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 19th Edition

‘HAISON’S P L E 8

IN T 0E H N A0L
M E D | C | N E
SELF-ASSESSMENT
AND BOARD REVIEW

WIENER

KASPER

by
Dr. Nigam Rashmi Dhar
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Graw
' . Hill
. Education
LOSCALZO
 SECTION I
General Considerations in Clinical Medicine

QUESTIONS

DIRECTIONS: Choose the one best response to each question.

I-1. All of the following statements regarding practice guidelines set forth by governing agencies and
professional organizations are true EXCEPT:
A. Clinical practice guidelines protect caregivers against inappropriate charges of malpractice, yet
do not provide protection for patients from receiving substandard care.
B. Practice guidelines have largely reached a stage of nuance allowing them to address every unique
illness and patient presented to the modern physician.
C. Practice guidelines provide a legal constraint to physicians, and deviation from guideline-based
care invariably leaves physicians vulnerable to legal action.
D. Where different organizations disagree regarding practice guidelines, a third-party agency has
been appointed to mitigate these disagreements such that now all major organizations’ guidelines
are consistent.
E. All of the above statements are not true.

I-2. Regarding molecular medicine, which of the following statements represents an INACCURATE
example of the listed area of study:
A. Exposomics: An endocrinologist studies sunlight exposure and population risk of hip fracture.
B. Metabolomics: A biochemist studies the rate of flux through the creatine kinase pathway during
the cardiac cycle.
C. Metagenomics: A biologist studies the genomic alterations in molds commonly found in human
dwellings.
D. Microbiomics: A microbiologist studies the genomic variation in thermophiles, bacteria that can
survive extreme heat near deep ocean vents.
E. Proteomics: A cardiologist studies desmosomal proteins and their posttranslational modifications
in studying arrhythmogenic right ventricular dysplasia.

I-3. Which of the following is the best definition of evidence-based medicine?

A. A summary of existing data from existing clinical trials with a critical methodologic review and
statistical analysis of summative data
B. A type of research that compares the results of one approach to treating disease with another
approach to treating the same disease
C. Clinical decision-making support tools developed by professional organizations that include
expert opinions and data from clinical trials
D. Clinical decision making supported by data, preferably randomized controlled clinical trials
E. One physician’s clinical experience in caring for multiple patients with a specific disorder over
many years
I-4. Which of the following is the standard measure for determining the impact of a health condition on
a population?
A. Disability-adjusted life-years
B. Infant mortality
C. Life expectancy
D. Standardized mortality ratio
E. Years of life lost

I-5. Which of the following statements regarding disease patterns worldwide is true?
A. Childhood undernutrition is the leading risk factor for global disease burden.
B. In a 2006 publication, the World Health Organization (WHO) estimated that 10% of the total
global burden of disease was due to modifiable environmental risk factors.
C. In 2010, ischemic heart disease was the leading cause of death among adults.
D. In the last two decades, mortality attributed to communicable diseases, maternal and perinatal
conditions, and nutritional deficiencies has remained fairly stable, with the majority (76%) of
mortality from these causes occurring in sub-Saharan Africa and southern Asia.
E. While poverty status has been shown to be linked to health status on the individual level, the
same relationship does not hold true when studying the link between national health indicators
and gross domestic product per capita among nations.

I-6. You are appointed to a governmental healthcare advisory subcommittee concerned with addressing
problems facing the global health community. Your task is to draw general conclusions from the
global fight against tuberculosis (TB) and human immunodeficiency virus (HIV)/acquired
immunodeficiency syndrome (AIDS) that may be applied in combatting other diseases, including
noncommunicable diseases. Which of the following conclusions is reasonable when considering
HIV/AIDS and TB as chronic diseases?
A. Barriers to adequate healthcare and patient adherence imposed by extreme poverty must be
concomitantly addressed to adequately treat and prevent chronic disease in developing nations.
B. Charging small fees for health services (e.g., AIDS prevention and care) supplies the patient with
a sense of the treatment’s value and increases compliance and overall public health.
C. Despite adequate available tools to practice their trade locally in developing nations, many
physicians and nurses emigrate to developed nations to practice their respective trades, a
phenomenon called “brain drain.”
D. In developed nations where physicians are abundant, community health worker supervision of
the care of chronically ill patients is not effective.
E. In the case of chronic infectious diseases, switching from one drug to another through a
prolonged course of treatment provides the highest cure rate by obviating the infectious agent’s
ability to develop resistance to any single drug.

I-7. Mrs. Jones, a 22-year-old African American woman, presents to Dr. Smith, an internal medicine
specialist, with a facial rash. Mrs. Jones states that the rash began after spending a day at the beach
with her family. She also notes that her metacarpophalangeal and proximal interphalangeal joints
have been painful and swollen for the preceding 2 weeks. On examination, the joints are swollen and
tender. Laboratory analysis discloses reduced creatinine clearance, proteinuria, and hemolytic
anemia. Antinuclear antibodies (a test with a high negative predictive value for systemic lupus
erythematosus) are detected at significant titer, and ultimately, the diagnosis of systemic lupus
erythematosus is made.
Two weeks later, Mrs. Johnson, a 24-year-old African American woman, presents with a facial rash
and elbow pain to Dr. Smith. After a cursory interview and brief physical exam, Dr. Smith sends
blood work only testing for antinuclear antibodies. When the test returns negative (no antibodies
detected), Dr. Smith presumes this to be a false-negative result and starts Mrs. Johnson on
hydroxychloroquine and prednisone for treatment of systemic lupus erythematosus. Which
heuristic(s) did Dr. Smith likely employ in diagnosing Mrs. Johnson with systemic lupus
erythematosus?
 A. Availability heuristic
B. Anchoring heuristic
C. Bayes’ rule
D. Confirmation bias
E. A and B

I-8. You have invented a blood test, which you name “veritangin,” to determine if patients are having a
myocardial infarction. You devise an experiment to determine the performance of your veritangin
assay by testing it versus the troponin assay, the currently accepted gold standard for determining
myocardial infarction, in 100 random emergency department patients with chest pain. You choose a
veritangin result >1 ng/dL as positive for myocardial infarction. Your results are listed in the table
below.

Which of the following statements regarding the characteristics of the veritangin assay in this trial is
true?
A. The posttest probability of the veritangin test does not depend on the population studied.
B. The sensitivity of the veritangin assay depends on the population studied and the disease
prevalence in that population.
C. The sensitivity of the veritangin assay will decrease by 50% if you reduce the threshold for a
positive result to >0.5 ng/dL.
D. The sensitivity of the veritangin test cannot be calculated based on the above data.
E. The specificity of the veritangin assay is 0.93 (70/75).

I-9. You are designing a clinical trial to test the use of a novel anticoagulant, clotbegone, in the
treatment of deep vein thrombosis. Which of the following statements regarding the design of the
trial is true?
A. An optimal study design would assign many patients to clotbegone and compare their outcomes
to the outcomes of prior (historical) patients not taking clotbegone. This would allow faster trial
completion.
B. If the trial returns a positive result (clotbegone is superior to placebo), that means that any
patient with a clot would benefit from clotbegone therapy.
C. Observing the outcomes of patients already taking clotbegone versus patients who are not is
preferable to assigning patients to clotbegone or placebo in a blinded fashion. The observational
strategy is more “real world,” applicable to the general population, and free of bias.
D. Population selection for the trial enrollment is not important as long as careful attention to
randomization and blinding is observed.
E. The advantage of performing a randomized clinical trial of clotbegone over a prospective
observational study of clotbegone is the avoidance of treatment selection bias.

I-10. A receiver operating characteristic (ROC) curve is constructed for a new test developed to diagnose
disease X. All of the following statements regarding the ROC curve are true EXCEPT:
A. One criticism of the ROC curve is that it is developed for testing only one test or clinical
parameter with exclusion of other potentially relevant data.
B. ROC curve allows the selection of a threshold value for a test that yields the best sensitivity with
the fewest false-positive tests.
 C. The axes of the ROC curve are sensitivity versus 1 – specificity.
D. The ideal ROC curve will have a value of 0.5.
E. The value of the ROC curve is calculated as the area under the curve generated from the true-
positive rate versus the false-positive rate.

I-11. When considering a potential screening test, what end points should be considered to assess the
potential gain from a proposed intervention?
A. Absolute and relative impact of screening on the disease outcome
B. Cost per life-year saved
C. Increase in the average life expectancy for the entire population
D. Number of subjects screened to alter the outcome in one individual
E. All of the above

I-12. You are appointed to an advisory committee in the WHO tasked with making recommendations
regarding breast cancer screening and prevention. In regard to screening and preventing breast
cancer in women, which of the following potential recommendations from your committee would be
valid?
A. Any breast cancer detected by screening mammography and adequately treated represents a
reduction in breast cancer mortality.
B. Screening is most effective when applied to relatively common diseases. Breast cancer, with a
lifetime risk of 10% in women, meets this criterion.
C. The presence of a latent (asymptomatic) stage of breast cancer renders it a less ideal disease
candidate for screening at the population level.
D. When studying the effectiveness of breast cancer screening with mammography in a population,
length of disease survival is the most important outcome to consider.
E. Women in the general population should undergo just as rigorous screening and prevention
measures for breast cancer as women with the BRCA1 or BRCA2 mutations.

I-13. You are seeing Mr. Brown today in the primary care clinic. He has a long history of tobacco abuse,
and you notice on his intake form that he wishes to discuss lung cancer screening today. Which of the
following statements regarding lung cancer screening can you truthfully make to Mr. Brown?
A. “Recently, a large National Heart, Lung, and Blood Institute study demonstrated a significant
reduction in mortality by employing low-dose chest computed tomography as a screening tool in
patients with a significant smoking history.”
B. “Screening for lung cancer has a long history of successful implementation given the ease of
obtaining a chest x-ray and the fact that most lung cancers are curable at the time of screening
detection.”
C. “Screening for lung cancer is a ‘no-brainer’; there is really no harm in a false-positive test. The
only real worry is always that you might have a cancer that we don’t know about.”
D. “Because the sensitivity and specificity of any screening test do not depend on the population
studied, your odds of having lung cancer after a positive chest x-ray do not depend on his
smoking history.”
E. “There is really no evidence of benefit for lung cancer screening by any modality.”

I-14. Which preventative intervention leads to the largest average increase in life expectancy for a target
population?
A. A regular exercise program for a 40-year-old man
B. Getting a 35-year-old smoker to quit smoking
C. Mammography in women age 50–70
D. Pap smears in women age 18–65
E. Prostate-specific antigen (PSA) and digital rectal examination for a man >50 years old

I-15. The U.S. Preventive Services Task Force (USPSTF) recommends which of the following screening
 tests for the listed patients?
A. 16-year-old male: immunoassay for HIV if not performed before
B. 32-year-old sexually active woman: nucleic acid amplification on a cervical swab for chlamydia
C. 50-year-old woman with a smoking history: dual-energy x-ray absorptiometry (DEXA) scan for
osteoporosis
D. 58-year-old prior smoker: ultrasound for abdominal aortic aneurysm
E. 80-year-old man: anti–hepatitis C virus (HCV) antibody for hepatitis C

I-16. Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?
A. Amoxicillin
B. Aspirin
C. Atorvastatin
D. Prevacid
E. Sildenafil

I-17. A 26-year-old woman received an allogeneic bone marrow transplantation 9 months ago for acute
myelogenous leukemia. Her transplant course is complicated by graft-versus-host disease with
diarrhea, weight loss, and skin rash. She is immunosuppressed with tacrolimus 1 mg twice a day (bid)
and prednisone 7.5 mg daily. She recently was admitted to the hospital with shortness of breath and
fevers to 101.5°F. She has a chest computed tomography (CT) showing nodular pneumonia, and
fungal organisms are seen on a transbronchial lung biopsy. The culture demonstrates Aspergillus
fumigatus, and a serum galactomannan level is elevated. She is initiated on therapy with voriconazole
6 mg/kg IV every 12 hours for 1 day, decreasing to 4 mg/kg IV every 12 hours beginning on day 2.
Two days after starting voriconazole, she is no longer febrile but is complaining of headaches and
tremors. Her blood pressure is 150/92 mmHg, up from 108/60 mmHg on admission. On examination,
she has developed 1+ pitting edema in the lower extremities. Her creatinine has risen to 1.7 mg/dL
from 0.8 mg/dL on admission. What is the most likely cause of the patient’s current clinical picture?
A. Aspergillus meningitis
B. Congestive heart failure
C. Recurrent graft-versus-host disease
D. Tacrolimus toxicity
E. Thrombotic thrombocytopenic purpura caused by voriconazole

I-18. A 43-year-old woman is diagnosed with pulmonary blastomycosis and is initiated on therapy with
oral itraconazole therapy. All of the following could affect the bioavailability of this drug EXCEPT:
A. Coadministration with a cola beverage
B. Coadministration with oral contraceptive pills
C. Formulation of the drug (liquid vs. capsule)
D. pH of the stomach
E. Presence of food in the stomach

I-19. Mr. Jonas is a 47-year-old truck driver with a history of HIV, hypertension, coronary artery disease,
atrial fibrillation, and ischemic cardiomyopathy. He is on antiretroviral therapy. He presents today
complaining of a new rash on his chest and axilla, which you astutely diagnose as tinea corporis. You
would like to prescribe a course of oral ketoconazole for therapy. You should consider dose
adjustment for all of the following medicines that he is already taking EXCEPT:
A. Carvedilol
B. Lovastatin
C. Mexiletine
D. Ritonavir
E. Saquinavir

I-20. Which of the following pharmacokinetic concepts is accurate?

 A. After four half-lives of a zero-order drug, 93.75% of drug elimination is achieved.
B. Elimination half-life is the sole determinant of the time required for steady-state plasma
concentrations to be achieved after any change in drug dosing.
C. First-order elimination refers to the priority a drug has for its elimination enzyme versus drugs of
alternative orders. For example, a first-order drug will have a higher affinity for the enzyme than
a second-order drug.
D. Steady state describes the situation during chronic drug dosing when the plasma concentration of
drug is identical from minute to minute. One can only truly achieve steady state with continuous
intravenous infusion.
E. The only method by which a drug can be removed from the central compartment is by
elimination.

I-21. Mr. Brooks has been seeing you in the primary care clinic for over 20 years. Recently, he was
diagnosed with amyotrophic lateral sclerosis (ALS), an almost universally fatal degenerative
neurologic condition. In consultation with his neurologist, you have started him on a high dose of a
new medication, Drug X, to alleviate muscle spasms. However, although Mr. Brooks’s muscle spasms
have improved drastically, he is experiencing dry mouth and dry eyes, side effects that were not
described in very large clinical trials of Drug X. A recent postmarketing study of Drug X was released
showing that patients with ALS taking it live, on average, 14 days less than patients not taking it. As
you discuss the plan regarding Drug X with Mr. Brooks, which statement would be valid?
A. “A recent study shows that patients taking Drug X die sooner, on average, than those not taking
it. I want to discuss your thoughts on continuing Drug X, perhaps at a lower dose, versus stopping
it.”
B. “A recent study shows that patients taking Drug X die sooner, on average, than those not taking
it. I recommend stopping it, and I anticipate the drug will be discontinued soon.”
C. “If you’re having side effects at the high dose, it’s certain that you’ll have the same side effects at
a lower dose.”
D. No discussion is needed given the postmarketing data. You should stop Drug X and report the
new side effect to the U.S. Food and Drug Administration (FDA).
E. “These side effects you describe were not described in clinical trials enrolling hundreds of
patients with ALS. They cannot be from Drug X. Let’s figure out what other medication might be
causing them.”

I-22. The graph below represents a plasma time-concentration curve after a single dose of Drug A.
Which of the following statements regarding Figure I-22A is true?

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FIGURE I-22A

A. This drug was likely administered orally.

B. This drug demonstrates zero-order kinetics.
C. The shift in rapid reduction in plasma concentration to a more gradual reduction (point B) likely
represents a saturation of the eliminating enzyme.
D. Point B represents the time when drug is distributed both to and from a peripheral compartment
and eliminated from the central compartment.
E. This drug does not have a half-life given the curvilinear shape of its elimination curve.

I-23. All of the following patients are correctly matched to the drug and dose adjustment that should be
considered given their concomitant listed comorbidity EXCEPT:
A. A 57-year-old man with cirrhosis: reduced dose of sotalol
B. A 35-year-old man with renal disease: reduced dose of meperidine
C. A 97-year-old man with normal creatinine and bilirubin: reduced dose of diazepam
D. A 42-year-old man with cirrhosis: reduced dose of meperidine
E. A 35-year-old woman with a known loss-of-function allele in CYP2C9: reduced initial dose of
warfarin

I-24. Which of the following sets of drug–drug interaction and mechanism is accurately described?
A. Ibuprofen and warfarin: increased risk of GI bleeding; ibuprofen inhibition of CYP2C9
B. Sotalol and furosemide: increased risk of QT prolongation and torsades de pointes; furosemide-
induced inhibition of CYP3A4
C. Sildenafil and sublingual nitroglycerin: increased risk of hypotension; sildenafil inhibition of the
phosphodiesterase type 5 isoform that inactivates cyclic guanosine monophosphate
D. Ritonavir and lovastatin: increased risk of myotoxicity; ritonavir inhibition of CYP2C19
E. Allopurinol and azathioprine: increased risk of blood dyscrasias; allopurinol inhibition of P-
glycoprotein

I-25. Which of the following statements regarding coronary heart disease (CHD) in women when
compared to men is true?
A. Angina is a rare symptom in women with CHD.
B. At the time of diagnosis of CHD, women typically have fewer comorbidities when compared to
men.
 C. Physicians are less likely to consider CHD in women and are also less likely to recommend both
diagnostic and therapeutic procedures in women.
D. Women and men present with CHD at similar ages.
E. Women are more likely to present with ventricular tachycardia, whereas men more commonly
have cardiac arrest or cardiogenic shock.

I-26. All of the following diseases are more common in women than men EXCEPT:
A. Depression
B. Hypertension
C. Obesity
D. Rheumatoid arthritis
E. Type 1 diabetes mellitus

I-27. Which of the following statements regarding sex differences in the United States is true?
A. Due to extensive public awareness campaigns, the majority of physicians are counseling their
female patients about their risk for cardiovascular disease.
B. The leading causes of death are the same for women and men.
C. Women’s bone density and their risk for cardiovascular disease decline after menopause.
D. Women have a longer average life expectancy than men, and this difference has been unchanged
for decades.
E. Women younger than age 65 correctly believe that breast cancer is their leading health risk.

I-28. You are seeing Mrs. Robin today, a 58-year-old woman with a history of tobacco use, treated
hypertension, and moderate obesity. She is recently menopausal. You note on her intake form that
she has questions about hormone replacement therapy to reduce her risk of coronary heart disease
and stroke. Which of the following statements to Mrs. Robin would be true?
A. “Most studies suggest that combined continuous equine estrogen combined with
medroxyprogesterone acetate is superior to combined continuous equine estrogen alone in regard
to risk for stroke or heart attack.”
B. “Studies suggest that initiating hormone therapy can reduce the incidence of hot flashes, night
sweats, mood, sexual function, and bone density, but there is no change in risk for stroke,
myocardial infarction, or venous thromboembolism.”
C. “The largest trial done on hormone therapy demonstrated a benefit for hormone therapy in
reducing the risk for heart attack and stroke.”
D. “What is truly important for hormone therapy is the timing of initiation. Since you are recently
menopausal, we know that starting hormone therapy now will reduce your risk of future heart
attack.”
E. “You should definitely take low-dose aspirin daily. It has been shown to reduce the risk of
coronary heart disease in women more than men.”

I-29. Which of the following statements is true regarding sex differences in disease?
A. Most autoimmune diseases are more prevalent in women than men. This is attributed to
stimulatory actions of estrogens and the inhibitory actions of androgens on the cellular mediators
of immunity, and hormone therapy with oral contraceptives increases the risk of autoimmune
disease.
B. Obesity decreases the risk of endometrial cancer in women.
C. Testosterone administered to hypogonadal men will increase the incidence or severity of
obstructive sleep apnea. This does not occur with testosterone administered to hypogonadal
women.
D. Women are more sensitive to insulin than are men, and thus, women’s risk for type 2 diabetes
mellitus is lower.
E. Women have a longer QT interval on average than men and are at higher risk for drug-induced
torsades de pointes.
I-30. A 67-year-old man with hypertension and sleep apnea presents to your clinic for routine follow-up.
As you open your discussion with him, he says that he has seen some commercials advising him to
ask his doctor about “low T” (low testosterone). He is interested in getting tested. Which of the
following statements to this patient is valid?
A. “If you are found to be testosterone deficient, therapy with exogenous testosterone may worsen
your sleep apnea.”
B. “It is recommended that every man above the age of 60 be tested for low total and bioavailable
testosterone.”
C. “Most studies show that testosterone concentration does not, on average, decline with advancing
age. Instead, the endogenous testosterone made is less potent.”
D. “Testosterone levels are associated with a risk for dementia in men.”
E. “While exogenous testosterone therapy can increase lean muscle mass, it also increases visceral
fat mass.”

I-31. A 29-year-old former competitive power-lifter who stopped competing 6 months earlier due to a
deltoid muscle tear confides that he and his wife have been unable to conceive despite over a year of
sexual intercourse without contraception. He wonders if there is a “shot or something that can, you
know, help me out.” You suspect that the patient may be using anabolic-androgenic steroids (AAS).
Which of the following statements is true regarding AAS use?
A. AAS users have the same mortality as the general population.
B. An elevated hematocrit should increase suspicion for AAS abuse.
C. Elevated luteinizing hormone levels and suppressed follicle-stimulating hormone levels are clues
suggesting AAS abuse.
D. Increased testicular volume is a clue for AAS abuse.
E. Several prolonged clinical trials of AAS abuse have provided the medical community with a
sophisticated understanding of the adverse effects of AAS abuse.

I-32. Mr. Brooks returns to clinic in August for his yearly follow-up. He is a 78-year-old former long-haul
trucker who enjoys fishing and traveling. During the spring and summer months, he takes
diphenhydramine daily for seasonal allergies. He has been generally feeling well, but has recently
noticed some urinary urgency, straining to void, and even urinary incontinence. You perform a
complete physical examination including a digital prostate exam and confirm benign prostatic
hypertrophy. The International Prostate Symptom Score indicates that Mr. Brooks’s symptoms are
moderate. Which of the following statements to Mr. Brooks would be appropriate?
A. “I recommend primary therapy with tolterodine, an anticholinergic agent targeted at treated
overactive bladder symptoms.”
B. “Therapy with finasteride can reduce progression to acute urinary retention and need for prostate
surgery.”
C. “Urodynamic studies are warranted; I’ll refer you now.”
D. “We should go straight to surgery. Given the severity of your symptoms, medical therapy is
unlikely to help much.”
E. “Your use of diphenhydramine is probably working to improve your lower urinary tract
symptoms given its anticholinergic properties.”

I-33. A 24-year-old woman comes to clinic for a routine visit. She is 28 weeks pregnant with her first
child. To date, her pregnancy has been unremarkable and she has no family history of complicated
pregnancies. Her past medical history is unremarkable except for a history of mitral valve prolapse. A
blood pressure greater than which of the following would be considered potentially abnormally
elevated?
A. 110/80 mmHg in the standing position
B. 120/80 mmHg in the standing position 2 minutes after rising from the supine position
C. 130/85 mmHg in the left lateral recumbent position
D. 130/85 mmHg in the seated position
 E. 140/90 mmHg in the seated position

I-34. A 36-year-old nulliparous woman is found to have a blood pressure of 150/95 mmHg on a routine
prenatal screening examination at 25 weeks’ gestation. Prior to this visit, her blood pressure was
typically 125/80 mmHg. She has a history of well-controlled diabetes and hyperlipidemia. Her exam
is notable for a body mass index (BMI) of 28, 2+ pretibial edema, and a 3/6 systolic flow murmur.
Laboratories are notable for normal electrolytes, serum creatinine of 1.0 mg/dL, and a urine
protein/creatinine ratio of 0.4. Which of the following findings in this patient is necessary to confirm
the diagnosis of preeclampsia?
A. Diabetes
B. Hyperlipidemia
C. Obesity
D. Pedal edema
E. Protein/creatine ratio

I-35. A 29-year-old woman who is 35 weeks pregnant has been managed with aspirin and labetalol for
preeclampsia after she was found to have elevated blood pressure and proteinuria. All of the
following findings characterize preeclampsia with severe features EXCEPT:
A. Asthma
B. Hemolysis
C. Hepatocellular injury
D. Seizure
E. Thrombocytopenia

I-36. A 33-year-old woman with diabetes mellitus, renal insufficiency, and hypertension presents to the
hospital with seizures during week 38 of her pregnancy. Her blood pressure is 165/95 mmHg. She
has 4+ proteinuria. Management should include all of the following EXCEPT:
A. Emergent delivery
B. Intravenous labetalol
C. Intravenous magnesium sulfate
D. Intravenous phenytoin

I-37. All of the following statements regarding a patient with type 1 diabetes who becomes pregnant are
true EXCEPT:
A. Early delivery should be avoided and undertaken only for obstetric or fetal indications.
B. Fasting blood glucose should be maintained 140–180 mg/dL to avoid fetal hypoglycemia.
C. Prenatal folate supplementation will decrease the risk of a fetal neural tube defect.
D. She and her child are at higher perinatal mortality risk than a patient without diabetes.
E. The child is at higher risk of macrosomia than a child from a mother without diabetes.

I-38. Which of the following thyroid function tests will likely be altered due to pregnancy?
A. Free T3
B. Free T4
C. Total T3
D. Thyroid-stimulating hormone (TSH)

I-39. Which of the following cardiovascular conditions is a contraindication to pregnancy?

A. Atrial septal defect without Eisenmenger syndrome
B. Idiopathic pulmonary arterial hypertension
C. Marfan syndrome
D. Mitral regurgitation
E. Prior peripartum cardiomyopathy with a current ejection fraction of 65%
I-40. All of the following are changes in the cardiovascular system seen in pregnancy EXCEPT:
A. Decreased blood pressure
B. Increased cardiac output
C. Increased heart rate
D. Increased plasma volume
E. Increased systemic vascular resistance

I-41. A 27-year-old woman develops left leg swelling during week 20 of her pregnancy. Left lower
extremity ultrasound reveals a left iliac vein deep vein thrombosis (DVT). Proper management
includes:
A. Bedrest
B. Catheter-directed thrombolysis
C. Enoxaparin
D. Inferior vena cava filter placement
E. Warfarin

I-42. In addition to a history and physical examination, which of the following should be performed
preoperatively to identify intermediate- or high-risk patients who may benefit from a more detailed
clinical evaluation?
A. Chest radiograph
B. Electrocardiogram
C. Liver function tests
D. Serum creatinine
E. Serum electrolytes (sodium, potassium, chloride, bicarbonate)

I-43. Which of the following patients should receive a cardiac catheterization prior to the proposed
surgery?
A. A 38-year-old man for elective bariatric surgery. He has a history of medically controlled familial
hyperlipidemia but no history of chest pain and a normal electrocardiogram (ECG). He has a
normal cardiac and pulmonary examination and can easily climb more than two flights of stairs
without stopping.
B. A 45-year-old man with a history of coronary artery bypass graft surgery 8 years ago who has
sustained a motor vehicle accident and has findings in the emergency department of abdominal
visceral bleeding.
C. A 54-year-old woman for elective cholecystectomy. She was evaluated for chest pain in the
emergency department and found to have no coronary artery calcifications on cardiac CT.
D. A 58-year-old man for elective pulmonary lobectomy to resect a malignant nodule. The patient
had an executive physical examination where the nodule was found on a chest CT; he also had an
abnormal exercise stress test.
E. A 68-year-old man for an elective radical prostatectomy. He had a coronary artery bypass graft 2
years ago and has no symptoms of heart failure or angina.

I-44. All of the following risk factors are components of the Revised Cardiac Risk Index (RCRI) that is
used to assess the risk of perioperative major cardiac events EXCEPT:
A. Congestive heart failure
B. High-risk surgery
C. Ischemic heart disease
D. Renal dysfunction
E. Thrombocytopenia

I-45. A 74-year-old man is scheduled to undergo total colectomy for recurrent life-threatening
diverticular bleeding. He has a history of idiopathic cardiomyopathy, renal insufficiency,
hypercholesterolemia, and chronic obstructive pulmonary disease (COPD). His current medications
 include metoprolol, atorvastatin, enalapril, metformin, and albuterol/ipratropium inhaler. His
symptoms are well controlled, and he has had no emergency department visits in the past year for
exacerbations of his cardiomyopathy or COPD. His blood pressure is 128/86 mmHg. His physical
examination is normal. His most recent hemoglobin A1C was 6.3%, and his creatinine is 1.5 mg/dL.
Which of his medications should be discontinued before surgery?
A. Albuterol/ipratropium inhaler
B. Atorvastatin
C. Enalapril
D. Metoprolol

I-46. A 73-year-old man with a history of COPD and an forced expiratory volume in 1 second (FEV1) of
1.3 L (40% predicted) is undergoing an elective cholecystectomy. In the postoperative period, which
of the following interventions has been shown to decrease the likelihood of pulmonary
complications?
A. Eliminating administration of narcotics
B. Incentive spirometry
C. Pulmonary artery catheterization
D. Total enteral nutrition
E. Total parenteral nutrition

I-47. Which of the following surgeries would be considered to have the greatest risk for postsurgical
complications?
A. Carotid endarterectomy
B. Nonemergent repair of a thoracic aortic aneurysm
C. Resection of a 5-cm lung cancer
D. Total colectomy for colon cancer
E. Total hip replacement

I-48. All of the following are risk factors for postoperative pulmonary complications EXCEPT:
A. Age >60 years
B. Asthma with a peak expiratory flow rate of 220 L/min
C. Chronic obstructive pulmonary disease
D. Congestive heart failure
E. FEV1 of 1.5 L

I-49. You are caring for a 56-year-old woman who was admitted to the hospital with a change in mental
status. She underwent a right-sided mastectomy and axillary lymph node dissection 3 years
previously for stage IIIB ductal carcinoma. Serum calcium is elevated at 15.3 mg/dL. A chest
radiograph demonstrates innumerable pulmonary nodules, and a head CT shows a brain mass in the
right frontal lobe with surrounding edema. Despite correcting her calcium and treating cerebral
edema, the patient remains confused. You approach the family to discuss the diagnosis of widely
metastatic disease and the patient’s poor prognosis. All of the following are components of the seven
elements for communicating bad news (P-SPIKES approach) EXCEPT:
A. Assess the family’s perception of her current illness and the status of her underlying cancer
diagnosis
B. Empathize with the family’s feelings and provide emotional support
C. Prepare mentally for the discussion
D. Provide an appropriate setting for discussion
E. Schedule a follow-up meeting in 1 day to reassess whether there are additional informational and
emotional needs

I-50. All of the following statements regarding end-of-life epidemiology in the United States are true
EXCEPT:
 A. More than 70% of deaths occur in people over 65 years old.
B. Approximately 30% of patients die as hospital inpatients.
C. Approximately 70% of deaths are preceded by a known illness.
D. Cardiovascular disease and cancer are the most common causes of death.
E. HIV/AIDS is one of the top 10 causes of death.

I-51. All of the following are components of a living will EXCEPT:

A. Delineation of specific interventions that would be acceptable to the patient under certain
conditions
B. Description of values that should guide discussions regarding terminal care
C. Designation of a healthcare proxy
D. General statements regarding whether the patient desires receipt of life-sustaining interventions
such as mechanical ventilation

I-52. A 72-year-old woman has stage IV ovarian cancer with diffuse peritoneal studding. She is
developing increasing pain in her abdomen and is admitted to the hospital for pain control. She
previously was treated with oxycodone 10 mg orally every 6 hours as needed. Upon admission, she is
initiated on morphine intravenously via patient-controlled analgesia. During the first 48 hours of her
hospitalization, she received an average daily dose of morphine of 90 mg and reports adequate pain
control unless she is walking. What is the most appropriate opioid regimen for transitioning this
patient to oral pain medication?

I-53. You are asked to consult on 62-year-old man who was recently found to have newly metastatic
disease. He was originally diagnosed with cancer of the prostate 5 years previously and presented to
the hospital with back pain and weakness. Magnetic resonance imaging (MRI) demonstrated bony
metastases to his L2 and L5 vertebrae with cord compression at the L2 level only. On bone scan
images, there was evidence of widespread bony metastases. He has been started on radiation and
hormonal therapy, and his disease has shown some response. However, he has become quite
depressed since the metastatic disease was found. His family reports that he is sleeping for 18 or
more hours daily and has stopped eating. His weight is down 12 lb over 4 weeks. He expresses
profound fatigue, hopelessness, and a feeling of sadness. He claims to have no interest in his usual
activities and no longer interacts with his grandchildren. What is the best approach to treating this
patient’s depression?
A. Do not initiate pharmacologic therapy because the patient is experiencing an appropriate
reaction to his newly diagnosed metastatic disease.
B. Initiate therapy with doxepin 75 mg nightly.
C. Initiate therapy with fluoxetine 10 mg daily.
D. Initiate therapy with fluoxetine 10 mg daily and methylphenidate 2.5 mg twice daily in the
morning and at noon.
E. Initiate therapy with methylphenidate 2.5 mg twice daily in the morning and at noon.
I-54. You are treating a 76-year-old woman with Alzheimer disease admitted to the intensive care unit
for aspiration pneumonia. After 7 days of mechanical ventilation, her family requests that care be
withdrawn. The patient is palliated with fentanyl intravenously at a rate of 25 μg/hr and midazolam
intravenously at 2 mg/hr. You are urgently called to the bedside 15 minutes after the patient is
extubated because the patient’s daughter is distraught. She states that you are “drowning” her mother
and is upset because her mother appears to be struggling to breathe. When you enter the room, you
hear a gurgling noise that is coming from accumulated secretions in the oropharynx. You suction the
patient for liberal amounts of thin salivary secretions and reassure the daughter that you will make
her mother as comfortable as possible. Which of the following interventions may help with the
treatment of the patient’s oral secretions?
A. Increased infusion rate of fentanyl
B. N-Acetylcysteine nebulized
C. Pilocarpine drops
D. Placement of a nasal trumpet and oral airway to allow easier access for aggressive suctioning
E. Scopolamine patches

I-55. You are caring for a 68-year-old man with end-stage idiopathic pulmonary fibrosis. His
performance status is currently 0; he is bed-bound and starting home hospice care. He is chronically
on nasal oxygen at 4 L/min with SaO2 of 94%. The patient reports relentless and severe dyspnea that
has worsened over the last 1–2 months. It is now his most notable complaint. Physical examination is
notable for normal vital signs other than a respiratory rate of 25/min. There is no evidence of
ongoing infection or other acute pulmonary process. Which of the following interventions would be a
reasonable first step to improve comfort for this patient?
A. Albuterol
B. Codeine
C. Increase nasal oxygen to 8 L/min
D. Lorazepam
E. Nebulized morphine

I-56. All of the following statements regarding euthanasia or physician-assisted suicide are true EXCEPT:
A. Over 70% of patients with terminal disease consider euthanasia or physician-assisted suicide for
themselves.
B. Over 75% of patients who seek physician-assisted suicide identify loss of autonomy or dignity
and inability to engage in enjoyable activities as their main reason.
C. Patients with cancer are the most common to consider euthanasia or physician-assisted suicide
for themselves.
D. Physician-assisted suicide is legal in some states in the United States.
E. Voluntary active euthanasia is not legal in the United States.

I-57. Which continent has the highest median population age?

A. Africa
B. Asia
C. Australia
D. Europe
E. North America

I-58. The systemic effects of aging cluster into four domains: body composition, discrepancy between
energy demand and utilization, homeostatic dysregulation, and neurodegeneration. All of the
following statements regarding these effects are true EXCEPT:
A. Lean muscle mass decreases after the third decade of life, whereas fat mass increases
progressively after middle age.
B. Most older individuals, even those who are healthy, develop mild increases in markers of
inflammation such as C-reactive protein and interleukin-6 when compared to younger
 individuals.
C. Peak oxygen consumption declines progressively with age.
D. The regions of the brain most likely to be atrophied with mild cognitive impairment are the
lateral prefrontal cortex and hippocampus.

I-59. Which of the following age groups is the fastest growing worldwide?
A. 1–20 years old
B. 21–40 years old
C. 41–60 years old
D. 61–79 years old
E. >80 years old

I-60. Which of the following is the most common type of preventable adverse event in hospitalized
patients?
A. Adverse drug events
B. Diagnostic failures
C. Falls
D. Technical complications of procedures
E. Wound infections

I-61. All of the following are steps in a cycle to rapidly improve a specific process EXCEPT:
A. Act
B. Check
C. Do
D. Plan
E. Reevaluate

I-62. Which of the following is projected to cause the most deaths in low- and middle-income countries
in 2030?
A. Cancer
B. Cardiovascular disease
C. HIV/AIDS, TB, malaria, and other infectious diseases
D. Intentional injuries
E. Road traffic accidents

I-63. The 2008 WHO World Health Report describes how a primary healthcare approach is necessary
“now more than ever” to address global health priorities. All of the following areas of reform were
highlighted in the report, EXCEPT:
A. Drug development
B. Leadership
C. Public policy
D. Service delivery
E. Universal health coverage

I-64. Which of the following statements regarding the Dietary Supplements Health and Education Act
(DSHEA), passed in 1994, is true?
A. Dietary supplement vendors can claim that dietary supplements maintain normal structure and
function of body systems.
B. Dietary supplement vendors can claim that dietary supplements prevent or treat diseases.
C. The FDA is given the authority to regulate advertising and marketing claims related to dietary
supplements.
D. The FDA is given the authority to regulate homeopathic products.
I-65. Which of the following descriptions best describes the term moral hazard as currently used in the
health insurance context?
A. A condition in which some individuals can be made better off without making anyone else worse
off
B. A situation in which physicians are reimbursed a fixed amount per patient and will have a
financial incentive to avoid sick patients
C. The branch of economics that seeks to explain actual phenomena without making a judgment
about the desirability of these phenomena
D. The incentives for better-insured individuals to use more medical services
E. The system in which the price of a good or service is dictated by a governmental or other
governing agency rather than by market forces

I-66. Independent of insurance status, income, age, and comorbid conditions, disparities exist between
the care received by black and white patients for which of the following scenarios?
A. Prescription of analgesics for pain control
B. Referral to renal transplantation
C. Surgical treatment for lung cancer
D. Referral for cardiac catheterization and bypass grafting
E. All of the above

I-67. All of the following are legally relevant criteria for a physician establishing decision-making
capacity in a patient EXCEPT:
A. The ability to answer basic orientation questions such as name, year, and home address
B. The ability to appreciate the situation and its consequences
C. The ability to communicate a choice
D. The ability to reason about treatment options
E. The ability to understand the relevant information

I-68. In which of the following conditions has stem cell therapy been shown to have in vivo benefit?
A. Cirrhosis
B. Ischemic heart disease
C. Parkinson disease
D. Spinal cord injury
E. Type 1 diabetes mellitus

I-69. The greatest source of nutrients and calories in an individual’s diet should come from which
source?
A. Alcohol
B. Carbohydrates
C. Fat
D. Protein

I-70. You are evaluating the vitamin D intake for a 32-year-old woman who is not pregnant or lactating.
It is found to be below the recommended dietary allowance (RDA), although a serum level of vitamin
D has been measured previously as within normal limits. Which statement is true with regard to this
scenario?
A. Dietary reference intakes (DRI) would have been a better tool to determine if her nutrient intake
was adequate.
B. Given the normal serum level of vitamin D, there is no reason to increase her intake of vitamin D.
C. RDA is not the best measure for evaluating the nutrient requirements of this individual.
D. All of the above statements are true with regard to this scenario.
I-71. A 56-year-old man was admitted to the surgical service for care due to exposure injury and
frostbite in his distal extremities. He has a longstanding history of alcoholism, drinking about 1 L of
vodka on a daily basis. You are asked to consult due to concerns of bizarre behaviors exhibited by the
patient. He is expressing a belief that his wounds were the result of burns that were inflicted upon
him by “torturers” in the government because he “knows too much” about government surveillance
plans. The surgical team reports it is difficult to keep the patient in his bed, and he seems unsteady
on his feet at times. He has been medicated throughout his stay for prevention of alcohol withdrawal
via a symptom-triggered approach and last received lorazepam 2 mg orally about 2 hours ago. At that
time, the patient was noted to be tremulous, tachycardic, and hypertensive. The delusional thoughts
are not responsive to treatment of alcohol withdrawal symptoms. When you see the patient, he is
sleeping quietly. Vital signs are blood pressure 110/82, heart rate 94, respiratory rate 16,
temperature 37.1°C, and SaO2 97% on room air. He awakens easily and has a minimal resting tremor.
On neurologic examination, he exhibits past pointing, difficulty with rapid alternating movements,
horizontal nystagmus, and decreased sensation to light touch and pinprick in the lower extremities
below the mid-tibia. His gait is wide based and ataxic. He no longer expresses his prior delusional
beliefs, but he is disoriented and thinks he is in jail. He states he was brought to “this gulag” so that
the government could experiment on him. He has 5% dextrose in half-normal saline infusing at 100
mL/hr and is also receiving nafcillin 2 g IV every 4 hours for cellulitis. What do you suspect is the
cause of the patient’s altered mental state?
A. Hypoglycemia
B. Hyponatremia
C. Niacin deficiency
D. Thiamine deficiency
E. Undertreated alcohol withdrawal

I-72. A 30-year-old woman expresses the desire to maintain a healthy lifestyle and has a focus on
preventative health. She believes that she can prevent illness and cancer through ingesting
supplements and antioxidants. When reviewing her current intake, you determine she is taking
vitamin A 20,000 IU daily and has been for the past 12 months. What advice can you give her
regarding this dose?
A. Chronic ingestion of this dose could be associated with an increased risk of lung cancer even in
nonsmokers.
B. Chronic ingestion of this dose is associated with yellowing of the skin but not the sclerae.
C. She should discontinue this dose prior to attempting a pregnancy as this dose could lead to an
increased risk of spontaneous abortions and congenital malformations, including craniofacial
abnormalities and valvular heart disease.
D. This dose is the highest daily recommended dose that is proven to be safe without toxicity.

I-73. A 48-year-old man is diagnosed with carcinoid syndrome after presenting with diarrhea, flushing,
and hypotension. With appropriate treatment, he experiences an appropriate response biochemically,
and his flushing and blood pressure are markedly improved. However, he continues to have some
mild diarrhea and also has mouth soreness. He remains fatigued with a loss of appetite and
irritability. On examination, you notice his tongue is bright red and somewhat enlarged. It is tender
to touch. In addition, he has a pigmented and scaling rash that is most prominent around his
neckline. What is the most likely vitamin or mineral deficiency in this patient?
A. Copper
B. Niacin
C. Riboflavin
D. Vitamin C
E. Zinc

I-74. Vitamin A deficiency is associated with an increased risk of which of the following:
A. Blindness
 B. Maternal infection and death
C. Mortality from dysentery
D. Mortality from malaria
E. All of the above

I-75. A 51-year-old alcoholic man presents to the emergency department complaining of vomiting blood.
Upon further evaluation including gastric lavage, you determine that he is not experiencing an upper
gastrointestinal (GI) bleed, but rather is having significant gingival bleeding. He is intoxicated and
complains of fatigue. Reviewing his chart, you find that he had a hemarthrosis evacuated 6 months
ago and has been lost to follow-up since then. He takes no medications. Laboratory data show
platelets of 250,000 and international normalized ratio (INR) of 0.9. He has a diffuse hemorrhagic
eruption on his legs that is centered around hair follicles. What is the recommended treatment for
this patient’s underlying disorder?
A. Folate
B. Niacin
C. Thiamine
D. Vitamin C
E. Vitamin K

I-76. A 21-year-old woman is admitted to the cardiac care unit after collapsing in her college dormitory.
When emergency personnel arrived at her home, she was found to be in a torsades de pointes
arrhythmia and was pulseless. She received cardiopulmonary resuscitation, defibrillation, and
magnesium en route to the hospital. Upon arrival, her initial potassium is 1.2 mEq/L. Her physical
examination is remarkable for an excessively thin appearance with lanugo hair on arms and chest.
Her BMI is 14.6 kg/m2. Which of the following statements is true regarding this patient’s nutritional
state?
A. Mortality in the disease is most commonly due to complications of malnutrition.
B. Poor wound healing and frequent skin infections are common complications.
C. Systemic inflammation is a predominant finding on laboratory examination.
D. The serum albumin is typically less than 2.8 g/dL.
E. Triceps skinfold <3 mm and mid-arm muscle circumference <15 cm are useful diagnostic
criteria.

I-77. A 74-year-old woman is hospitalized in the surgical intensive care unit after undergoing an
emergent colectomy for ischemic colitis related to vascular disease. At the time of surgery, she had
experienced a bowel perforation. She is currently postoperative day 10 and remains intubated and
sedated with evidence of ongoing multiorgan system failure. She requires norepinephrine infusion
continuously at a rate of 10 μg/min. She has acute renal failure and is on continuous venovenous
hemodialysis. Her blood cultures were positive for Escherichia coli, and she is being treated with
cefepime 2 g IV every 8 hours and metronidazole 500 mg every 8 hours. She has a colostomy in her
right lower quadrant, but the surgeons were unable to primarily close her abdomen due to the bowel
perforation. She has returned to the operating room for reexploration and wash out of the
peritoneum. Since admission, her fluid balance is positive more than 30 L. She has marked anasarca
and has not been fed since admission, although the team plans to initiate total parenteral nutrition
today. Which statement is most likely true regarding her nutritional state?
A. Aggressive nutritional support should be avoided.
B. Immune function is not affected.
C. The albumin is less than 2.8 g/dL.
D. The body mass index will be less than 18.5 kg/m2.
E. The nutritional state does not confer any increased mortality risk for this patient.

I-78. Which of the following patients would be LEAST likely to be at high risk of nutritional depletion?
A. A 21-year-old woman with a history of anorexia nervosa in remission for 2 months with a BMI of
 19.1 kg/m2 admitted to the hospital with an asthma exacerbation
B. A previously healthy 28-year-old man admitted to the intensive care unit with third-degree burns
covering 85% of his body surface area
C. A 32-year-old man with alcoholism admitted with acute pancreatitis who has been NPO for 6
days
D. A 41-year-old woman with short gut syndrome following resection of small bowel for a
gastrointestinal stromal tumor admitted to the hospital with dehydration
E. A 55-year-old woman admitted to the hospital for right mastectomy for breast cancer who has
recently lost 25 lb (from 200 to 175 lb) unintentionally

I-79. You are caring for a 54-year-old woman in the intensive care unit who was admitted for treatment
of severe sepsis and pneumonia. You would like to initiate enteral nutrition and plan to calculate
basal energy expenditure for the patient. All of the following factors are used to determine the
patient’s caloric needs EXCEPT:
A. Age
B. Albumin
C. Gender
D. Height
E. Weight

I-80. A 65-year-old man is admitted for colectomy for stage III colon cancer. On the second
postoperative day, he requires repeat exploratory laparotomy due to bleeding complications. It is now
postoperative day 7 from his original resection, and the patient has had no nutrition since before
surgery. His BMI before surgery was 28.7 kg/m2, and he was felt to have normal nutritional status.
He is currently clinically stable, but delirious and at high aspiration risk. He has bowel sounds
present, and ileostomy output is good. What would be recommended at the present time for this
patient?
A. Continued NPO status because 5–7 days without nutritional support is acceptable for this patient
B. Initiate a clear liquid diet and supplement with intravenous fluids with dextrose to maintain
adequate intake
C. Placement of a central venous catheter and initiation of total parenteral nutrition
D. Placement of a nasogastric tube and initiation of enteral nutrition
E. Placement of a nasojejunal tube and initiation of enteral nutrition

I-81. All of the following statements support the use of enteral feeding for critically ill patients EXCEPT:
A. Enteral feeding increases splanchnic blood flow.
B. Enteral feeding stimulates secretion of gastrointestinal hormones to promote trophic gut activity.
C. Immunoglobulin (Ig) A antibody release is stimulated by enteral feeding.
D. Neuronal activity to the gut is decreased by enteral feeding.
E. Seventy percent of nutrients used by the gut are directly derived from food within the lumen of
the gut.

I-82. What body mass index is likely to be lethal in males?

A. <10 kg/m2
B. 11 kg/m2
C. 13 kg/m2
D. 16 kg/m2
E. 18.5 kg/m2

I-83. A 43-year-old woman develops hemorrhagic pancreatitis with severe systemic inflammation
response syndrome. She is intubated and sedated in the medical intensive care unit with acute
respiratory distress syndrome, hypotension, and renal dysfunction. She has ongoing daily fevers to as
 high as 104.5°F (40.3°C). She is initiated on parenteral nutrition (PN) and develops hyperglycemia as
high as 500 g/dL. She is also noted to have an increasingly positive fluid balance of more than 2 L
daily. What is the most appropriate approach to management of PN in the context of her
hyperglycemia and fluid retention?
A. Addition of regular insulin to the total PN formula
B. Limiting sodium to less than 40 mEq/d
C. Limiting glucose to less than 200 g/d
D. Providing both glucose and fat to the total PN mixture
E. All of the above

I-84. Microbial agents have been used as bioweapons since ancient times. All of the following are key
features of microbial agents that are used as bioweapons EXCEPT:
A. Environmental stability
B. High morbidity and mortality rates
C. Lack of rapid diagnostic capability
D. Lack of readily available antibiotic treatment
E. Lack of universally available and effective vaccine

I-85. Ten individuals in Arizona are hospitalized over a 4-week period with fever and rapidly enlarging
and painful lymph nodes. Seven of these individuals experience severe sepsis and three die. While
reviewing the epidemiologic characteristics of these individuals, you note that they are all illegal
immigrants and have recently stayed in the same immigrant camp. Blood cultures are growing gram-
negative rods that are identified as Yersinia pestis. You notify local public health officials and the
Centers for Disease Control and Prevention. Which of the following factors indicates that this is NOT
likely to be an act of bioterrorism?
A. The area affected was limited to a small immigrant camp.
B. The individuals presented with symptoms of bubonic plague rather than pneumonic plague.
C. The individuals were in close contact with one another, suggesting possible person-to-person
transmission.
D. The mortality rate was less than 50%.
E. Y pestis is not environmentally stable for longer than 1 hour.

I-86. Which of the following routes of dispersal is/are likely for botulinum toxin used as a bioweapon?
A. Aerosol
B. Contamination of the food supply
C. Contamination of the water supply
D. A and B
E. All of the above

I-87. Anthrax spores can remain dormant in the respiratory tract for how long?
A. 1 week
B. 6 weeks
C. 6 months
D. 1 year
E. 3 years

I-88. Twenty recent attendees at a National Football League game arrive at the emergency department
complaining of shortness of breath, fever, and malaise. Chest roentgenograms show mediastinal
widening on several of these patients, prompting a concern for inhalational anthrax as a result of a
bioterror attack. Antibiotics are initiated and the Centers for Disease Control and Prevention is
notified. What form of isolation should be instituted for these patients in the hospital?
A. Airborne
 B. Contact
C. Droplet
D. None

I-89. The Centers for Disease Control and Prevention has designated several biologic agents as category
A in their ability to be used as bioweapons. Category A agents include agents that can be easily
disseminated or transmitted, result in high mortality, can cause public panic, and require special
action for public health preparedness. All the following agents are considered category A EXCEPT:
A. Bacillus anthracis
B. Francisella tularensis
C. Ricin toxin from Ricinus communis
D. Smallpox virus
E. Y pestis

I-90. In September 2001, the U.S. public was exposed to a bioweapon agent delivered through the U.S.
Postal Service. Characteristic lesions of this infectious agent are shown in Figure I-90, Parts A and B,
below.
FIGURE I-90

Which of the following was the agent responsible for this event?
A. B anthracis
B. Botulinum toxin
C. Ebola virus
D. Variola major
E. Y pestis

I-91. All of the following chemical agents of bioterrorism are correctly identified by their mechanism of
injury EXCEPT:
A. Arsine—asphyxiant
B. Chlorine gas—pulmonary damage
C. Cyanogen chloride—nerve agent
D. Mustard gas—vesicant
E. Sarin—nerve agent

I-92. Over the course of 12 hours, 24 individuals present to a single emergency department complaining
of a sunburn-like reaction with development of large blisters. Most of these individuals are also
experiencing irritation of the eyes, nose, and pharynx. Two individuals developed progressive
dyspnea, severe cough, and stridor requiring endotracheal intubation. On physical examination, all of
the patients exhibited conjunctivitis and nasal congestion. Erythema of the skin was greatest in the
axillae, neck, and antecubital fossae. Many of the affected individuals had large, thin-walled bullae
on the extremities that were filled with a clear or straw-colored fluid. On further questioning, all of
the affected individuals had been shopping at a local mall within the past 24-hours and ate at the
 food court. Many commented on a strong odor of burning garlic in the food court at that time. You
suspect a bioterrorism act. Which of the following statements is true with regard to the likely agent
causing the patients’ symptoms?
A. 2-Pralidoxime should be administered to all affected individuals.
B. The associated mortality of this agent is more than 50%.
C. The cause of respiratory distress in affected individuals is related to direct alveolar injury and
adult respiratory distress syndrome.
D. The erythema that occurs can be delayed as long as 2 days following exposure and depends upon
several factors including ambient temperature and humidity.
E. The fluid within the bullae should be treated as a hazardous substance that can lead to local
reactions and blistering with exposure.

I-93. A 24-year-old man is evaluated immediately following exposure to chlorine gas as an act of
chemical terrorism. He currently denies dyspnea. His respiratory rate is 16/min, and oxygen
saturation is 97% on room air. All of the following should be included in the immediate treatment of
this individual EXCEPT:
A. Aggressive bathing of all exposed skin areas
B. Flushing of the eyes with water or normal saline
C. Forced rest and fresh air
D. Immediate removal of clothing if no frostbite
E. Maintenance of a semi-upright position

I-94. You are a physician working in an urban emergency department when several patients are brought
in after the release of an unknown gas at the performance of a symphony. You are evaluating a 52-
year-old female who is not able to talk clearly because of excessive salivation and rhinorrhea,
although she is able to tell you that she feels as if she lost her sight immediately upon exposure. At
present, she also has nausea, vomiting, diarrhea, and muscle twitching. On physical examination, the
patient has a blood pressure of 156/92 mmHg, a heart rate of 92, a respiratory rate of 30, and a
temperature of 37.4°C (99.3°F). She has pinpoint pupils with profuse rhinorrhea and salivation. She is
also coughing profusely, with production of copious amounts of clear secretions. A lung examination
reveals wheezing on expiration in bilateral lung fields. The patient has a regular rate and rhythm
with normal heart sounds. Bowel sounds are hyperactive, but the abdomen is not tender. She is
having diffuse fasciculations. At the end of your examination, the patient abruptly develops tonic-
clonic seizures. Which of the following agents most likely caused this patient’s symptoms?
A. Arsine
B. Cyanogen chloride
C. Nitrogen mustard
D. Sarin
E. VX

I-95. All the following should be used in the treatment of the patient in the previous question EXCEPT:
A. Atropine
B. Decontamination
C. Diazepam
D. Phenytoin
E. 2-Pralidoxime chloride

I-96. All of the following statements regarding the results of detonation of a low-yield nuclear device by
a terror group are true EXCEPT:
A. After recovery of initial exposure symptoms, the patient remains at risk of systemic illness for up
to 6 weeks.
B. Appropriate medical therapy can change the median lethal dose from approximately 4 Gy to 8
Gy.
 C. Initial mortality is mostly due to shock blast and thermal damage.
D. Most of the total mortality is related to release of alpha and beta particles.
E. The hematopoietic, gastrointestinal, and neurologic systems are most likely involved in acute
radiation syndrome.

I-97. A “dirty” bomb is detonated in downtown Boston. The bomb was composed of cesium-137 with
trinitrotoluene. In the immediate aftermath, an estimated 30 people were killed due to the power of
the blast. The fallout area was about 0.5 mile, with radiation exposure of approximately 1.8 Gy. An
estimated 5000 people have been potentially exposed to beta and gamma radiation. Most of these
individuals show no sign of any injury, but about 60 people have evidence of thermal injury. What is
the most appropriate approach to treating the injured victims?
A. All individuals who have been exposed should be treated with potassium iodide.
B. All individuals who have been exposed should be treated with Prussian blue.
C. All individuals should be decontaminated prior to transportation to the nearest medical center for
emergency care to prevent exposure of healthcare workers.
D. Severely injured individuals should be transported to the hospital for emergency care after
removing the victims’ clothes, because the risk of exposure to healthcare workers is low.
E. With this degree of radiation exposure, no further testing and treatment are needed.

I-98. A 38-year-old man was hiking in a national forest near Tallahassee, Florida, when he was bitten on
his lower right leg by a snake that his hiking companion identified as a rattlesnake. The man was
wearing shorts and hiking boots. There are two clear puncture wounds that are oozing blood just
above the sock line of his right boot, and the man is beginning to complain of increasing pain in the
right leg. The man and his companion are about 15 minutes away from the trailhead and do not have
a cell phone. What should be done immediately in the care of this patient?
A. Apply a splint if available to support the limb and decrease pain and seek immediate medical
care
B. Apply a tourniquet superior to the bite to limit circulation of the venom
C. Incise or apply suction to the site of the bite immediately to attempt to remove injected venom
D. When possible, elevate the limb to heart level
E. A and D only
F. All of the above

I-99. The companion of the patient in Question I-98 assists him to the trailhead and activates emergency
medical services. Upon arrival to the emergency department, the patient is noted to have increasing
swelling and pain in the right lower extremity. The vital signs are blood pressure 98/52 mmHg, heart
rate 132 bpm, respiratory rate 24/min, SaO2 96% on room air, and temperature 37.0°C. The limb is
positioned at the level of the heart. The maximum level and progression of swelling is marked. Two
large-bore IV’s are placed, and aggressive fluid resuscitation is begun. Which of the following is an
indication for administration of antivenom?
A. Coagulopathy
B. Hypotension unresponsive to fluid administration
C. Swelling in the right lower leg that crosses the ankle
D. Swelling in the right lower leg that involves more than half of the leg
E. All of the above would be indications for antivenom administration

I-100. Four individuals from the same family present to the emergency department with symptoms of
abdominal pain, nausea, vomiting, and diarrhea. Two of the family members are also reporting
strange tingling sensations around their lips, and one person says he feels like he is swallowing
bubbles. The family is vacationing in Florida and have been deep sea fishing all day. For dinner, they
ate some of the fish they had caught, including some small barracuda. Emergency department
evaluation is unrevealing, and they are discharged with only symptomatic nausea treatment. Over the
next 24 hours, their GI symptoms peak and then resolve within 3 days. The two individuals with mild
paresthesias also resolve over 3 days. However, one individual develops reversal of hot and cold
 perception after 3 days. This symptom continued to persist after 6 weeks. What was the likely cause
of the patients’ illness?
A. Ciguatera poisoning
B. Diarrhetic shellfish poisoning
C. Domoic acid intoxication
D. Scombroid poisoning
E. Tetrodotoxin poisoning

I-101. A 42-year-old woman and her 6-year-old daughter have each been treated for head lice with two
applications of over-the-counter 1% permethrin separated by 10 days. Mechanical removal of lice and
their eggs was performed after each application. Environmental measures have included washing all
bedding in hot water and drying at >55°C. The father’s head is shaved. Despite this, the daughter is
again found to have live lice on her scalp. What measures would you recommend at this time?
A. Apply topical treatments such as petrolatum to avoid further exposure to pesticide
B. Complete an additional treatment with 1% permethrin
C. Perform a more thorough environmental investigation for possible fomite transmission
D. Refrain from all participation in school until the child is determined to be free of all nits (lice
eggs)
E. Treat with topical spinosad due to permethrin resistance

I-102. A 56-year-old man seeks evaluation due to a spider bite. He was dressing this morning and pulled
a sweatshirt over his head. He felt a sharp sting on his upper arm and found a brown recluse spider in
his clothing. He has noticed some redness in this area. On examination, you see a 3 × 2 cm lesion on
the inner area of his upper arm. In the center, it is somewhat pale and indurated, but the surrounding
area is erythematous and painful to touch. What is the best treatment for this patient?
A. Administer antivenom
B. Advise the patient that most patients develop ischemic necrosis that requires prolonged healing
C. Apply RICE (rest, ice, compression, and elevation) and observe closely for signs of ischemia
D. Prescribe clindamycin 600 mg qid for cellulitis
E. Refer to the emergency department for further evaluation and possible debridement

I-103. One of your patients is contemplating a trekking trip to Nepal at elevations between 2500 and
3000 meters. Five years ago, while skiing at Telluride (altitude 2650 meters), she recalls having
headache, nausea, and fatigue within a day of arriving that lasted about 2–3 days. All of the
following statements are true regarding the development of acute mountain sickness in this patient
EXCEPT:
A. Acetazolamide starting 1 day before ascent is effective in decreasing the risk.
B. Ginkgo biloba is not effective in decreasing the risk.
C. Gradual ascent is protective.
D. Her prior episode increases her risk for this trip.
E. Improved physical conditioning before the trip decreases the risk.

I-104. A 36-year-old man develops shortness of breath, dyspnea, and dry cough 3 days after arriving for
helicopter snowboarding in the Bugaboo mountain range in British Columbia (elevation 3000
meters). Over the next 12 hours, he becomes more short of breath and produces pink frothy sputum.
An emergency medical technician (EMT)–trained guide hears crackles on chest examination. All of
the following statements are true regarding his illness EXCEPT:
A. Descent and oxygen are most therapeutic.
B. Exercise increased his risk.
C. Fever and leukocytosis may occur.
D. He should never risk return to high altitude after recovery.
E. Pretreatment with nifedipine or tadalafil would have lowered his risk.
I-105. Which of the following is considered an absolute contraindication to hyperbaric oxygen therapy?
A. Carbon monoxide poisoning
B. History of COPD
C. History of high-altitude pulmonary edema
D. Radiation proctitis
E. Untreated pneumothorax

I-106. A 35-year-old woman is scuba diving while vacationing in Malaysia. During her last dive of the
day, her regulator malfunctioned, requiring her to ascend from 20 meters to the surface rapidly.
Upon returning to the boat she felt well. However, about 6 hours after returning to shore, she
develops diffuse itching and muscle aches, leg pain, blurred vision, slurred speech, and nausea.
Which of the following statements regarding her condition is true?
A. Decompression illness is unlikely at 20-meter water depth.
B. Inhalation of 100% oxygen is contraindicated.
C. She can never again scuba dive to a depth greater than 6 meters.
D. She should receive recompression and hyperbaric oxygen therapy.
E. She should remain upright as much as possible.

I-107. A 48-year-old man is brought to the emergency department in January after being found
unresponsive in a city park. He suffers from alcoholism and was last seen by his daughter about 12
hours before being brought to the emergency department. At that time, he left their home intoxicated
and agitated. He left seeking additional alcohol as his daughter had poured out his last bottle of
vodka hoping that he would seek treatment. On presentation, he has a core body temperature of
88.5°F (31.4°C), heart rate of 48 bpm, respiratory rate of 28/min, and blood pressure of 88/44
mmHg; oxygen saturation is unable to be obtained. The arterial blood gas demonstrates a pH of 7.05,
PaCO2 of 32 mmHg, and PaO2 of 56 mmHg. Initial blood chemistries demonstrate a sodium of 132
mEq/L, potassium of 5.2 mEq/L, chloride of 94 mEq/L, bicarbonate of 10 mEq/L, blood urea
nitrogen (BUN) of 56 mg/dL, and creatinine of 1.8 mg/dL. Serum glucose is 63 mg/dL. The serum
ethanol level is 65 mg/dL. The measured osmolality is 328 mOsm/kg. ECG demonstrates sinus
bradycardia with a long first-degree atrioventricular block and J waves. In addition to initiating a
rewarming protocol, what additional tests should be performed in this patient?
A. Endotracheal intubation with hyperventilation to a goal PaCO2 of less than 20 mmHg
B. Intravenous hydration with a 1- to 2-L bolus of warmed lactated Ringer’s solution
C. No other measures necessary because interpretation of the acid-base status is unreliable with this
degree of hypothermia
D. Measure levels of ethylene glycol and methanol
E. Placement of a transvenous cardiac pacemaker

I-108. A homeless male is evaluated in the emergency department. He has noted that after he slept
outside during a particularly cold night his left foot has become clumsy and feels “dead.” On
examination, the foot has hemorrhagic vesicles distributed throughout the foot distal to the ankle.
The foot is cool and has no sensation to pain or temperature. The right foot is hyperemic but does not
have vesicles and has normal sensation. The remainder of the physical examination is normal. Which
of the following statements regarding the management of this disorder is true?
A. Active foot rewarming should not be attempted.
B. During the period of rewarming, intense pain can be anticipated.
C. Heparin has been shown to improve outcomes in this disorder.
D. Immediate amputation is indicated.
E. Normal sensation is likely to return with rewarming.

I-109. Which of the following is the major source of heat loss in normal adults?
A. Kidney/urine
B. Skin
 C. Stomach/bowel
D. Upper/lower respiratory system

I-110. A 74-year-old man is brought to the emergency department by ambulance after being found in his
yard confused and somnolent. He was outside trimming hedges with an electric cutter during a hot
summer day for about 2–3 hours prior to being found by his wife. He has a history of mild-moderate
systolic heart failure, and his medications include atorvastatin, metoprolol, and losartan. He lives
with his wife and works as a TSA officer in the airport. On examination, he is difficult to arouse and
confused, with a heart rate of 120 bpm, blood pressure of 100/50 mmHg, respiratory rate of 26
breaths/min, oxygen saturation of 97% on room air, and temperature of 41°C. His skin is dry and
warm with the rest of the physical examination unremarkable. His laboratory studies are notable for
a sodium of 146 mEq/L, potassium of 3.8 mEq/L, creatine kinase of 250 U/L (reference 25–200 U/L),
glucose of 120 mg/dL, BUN of 35 mg/dL, and creatinine of 1.2 mg/dL. Which of the following is the
most likely diagnosis?
A. Cerebral hemorrhage
B. Classic heat stroke
C. Exertional heat stroke
D. Neuroleptic malignant syndrome
E. Statin-induced rhabdomyolysis

I-111. In the patient described in Question I-110, which is the most appropriate therapy?
A. Cold water bladder irrigation
B. Cooling blankets
C. Evaporative cooling
D. Immersion cooling
E. Phenylephrine

ANSWERS

I-1. The answer is E. (Chap. 1) Practice guidelines have been developed by many professional
organizations and agencies as a decision-making aid to caregivers. Most organizations attempt to
incorporate the most recent available evidence and concerns of cost-effectiveness into their
guideline formulations. Despite increasing levels of nuance in current guidelines, they cannot be
expected to account for the uniqueness of each individual and his or her illness. Furthermore,
many discrepancies exist in guidelines from major organizations. By setting a standard of
reasonable care in most cases, clinical guidelines provide protection to both clinicians (from
inappropriate charges of malpractice) and to patients, particularly those with inadequate
healthcare resources. Even though guidelines do provide this protection, they do not provide a
rigid legal constraint for the conscientious physician. The physician’s challenge is to incorporate
the useful recommendations provided by the experts in guidelines and incorporate them into the
care of each individual patient.

I-2. The answer is D. (Chap. 1) The field of molecular medicine is seeing rapid progress in fields
other than genetics, bringing a new era of “-omics.” Metagenomics is the genomic study of
environmental species that have the potential to influence human biology directly or indirectly.
Metabolomics is the study of the range of metabolites in cells or organs and ways in which they are
altered in disease states. Microbiomics is the study of the resident microbes in humans and other
mammals. Thermophiles do not reside in humans or other mammals by definition, and thus, their
study would not be included in the field of microbiomics. This field has proven particularly rich;
the microbes residing on and in the human body comprise over 3–4 million genes (vs. the 20,000
genes in the human haploid genome). Proteomics is the study of the library of proteins made in a
cell or organ (including posttranslational modifications) and its complex relationship to disease.
Exposomics is the study cataloguing environmental exposures and their impact on health and
 disease.

I-3. The answer is D. (Chap. 1) Evidence-based medicine (EBM) is an important cornerstone to the
effective and efficient practice of medicine. EBM refers to the concept that clinical decisions
should be supported by data with the strongest evidence gleaned from randomized controlled
clinical trials. In many situations, data from observational studies such as cohort or case-control
studies supply important information and contribute to the evidence used in clinical decisions in
EBM. EBM is used by professional organizations and other agencies to formulate clinical practice
guidelines, which are support tools to aid clinical decision making (option C). Systematic reviews
summarize the accumulated data from all existing clinical trials (option A). Comparative
effectiveness research (option B) compares different approaches to treating disease to determine
effectiveness from a clinical and cost-effectiveness standpoint. Anecdotal evidence (option E) is
the weakest type of evidence, represents one individual’s clinical experience, and is subject to the
bias inherent in one practitioner’s personal experience.

I-4. The answer is A. (Chap. 2) The disability-adjusted life-year (DALY) is the standard measure for
determining global burden of disease by the World Health Organization. This measure takes into
account both absolute years of life lost due to disease (premature death) as well as productive
years lost due to disability. DALY is felt to more accurately reflect the true effects of disease
within a population because individuals who become disabled cannot contribute fully to society.
Life expectancy, years of life lost due to disease, standardized mortality ratios, and infant
mortality do provide important information about the general health of a population but do not
capture the true burden of disease.

I-5. The answer is C. (Chap. 2) Although 24.6% of deaths worldwide were due to communicable
diseases, maternal and perinatal conditions, and nutritional deficiencies in 2010, this represented
a striking decrease with figures from 1990, when these conditions accounted for 34% of
worldwide mortality (option A). The majority of mortality from these causes occurs in sub-
Saharan Africa or southern Asia (76%). Poverty status and health are strongly linked both at the
individual and national levels (option C). In 1990, childhood undernutrition was the leading risk
factor for global disease burden. However, in 2010, the three leading risk factors for global
disease burden were high blood pressure, tobacco smoking (including secondhand smoke), and
alcohol use (option D). Childhood undernutrition ranked eighth in 2010, which remains vexing
given the rise of obesity as a global risk factor for disease. The WHO in 2006 estimated that a full
25% of total global burden of disease was due to modifiable risk factors. This includes remarkable
estimates that 80% of cardiovascular disease and type 2 diabetes and 40% of all cancers can be
prevented through healthier diets, increased physical activity, and avoidance of tobacco.

I-6. The answer is A. (Chap. 2) Examining AIDS and TB as chronic diseases—instead of simply
communicable diseases—makes it possible to draw a number of conclusions, many of them
pertinent to global health in general. One of the most striking lessons is that these chronic
infections are best treated with multidrug regimens to which the infecting strains are susceptible.
This involves the concomitant administration of several drugs, instead of a switching from one
drug to another throughout the course of treatment (option E), a strategy more likely to lead to
multidrug resistance in chronic infections. For people living in poverty, even small fees (option A)
for health services often pose insurmountable problems and obviates these people’s ability to
obtain important healthcare. Such services might best be seen as a public good promoting public
health. Many physicians and nurses do indeed emigrate from their homes in resource-poor
settings to practice their trades elsewhere (option C). However, a lack of tools necessary for their
practice in their home nations is the primary reason cited for their emigration. Even in areas
where physicians are abundant, community-based supervision represents the highest standard of
care for chronic disease (option D). Option B is correct;– barriers to adequate healthcare and
adherence imposed by extreme poverty (e.g., food supplements for the hungry, child care,
housing) must be addressed when treating and preventing chronic diseases in developing nations.

I-7. The answer is E. (Chap. 3) Dr. Smith likely employed both the availability heuristic and
anchoring heuristic in diagnosing Mrs. Johnson with systemic lupus erythematosus (SLE).
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spectators and the lantern. The images are made to appear
approaching and receding, by removing the lantern further from the
screen, or bringing it nearer to it. This is a great advantage over the
arrangements of the magic lantern, and by it the most astonishing
effects are often produced.

Dissolving Views.
The dissolving views, by which one landscape or scene appears to
pass into the other while the scene is changing, are produced by
using two magic lanterns, placed side by side, and that can be
inclined towards each other when necessary, so as to mix the rays of
light, proceeding from the lenses of each, together, which produces
that confusion of images, in which one view melts, as it were, into
the other, which gradually becomes clear and distinct.

How to Raise a Ghost.

The magic lantern or phantasmagoria may be used in a number of
marvelous ways, but in none more striking than in raising an
apparent specter. Let an open box, about three feet long, a foot and
a half broad, and two feet high, be prepared. At one end of this place
a small swing dressing-glass, and at the other let a magic lantern be
fixed, with the lenses in a direction towards the glass. A glass should
now be made to slide up and down in the groove to which a cord and
pulley should be attached, the end of the cord coming to the lower
part of the left hand side. On this glass the most hideous specter that
can be imagined may be painted, but in a squat or contracted
position, and when all is done, the lid of the box must be prepared by
raising a kind of gable at the end of the box, and in its lower part an
oval hole should be cut sufficiently large to suffer the rays reflected
from the glass to pass through them. On the top or the box place a
chafing-dish, upon which put some burning charcoal. Now light the
lamp in the lantern, sprinkle some powdered camphor or white
incense on the charcoal, adjust the slide on which the specter is
painted, and the image will be thrown upon the smoke. In performing
the feat the room must be darkened, and the box should be placed
on a high table, that the hole through which the light comes may not
be noticed.

To Imitate a Mirage.
Provide a glass tumbler two-thirds full of water, and pour spirits of
wine upon it; or pour into a tumbler some syrup, and fill it up with
water; when mixed, the object seen through it will be inverted.

Two-fold Reflections.
Provide a circular piece of glass, and with a common awl, moistened
with spirits of turpentine, pierce the center of the glass; hold it
encircled with the fingers and thumb in the sunshine, or the strong
light of a lamp, when these striking effects will be produced: If the
glass be red, the hole pierced in the middle will be reflected green; if
the glass be green, the spot will be red; if blue, orange; and if yellow,
indigo.

The Thaumatrope.
Cut out a piece of card-board of circular form, and affix to it six
pieces of string, three on each side. Paint on one side of the card a
bird, and on the other a cage, taking care to paint the bird upside
down, or the desired effect will not be produced. When showing the
toy, take hold of the center strings, between the forefinger and
thumb, and twirl the card rapidly around, and the bird will appear
snugly ensconced in its cage. The principle on which this effect is
produced is, that the image of any object received on the retina or
optic nerve is retained on the mind about eight seconds after the
object causing the impression is withdrawn, being the memory of the
object; consequently, the impression of the painting on one side of
the card is not obliterated ere the painting on the other side is
brought before the eye. It is easy to understand from this fact how
both are seen at once. Many objects will suit the thaumatrope, such
as a juggler throwing up two balls on one side, and two balls on the
other; and according to the pairs of strings employed, he will appear
to throw up two, three, or four balls; the body and legs of a man on
one side, and the arms and head on another; a horse and his rider; a
mouse and trap. But we leave it to the ingenuity of our readers to
devise for themselves.
 PNEUMATIC AMUSEMENTS.
The branch of the physical sciences which relates to the air and its
various phenomena is called Pneumatics. By it we learn many
curious particulars. By it we find that the air has weight and pressure,
color, density, elasticity, compressibility, and some other properties
with which we shall endeavor to make the young reader acquainted,
by many pleasing experiments, earnestly impressing upon him to
lose no opportunity of making physical science his study.
To show that the air has weight and pressure, the common leather
sucker by which boys raise stones will show the pressure of the
atmosphere. It consists of a piece of soft but firm leather, having a
piece of string drawn through its center. The leather is made quite
wet and pliable, and then its under part is placed upon the stone and
stamped down by the foot. This pressing of the leather excludes the
air from between the leather and the stone, and by pulling the string
a vacuum is left underneath its center; consequently the weight of
the air about the edges of the leather not being counterbalanced by
any air between it and the stone, enables the boy to lift it.

The Magic Tumbler.

The air which for about forty miles surrounds our earth has a definite
weight; and although we can neither see nor feel it, we are
conscious of its presence by the momentary operation of breathing.
The weight of a column of air one inch square, and forty miles high,
is about fifteen pounds.
The reason why we are not crushed down by this enormous weight
is because we are surrounded on all sides by it, and as the pressure
of weight is equal all around, it becomes, as far as we are personally
concerned, insensible.
That the air does exert a definite pressure, in consequence of its
weight, may be easily proved by any one with the above simple
apparatus—only a tumbler and a sheet of paper. Fill a tumbler quite
full of water, and carefully draw over its top a sheet of clean letter
paper, and be careful to see that there are no bubbles of air in the
water; place your hand over the paper while inverting it, and when
the glass is mouth downward the water will be kept in, until the paper
becomes wet through. The air pressing against the mouth of the
tumbler is of greater weight than the contained water, and so, until
some air can get in to supply the place of the water, it cannot fall out.

The Weight of the Air Proved by a Pair of

Bellows.
Shut the nozzle and valve-hole of a pair of bellows, and after having
squeezed the air out of them, if they are perfectly air-tight, we shall
find that a very great force, even some hundreds of pounds, is
necessary for separating the boards. They are kept together by the
weight of the heavy air which surrounds them, in the same manner
as if they were surrounded by water.

The Revolving Serpent.

This illustration represents an amusing and instructive experiment,
which proves the ascension of heated air by rendering its effects
visible, and it may also be used to test the direction of the currents in
our rooms and dwellings. To construct one, a piece of card-board is
taken and cut in the form of a spiral, and to give effect it may be
painted to represent a serpent. Then prepare a stand, having a
needle in its upper end, and suspend the serpent from its center on
the needle. If this be now placed over a stove, or the tail of the
serpent suspended by a bit of thread over a lamp, the heated air
ascending through it will cause it to revolve in a very amusing
manner. Two serpents may be made to turn in opposite directions,
by pulling out one from the one side, and the other in the reverse
direction, so that their heads may point toward each other when
suspended.

To Put a Lighted Candle Under Water.

Procure a good-sized cork, or bung; upon this place a small, lighted
taper; then set it afloat in a pail of water. Now, with a steady hand,
invert a large drinking glass over the light, and push it carefully down
into the water. The glass being full of air, prevents the water from
entering it. You may thus see the candle burn under water, and bring
it up again to the surface, still alight. This experiment, simple as it is,
serves to elucidate that useful contrivance called the diving-bell,
being performed on the same principle.
The largest drinking-glass holds but half a pint, so that your diving
light soon goes out for the want of air. As an average, a burning
candle consumes as much air as a man, and he requires nearly a
gallon of air every minute, so that, according to the size of the glass
over the flame, you can calculate how many seconds it will remain
alight; of course, a large flame requires more air than a small one.
For this, and several other experiments, a quart bell-glass is very
useful, but being expensive it is not found in every parlor laboratory:
one is, however, easily made from a green glass pickle-bottle; get a
glazier to cut off the bottom, and you have a bell-glass that Chilton
would not reject.

To Place Water in a Drinking-Glass Upside Down.

Procure a plate, a tumbler, and a small piece of tissue or silver
paper. Set the plate on a table, and pour water in it up to the first rim.
Now slightly crumple up the paper, and place it in the glass; then set
it on fire. When it is burnt out, or rather just as the last flame
disappears, turn the glass quickly upside down into the water.
Astonishing! the water rushes with great violence into the glass! Now
you are satisfied that water can be placed in a drinking-glass upside
down. Hold the glass firm, and the plate also. You can now reverse
the position of the plate and glass, and thus convince the most
skeptical of the truth of your pneumatic experiment. Instead of
burning paper, a little brandy or spirits of wine can be ignited in the
glass; the result of its combustion being invisible, the experiment is
cleaner.
 AMUSEMENTS IN MECHANICS.
There is no subject so important as mechanics, as its principles are
founded upon the properties of matter and the laws of motion; and,
knowing something of these, the tyro will lay the foundation of all
substantial knowledge.
The properties of matter are the following: Solidity (or
impenetrability), divisibility, mobility, elasticity, brittleness, malleability,
ductility and tenacity.
The laws of motion are as follows:
1. Every body continues in a state of rest, or uniform rectilineal
motion, unless affected by some extraneous force.
2. The change of motion is always proportionate to the impelling
force.
3. Action and reaction are always equal and contrary.

Experiment of the Law of Motion.

In shooting at “taw,” if the marble be struck “plump,” as it is called, it
moves forward exactly in the same line of direction; but if struck
sideways, it will move in an oblique direction, and its course will be in
a line situated between the direction of its former motion and that of
the force impressed. It is called the resolution of forces.

Balancing.
The center of gravity in a body is that part about which all the other
parts equally balance each other. In balancing a stick upon the
finger, or upon the chin, it is necessary only to keep the chin or finger
exactly under the point which is called the center of gravity.

The Balanced Coin.

It seems to be an astounding statement that a quarter, or other piece
of money, can be made to spin on the point of a needle. To perform
this experiment, procure a bottle, cork it, and in the cork place a
needle. Now take another cork and cut a slit in it, so that the edge of
the coin will fit into the slit; next place two forks in the cork, and
placing the edge of the coin on the needle, it will spin around without
falling off. The reason is this: that the weight of the forks projecting
as they do so much below the coin, brings the center of gravity of the
arrangement much below the point of suspension, or the point of the
needle, and therefore the coin remains perfectly safe and upright.

The Spanish Dancer.

The laws which govern the motion of bodies are capable of many
pleasing illustrations, and the example which we now give of causing
rotary motion is very interesting and easily performed.
Take a piece of card, and cut out a little figure, and paste or gum it in
an erect position on the inside of a watch-glass. Then procure a
black japanned waiter, or a clean plate will do, and, holding it in an
inclined position, place the figure and watch-glass on it, and they will,
of course, slide down. Next let fall a drop of water on the waiter,
place the watch-glass on it, and again incline the waiter, and instead
of the watch-glass sliding down, it will begin to revolve. It will
continue to revolve with increasing velocity, obeying the inclination
and position of the plane, as directed by the hand of the
experimentalist. The reason of this is, in the first place, in
consequence of the cohesion of the water to the two surfaces, a new
force is introduced, by which an unequal degree of resistance is
imparted to different parts of the watch-glass in contact with the
waiter, and, consequently, in its effort to slide down, it revolves.
Again, if the drop of water be observed, it will be seen that it
undergoes a change of figure; a film of water, by capillary action, is
drawn to the foremost portion of the glass, while, by the centrifugal
force, a body of water is thrown under the under part of it. The effect
of both these actions is to accelerate the motion, or, in other words,
to gradually increase the speed.
 The Mechanical Bucephalus.
The illustration of the horse furnishes a very good solution of a
popular paradox in mechanics: Given, a body having a tendency to
fall by its own weight; required, how to prevent it from falling by
adding to it a weight on the same side on which it tends to fall. Take
a horse in an erect position, the center of gravity of which is
somewhere about the middle of its body. It is evident, therefore, that
were it placed on its hinder legs, on a table, the line of its direction,
or center, would fall considerably beyond its base, and the horse
would fall on the ground; but to prevent this, there is a stiff wire
attached to a weight or bullet, connected with the body of the horse,
and by this means a horse prances on a table without falling off; so
that the figure that was incapable of supporting itself, is actually
prevented from falling by adding a weight to its unsupported end.
This seems almost impossible, but when we consider that in order to
have the desired effect, the wire must be bent, and the weight be
further under the table than the horse’s feet are on it, the mystery is
solved, as it brings the total weight of bullet and horse in such a
position that the tendency is rather to make it stand up than to let it
fall down.

The Revolving Image.

This little figure may be made to balance itself amusingly. Get a
piece of wood, about two inches long; cut one end of it into the form
of a man’s head and shoulders, and let the other end taper off to a
fine point. Next furnish the little gentleman with a pair of wafters,
shaped like oars, instead of arms, but they must be more than
double the length of his body; stick them in his shoulders, and he is
complete. When you place him on the tip of your finger, if you have
taken care to make the point exactly in the center, he will stand
upright. By blowing on the waiters he may be made to turn around
very quickly. It is explained by the reasons that were given in the
experiment of the “balanced coin.”

The Bridge of Knives.

Place three glasses in the form of a triangle, and arrange the
handles of three knives upon them. Nos. 1, 2, and 3, the blade of No.
1 over that of No. 2, and that over No. 3, which rests on No. 1. The
bridge so made will be self-supported.

The Parlor Boomerang.

The boomerang is a weapon used by the savages of Australia. By
them it is made of a flat piece of hard wood. The peculiarity of this
instrument is, that in whatever direction it is thrown, it will return to
the place from whence it started, in a curve. The Australian
aborigines use it with great dexterity, making it travel around a house
and return to their feet, or they can throw it on the ground so that it
will fly into the air, form a perfect arc over their heads, and strike
them on the back. This curious instrument can be made in miniature,
and is a very amusing toy for the parlor.
Get a piece of tolerably stiff cardboard, and cut from it a figure
resembling a boomerang.
The next thing is to propel it through the air so that it will return to
your feet; to do this, lay the boomerang on a flat book, allowing one
end to project about an inch; then, holding the book to a slight angle,
strike the projecting end of the boomerang with a piece of stick, or
heavy pen-holder, when it will fly across the room and return to your
feet.

The Balanced Turk.

A decanter or bottle is first obtained, and in its cork is placed a
needle; on this is balanced a ball of wood, having a cork or wooden
figure cut out, standing on the top. From the ball project two wires,
bent semicircularly, having at their extremities two bullets. Push the
bullets, and the whole will turn around on the needle, the figure
standing upright all the while; and, twist it about from side to side as
much as you like, it will always regain its erect position. The two
bullets in this case cause the center of gravity to fall below the ball
on which the figure is placed, and, in consequence, as the center of
gravity always assumes the lowest position, it cannot do so without
making the figure stand erect, or, in other words, until the bullets
themselves are equally balanced. Any boy may whittle one of these
toys out with a jack-knife.

The Complacent Vizier.

Among the novelties which scientific investigation has added to our
toys, are several figures which will raise themselves upright when
thrown down, and regain the erect position, notwithstanding their
equilibrium is disturbed. The figures themselves are made of the pith
of elder trees, or any other very light substance. Each is placed on
half a bullet, or may be made to stand on its head, by making its cap
of lead. Their appearance is very droll when they are moved about,
as they seem every moment to be falling over, and yet continually
right themselves. The philosophy of this is, that the center of gravity
being in the base, and always trying to assume the lowest position, it
keeps the figures upright. However much the equilibrium is
disturbed, it will always try to regain its original position.
 ARITHMETICAL AMUSEMENTS.
As the principal object of these articles is to enable the young reader
to learn something in his sports, and to understand what he is doing,
we shall, before proceeding to the curious tricks and feats connected
with the science of numbers, present him with some arithmetical
aphorisms, upon which most of the following examples are founded:

Aphorisms of Number.
1. If two even numbers be added together, or subtracted from each
other, their sum or difference will be an even number.
2. If two uneven numbers be added or subtracted, their sum or
difference will be an even number.
3. The sum or difference of an even and an uneven number added
or subtracted will be an uneven number.
4. The product of two even numbers will be an even number, and the
product of two uneven numbers will be an uneven number.
5. The product of an even and uneven number will be an even
number.
6. If two different numbers be divisible by any one number, their sum
and their difference will also be divisible by that number.
7. If several different numbers, divisible by 3, be added or multiplied
together, their sum and their product will also be divisible by 3.
8. If two numbers divisible by 9, be added together, their sum of the
figures in the amount will be either 9 or a number divisible by 9.
9. If any number be multiplied by 9, or by any other number divisible
by 9, the amount of the figures of the product will be either 9 or a
number divisible by 9.
10. In every arithmetical progression, if the first and last term be
each multiplied by the number of terms, and the sum of the two
products be divided by 2, the quotient will be the sum of the series.
11. In every geometric progression, if any two terms be multiplied
together, their product will be equal to that term which answers to the
sum of these two indices. Thus, in the series:
1 2 3 4 5
2 4 8 16 32
If the third and fourth terms, 8 and 16, be multiplied together, the
product, 128, will be the seventh term of the series. In like manner, if
the fifth term be multiplied into itself, the product will be the tenth
term; and if that sum be multiplied into itself, the product will be the
twentieth term. Therefore, to find the last, or twentieth term of a
geometric series, it is not necessary to continue the series beyond a
few of the first terms.
Previous to the numerical recreations, we shall here describe certain
mechanical methods of performing arithmetical calculations, such as
are not only in themselves entertaining, but will be found more or
less useful to the young reader.

To Find a Number Thought of.

FIRST METHOD.
EXAMPLE.
Let a person think of a number, say 6
1. Let him multiply by 3 18
2. Add 1 19
3. Multiply by 3 57
4. Add to this the number thought of 63
Let him inform you what is the number produced; it will always end
with 3. Strike off the 3, and inform him that he thought of 6.
SECOND METHOD.
EXAMPLE.
Suppose the number thought of to be 6
1. Let him double it 12
 2. Add 4 16
3. Multiply by 5 80
4. Add 12 92
5. Multiply by 10 920
Let him inform you what is the number produced. You must then, in
every case, subtract 320; the remainder is, in this example, 600;
strike off the 2 ciphers, and announce 6 as the number thought of.
THIRD METHOD.
Desire a person to think of a number—say 6. He must then proceed:
EXAMPLE.
1. To multiply this number by itself 36
2. To take 1 from the number thought of 5
3. To multiply this by itself 25
4. To tell you the difference between this 11
product and the former
You must then add 1 to it 12
And halve this number 6
Which will be the number thought of.
FOURTH METHOD.
Desire a person to think of a number—say 6. He must then proceed
as follows:
EXAMPLE.
1. Add 1 to it 7
2. Multiply by 3 21
3. Add 1 again 22
4. Add the number thought of 28
Let him tell you the figures produced 28
5. You then subtract 4 from it 24
6. And divide by 4 6
Which you can say is the number he thought of.
FIFTH METHOD.
 EXAMPLE.
Suppose the number thought of be 6
1. Let him double it 12
2. Desire him to add to this a number you tell 16
him—say 4
3. To halve it 8
You can then tell him that if he will subtract from this the number he
thought of, the remainder will be, in the case supposed, 2.
Note.—The remainder is always half the number you tell him to add.

To Discover Two or More Numbers that a Person

has Thought of.
FIRST CASE.
Where each of the numbers is less than 10. Suppose the numbers
thought of were 2, 3, 5.
EXAMPLE.
1. Desire him to double the first number, 4
making
2. To add one to it 5
3. To multiply by 5 25
4. To add the second number 28
There being a third number, repeat the
process.
5. To double it 56
6. To add 1 to it 57
7. To multiply by 5 285
8. To add the third number 290
And to proceed in the same manner for as many numbers as were
thought of. Let him tell you the last sum produced (in this case, 290).
Then, if there were two numbers thought of, you must subtract 5; if
three, 55; if four, 555. You must here subtract 55; leaving a
remainder of 235, which are the numbers thought of, 2, 3, and 5.
 SECOND CASE.
Where one or more of the numbers are 10, or more than 10, and
where there is an odd number of numbers thought of.
Suppose he fixes upon five numbers, viz., 4, 6, 9, 15, 16.
He must add together the numbers as follows, and tell you the
various sums:
1. The sum of the 1st and 2d 10
2. The sum of the 2d and 3d 15
3. The sum of the 3d and 4th 24
4. The sum of the 4th and 5th 31
5. The sum of the 1st and last 20
You must then add together the 1st, 3d, and 5th sums, viz., 10 + 24
+ 20 = 54, and the 2d and 4th, 15 + 31 = 46; take one from the other,
leaving 8. The half of this is the first number, 4; if you take this from
the sum of the 1st and 2d you will have the 2d number, 6; this taken
from the sum of the 2d and 3d will give you the 3d, 9; and so on for
the other numbers.
THIRD CASE.
Where one or more of the numbers are 10, or more than 10, and
where an even number of numbers has been thought of.
Suppose he fixes on six numbers, viz: 2, 6, 7, 15, 16, 18. He must
add together the numbers as follows, and tell you the sum in each
case:
1. The sum of the 1st and 2d 8
2. The sum of the 2d and 3d 13
3. The sum of the 3d and 4th 22
4. The sum of the 4th and 5th 31
5. The sum of the 5th and 6th 34
6. The sum of the 2d and last 24
You must then add together the 2d, 4th, and 6th sums, 13 + 31 + 24
= 68, and the 3d and 5th sums, 22 + 34 = 56. Subtract one from the
other, leaving 12; the 2d number will be 6, the half of this; take the 2d
from the sum of the 1st and 2d, and you will get the 1st; take the 2d
from the sum of the 2d and 3d, and you will have the 3d, and so on.

How Many Counters Have I in My Hands?

A person having an equal number of counters in each hand, it is
required to find how many he has altogether.
Suppose he has 16 counters, or 8 in each hand. Desire him to
transfer from one hand to the other a certain number of them, and to
tell you the number so transferred. Suppose it be 4, the hands now
contain 4 and 12. Ask him how many times the smaller number is
contained in the larger; in this case it is three times. You must then
multiply the number transferred, 4, by the 3, making 12, and add the
4, making 16; then divide 16 by the 3 minus 1; this will bring 8, the
number in each hand.
In most cases fractions will occur in the process; when 10 counters
are in each hand and if four be transferred, the hands will contain 6
and 14.
He will divide 14 by 6 and inform you that the quotient is 2 1/3.
You multiply 4 by 2 1/3, which is 9 1/3.
Add four to this, making 13 1/3 equal to 40/3.
Subtract 1 from 2 1/3, leaving 1 1/3 or 4/3.
Divide 40/3 by 4/3, giving 10, the number in each hand.

The Three Travelers.

Three men met at a caravansary or inn, in Persia; and two of them
brought their provisions along with them, according to the custom of
the country; but the third, not having provided any, proposed to the
others that they should eat together, and he would pay the value of
his proportion. This being agreed to, A produced 5 loaves, and B 3
loaves, all of which the travelers ate together, and C paid 8 pieces of
money as the value of his share, with which the others were
satisfied, but quarreled about the division of it. Upon this the matter
was referred to the judge, who decided impartially. What was his
decision?
At first sight it would seem that the money should be divided
according to the bread furnished; but we must consider that as the 3
ate 8 loaves, each one ate 2 2/3 loaves of the bread he furnished.
This from 5 would leave 2 1/3 loaves furnished the stranger by A; and
3 - 2 2/3 = 1/3 furnished by B, hence 2 1/3 to 1/3 = 7 to 1, is the ratio in
which the money is to be divided. If you imagine A and B to furnish,
and C to consume all, then the division will be according to amounts
furnished.

The Money Game.

A person having in one hand a piece of gold, and in the other a piece
of silver, you may tell in which hand he has the gold, and in which
the silver, by the following method: Some value, represented by an
even number, such as 8, must be assigned to the gold; and a value
represented by an odd number, such as 3, must be assigned to the
silver; after which, desire the person to multiply the number in the
right hand by any even number whatever, such as 2, and that in the
left by an odd number, as 3; then bid him add together the two
products, and if the whole sum be odd, the gold will be in the right
hand, and the silver in the left; if the sum be even, the contrary will
be the case.
To conceal the artifice better, it will be sufficient to ask whether the
sum of the two products can be halved without a remainder, for in
that case the total will be even, and in the contrary case odd.
It may be readily seen that the pieces, instead of being in the two
hands of the same person, may be supposed to be in the hands of
two persons, one of whom has the even number, or piece of gold,
and the other the odd number, or piece of silver. The same
operations may then be performed in regard to these two persons,
as are performed in regard to the two hands of the same person,
calling the one privately the right, and the other the left.
 The Philosopher’s Pupils.
To find a number of which the half, fourth, and seventh, added to
three, shall be equal to itself.
This was a favorite problem among the ancient Grecian
arithmeticians, who stated the question in the following manner: “Tell
us, illustrious Pythagoras, how many pupils frequent thy school?”
“One-half,” replied the philosopher, “study mathematics, one-fourth
natural philosophy, one-seventh preserve silence, and there are
three females besides.”
The answer is 28: 14 + 7 + 4 + 3 = 28.

The Certain Game.

Two persons agree to take, alternately, numbers less than a given
figure, for example, 11, and to add them together till one of them has
reached a certain sum, such as 100. By what means can one of
them infallibly attain to that number before the other?
The whole artifice in this consists in immediately making choice of
the numbers, 1, 12, 23, 34, and so on, or of a series which
continually increases by 11, up to 100. Let us suppose that the first
person, who knows the game, makes choice of 1, it is evident that
his adversary, as he must count less than 11, can at most reach 11,
by adding 10 to it. The first will then take 1, which will make 12; and
whatever number the second may add, the first will certainly win,
provided he continually add the number which forms the complement
of that of his adversary to 11; that is to say, if the latter take 8, he
must take 3; if 9, he must take 2; and so on. By following this
method, he will infallibly attain to 89, and it will then be impossible for
the second to prevent him from getting first to 100; for whatever
number the second takes he can attain only to 99; after which the
first may say—“and 1 makes 100.” If the second take 1 after 89, it
would make 90, and his adversary would finish by saying—“and 10
make 100.” Between two persons who are equally acquainted with
the game, he who begins must necessarily win.
 The Dice Guessed Unseen.
A pair of dice being thrown, to find the number of points on each die
without seeing them. Tell the person who cast the dice to double the
number of points upon one of them, and add 5 to it; then to multiply
the sum produced by 5, and to add to the product the number of
points upon the other die. This being done, desire him to tell you the
amount, and having thrown out 25, the remainder will be a number
consisting of two figures, the first of which, to the left, is the number
of points on the first die, and the second figure, to the right, the
number of the other. Thus:
Suppose the number of points of the first die which comes up to be
2, and that of the other 3; then, if to 4, the double of the points of the
first, there be added 5, and the sum produced, 9, be multiplied by 5,
the product will be 45; to which, if 3, the number of points on the
other die, be added, 48 will be produced, from which, if 25 be
subtracted, 23 will remain; the first figure of which is 2, the number of
points on the first die, and the second figure 3, the number on the
other.

The Famous Forty-five.

How can number 45 be divided into four such parts that, if to the first
part you add 2, from the second part you subtract 2, the third part
you multiply by 2, and the fourth part you divide by 2, the sum of the
addition, the remainder of the subtraction, the product of the
multiplication, and the quotient of the division, be all equal?
The first is 8; to which 2, the sum is 10
add
The second 12; subtract 2, the remainder 10
is is
The third is 5; multiplied 2, the product is 10
by
The fourth is 20; divided by 2, the quotient is 10
45
Required to subtract 45 from 45, and leave 45 as a remainder.