein-Jensen medium for 6 to 8 weeks and use of the acid-fast type of Ziehl-Neelsen stain.

d. A positive PPD reaction is defined as an area of induration of 5 mm or greater read 48 to 72 hours after administration.

15. Which of the following is part of the normal flora that is present in the oral cavity, lower gastrointestinal tract, and female genital tract?

a. Histoplasma capsulatum.

b. Candida albicans.

c. Aspergillus fumigatus.

d. Blastomyces dermatitidis.

16. Toxoplasmosis is most commonly caused by

a. exposure to cat feces.

b. exposure to dog feces.

c. eating raw eggs.

d. exposure to human feces.

17. Which of the following statements about herpes-viruses is false?

a. EBV is associated with nasopharyngeal carcinoma.

b. EBV is associated with Burkitt’s lymphoma.

c. Resolution of lesions caused by herpes simplex may be followed by postherpetic neuralgia.

d. Untreated neonatal herpes infection carries an 80% mortality rate.

18. Which of the following methods of transmission of hepatitis viruses is incorrect?

a. hepatitis A: fecal–oral route.

b. hepatitis B: fecal–oral route.

c. hepatitis C: blood transfusions.

d. hepatitis D: sexual transmission.

19. Which of the following is false of these viruses or viral conditions?

a. Severe acute respiratory syndrome (SARS) originated in China and rapidly spread by air travel to other countries.

b. The hantavirus is a highly virulent respiratory pathogen transmitted by ticks.

c. The Ebola virus can cause severe hemorrhage, generally occurring from the gastrointestinal tract.

d. The West Nile virus is transmitted by a mosquito vector, and illness may vary from a flulike syndrome to meningitis and encephalitis.

20. Which of the following statements regarding AIDS is true?

a. Approximately 200 million people in the world have AIDS.

b. The majority of individuals infected with HIV live in the United States.

c. The ELISA test for HIV is 99% sensitive, but only 75% specific for HIV.

d. Breast milk can also be a method of transmission of HIV.

21. Pneumocystis carinii pneumonia is generally treated with

a. trimethoprim–sulfamethoxazole.

b. ceftriaxone.

c. doxycycline.

d. penicillin.

22. Ganciclovir is used in the treatment of CMV retinitis and colitis in immunocompromised patients. Ganciclovir’s major toxicity is

a. hepatotoxicity

b. bone marrow suppression.

c. nephrotoxicity

d. encephalopathy

23. Hypertension is defined as

a. systolic blood pressure of 140 mm Hg or higher.

b. a single blood pressure reading of 140/80.

c. diastolic pressure of 80 mm Hg or higher.

d. systolic blood pressure of 130 mm Hg or higher.

24. Causes of secondary hypertension include all of the following, except

a. pheochromocytoma.

b. hypothyroidism.

c. hyperaldosteronism.

d. Cushing’s syndrome.

25. Which of the following statements about lifestyle factors affecting blood pressure is false?

a. Processed foods account for 75% of sodium intake in the United States.

b. Patients with mild hypertension who smoke a pack of cigarettes a day have a fivefold higher risk of coronary artery disease.

c. Alcohol consumption of more than 1 oz of ethanol (10 oz of wine or 24 oz of beer) is associated with resistance to antihypertensive therapy.

d. Regular aerobic exercise contributes to reduced mortality and morbidity from hypertension.

26. Which medication is incorrectly paired with a common side effect?

a. doxazosin: postural hypotension.

b. atenolol: bronchospasm.

c. spironolactone: gynecomastia.

d. amlodipine: drug-induced lupus.

27. What types of antihypertensive agent should be used to start initial therapy for hypertension in a newly diagnosed patient without other comorbidity?

a. thiazide diuretics.

b. calcium channel blockers.

c. angiotensin II receptor blockers (ARBs).

d. alpha-adrenergic antagonists.

28. What is the definition of a transient ischemic attack (TIA)?

a. a loss of neurologic function caused by ischemia that lasts for <24 hours and clears without residual signs.

b. a progressively enlarging cerebral infarct that produces neurological deficits, which worsen over 24 to 48 hours.

c. an ischemic event that produces a stable permanent neurological disability.

d. an ischemic, but not infarcted area of the brain, which has been shown to have some plasticity with regard to recovery.

29. Which of the following statements with regard to stroke is false?

a. Clopidogrel has a better side effect profile than ticlopidine with regard to bone marrow suppression.

b. The use of tissue plasminogen activator (TPA) within 24 hours of the onset of symptoms improves outcome in patients with stroke.

c. Aspirin offers a moderate benefit in the prevention of recurrent stroke.

d. Hypertension should be controlled, although blood pressure reduction during acute ischemic stroke may cause harmful decreases in local perfusion.

30. Which of the following statements regarding intracranial hemorrhage or causes of intracranial hemorrhage is false?

a. The most common site of berry aneurysms is at the origin of the posterior communicating artery from the internal carotid artery.

b. Immediate CT examination demonstrates blood in the subarachnoid space in approximately 95% of the cases of ruptured aneurysm or AVM.

c. The most common symptom of subarachnoid hemorrhage is a generalized seizure.

d. Initial restoration of normal blood pressure and its maintenance at normal levels are mandatory in the treatment of ruptured aneurysms.

31. Ocular and cerebral conditions associated with carotid stenosis include all of the following, except

a. amaurosis fugax.

b. ocular ischemic syndromes.

c. transient ischemic attack (TIA).

d. intracranial hemorrhage.

32. Which of the following statements about carotid endarterectomy (CEA) is false?

a. CEA should only be considered if the surgeon performing the operation has a perioperative morbidity rate of <3%.

b. In the Asymptomatic Carotid Atherosclerosis Study, patients with asymptomatic carotid stenosis of >60% who underwent CEA did not show a significantly lower risk of having another major ischemic stroke, compared to patients who solely had medical management.

c. CEA provided a significant benefit in reducing the risk of ipsilateral stroke in patients with symptomatic stenosis of 50% or more.

d. In the North American Symptomatic Carotid Endarterectomy Trial, CEA was shown to have increasing benefit with higher degrees of carotid stenosis.

33. Folic acid can reduce the risk of stroke in patients by reducing the plasma levels of

a. high-density cholesterol (HDL).

b. homocysteine.

c. triglycerides.

d. low-density cholesterol (LDL).

34. What is the best procedure for determining a cardiac source in patients presenting with isolated amaurosis fugax or transient vision loss?

a. transesophageal echocardiography.

b. transthoracic echocardiography.

c. MRI of the chest.

d. CT scan of the chest.

35. What is the number one killer in the United States and around the world?

a. lung cancer.

b. breast cancer.

c. coronary artery disease.

d. HIV.

36. What is the number one preventable risk factor for cardiovascular disease worldwide?

a. physical inactivity.

b. smoking.

c. obesity.

d. diet high in saturated fat and cholesterol.

37. All of the following can impede the supply of oxygen to the myocardium except

a. anemia.

b. carotid artery stenosis.

c. reduced mean arterial pressure.

d. hypoxemia.

38. It has become clear that markers of inflammation are strong risk factors for CAD. What is the best marker that correlates most with future cardiovascular events?

a. interleukin-6.

b. TNF-alpha.

c. high-sensitivity C-reactive protein (hs-CRP).

d. serum amyloid A (SAA).

39. The metabolic syndrome is characterized by a group of metabolic risk factors in one person that increase the risk of cardiovascular disease. What is not one of these risk factors?

a. elevated liver function tests (LFTs).

b. abdominal obesity.

c. low HDL level.

d. hypertension.

40. Which of the following is a clear risk factor for ischemic heart disease?

a. female gender.

b. stress.

c. personality type.

d. diabetes.

41. The difference between a non–Q-wave myocardial infarction and unstable angina is

a. non–Q-wave infarcts will have angina at rest, whereas unstable angina will not.

b. non–Q-wave infarcts will have elevated cardiac enzymes, whereas unstable angina will not.

c. non–Q-wave infarcts can have T wave inversions, whereas unstable angina will not.

d. non–Q-wave infarcts can have ST segment depression on ECG, whereas unstable angina will not.

42. What portion of all myocardial infarctions are painless?

a. 5%.

b. 10%.

c. 25%.

d. 50%.

43. Dressler’s syndrome is characterized by all of the following, except

a. pleuropericardial pain.

b. fever.

c. arthralgias.

d. vomiting.

44. All of the following can cause sudden cardiac death except

a. pneumonia.

b. Wolfe-Parkinson-White syndrome.

c. long QT syndrome.

d. ventricular fibrillation.

45. Noninvasive diagnostic testing in patients with ischemic heart disease (IHD) includes all of the following, except

a. chest C T.

b. electrocardiography (ECG).

c. cardiac enzymes.

d. echocardiography.

46. All of the following are used to treat acute coronary syndrome (ACS), except

a. metoprolol.

b. low–molecular-weight heparin.

c. nitroglycerin.

d. HCTZ.

47. Percutaneous transluminal coronary angioplasty (PTCA) is usually superior to thrombolytic therapy in acute coronary syndromes in all of the following situations except

a. initiation of therapy more than 90 minutes after acute coronary syndrome.

b. patients with an increased risk of intracranial hemorrhage.

c. patients with a prior history of CABG.

d. patients with a history of recent extensive abdominal surgery.

48. Clinical signs of acute left ventricular heart failure can include all of the following, except

a. dyspnea.

b. hemoptysis.

c. diaphoresis.

d. hepatomegaly.

49. The lower limit of normal for ejection fraction is

a. 30%.

b. 40%.

c. 50%.

d. 60%.

50. What is the most common cause of congestive heart failure (CHF) in the United States?

a. aortic stenosis.

b. mitral regurgitation.

c. myocarditis.

d. ischemic heart disease (IHD).

51. The most common cause of right-sided heart failure is

a. left-sided heart failure.

b. primary pulmonary hypertension.

c. pulmonary embolism.

d. coarctation of the aorta.

52. Usually, the most effective way of treating systolic dysfunction is to

a. reduce preload.

b. increase preload.

c. reduce afterload.

d. increase afterload.

53. The calcium channel blocker of choice in CHF patients with IHD is

a. captopril.

b. amlodipine.

c. diltiazem.

d. doxazosin.

54. Usually, the most effective way of treating diastolic dysfunction is to

a. reduce preload.

b. increase preload.

c. reduce afterload.

d. increase afterload.

55. The primary pacemaker of the heart is the

a. sinoatrial (SA) node.

b. atrioventricular (AV) junction.

c. bundle of His.

d. chordae tendineae.

56. Which one of the following bradyarrhythmias or conduction disturbances is the most innocuous?

a. sinus bradycardia.

b. second-degree AV block.

c. third-degree AV block.

d. left bundle branch block.

57. Which of the following supraventricular tachycardias are incorrectly matched with their ECG findings?

a. Wolff-Parkinson-White syndrome: Delta wave (initial upsloping of QRS complex).

b. atrial flutter: P waves have saw tooth appearance.

c. paroxysmal atrial tachycardia: Prolonged PR interval.

d. atrial fibrillation: No identifiable P wave.

58. The preferred first-line therapy to treat arrhythmias in patients who have had prior cardiac arrest or hemodynamically unstable ventricular tachycardia is

a. automated implantable cardioverter-defibrillator (ICD).

b. pacemaker.

c. amiodarone.

d. adenosine.

59. Major risk factors in which it is necessary to have lower LDL goals in patients include all of the following except

a. an age of 45 or greater in males and 55 or greater in females.

b. cigarette smoking.

c. high HDL cholesterol (>60 mg/dL).

d. hypertension.

60. Common adverse reactions from HMG-CoA reductase inhibitors, also known as “statins,” include

a. incontinence and constipation.

b. muscle soreness.

c. renal stones and diabetes.

d. palpitations and anxiety.

61. Which of the following is not an irreversible obstructive disease?

a. asthma.

b. emphysema.

c. chronic bronchitis.

d. peripheral airway disease.

62. Which of the following is a restrictive lung disease?

a. chronic bronchitis.

b. emphysema

c. fibrosis of the lung parenchyma.

d. pneumothrorax.

63. What is the single most effective and cost-effective intervention to reduce the risk of COPD and to slow COPD progression?

a. supplemental oxygen.

b. smoking cessation.

c. continuous positive airway pressure (CPAP).

d. beta adrenergic agonists.

64. Which of the following could be used to manage an acute asthma attack?

a. subcutaneous epinephrine.

b. salmeterol.

c. inhaled beclomethasone.

d. cromolyn sodium.

65. Which of the following has been proven to increase survival in patients with severe COPD?

a. oral corticosteroids.

b. nitroglycerin.

c. captopril.

d. supplemental oxygen.

66. The average lifespan of an erythrocyte is

a. 2 weeks.

b. 6 weeks.

c. 120 days.

d. 1 year.

67. Erythropoiesis is stimulated by erythropoietin which is produced mainly in the

a. lungs.

b. liver.

c. kidney.

d. bone marrow.

68. What is by far the most common type of anemia worldwide?

a. iron deficiency anemia.

b. anemia of chronic disease.

c. thalassemia.

d. vitamin B12 deficiency anemia.

69. Which of the following is not a cause of microcytic anemia?

a. iron deficiency.

b. thalassemia.

c. sideroblastic anemia.

d. pernicious anemia.

70. Manifestations of sickle cell disease include all of the following except

a. acute painful episodes.

b. necrosis of the bone.

c. hematuria.

d. aphthous ulcers.

71. What blood test is typically used to measure the effect of heparin therapy?

a. prothrombin time (PT).

b. partial thromboplastin time (PTT).

c. bleeding time.

d. international normalized ratio (INR).

72. What blood test is typically used to measure the effect of warfarin therapy?

a. prothrombin time (PT).

b. partial thromboplastin time (PTT).

c. bleeding time.

d. international normalized ratio (INR).

73. The most common cause of abnormal bleeding in individuals is

a. platelet disorders.

b. hemophilia A.

c. von Willebrand’s disease.

d. Vitamin K deficiency.

74. All of the following can cause thrombocytopenia except

a. von Willebrand’s disease.

b. idiopathic thrombocytopenic purpura (ITP).

c. sulfonamides.

d. posttransfusion reactions.

75. Which of the following medications irreversibly inhibits platelet aggregation?

a. antihistamines.

b. tricyclic antidepressants.

c. aspirin.

d. NSAIDs.

76. What is the most common and severe hereditary coagulation disorder?

a. factor II deficiency.

b. factor V deficiency.

c. factor VIII deficiency.

d. protein C deficiency.

77. Which of the following statements about Vitamin K is false?

a. Vitamin K is necessary for the production of factors II, VII, IX, and X in the liver.

b. Vitamin K should not be given intramuscularly because of the risk of sudden death from an anaphylactoid reaction.

c. Celiac sprue, cystic fibrosis, and biliary obstruction can be causes of Vitamin K deficiency.

d. Vitamin K is routinely administered to newborns to prevent hemorrhagic disease in newborns.

78. Which of the following is not a primary hypercoagulable state?

a. antithrombin III deficiency.

b. protein C deficiency.

c. hyperhomocysteinemia.

d. factor IX deficiency.

79. The phospholipid antibody syndrome is characterized by all of the following except

a. cerebral aneurysms.

b. recurrent spontaneous abortions.

c. DVT.

d. venous and arterial thrombosis.

80. The most common rheumatic disorder is

a. Behçet’s disease.

b. relapsing polychondritis.

c. Wegener’s granulomatosis.

d. rheumatoid arthritis.

81. Which of the following is not a seronegative spondylopathy?

a. relapsing polychondritis.

b. ankylosing spondylitis.

c. inflammatory bowel disease.

d. psoriatic arthritis.

82. The classic triad for Reiter’s syndrome includes all of the following except

a. conjunctivitis.

b. arthritis.

c. uveitis.

d. urethritis.

83. Which of the following findings would lead a clinician to suspicion of ankylosing spondylitis?

a. atrophy of the distal phalanges (“pencil-in-cup” appearance on radiographic films).

b. fusion of the spine (“bamboo spine”).

c. knee and ankle pain.

d. interphalangeal arthritis (“sausage digits”).

84. Which of the following is not part of the criteria needed to diagnose systemic lupus erythematosus (SLE)?

a. oral ulcers.

b. arthritis.

c. positive for HLA-DR2.

d. antinuclear antibody positivity.

85. More than 95% of patients with scleroderma have

a. calcinosis.

b. Raynaud’s phenomenon.

c. sclerodactyly.

d. telangiectasias.

86. A patient who has a Schirmer-1 test of <5 mm in 5 minutes has had recurrent or persistent swollen salivary glands and who is positive for rheumatoid factor probably has

a. scleroderma.

b. Sjögren’s syndrome.

c. juvenile rheumatoid arthritis.

d. relapsing polychondritis.

87. The findings below would make one suspicious for

a. dermatomyositis.

b. scleroderma.

c. polymyositis.

d. relapsing polychondritis.

88. The most common clinical findings in relapsing polychondritis are

a. laryngeal collapse.

b. conjunctivitis and iritis.

c. aortic insufficiency and vasculitis.

d. arthropathy, auricular, and nasal chondritis.

89. What is the gold standard for diagnosing giant cell arteritis (GCA)?

a. ESR.

b. C-reactive protein (CRP).

c. temporal artery biopsy.

d. ESR and CRP.

90. Cogan’s syndrome can be associated with which of the following in up to 50% of cases?

a. Churg-Strauss angiitis.

b. Wegener’s granulomatosis.

c. polyarteritis nodosa (PAN).

d. Takayasu’s arteritis.

91. What is the most common clinical manifestation of Behçet’s syndrome?

a. oral ulcers.

b. genital ulcers.

c. polyarthritis.

d. erythema nodosum.

92. All of the following are potential side effects from administration of exogenous corticosteroids, except

a. hypokalemia.

b. osteoporosis.

c. peptic ulcer.

d. orthostatic hypotension

93. What is the most common side effect of oral NSAIDs?

a. myelosuppression.

b. gastrointestinal upset.

c. hepatic toxicity.

d. corneal melt.

94. The American Diabetes Association recommends a diagnosis of diabetes when 1 of 3 criteria is met. These criteria include all of the following except

a. fasting glucose level ≤ 126 mg/dL.

b. fasting glucose level < 126 mg/dL, but ≤ 200 mg/dL 2 hours after ingestion of 75 g of oral glucose.

c. hemoglobin A1c (HbA1c) ≤ 7.

d. a glucose level of ≤ 200 mg/dL at any time with classic symptoms of diabetes.

95. Which of the following is true of type 1 diabetes?

a. Most often due to an immune-mediated destruction of insulin-producing beta cells in the pancreas.

b. Occurs most commonly after the age of 40.

c. Monozygotic twins show a concordance rate of having diabetes of >90%.

d. Obesity is present in 80% to 90% of these patients.

96. Risk factors for developing type 2 diabetes include all of the following except

a. low socioeconomic status.

b. hypertension.

c. obesity.

d. stress.

97. What is the earliest sign of malignant hyperthermia?

a. elevated body temperature.

b. tachycardia.

c. metabolic acidosis.

d. muscular rigidity.

98. Which of the following describes the Somogyi phenomenon?

a. high sugars following episodes of hypoglycemia.

b. hypoglycemia following episodes of very high sugar levels.

c. hyperglycemia following insulin administration.

d. hypoglycemia following insulin administration.

99. The most sensitive and specific screening test for thyroid disease is

a. free T3.

b. free T4 and TSH.

c. transthyretin.

d. thyroid microsomal antibody detection.

100. 85% to 90% of patients with the disease characterized by findings in the image below have antibodies to

a. TSH.

b. TSH receptor.

c. T3.

d. T4.

Answers

10. b. Meningococcal infections include meningitis, respiratory tract infections, endocarditis, arthritis, pericarditis, pneumonia, endophthalmitis, and purpura fulminans. The treatment of choice for meningococcal meningitis has been high-dose penicillin or in the case of allergy or resistance, chlor-amphenicol or third-generation cephalosporin. Routine administration of meningococcal vaccines is not recommended except in patients who have undergone splenectomy, complement-deficient persons, military personnel, travelers to endemic regions, and close contacts of infected patients.

11. a. The treatment of choice for neurosyphilis is 2.4 million units of Penicillin G intravenously every 4 hours for 10 days. Early-stage syphilis (e.g., within 1 year of infection) is treated with 1 dose of 2.4 million units of Penicillin G intramuscularly. In patients who have neurosyphilis, the serum VDRL may be negative, but the CSF VDRL will be positive. False-positive VDRLs can occur in patients with systemic lupus erythematosus, liver disease, pregnancy, or other treponemal infections.

12. c. Ixodes scapularis is the deer tick that transmits the spirochete Borrelia burgdorferi to deer and humans. Lyme disease is the most common vector-borne disease in the United States.

13. a. Chlamydia is a small, obligate, intracellular parasite that contains DNA and RNA. C trachomatis can survive only briefly outside the body. Chlamydia trachomatis is the most common sexually transmitted infection, with 4 million new cases per year. Third-generation cephalosporins are used to treat gonococcal infections, which often coexist with chlamydial infections. Treatment of choice for chlamydial infection is the tetracycline family of antibiotics.

14. d. A positive PPD is defined as an area of induration 10 mm or greater read 48 to 72 hours after intradermal injection. All of the agents currently used to treat tuberculosis have toxic side effects, especially hepatic and neurologic. Isoniazid and ethambutol can cause optic neuritis and rifampin may cause pink-tinged tears and blepharoconjunctivitis.

15. b. Candida albicans is a yeast normally present in the oral cavity, lower gastrointestinal tract, and female genital tract. Under conditions of disrupted local defenses or depressed immunity, overgrowth or parenchymal invasion can occur. Treatment of serious systemic infections has traditionally involved the use of intravenous amphotericin B.

16. a. Toxoplasmosis can be caused by eating undercooked or raw meat. Toxoplasma can also be transmitted to humans by ingestion of oocysts through exposure to cat feces, water, or soil containing the parasite. Pregnant women should avoid changing cat litter as toxoplasma can be transmitted to the fetus and cause severe complications including mental retardation, blindness, and epilepsy. The most commonly used therapeutic regimen includes a combination of pyrimethamine, sulfadiazine, and folinic acid.

17. c. Resolution of lesions caused by Varicella-zoster may be followed by postherpetic neuralgia. In some patients, tricyclic antidepressants, carbam-azepine, and gabapentin have reduced the pain of postherpetic neuralgia.

18. b. Hepatitis B is parenterally or sexually transmitted. Hepatitis C can also be transmitted through parenteral drug use, hemodialysis, and occupational exposure to blood. Hepatitis E is transmitted through the fecal–oral route.

19. b. Severe acute respiratory syndrome (SARS) emerged in late 2002 and early 2003 and originated in the Guangdong Province of China. Early, the infection was transmitted primarily through household contacts and in health care facilities and was rapidly spread by air travel to other countries. The hantavirus is a virulent respiratory pathogen transmitted from rodent carriers, particularly deer mice.

20. d. By 2003, more than 35 million people in the world were living with HIV/AIDS. The majority of these individuals (more than 95%) live in developing countries. The ELISA test is 99% sensitive and 99% specific for HIV, but false-negatives can occur in the first few weeks after initial infection.

21. a. Pneumocystis carinii is generally treated with trimethoprim–sulfamethoxazole (trade names Bactrim, Septra).

22. b. Ganciclovir’s major toxicity is reversible bone marrow suppression. One-third of patients using systemic ganciclovir develop significant granulocytopenia. Foscarnet is also used to treat CMV and its main side effect is nephrotoxicity.

23. a. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has defined hypertension as a systolic blood pressure 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher. The classification is based on the average of two or more properly measured seated blood pressure readings on each of two or more office visits.

24. b. Hypothyroidism is often associated with hypotension. All of the other conditions listed are causes of secondary hypertension. Approximately 90% of cases of hypertension are primary, in which the etiology is unknown, and 10% are secondary to identifiable causes. Other causes of secondary hypertension include polycystic kidney disease, renovascular disease, and coarctation of the aorta.

25. b. Cigarette smoking is associated with a 25-fold higher risk of coronary artery disease in patients with mild hypertension. In patients without hypertension, cigarette smoking increases the risk fivefold.

26. d. Hydralazine is commonly reported to have drug-induced lupus as a side effect. Doxazosin and other alpha-blockers can result in postural hypotension. Beta-blockers often can cause bron-choconstriction and should be avoided in patients with asthma. ACE inhibitors also commonly have the common side effect of a dry cough.

27. a. Thiazide-type diuretics are the treatment of choice for initial hypertension. Special considerations should be taken into account in patients with certain conditions. ACE inhibitors and beta-blockers are recommended as first-line drugs in patients with acute coronary syndromes and patients with ventricular dysfunction. ACE inhibitors and ARBs are beneficial for those with diabetic nephropathy. ACE inhibitors and ARBs are contraindicated in pregnancy because of tera-togenic effects.

28. a. A TIA lasts <24 hours but must be taken as a harbinger for repeat strokes. Answer B is the definition of an evolving stroke. Answer C defines a completed stroke. Answer D is the definition of the penumbra, a term used to describe the ischemic area of brain tissue surrounding the main infarct. The penumbra has been shown to recover in some cases.

29. b. TPA is best used within 3 hours of onset of symptoms and is associated with improved outcomes in select patients. Unfortunately, TPA is often underutilized because of the lack of availability and awareness and because patients can present to the hospital or emergency department several hours after the onset of symptoms.

30. c. The most common symptom of subarachnoid hemorrhage is the sudden development of a violent, usually localized headache.

31. d. Ischemic stroke is also associated with carotid stenosis. The annual stroke rate among patients with isolated amaurosis fugax, retinal infarcts, or TIAs is approximately 2%, 3%, and 8%, respectively. Untreated patients with amaurosis fugax, retinal infarcts, or TIAs have a 30% risk of myocardial infarction and an 18% risk of death over a 5-year period.

32. c. 4% of individuals over the age of 40 have asymptomatic carotid bruits. Patients with TIA or previous stroke in the territory of the carotid circulation are judged to be “symptomatic.” CEA was shown to be effective in symptomatic patients with high-grade stenosis, 70% to 99%. There is still uncertainty regarding the benefit of CEA for symptomatic stenosis in the range of 30% to 69%.

33. b. High homocysteine levels have been associated with an increased risk of stroke and vascular disease. Folic acid helps reduce homocysteine levels and can be recommended to all patients with cardiovascular or atherosclerotic disease.

34. a. Transesophageal echocardiography is the best procedure for determining the cardiac source of an embolus.

35. c. Atherosclerotic coronary artery disease (CAD) remains by far the number one killer in the United States and around the world. CAD accounts for approximately a third of all deaths in the United States. The number of people that die from CAD is far greater than the number of people that die from all types of cancers combined.

36. b. Smoking remains the number one preventable risk factor for cardiovascular disease worldwide. The risk of CAD can be decreased by 50% in just 1 year after an individual stops smoking.

37. b. Coronary artery stenosis, not carotid artery stenosis, can lead to myocardial ischemia. The balance between arterial supply and myocardial demand for oxygen determines whether ischemia occurs. Coronary stenosis, thrombosis, reduced arterial pressure, hypoxemia, or severe anemia can impede the supply of oxygen to the myocardium. On the demand side, an increase in heart rate, ventricular contractility, or wall tension may each increase utilization of oxygen.

38. c. All of the answer choices are inflammatory markers. Hs-CRP is the best marker of inflam-mation for cardiovascular disease. C-reactive protein levels <1, between 1 and 3, and >3 mg/mL identify patients at low, medium, and high risk, respectively, for future cardiovascular events.

39. a. The metabolic syndrome is defined as a constellation of three or more of the following: abdominal obesity, hypertriglyceridemia, low HDL level, fasting glucose level of 110 mg/dL or more, and hypertension.

40. d. A family history of ischemic heart disease, hypertension, elevated serum cholesterol, smoking, and diabetes are risk factors for ischemic heart disease.

41. b. Both unstable angina and non–Q-wave MI can have very similar presentations. The presence of elevated cardiac enzymes can serve to differentiate non–Q-wave MI from unstable angina.

42. c. Painless myocardial infarcts are more common in patients with diabetes and elderly patients, and painless MI can present as syncope or congestive heart failure. Women can also present with atypical symptoms of an MI (e.g., stomach upset, malaise) instead of the classic “chest pain radiating down the arm” presentation.

43. d. Dressler’s syndrome occurs after myocardial infarction, typically 2 to 3 days later, and is caused by a postinfarct pericarditis. Dressler’s syndrome, or post-MI, is characterized by a pericardial friction rub. This rub can be accompanied by fever, arthralgias, and pleuropericardial pain. Dressler’s syndrome is typically treated with NSAIDs, aspirin, or corticosteroids.

44. a. Sudden cardiac death is defined as unexpected nontraumatic death occurring within 1 hour after onset of symptoms in clinically stable patients. Arrhythmias, such as ventricular tachycardia or fibrillation, are usually the cause of sudden cardiac death. Other causes include torsade de pointes, hypertrophic cardiomyopathy, Wolfe-Parkinson-White syndrome, long QT syndrome, and pulmonary embolism.

45. a. Noninvasive diagnostic testing in ischemic heart disease includes ECG, serum enzyme measurement, echocardiography, and various types of stress testing. During angina or myocardial infarction (MI), ST segments become elevated or depressed, and T waves may be inverted or become peaked. Cardiac enzymes are released into the bloodstream when myocardial necrosis occurs. CK-MB and troponins T and I are important cardiac enzymes in detecting myocardial infarction. Troponins T and I have been shown to be more cardiac specific and sensitive than CK-MB. Troponin levels remain elevated from 3 hours to 14 days after MI, whereas CK-MB levels rise approximately 4 hours after MI, peaking between 12 and 24 hours after the event. Echocardiography is used to image the ventricles and atria, the heart valves, left ventricular contraction and wall-motion abnormalities, left ventricular ejection fraction, and the pericardium. Patients with IHD, particularly following infarction, commonly have regional wall-motion abnormalities that correspond to the areas of myocardial injury.

46. d. HCTZ is used in the treatment of hypertension, not ACS. Beta-blocker therapy reduces myocardial oxygen demands and should be considered for all patients with evolving MI. ACE inhibitors given orally during the acute phase of MI can decrease the risk of mortality when initiated within the first 24 hours of acute MI. Nitrates and an antithrombin agent are also commonly given in patients with ACS.

47. a. Optimal myocardial salvation requires that nearly complete reperfusion be achieved as soon as possible. If significant delay occurs (>90 minutes) before PTCA can be performed, thrombolysis is preferable. Contraindications to thrombolysis using intravenous thrombolytic agents include known sites of potential bleeding, a history of prior cerebrovascular accident, recent surgery, or prolonged cardiopulmonary resuscitation efforts.

48. d. Hepatomegaly, pedal edema, and cyanosis are signs of right ventricular failure. The most frequent symptoms of left ventricular failure are dyspnea with exertion or at rest, orthopnea, paroxysmal nocturnal dyspnea, diaphoresis, generalized weakness, fatigue, anxiety, and lightheadedness.

49. c. In patients without CHF, the ejection fraction (EF) is more than 0.50. EF of <0.50 indicates impairment. Echocardiography is the most useful and least invasive method of determining ejection fraction.

50. d. All of the other answers listed can also be causes of CHF as well, but IHD is the most common cause.

51. a. The most common cause of right-sided heart failure is left-sided heart failure.

52. c. Preload refers to the amount of stretch to which muscle fibers are subjected at the end of diastole or refilling. Afterload is the amount of tension or force in the ventricular muscle mass just after onset of contraction. Reducing afterload is usually the most effective way of treating systolic dysfunction. Reducing vascular resistance and lowering arterial blood pressure decrease the burden on the left ventricle and enhance contraction and ejection. ACE inhibitors are the medication of choice to accomplish this, although angiotensin receptor blockers, hydralazine, and other medications can be considered if the patient is unable to tolerate ACE inhibitors.

53. b. Amlodipine has been shown to be safe in patients with CHF. Other calcium channel blockers such as diltiazem have shown to actually increase mortality in patients with CHF. Doxazosin and prazosin are alpha-adrenergic blockers. Captopril is an ACE inhibitor.

54. a. Diastolic function can be improved by reducing preload, which in turn lowers filling pressures in the ventricle. Preload can be reduced by reducing circulating blood volume, by increasing the capacitance of the venous bed, and by improving systolic function to more effectively empty the ventricle. Diuretics are the most effective agents for reducing blood volume. Oral thiazide or loop diuretics are effective for long-term diuresis, but intravenous loop diuretics such as furosemide or bumetanide are more potent for severe CHF or pulmonary edema.

55. a. The SA node is the primary pacemaker of the heart and is located in the right atrium just inferior to the entrance to the superior vena cava. The electrical impulse that originates in the SA node is conducted down through the atria and ventricles. If the SA node function is absent, secondary pacemakers in the AV junction, the bundle of His, or the ventricle can generate stimuli and maintain the heartbeat. Normally, stimulus formation in these other secondary pacemaker sites is slower than that of the SA node.

56. a. A bradyarrhythmia is any rhythm resulting in a ventricular rate of <60 beats per minute (bpm). Sinus bradycardia is a sinus rhythm (initiated by the SA node) that is slower than 60 bpm. Sinus bradycardia is usually harmless and can be found in normal individuals and athletes. Treatment is usually not indicated. AV block is caused by a delay or block in conduction through the AV junction. First-degree AV block is asymptomatic and is diagnosed by prolongation of the PR interval. There are two types of second-degree AV block. In the Wenckebach type, the ECG reveals progressive PR prolongation prior to a nonconducted P wave. In Mobitz type II AV block, the QRS complex is dropped at regular intervals. In complete, or third-degree, AV block, all of the atrial stimuli are blocked at the AV node, so the P waves from the atria and the QRS complexes are completely asynchronous. Complete AV block is usually more ominous. The right ventricle and left ventricle receives its electrical impulse from the bundle of His from the right bundle branch and left bundle branch respectively. Conduction deficits in either of these can lead to either a right bundle branch block or left bundle branch block and should be evaluated for cardiac disease.

57. c. In paroxysmal atrial tachycardia (PAT), the P waves have an abnormal configuration and axis. The treatment of choice for PAT is intravenous adenosine, which has a very short half-life and success rate of converting to sinus rhythm of over 90%. In atrial fibrillation, atrial thrombi may accumulate from stagnation of blood. Anticoagulation is indicated for patients with chronic atrial fibrillation associated with valvular disease, cardiomyopathy, or cardiomegaly and before conversion to sinus rhythm is attempted.

58. a. Automated ICDs are now the first-line therapy to treat arrhythmias in patients with prior cardiac arrest or prior episodes of hemodynamically unstable ventricular tachycardia.

59. c. High HDL cholesterol is actually a “negative” risk factor and allows one to remove one risk factor from the total count. The other answer choices are major risk factors that lower LDL goals. Low HDL level (<40 mg/dL) and family history of premature CHD also make it necessary to have lower LDL goals. Anyone with coronary heart disease or diabetes should have an LDL of <100. Anyone with two or more risk factors listed in the answers should have an LDL goal of <130. Anyone with zero to one risk factor should have an LDL of <160.

60. b. HMG-CoA reductase inhibitors, or “statins,” can cause muscle soreness, tenderness, and pain. It is important to evaluate baseline muscle symptoms and CK prior to initiating therapy, every 6 to 12 weeks, and when the patient is having muscle soreness or pain. These medications can also cause diarrhea and increase liver transaminases. Baseline liver function tests as well as subsequent measurements should be taken in anyone who is starting a statin.

61. a. In obstructive lung disease, changes in the bronchi, bronchioles, and lung parenchyma can cause airway obstruction. Asthma is a reversible obstructive disease secondary to bronchospasm. In asthma, the airways are hyperresponsive and develop an inflammatory response to various stimuli. Irreversible obstructive disease, also referred to as chronic obstructive pulmonary disease (COPD), is the fourth leading cause of death in the United States.

62. c. Restrictive lung diseases are a diffuse group of conditions that cause diffuse parenchymal damage. The consequences of this damage include a reduction in total lung volume, diffusing capacity, and vital capacity.

63. b. Although all of the answer choices can reduce the symptoms in patients with COPD, smoking cessation is still the most effective means of reducing the risks and slowing progression of COPD.

64. a. Subcutaneous epinephrine can be used to manage an acute asthma attack. More commonly used medications for an acute asthma attack are the short-acting beta-2 adrenergic agonists such as albuterol and terbutaline. Salmeterol is a long-acting beta-2 adrenergic agonist and is helpful for maintenance treatment of asthma, not for acute exacerbations. Cromolyn is a mast cell stabilizer and is not used acutely. Inhaled steroids such as beclomethasone can be used for long-term therapy for reducing bronchial hyperreactivity.

65. d. The Nocturnal Oxygen Therapy Trial (NOTT), a multicenter randomized trial, demonstrated that continuous low-flow oxygen therapy for patients with severe COPD resulted in improved survival. Patients receiving supplemental oxygen, however, must be carefully monitored because such treatment may decrease the respiratory drive to eliminate carbon dioxide.

66. c. Circulating RBCs have a lifespan of about 120 days.

67. c. Erythropoietin is produced mainly in the kidneys. Any reduction in oxygen tension in the kidneys, for example, hypoxemia, low hemoglobin level, or arterial insufficiency, stimulates production of erythropoietin.

68. a. Anemia is diagnosed in adults if the hematocrit is <13.5 g/dL in males and <12 g/dL in females. Iron deficiency anemia is by far the most common type of anemia worldwide. A source of blood loss must be ruled out in any patient with iron deficiency anemia. Menstrual blood loss plays a major role in females. Gastrointestinal blood loss plays a major role in both men and women.

69. d. The usual classification of anemias is based on their pathophysiologic mechanism, for example, iron deficiency or folic acid deficiency anemia. However, the anemias can also be classified according to the size of the RBC. Possible causes of microcytic anemia include iron deficiency, thalassemia, and anemia of chronic disease. Possible causes of macrocytic anemia include vitamin B12 or folate deficiency.

70. d. In sickle cell anemia, an abnormal hemoglobin leads to a chronic hemolytic anemia. One out of every 400 African Americans born in the United States has sickle cell anemia. Chronic hemolytic anemias can produce jaundice, gallstones, splenomegaly, and poorly healing ulcers over the lower tibia. A manifestation of sickle cell disease is acute painful episodes that are caused by the sickling of the RBCs. These painful episodes are precipitated by infection, dehydration, or hypoxia.

71. b. The PTT is most commonly used to measure the effect of heparin therapy. However, blood tests are not typically used to measure the effects of low–molecular-weight heparin.

72. d. While the PT does change with warfarin, the INR is a more useful test to measure the therapeutic effect of warfarin. For deep vein thromboses and tissue replacement heart valves, the INR typically is maintained between 2.0 and 3.0; for mechanical prosthetic replacement heart valves, the INR is maintained between 2.5 and 3.5.

73. a. Platelet disorders are by far the most common cause of abnormal bleeding. Platelet disorders may result from an insufficient number of platelets, inadequate function, or both. Mild platelet dysfunction may be asymptomatic or may cause minor bruising, menorrhagia, or bleeding after surgery. More severe dysfunction leads to petechiae, purpura, and gastrointestinal bleeding.

74. a. Von Willebrand’s disease is caused by defi-ciency or abnormality of a portion of the factor VIII molecule, called von Willebrand factor, which causes platelet adhesion abnormalities, not thrombocytopenia. ITP is the result of platelet injury by antiplatelet antibodies. Many drugs can also cause immunologic platelet destruction. These include quinine, quinidine, digitalis, procainamide, sulfonamides, and gold to name a few.

75. c. Aspirin irreversibly inhibits platelet aggregation for the lifespan of the circulating platelets present. This causes a prolongation in the bleeding time for at least 48 to 72 hours following ingestion. NSAIDs cause reversible inhibition of platelet function. The other answer choices can have an effect on platelet function as well.

76. c. The most common and most severe is factor VIII deficiency, called hemophilia A. Typical manifestations of this X-linked disease include severe and protracted bleeding after minor trauma and spontaneous bleeding into joints (hemarthroses), the central nervous system, and the abdominal cavity. Treatment involves infusion of coagulation factor VIII.

77. b. Vitamin K should not be given intravenously because of the risk of an anaphylactoid reaction. Vitamin K deficiency leads to prolongation of both the PT and PTT.

78. d. Factor IX deficiency, also called hemophilia B, leads to a bleeding disorder. This is much less common than hemophilia A, which is caused by a factor VIII deficiency. Protein S deficiency, prothrombin gene mutation, and factor V Leiden (which is a point mutation in the factor V gene) are all also primary hypercoagulable states. Factor V Leiden mutation is found in 3% to 7% of the white population and is far less prevalent or even absent in the black and Asian populations.

79. a. The phospholipid antibody syndrome can also lead to cerebrovascular arterial thrombotic events, not cerebral aneurysms. Ophthalmic complications include retinal vein and artery occlusion, retinal vasculitis, choroidal infarction, and anterior ischemic optic neuropathy. Tests for patients with this syndrome include anticardiolipin antibodies and lupus anticoagulants.

80. d. Rheumatoid arthritis (RA) is the most common rheumatic disorder, affecting approximately 1% of adults. RA is a symmetrical, deforming, peripheral polyarthritis characterized by synovial membrane inflammation. Approximately 80% of patients with RA are positive for rheumatoid factor. Human leukocyte antigen DR4 (HLA-DR4) is found in 70% of Caucasian seropositive patients.

81. a. The term spondyloarthropathy refers to a spectrum of diseases that share certain clinical features, including axial inflammation, asymmetric arthritis, genital lesions, skin lesions, eye inflammation, and bowel inflammation. The seronegative spondyloarthropathies are ankylosing spondylitis, reactive arthritis (also known as Reiter’s syndrome), inflammatory bowel disease (Crohn disease and ulcerative colitis), psoriatic arthritis, and juvenile idiopathic arthritis (JIA). These diseases all share an association with HLA-B27. The most common ophthalmic finding in patients with seronegative spondyloarthropathies is a nongranulomatous anterior uveitis. They are termed “seronegative” because of the lack of IgG antibodies to rheumatoid factor in serum.

82. c. While uveitis does occur in 15% to 25% of patients with reactive arthritis, it is not part of the classic triad. There is a clear genetic predisposition in that 63% to 95% of these patients are positive for HLA-B27. The male-to-female ratio is at least 5:1. Precipitating agents include Chlamydia trachomatis in the genitourinary tract and Salmonella, Shigella, Yersinia, and Campylobacter organisms in the gastrointestinal tract.

83. b. The classic features of ankylosing spondylitis are inflammatory low back pain, fusion of the axial skeleton, and sacroiliitis. The last stage of this process is a completely fused and immobilized spine, also known as “bamboo” or “poker spine.” Men are affected three times more often than women in this disease. There is a strong association with HLA-B27 (90% of patients). In Reiter’s syndrome, the arthritis typically appears within 1 to 3 weeks after the inciting urethritis or diarrhea. It is an episodic oligoarthritis primarily affecting the lower extremities, particularly the knees and ankles. Interphalangeal arthritis of the toes and fingers can lead to “sausage digits” in Reiter’s syndrome. Whittling of the distal phalanges is seen in psoriatic arthritis.

84. c. Even though HLA types DR2 and DR3 are associated with SLE suggesting a genetic predisposition, they are not used as part of the criteria for diagnosing SLE. Other criteria include malar rash, discoid rash, photosensitivity, serositis, renal disorder, neurologic disorder, hematologic disorder, and immunologic disorder. Four of these criteria are required to make the diagnosis of SLE. Also, the ANA test is virtually positive in all SLE patients but not very specific. Tw o antibodies that are highly specific for SLE are anti– double-stranded DNA (dsDNA) antibodies and anti-Smith (anti-SM) antibodies.

85. b. Scleroderma, also known as progressive systemic sclerosis, is characterized by fibrous and degenerative changes in the viscera, skin, or both. CREST (calcinosis, Raynaud’s phenomenon, esophageal involvement, sclerodactyly, and telangiectasias) is a limited form of systemic scleroderma. Renal involvement is often associated with malignant hypertension and can be a major cause of mortality in patients with scleroderma.

86. b. Sjögren’s syndrome is characterized by rheumatoid arthritis, dry mouth, and dry eyes. The dry mouth and dry eyes is because of an inflammatory infiltrate into the lacrimal and salivary glands. Patients with Sjögren’s syndrome often have autoantibodies known as anti-SS-A and anti-SS-B.

87. a. A heliotrope rash around the eyelids (image A, violaceous erythema) and Gottron’s sign (image B, plaques on finger knuckles) are seen in dermatomyositis. The heliotrope rash is the most specific rash in dermatomyositis, but it is present in only a minority of patients. Dermatomyositis is distinguished from polymyositis by the presence of cutaneous lesions. Laboratory findings include elevated serum levels of skeletal muscle enzymes and abnormal electromyography results.

88. d. Laryngotracheobronchial disease may lead to a fatal complication from laryngeal collapse. Cardiovascular lesions include aortic insufficiency and vasculitis. Ocular manifestations occur in approximately 50% of patients with this disease with the most common ocular conditions being conjunctivitis, scleritis, uveitis, and retinal vasculitis.

89. c. Caucasians are most commonly affected with GCA. It is particularly common in northern European countries such as Scandinavia. Clinical features include headache, polymyalgia rheumatica, jaw claudication, constitution symptoms, and ophthalmic symptoms. Signs include tenderness over the temporal artery, a pulseless temporal artery, scalp tenderness, fever, and loss of vision. The most common laboratory result in GCA is an elevated ESR. Temporal artery biopsy is suggested for all cases of suspected GCA. Treatment with corticosteroids should not be delayed pending laboratory results.

90. c. Cogan’s syndrome is a constellation of hearing loss, tinnitus, vertigo, and interstitial keratitis. Polyarteritis nodosa (PAN) is characterized by necrotizing vasculitis of the medium-sized and small-muscular arteries. Takayasu arteritis affects large arteries, particularly branches of the aorta. Other names for Takayasu arteritis are aortic arch arteritis, aortitis syndrome, and pulseless disease. It occurs primarily in children and young women and is common in the Far East, particularly Japan. Wegener’s granulomatosis is a necrotizing granulomatous vasculitis of both the upper and lower respiratory tract and can lead to a focal segmental glomerulonephritis; 80% of patients with Wegener’s granulomatosis are serum positive for a cytoplasmic pattern of antineutrophil cyto-plasmic antibodies (c-ANCA). In Churg-Strauss syndrome, eosinophilia is generally present and asthma is the principal feature.

91. a. Behçet’s syndrome was initially described as a triad of oral ulcers, genital ulcers, and uveitis with hypopyon. Oral ulcers are the most common clinical feature, affecting over 98% of patients. Genital ulcers occur in 80% to 87% of these patients and skin disease occurs in 69% to 90% of these patients. Pathergy, which is a pustular response to skin injury, and dermatographism can also be seen. Behçet’s syndrome is most common in the Middle East and Far East. HLA-B51 is associated with this disease.

92. d. Orthostatic hypotension can be an effect of rapid exogenous steroid withdrawal, which can lead to adrenal insufficiency. One important mechanism in which corticosteroids have anti-inflammatory effects is through the inhibition of prostaglandin synthesis. This results from preventing the release of the prostaglandin precursor arachidonic acid from membrane phospholipids. Systemic complications include peptic ulceration, osteoporosis, aseptic necrosis of the femoral head, muscle and skin atrophy, hyperglycemia, hypertension, edema, weight gain, mental status changes, and hypokalemia.

93. b. Corneal melts and punctate keratopathy have been reported to be associated with topical NSAID administration. The most significant adverse effects from use of oral NSAIDs are gastrointestinal bleeding, renal failure, worsening hypertension, and heart failure. They can also interfere with platelet function and cause bone marrow suppression, hepatic toxicity, and CNS symptoms.

94. c. Diabetes mellitus is now defined as a group of metabolic diseases characterized by hyper-glycemia resulting from defects in insulin secretion, insulin action, or both. All of the conditions are diagnostic of having diabetes except answer choice c. Note that HbA1c measurement is not currently recommended for diagnosing diabetes.

95. a. Type 1 diabetes was previously called insulin-dependent diabetes mellitus or juvenile-onset diabetes. The peak incidence of diabetes is around the time of puberty. This form of diabetes is due to a deficiency in endogenous insulin secretion secondary to destruction of insulin-producing beta cells in the pancreas. Most type 1 diabetes is due to immune-mediated destruction characterized by the presence of various autoantibodies. One or more autoantibodies are present in 90% of patients at initial presentation, and these patients are prone to other autoimmune disorders. It appears that environmental factors play a role in this disease as well, as studies of monozygotic twins have shown that both twins develop diabetes only 30% to 50% of the time. Obesity is present in 80% to 90% of type 2 diabetics.

96. d. Type 2 diabetes accounts for 90% of Americans with diabetes. Type 2 diabetics are usually older than 40 at presentation, and obesity is a frequent finding. Other risk factors include hypertension, gestational diabetes, physical inactivity, and low socioeconomic status. There is also a strong genetic tendency for developing type 2 diabetes, though no specific genetic locus has been associated with the disease. Autoimmune destruction of beta cells does not usually occur in type 2 diabetes. Instead, there is insulin resistance in target tissues and a gradual loss of compensatory insulin production by the beta cells.

97. b. Volatile anesthetics such as halothane, enflurane, isofulrane, and most notably intravenous succinylcholine are all known to trigger malignant hyperthermia. Tachycardia and elevated carbon dioxide levels at end-tidal volumes are the earliest signs of malignant hyperthermia. Labile blood pressure, tachypnea, sweating, muscle rigidity, blotchy discoloration of the skin, cyanosis, and dark urine all signal progression of the disorder. This disorder can be fatal if diagnosis is delayed.

98. a. The Somogyi phenomenon is the occurrence of posthypoglycemic rebound hyperglycemia. Growth hormone and catecholamines are thought to cause the Somogyi phenomenon. Recognition of this process is important because patients may incorrectly decide to increase their longer-acting insulin dose to treat the hyperglycemia and thereby increase the hypoglycemia that precipitated the problem.

99. b. In screening for thyroid disease, the combination of free T4 and sensitive TSH assays has a sensitivity of 99.5% and a specificity of 98%.

100. b. Patients with Graves hyperthyroidism exhibit various combinations of hypermetabolism, diffuse enlargement of the thyroid gland, ophthalmopathy (exophthalmos and lid retraction seen in the figure), and infiltrative dermopathy. Although the exact cause is not known, Graves hyperthyroidism is thought to be an autoimmune disorder, with 85% to 90% of patients having circulating TSH receptor antibodies. This disease is common with a 10:1 female preponderance. The incidence peaks in the third and fourth decades of life. Current smoking is associated with an increased incidence of ophthalmopathy.

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