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Harrison's Principles of Internal Medicine HARRISON'S INTERNAL MEDICINE SELF-ASSESSMENT AND BOARD REVIEW Editorial Board ANTHONY S. FAUCI, MD Chief, Laboratory of Immunoregulation Director, National Institute of Allergy and Infectious Diseases National Institutes of Health Bethesda EUGENE BRAUNWALD, MD Distinguished Hersey Professor of Medicine Harvard Medical School Chairman, TIMI Study Group, Brigham and Women’s Hospital Boston DENNIS L. KASPER, MD William Ellery Channing Professor of Medicine Professor of Microbiology and Molecular Genetics Harvard Medical School Director, Channing Laboratory Department of Medicine Brigham and Women’s Hospital Boston STEPHEN L. HAUSER, MD Robert A. Fishman Distinguished Professor and Chairman, Department of Neurology University of California, San Francisco San Francisco DAN L. LONGO, MD Scientific Director, National Institute on Aging National Institutes of Health Bethesda and Baltimore, Maryland J. LARRY JAMESON, MD, PhD Professor of Medicine Vice-President for Medical Affairs and Lewis Landsberg Dean Northwestern University Feinberg School of Medicine Chicago JOSEPH LOSCALZO, MD, PhD Hersey Professor of the Theory and Practice of Medicine Harvard Medical School Chairman, Department of Medicine Physician-in-Chief, Brigham and Women’s Hospital Boston HARRISON'S INTERNAL MEDICINE SELF-ASSESSMENT AND BOARD REVIEW For use with the 17th edition of HARRISON’S PRINCIPLES OF INTERNAL MEDICINE EDITED BY CHARLES WIENER, MD Professor of Medicine and Physiology Vice Chair, Department of Medicine Director, Osler Medical Training Program The Johns Hopkins University School of Medicine Baltimore Contributing Editors Gerald Bloomfield, MD, MPH Cynthia D. Brown, MD Joshua Schiffer, MD Adam Spivak, MD Department of Internal Medicine The Johns Hopkins University School of Medicine Baltimore New York Chicago San Francisco Lisbon London Madrid Mexico City New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc. All rights reserved. Manufactured in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. 0-07-164131-9 The material in this eBook also appears in the print version of this title: 0-07-149619-X. All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. For more information, please contact George Hoare, Special Sales, at [email protected] or (212) 904-4069. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decom- pile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. 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DOI: 10.1036/007149619X CONTENTS Preface vii SECTION I INTRODUCTION TO CLINICAL MEDICINE Questions 1 Answers 18 SECTION II NUTRITION Questions 47 Answers 50 SECTION III ONCOLOGY AND HEMATOLOGY Questions 55 Answers 71 SECTION IV INFECTIOUS DISEASES Questions 103 Answers 130 SECTION V DISORDERS OF THE CARDIOVASCULAR SYSTEM Questions 175 Answers 202 SECTION VI DISORDERS OF THE RESPIRATORY SYSTEM Questions 237 Answers 254 SECTION VII DISORDERS OF THE URINARY AND KIDNEY TRACT Questions 283 Answers 293 SECTION VIII DISORDERS OF THE GASTROINTESTINAL SYSTEM Questions 307 Answers 321 SECTION IX RHEUMATOLOGY AND IMMUNOLOGY Questions 345 Answers 358 v vi CONTENTS SECTION X ENDOCRINOLOGY AND METABOLISM Questions 379 Answers 393 SECTION XI NEUROLOGIC DISORDERS Questions 421 Answers 435 SECTION XII DERMATOLOGY Questions 457 Answers 460 References 465 Color Atlas 473 PREFACE People who pursue careers in Internal Medicine are drawn to ent book and often contain useful figures or algorithms ap- the specialty by a love of patients, mechanisms, discovery, propriate to the question. We recommend this book to education, and therapeutics. We love hearing the stories told students and clinicians looking for an active method of life- to us by our patients, linking signs and symptoms to patho- long learning and as a resource for preparing for the Internal physiology, solving the diagnostic dilemmas, and proposing Medicine board examination. strategies to prevent and treat illness. It is not surprising We appreciate the confidence of the editors of Harri- given these tendencies that internists prefer to continue their son’s,17th edition, to allow us to do this book. We thank our life-long learning through problem solving. families and loved ones who had to watch us pore over page This book is offered as a companion to the remarkable proofs to come up with original questions and answers. All 17th edition of Harrison’s Principles of Internal Medicine. It is of the authors are (or were) affiliated with Osler Medical designed for the student of medicine to reinforce the knowl- Training Program at the The Johns Hopkins School of Medi- edge contained in the parent book in an active, rather than cine. The dedicated physicians of the Osler Medical Service passive, format. This book contains over 1000 questions, inspire us daily to constantly learn and improve. We thank most centered on a patient presentation. Answering the them for their constant appreciation of high standards and questions requires understanding pathophysiology, epide- their dedication to outstanding patient care. Many of the miology, differential diagnosis, clinical decision making, and case presentations derive from actual patients we’ve cared therapeutics. We have tried to make the questions and the for, and we thank the patients of Johns Hopkins Hospital for discussions timely and relevant to clinicians. All answer dis- their nobility and their willingness to participate in our clin- cussions are referenced to the relevant chapter(s) in the par- ical and educational missions. vii This page intentionally left blank I. INTRODUCTION TO CLINICAL MEDICINE QUESTIONS DIRECTIONS: Choose the one best response to each question. I-1. A physician is deciding whether to use a new test to I-5. (Continued) screen for disease X in his practice. The prevalence of dis- nesses. She reports occasional intermittent chest pain that ease X is 5%. The sensitivity of the test is 85%, and the is unrelated to exercise but is related to eating spicy food. specificity is 75%. In a population of 1000, how many pa- The physician’s pretest probability for coronary artery tients will have the diagnosis of disease X missed by this disease causing these symptoms is low; however, the pa- test? tient is referred for an exercise treadmill test, which shows ST depression after moderate exercise. Using Bayes’ theo- A. 50 rem, how does one interpret these test results? B. 42 C. 8 A. The pretest probability is low, and the sensitivity D. 4 and specificity of exercise treadmill testing in fe- males are poor; therefore, the exercise treadmill I-2. How many patients will be erroneously told they have test is not helpful in clinical decision making in diagnosis X on the basis of the results of this test? this case. A. 713 B. Regardless of the pretest probability, the abnormal B. 505 result of this exercise treadmill testing requires fur- C. 237 ther evaluation. D. 42 C. Because the pretest probability for coronary artery disease is low, the patient should be referred for fur- I-3. Which type of health care delivery system encourages ther testing to rule out this diagnosis. physicians to see more patients but to provide fewer D. Because the pretest probability was low in this case, services? a diagnostic test with a low sensitivity and specificity is sufficient to rule out the diagnosis of coronary ar- A.
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