Tài liệu 17th edition of Harrison’s Principles of Internal Medicine docx

SELF-ASSESSMENT

AND BOARD REVIEW

HARRISON'S

INTERNAL

MEDICINE

Editorial Board

ANTHONY S. FAUCI, MD

Chief, Laboratory of Immunoregulation

Director, National Institute of Allergy and Infectious Diseases

National Institutes of Health

Bethesda

EUGENE BRAUNWALD, MD

Distinguished Hersey Professor of Medicine

Harvard Medical School

Chairman, TIMI Study Group, Brigham and Women’s Hospital

Boston

DENNIS L. KASPER, MD

William Ellery Channing Professor of Medicine

Professor of Microbiology and Molecular Genetics

Harvard Medical School

Director, Channing Laboratory

Department of Medicine

Brigham and Women’s Hospital

Boston

STEPHEN L. HAUSER, MD

Robert A. Fishman Distinguished Professor and

Chairman, Department of Neurology

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

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

HARRISON'S

INTERNAL

MEDICINE

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v

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

For more information about this title, click here

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

vii

PREFACE

People who pursue careers in Internal Medicine are drawn to

the specialty by a love of patients, mechanisms, discovery,

education, and therapeutics. We love hearing the stories told

to us by our patients, linking signs and symptoms to patho￾physiology, solving the diagnostic dilemmas, and proposing

strategies to prevent and treat illness. It is not surprising

given these tendencies that internists prefer to continue their

life-long learning through problem solving.

This book is offered as a companion to the remarkable

17th edition of Harrison’s Principles of Internal Medicine. It is

designed for the student of medicine to reinforce the knowl￾edge contained in the parent book in an active, rather than

passive, format. This book contains over 1000 questions,

most centered on a patient presentation. Answering the

questions requires understanding pathophysiology, epide￾miology, differential diagnosis, clinical decision making, and

therapeutics. We have tried to make the questions and the

discussions timely and relevant to clinicians. All answer dis￾cussions are referenced to the relevant chapter(s) in the par￾ent book and often contain useful figures or algorithms ap￾propriate to the question. We recommend this book to

students and clinicians looking for an active method of life￾long learning and as a resource for preparing for the Internal

Medicine board examination.

We appreciate the confidence of the editors of Harri￾son’s,17th edition, to allow us to do this book. We thank our

families and loved ones who had to watch us pore over page

proofs to come up with original questions and answers. All

of the authors are (or were) affiliated with Osler Medical

Training Program at the The Johns Hopkins School of Medi￾cine. The dedicated physicians of the Osler Medical Service

inspire us daily to constantly learn and improve. We thank

them for their constant appreciation of high standards and

their dedication to outstanding patient care. Many of the

case presentations derive from actual patients we’ve cared

for, and we thank the patients of Johns Hopkins Hospital for

their nobility and their willingness to participate in our clin￾ical and educational missions.

Copyright © 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc.

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1

I. INTRODUCTION TO CLINICAL MEDICINE

QUESTIONS

DIRECTIONS: Choose the one best response to each question.

I-1. A physician is deciding whether to use a new test to

screen for disease X in his practice. The prevalence of dis￾ease X is 5%. The sensitivity of the test is 85%, and the

specificity is 75%. In a population of 1000, how many pa￾tients will have the diagnosis of disease X missed by this

test?

A. 50

B. 42

C. 8

D. 4

I-2. How many patients will be erroneously told they have

diagnosis X on the basis of the results of this test?

A. 713

B. 505

C. 237

D. 42

I-3. Which type of health care delivery system encourages

physicians to see more patients but to provide fewer

services?

A. Capitation

B. Fee-for-service

C. Fixed salary compensation

D. Out-of-pocket

I-4. The curve that graphically represents the family of cut￾off points for a positive vs. negative test is a receiver oper￾ating characteristic (ROC) curve. The area under this

curve is a quantitative measure of the information con￾tent of a test. The ROC axes are

A. negative predictive value vs. (1 – positive predictive

value)

B. positive predictive value vs. (1 – negative predictive

value)

C. sensitivity vs. (1 – specificity)

D. specificity vs. (1 – sensitivity)

I-5. A patient is seen in the clinic for evaluation of chest

pain. The patient is 35 years old and has no medical ill￾nesses. She reports occasional intermittent chest pain that

is unrelated to exercise but is related to eating spicy food.

The physician’s pretest probability for coronary artery

disease causing these symptoms is low; however, the pa￾tient is referred for an exercise treadmill test, which shows

ST depression after moderate exercise. Using Bayes’ theo￾rem, how does one interpret these test results?

A. The pretest probability is low, and the sensitivity

and specificity of exercise treadmill testing in fe￾males are poor; therefore, the exercise treadmill

test is not helpful in clinical decision making in

this case.

B. Regardless of the pretest probability, the abnormal

result of this exercise treadmill testing requires fur￾ther evaluation.

C. Because the pretest probability for coronary artery

disease is low, the patient should be referred for fur￾ther testing to rule out this diagnosis.

D. Because the pretest probability was low in this case,

a diagnostic test with a low sensitivity and specificity

is sufficient to rule out the diagnosis of coronary ar￾tery disease.

E. The testing results suggest that the patient has a very

high likelihood of having coronary artery disease

and should undergo cardiac catheterization.

I-6. An effective way to measure the accuracy of a diag￾nostic test is a positive likelihood ratio [sensitivity/(1 –

specificity)], which is also defined as the ratio of the

probability of a positive test result in a patient with dis￾ease to the probability of a positive test result in a patient

without disease. What other piece of information is

needed along with a positive likelihood ratio to estimate

the possibility of a given disease in a certain patient with a

positive test result?

A. Disease prevalence in the patient’s geographic region

B. Negative predictive value of the test

C. Positive predictive value of the test

D. Pretest probability of the disease in a patient

I-5. (Continued)

Copyright © 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc.

Click here for terms of use.

2 I. INTRODUCTION TO CLINICAL MEDICINE — QUESTIONS

I-7. Drug X is investigated in a meta-analysis for its effect on

mortality after a myocardial infarction. It is found that mor￾tality drops from 10 to 2% when this drug is administered.

What is the absolute risk reduction conferred by drug X?

A. 2%

B. 8%

C. 20%

D. 200%

E. None of the above

I-8. How many patients will have to be treated with drug X

to prevent one death?

A. 2

B. 8

C. 12.5

D. 50

E. 93

I-9. A healthy 23-year-old female is referred to your clinic af￾ter being seen in the emergency department for intermittent

severe chest pain. During her visit, she is ruled out for car￾diac ischemia, with negative biomarkers for cardiac is￾chemia and unremarkable electrocardiograms. An exercise

single photon emission CT (SPECT) myocardial perfusion

test was performed, and a reversible exercise-induced perfu￾sion defect was noted. The test was read as positive. The pa￾tient was placed on aspirin. She is quite concerned that she

continues to have chest pain intermittently on a daily basis

without any consistency in regards to time or antecedent ac￾tivity. She is otherwise active and feeling well. She smokes

socially on weekends. She has no family history of early cor￾onary disease. What would be the best next course of action?

A. Cardiac catheterization

B. CT of her coronary arteries

C. Dobutamine stress echocardiogram

D. Evaluation for non-cardiac source of her chest pain

E. Repeat exercise SPECT test

I-10. Which of the following statements regarding gender

health is true?

A. Alzheimer’s disease affects men and women at equal

rates.

B. Alzheimer’s disease affects men two times more

commonly than women.

C. In a recent placebo-controlled trial, postmenopausal

hormone therapy did not show improvement in dis￾ease progression in women with Alzheimer’s disease.

D. Women with Alzheimer’s disease have higher levels of

circulating estrogen than women without Alzheimer’s

disease.

I-11. All of the following statements regarding women’s

health are true except

A. Coronary heart disease mortality rates have been

falling in men over the past 30 years, while increasing

in women.

B. Women have longer QT intervals on resting ECG,

predisposing them to higher rates of ventricular ar￾rhythmia.

C. Women are more likely than men to have atypical

symptoms of angina such as nausea, vomiting, and

upper back pain.

D. Women with myocardial infarction (MI) are more

likely to present with ventricular tachycardia, whereas

men are more likely to present with cardiogenic

shock.

E. Women under the age of 50 experience twice the

mortality rate compared to men after MI.

I-12. When ordering an evaluation of coronary artery

disease in a female patient, all of the following are true

except

A. Exercise stress testing has more false positives in

women than in men.

B. Exercise stress testing has more false negatives in

women than in men.

C. Women are less likely than men to undergo angio￾plasty and coronary artery bypass grafting (CABG).

D. Women undergoing coronary artery bypass surgery

have lower 5- and 10-year survival rates than men.

E. Women undergoing coronary artery bypass surgery

have less relief of angina and less graft patency than

men.

I-13. Which of the following statements regarding cardio￾vascular risk is true?

A. Aspirin is effective as a means of primary prevention

in women for coronary heart disease.

B. Cholesterol-lowering drugs are less effective in

women than in men for primary and secondary pre￾vention of coronary heart disease.

C. Low high-density lipoprotein (HDL) and diabetes

mellitus are more important risk factors for men

than for women for coronary heart disease.

D. Total triglyceride levels are an independent risk factor

for coronary heart disease in women but not in men.

I-14. Which of the following alternative medicines has

shown proven benefit compared to placebo in a large ran￾domized clinical trial?

A. Echinacea root for respiratory infection

B. Ginkgo biloba for improving cognition in the elderly

C. Glucosamine/chondroitin sulfate for improving per￾formance and slowing narrowing of the joint space in

patients with moderate to severe osteoarthritis

D. Saw palmetto for men with symptomatic benign

prostatic hyperplasia (BPH)

E. St.-John’s-wort for major depression of moderate

severity

I-15. You prescribe an extended-release antihypertensive

agent for your patient at a dosing interval of 24 h. The

I-11. (Continued)

I. INTRODUCTION TO CLINICAL MEDICINE — QUESTIONS 3

half-life of the agent is 48 h. Three days later the patient’s

blood pressure is not controlled. At this point you should

A. add a second agent

B. double the dose of the current agent

C. increase the frequency of the current dose to twice/day

D. recheck the blood pressure in 1 week

E. switch to an agent from a different class

I-16. A 56-year-old patient arrives in your clinic with wors￾ening somnolence, per his wife. You have followed him

for several years for his long-standing liver disease related

to heavy alcohol use in the past and hepatitis C infection,

as well as chronic low back pain related to trauma. He has

recently developed ascites but has had a good response to

diuretic therapy. He has no history of gastrointestinal

bleeding, he denies fever, chills, abdominal pain, tremor,

or any recent change in his medicines, which include fu￾rosemide, 40 mg daily; spironolactone, 80 mg daily; and

extended-release morphine, 30 mg twice a day. He is afe￾brile with normal vital signs. His weight is down 5 kg

since initiating diuretic therapy. Physical examination is

notable for a somnolent but conversant man with mild

jaundice, pinpoint pupils, palmar erythema, spider he￾mangiomas on his chest, a palpable nodular liver edge at

the costal margin, and bilateral 1+ lower extremity

edema. He does not have asterixis, abdominal tenderness,

or an abdominal fluid wave. Laboratory results compared

to 3 months previously reveal an increased INR, from 1.4

to 2.1; elevated total bilirubin, from 1.8 to 3.6 mg/dL; and

decreased albumin from 3.4 to 2.9 g/L; as well as baseline

elevations of his aspartate and alanine aminotransferases

(54 U/L and 78 U/L, respectively). Serum NH4 is 16.

What would be a sensible next step for this patient?

A. Decrease his morphine dose by 50% and reevaluate

him in a few days

B. Initiate antibiotic therapy

C. Initiate haloperidol therapy

D. Initiate lactulose therapy

E. Perform a paracentesis

I-17. A homeless male is evaluated in the emergency depart￾ment. He has noted that after he slept outside during a par￾ticularly cold night his left foot has become clumsy and

feels “dead.” On examination, the foot has hemorrhagic

vesicles distributed throughout the foot distal to the ankle.

The foot is cool and has no sensation to pain or tempera￾ture. The right foot is hyperemic but does not have vesicles

and has normal sensation. The remainder of the physical

examination is normal. Which of the following statements

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-18. A 78-year-old female is seen in the clinic with com￾plaints of urinary incontinence for several months. She

finds that she is unable to hold her urine at random times

throughout the day; this is not related to coughing or

sneezing. The leakage is preceded by an intense need to

empty the bladder. She has no pain associated with these

episodes, though she finds them very distressing. The pa￾tient is otherwise independent in the activities of daily

living, with continued ability to cook and clean for her￾self. Which of the following statements is true?

A. The abrupt onset of similar symptoms should

prompt cystoscopy.

B. First-line therapy for this condition consists of des￾mopressin.

C. Indwelling catheters are rarely indicated for this dis￾order.

D. Referral to a genitourinary surgeon is indicated for

surgical correction.

E. Urodynamic testing must be performed before the

prescription of antispasmodic medications.

I-19. All of the following statements regarding medications

in the geriatric population are true except

A. Falling albumin levels in the elderly lead to in￾creased free (active) levels of some medications, in￾cluding warfarin.

B. Fat-soluble drugs have a shorter half-life in geriatric

patients.

C. Hepatic clearance decreases with age.

D. The elderly have a decreased volume of distribution

for many medications because of a decrease in total

body water.

E. Older patients are two to three times more likely to

have an adverse drug reaction.

I-20. Which of the following class of medicines has been

linked to the occurrence of hip fractures in the elderly?

A. Benzodiazepines

B. Opiates

C. Angiotensin-converting enzyme inhibitors

D. Beta blockers

E. Atypical antipsychotics

I-21. Patients taking which of the following drugs should

be advised to avoid drinking grapefruit juice?

A. Amoxicillin

B. Aspirin

C. Atorvastatin

D. Prevacid

E. Sildenafil

I-22. A recent 18-year-old immigrant from Kenya presents

to a university clinic with fever, nasal congestion, severe

I-15. (Continued) I-17. (Continued)

4 I. INTRODUCTION TO CLINICAL MEDICINE — QUESTIONS

fatigue, and a rash. The rash started with discrete lesions

at the hairline that coalesced as the rash spread caudally.

There is sparing of the palms and soles. Small white spots

with a surrounding red halo are noted on examination of

the palate. The patient is at risk for developing which of

the following in the future?

A. Encephalitis

B. Epiglottitis

C. Opportunistic infections

D. Postherpetic neuralgia

E. Splenic rupture

I-23. You are a physician working in an urban emergency de￾partment when several patients are brought in after the re￾lease 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, al￾though 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 physi￾cal examination the patient has a blood pressure of 156/92, 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 rhi￾norrhea and salivation. She also is 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 nor￾mal heart sounds. Bowel sounds are hyperactive, but the ab￾domen is not tender. She is having diffuse fasciculations. At

the end of your examination, the patient abruptly develops

tonic-clonic seizures. Which of the following agents is most

likely to cause this patient’s symptoms?

A. Arsine

B. Cyanogen chloride

C. Nitrogen mustard

D. Sarin

E. VX

I-24. All the following should be used in the treatment of

this patient except

A. atropine

B. decontamination

C. diazepam

D. phenytoin

E. 2-pralidoxime chloride

I-25. A 24-year-old male is brought to the emergency de￾partment after taking cyanide in a suicide attempt. He is

unconscious on presentation. What drug should be used

as an antidote?

A. Atropine

B. Methylene blue

C. 2-Pralidoxime

D. Sodium nitrite alone

E. Sodium nitrite with sodium thiosulfate

I-26. A 40-year-old female is exposed to mustard gas dur￾ing a terrorist bombing of her office building. She pre￾sents to the emergency department immediately after

exposure without complaint. The physical examination is

normal. What is the next step?

A. Admit the patient for observation because symp￾toms are delayed 2 h to 2 days after exposure and

treat supportively as needed.

B. Administer 2-pralidoxime as an antidote and ob￾serve for symptoms.

C. Irrigate the patient’s eyes and apply ocular glucocor￾ticoids to prevent symptoms from developing.

D. Discharge the patient to home as she is unlikely to

develop symptoms later.

E. Discharge the patient to home but ask that she return

in 7 days for monitoring of the white blood cell count.

I-27. A 24-year-old healthy man who has just returned from a

1-week summer camping trip to the Ozarks presents to the

emergency room with fever, a severe headache, mild abdom￾inal pain, and severe myalgias. He is discharged home but 1

day later feels even worse and therefore returns. Temperature

is 38.4°C; heart rate is 113 beats/min; blood pressure is 120/

70. Physical examination is notable for a well-developed,

well-nourished, but diaphoretic and distressed man. He is

alert and oriented to time and place. His lungs are clear to

auscultation. He has no heart murmur. His abdomen is

mildly tender with normal bowel sounds. Neurologic exam￾ination is nonfocal. There is no evidence of a rash. Labora￾tory evaluation is notable for a platelet count of 84,000/µL. A

lumbar puncture is notable for 5 monocytes, no red blood

cells, normal protein levels, and normal glucose levels. What

should be the next step in this patient’s management?

A. Atovaquone

B. Blood cultures and observation

C. Doxycycline

D. Rimantadine

E. Vancomycin, ceftriaxone, and ampicillin

I-28. A 23-year-old woman with a chronic lower extremity

ulcer related to prior trauma presents with rash, hypoten￾sion, and fever. She has had no recent travel or outdoor

exposure and is up to date on all of her vaccinations. She

does not use IV drugs. On examination, the ulcer looks

clean with a well-granulated base and no erythema,

warmth, or pustular discharge. However, the patient does

have diffuse erythema that is most prominent on her

palms, conjunctiva, and oral mucosa. Other than pro￾found hypotension and tachycardia, the remainder of the

examination is nonfocal. Laboratory results are notable

for a creatinine of 2.8 mg/dL, aspartate aminotransferase

of 250 U/L, alanine aminotransferase of 328 U/L, total

bilirubin of 3.2 mg/dL, direct bilirubin of 0.5 mg/dL, INR

of 1.5, activated partial thromboplastin time of 1.6 × con￾trol, and platelets at 94,000/µL. Ferritin is 1300 µg/mL.

The patient is started on broad-spectrum antibiotics after

I-22. (Continued)

I. INTRODUCTION TO CLINICAL MEDICINE — QUESTIONS 5

appropriate blood cultures are drawn and is resuscitated

with IV fluid and vasopressors. Her blood cultures are

negative at 72 h: at this point her fingertips start to

desquamate. What is the most likely diagnosis?

A. Juvenile rheumatoid arthritis (JRA)

B. Leptospirosis

C. Staphylococcal toxic shock syndrome

D. Streptococcal toxic shock syndrome

E. Typhoid fever

I-29. The Centers for Disease Control and Prevention (CDC)

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, re￾sult in high mortality, can cause public panic, and require

special action for public health preparedness. All the fol￾lowing agents are considered category A except

A. Bacillus anthracis

B. Francisella tularensis

C. ricin toxin from Ricinus communis

D. smallpox

E. Yersinia pestis

I-30. A 50-year-old alcoholic woman with well-controlled

cirrhosis eats raw oysters from the Chesapeake Bay at a

cookout. Twelve hours later she presents to the emer￾gency department with fever, hypotension, and altered

sensorium. Her extremity examination is notable for dif￾fuse erythema with areas of hemorrhagic bullae on her

shins. What is the most likely diagnosis?

A. Escherichia coli sepsis

B. Hemolytic uremic syndrome

C. Meningococcemia

D. Staphylococcal toxic shock syndrome

E. Vibrio vulnificus infection

I-31. Hyperthermia is defined as

A. a core temperature >40.0°C

B. a core temperature >41.5°C

C. an uncontrolled increase in body temperature de￾spite a normal hypothalamic temperature setting

D. an elevated temperature that normalizes with anti￾pyretic therapy

E. temperature >40.0°C, rigidity, and autonomic dys￾regulation

I-32. A patient in the intensive care unit develops a temper￾ature of 40.8°C, profoundly rigid tone, and hemody￾namic shock 2 min after a succinylcholine infusion is

started. Immediate therapy should include

A. intravenous dantrolene sodium

B. acetaminophen

C. external cooling devices

D. A and C

E. A, B, and C

I-33. Which of the following conditions is associated with

increased susceptibility to heat stroke in the elderly?

A. A heat wave

B. Antiparkinsonian therapy

C. Bedridden status

D. Diuretic therapy

E. All of the above

I-34. A 68-year-old alcoholic arrives in the emergency de￾partment after being found in the snow on a cold winter

night in Chicago. His core temperature based on rectal

and esophageal probe is 27°C. Pulse is 30 beats/min and

blood pressure is 75/40 mmHg. He is immobile and lacks

corneal, oculocephalic, and peripheral reflexes. He is im￾mediately intubated and placed on a cardiac monitor. He

then converts to ventricular fibrillation: a defibrillation

attempt at 2 J/kg is not successful. What should be the

next immediate step in management?

A. Active rewarming with forced-air heating blankets,

heated humidified oxygen, heated crystalloid infusion

B. Amiodarone infusion

C. Insertion of a transvenous pacemaker

D. Passive rewarming with numerous blankets for in￾sulation

E. Repeat defibrillation

I-35. In the evaluation of malnutrition, which of the fol￾lowing proteins has the shortest half-life and thus is most

predictive of recent nutritional status?

A. Albumin

B. Fibronectin

C. Retinol-binding protein complex

D. Prealbumin

E. Transferrin

I-36. A 45-year-old man is stranded overnight in the cold after

an avalanche. He is airlifted to your medical center and

found to have anesthesia and a clumsy sensation in the distal

extent of the fingers on his left hand (see Color Atlas, Figure

I-36). What is the best initial management of his hand?

A. Intravenous nitroglycerine

B. Oral nifedipine

C. Rapid rewarming

D. Surgical debridement

E. Topical nitroglycerine paste

I-37. Fecal occult blood testing (FOBT) was shown to de￾crease colon cancer–related mortality from 8.8/1000 per￾sons to 5.9/1000 persons over a 13-year period. What is

the approximate absolute risk reduction (ARR) of this in￾tervention in the studied population?

A. 50%

B. 30%

C. 3%

D. 0.3%

E. 0%

I-28. (Continued)