Harrisons Principles of Internal Medicine Self-Assessment and Board Review 18th Ed.

SECTION XI. Neurologic Disorders

QUESTIONS

DIRECTIONS: Choose the one best response to each question.

XI-1. All of the following neurologic conditions have a mechanistic association with abnormalities of ion channel function EXCEPT:

A.  Epilepsy

B.  Lambert-Eaton syndrome

C.  Migraine

D.  Parkinson’s disease

E.  Spinocerebellar ataxia

XI-2. All of the following neurologic diseases are matched correctly with the neurotransmitter system that is dysfunctional EXCEPT:

A.  Lambert-Eaton syndrome: acetylcholine

B.  Myasthenia gravis: acetylcholine

C.  Orthostatic tachycardia syndrome: serotonin

D.  Parkinson’s disease: dopamine

E.  Stiff-person syndrome: GABA

XI-3. During a neurologic examination, you ask a patient to stand with both arms fully extended and parallel to the ground with his eyes closed for 10 seconds. What is the name of this test?

A.  Babinski sign

B.  Dysdiadochokinesis

C.  Lhermitte symptom

D.  Pronator drift

E.  Romberg sign

XI-4. This sign is considered positive if there is flexion at the elbows or forearms, or if there is pronation of the forearms. A positive test is a sign of:

A.  Abnormal sensation

B.  Early dementia

C.  Localized brainstem disease

D.  Potential weakness

E.  Underlying cerebellar dysfunction

XI-5. A 55-year-old woman with known metastatic breast cancer presents to the emergency department complaining of new-onset weakness and numbness. The symptoms involve both arms and legs. She also has developed urinary incontinence over the past 24 hours. On physical examination, strength is 3/5 in the lower extremities and 4/5 in the upper extremities. Anal sphincter tone is decreased. Babinski sign is positive. Sensation is decreased in the extremities, but not in the face. Cranial nerves are symmetric and intact, and mental status is normal. Based on this information, what is the most likely site of the lesion causing the patient’s symptoms?

A.  Brainstem

B.  Cerebrum

C.  Cervical spinal cord

D.  Lumbar spinal cord

E.  Neuromuscular junction

XI-6. A 54-year-old woman presents to the emergency department complaining of the abrupt onset of what she describes as the worst headache of her life. You are concerned about the possibility of subarachnoid hemorrhage. What is the most appropriate initial test for diagnosis?

A.  Cerebral angiography

B.  CT of the head with IV contrast

C.  CT of the head without IV contrast

D.  Lumbar puncture

E.  Transcranial Doppler ultrasound

XI-7. A 74-year-old woman has a recent diagnosis of small cell lung cancer. She is now complaining of headaches, and her family has noticed confusion as well. Metastatic disease to the brain is suspected. A mass lesion on magnetic resonance imaging (MRI) is demonstrated in the right parietal lobe. Which MRI technique would best identify the extent of the edema surrounding the lesion?

A.  MR angiography

B.  FLAIR

C.  T1-weighted

D.  T2-weighted

E.  B and D

XI-8. Which of the following is a possible complication of administration of gadolinium to a patient with chronic kidney disease?

A.  Acute renal failure

B.  Hyperthyroidism

C.  Hypocalcemia

D.  Lactic acidosis

E.  Nephrogenic systemic sclerosis

XI-9. In a patient with coma, an EEG showing triphasic waves is most suggestive of which of the following clinical disorders?

A.  Brain abscess

B.  Herpes simplex encephalitis

C.  Locked-in syndrome

D.  Metabolic encephalopathy

E.  Nonconvulsive status epilepticus

XI-10. An 18-year-old man seeks evaluation at his university health center for increasing episodes of sudden onset smelling of burning kerosene. These episodes had occurred every few months during high school and he never told anyone. However, since starting college, he notes an increasing frequency, often when sleep deprived. The episodes typically start without warning and he’ll smell a distinct kerosene smell no matter the environment. The episodes last about 3–5 minutes and stop spontaneously. He has never lost consciousness. During the episodes, he can communicate with friends. An EEG during an episode shows abnormal discharges distinctly localized to an area of the frontal lobe. Which of the following is the most accurate classification of his seizure disorder?

A.  Focal seizures with dyscognitive features

B.  Focal seizures without dyscognitive features

C.  Generalized seizure

D.  Myoclonic seizures

E.  Typical absence seizure

XI-11. On the neurologic consultation service, you are asked to evaluate a patient with mesial temporal lobe epilepsy syndrome. The patient has a history of intractable focal seizures that rarely generalize. Her seizures often begin with an aura and commonly manifest as behavioral arrests, complex automatisms, and unilateral posturing. MRI findings include small temporal lobes and a small hippocampus with increased signal on T2-weighted sequences. Which of these additional historic factors is also likely to be present in this patient?

A.  History of febrile seizures

B.  Hypothyroidism

C.  Neurofibromas

D.  Recurring genital ulcers

E.  Type 2 diabetes mellitus

XI-12. You have just admitted a young man with a prior history of seizure disorder who was witnessed to have a seizure. His family’s description suggests a focal seizure involving the left hand that spread to involve the entire arm. He did not lose consciousness. He was brought in 2 hours after symptom onset and is currently awake, alert, and oriented. He has not had any further seizures but has been unable to move his left hand since his seizure. His electrolytes and complete blood count are within normal limits. A noncontrast CT scan of his head is unremarkable. On examination, sensation is intact in the affected limb, but his strength is 0 out of 5 in the musculature of the left hand. What is the best course of action at this time?

A.  Cerebral angiogram

B.  Lumbar puncture

C.  Magnetic resonance angiogram

D.  Psychiatric evaluation

E.  Reassess in a few hours

XI-13. A 37-year-old man is witnessed by his family to have a generalized tonic-clonic seizure at a party. He does not have a known seizure disorder. There is no history of head trauma, stroke, or tumor. The patient is unemployed, married, and takes no medication. Physical examination shows no skin abnormalities and no stigmata of chronic liver or renal disease. The patient is postictal. His neck is difficult to maneuver due to stiffness. His white blood cell count is 19,000/μL, hematocrit 36%, and platelets 200,000/μL. Glucose is 102 mg/dL, sodium 136 meq/dL, calcium 9.5 mg/dL, magnesium 2.2 mg/dL, SGOT 18 U/L, blood urea nitrogen 7 mg/dL, and creati-nine 0.8 mg/dL. Urine toxicology screen is positive for cocaine metabolites. Which next step is most appropriate in this patient’s management?

A.  Electroencephalogram (EEG)

B.  IV loading with antiepileptic medication

C.  Lumbar puncture

D.  Magnetic resonance imaging

E.  Substance abuse counseling

XI-14. All of the following statements regarding epilepsy are true EXCEPT:

A.  The incidence of suicide is higher in epileptic patients than it is in the general population.

B.  Mortality is no different in patients with epilepsy than it is in age-matched controls.

C.  A majority of patients with epilepsy that is completely controlled with medication eventually will be able to discontinue therapy and remain seizure-free.

D.  Surgery for mesial temporal lobe epilepsy (MTLE) decreases the number of seizures in over 70% of patients.

E.  Tricyclic antidepressants lower the seizure threshold and may precipitate seizures.

XI-15. A 20-year-old woman is brought to the emergency department after a witnessed generalized tonic-clonic seizure. She has no identifying information, and her past medical history is unknown. What is the most likely cause of her seizure?

A.  Amyloid angiopathy

B.  Fever

C.  Genetic disorder

D.  Illicit drug use

E.  Uremia

XI-16. A 36-year-old man is brought to the emergency department because of a seizure. His family reports he has a history of seizure disorder but stopped his medications a month ago due to financial issues. He had a brief seizure at home that stopped within a few minutes. However, 15 minutes later he began seizing again and the tonic-clonic activity has persisted for 30 minutes. On physical examination he is afebrile, hypertensive, and actively seizing. All of the following are potential therapies for his condition EXCEPT:

A.  Carbamazepine

B.  Fosphenytoin

C.  Lorazepam

D.  Phenobarbital

E.  Valproate

XI-17. The most common cause of a cerebral embolism is:

A.  Atrial fibrillation

B.  Cardiac prosthetic valves

C.  Dilated cardiomyopathy

D.  Endocarditis

E.  Rheumatic heart disease

XI-18. A 54-year-old male is referred to your clinic for evaluation of atrial fibrillation. He first noted the irregular heartbeat 2 weeks ago and presented to his primary care physician. He denies chest pain, shortness of breath, nausea, or gastrointestinal symptoms. Past medical history is unremarkable. There is no history of hypertension, diabetes, or tobacco use. His medications include metoprolol. The examination is notable for a blood pressure of 126/74 mmHg and a pulse of 64 beats/min. The jugular venous pressure is not elevated. His heart is irregularly irregular, with normal S1 and S2. The lungs are clear, and there is no peripheral edema. An echocardiogram shows a left atrial size of 3.6 cm. Left ventricular ejection fraction is 60%. There are no valvular or structural abnormalities. Which of the following statements regarding his atrial fibrillation and stroke risk is true?

A.  He requires no antiplatelet therapy or anticoagulation because the risk of embolism is low.

B.  Lifetime vitamin K antagonist therapy is indicated for atrial fibrillation in this situation to reduce the risk of stroke.

C.  He should be admitted to the hospital for IV heparin and undergo electrical cardioversion; afterward there is no need for anticoagulation.

D.  His risk of an embolic stroke is less than 1%, and he should take a daily aspirin.

E.  He should be started on SC low-molecular-weight heparin and transitioned to warfarin.

XI-19. All the following have been shown to reduce the risk of atherothrombotic stroke in primary or secondary prevention EXCEPT:

A.  Aspirin

B.  Blood pressure control

C.  Clopidogrel

D.  Statin therapy

E.  Warfarin

XI-20. A 57-year-old man is brought to the emergency department after falling while playing tennis and developing garbled speech. He has a past history of hypertension and hypercholesterolemia. His medications include atorvastatin and enalapril. On physical examination, his blood pressure is 210/115 mmHg with heart rate 105 beats/min, respirations 28 breaths/min, temperature 37°C (98.6°F), and oxygen saturation 94% on room air. He is alert but aphasic with upper and lower left extremity hemiparesis. He is able to move his right side normally. Based on the results of immediate imaging, all of the following are potential therapeutic considerations for his condition EXCEPT:

A.  Anticoagulation

B.  Blood pressure lowering

C.  Hypothermia protocol

D.  Intracerebral stent placement

E.  IV thrombolysis

XI-21. Which of the following statements regarding Alzheimer’s disease is true?

A.  Delusions are uncommon.

B.  It accounts for over half of the cases of significant memory loss in patients over 70 years of age.

C.  It typically presents with rapid (<6 months) significant memory loss.

D.  Less than 5% of patients present with nonmemory complaints.

E.  Pathologically, the most notable abnormalities are in the cerebellar regions.

XI-22. All of the following medications have been shown to have potential efficacy in the treatment of Alzheimer’s disease EXCEPT:

A.  Donepezil

B.  Galantamine

C.  Memantine

D.  Oxybutynin

E.  Rivastigmine

XI-23. A 72-year-old right-handed male with a history of atrial fibrillation and chronic alcoholism is evaluated for dementia. His son gives a history of a stepwise decline in the patient’s function over the last 5 years with the accumulation of mild focal neurologic deficits. On examination he is found to have a pseudobulbar affect, mildly increased muscle tone, and brisk deep-tendon reflexes in the right upper extremity and an extensor plantar response on the left. The history and examination are most consistent with which of the following?

A.  Alzheimer’s disease

B.  Binswanger’s disease

C.  Creutzfeldt-Jakob disease

D.  Multi-infarct dementia

E.  Vitamin B12 deficiency

XI-24. A 49-year-old woman presents for a second opinion regarding symptoms of tremors, difficulty with ambulation, and periodic flushing. Her symptoms originally began approximately 3 years ago. At that time, she was hospitalized for a syncopal episode, after which she was told to increase her salt intake. Since then, she has had progressive motor difficulties including bilateral tremors and a stiff, slow gait. She also has had several more episodes of syncope. She states that she knows when these syncopal events will occur because she feels faint and weak. She has never had an injury from syncope. A final recent symptom has been periodic flushing and sweating. A neurologist previously diagnosed her with Parkinson’s disease and prescribed therapy with ropinirole. Despite increasing doses, she does not feel improved, but rather has recently noticed uncontrollable movements that she describes as tics of her face. Her only other medical history is recent recurrent urinary tract infections. Her medications are ropinirole 24 mg daily and nitrofurantoin 100 mg daily. She reports no history of drug use. On physical examination, her blood pressure is 130/70 mmHg with a heart rate of 78 beats/min while sitting. Upon standing, her blood pressure drops to 90/50 mmHg with a heart rate of 110 beats/min. Her ocular movements are full and intact. She has recurrent motor movements of the right side of her face. Her neurologic examination shows increased muscle tone in the lower extremities with bilateral 4-Hz tremor. Deep tendon reflexes are brisk and 3+ in upper and lower extremities. Three beats of myoclonus are present at the ankles bilaterally. She walks with a spastic gait. Strength is normal. What is the most likely diagnosis?

A.  Corticobasal degeneration

B.  Diffuse Lewy body dementia

C.  Drug-induced Parkinson’s disease

D.  Multiple system atrophy with parkinsonian features

E.  Parkinson’s disease with inadequate treatment

XI-25. A 65-year-old man presents to your office complaining of a tremor and progressive gait abnormalities. He states that he first noticed a slowing of his gait approximately 6 months ago. He has difficulty rising to a standing position and states that he shuffles when he walks. In addition, he states that his right hand shakes more so than his left, and he is right handed. He believes it to be worse when not moving but states there are times when he spills his morning coffee because of the tremors. He has retired but states he is not able to play tennis and golf any longer because of his motor symptoms. He denies syncope or presyncope, difficulty swallowing, changes to his voice, or memory difficulties. His past medical history is significant for hypertension and hypercholesterolemia. His medications are hydrochlorothiazide 25 mg daily, ezetimibe 10 mg daily, and lovastatin 40 mg daily. He drinks a glass of wine with dinner daily and is a lifelong nonsmoker. On physical examination, he has masked facies. His gait shows decreased arm swing with slow shuffling steps. He turns en bloc. A pill-rolling tremor is present on the right side. There is cogwheel rigidity bilaterally. Eye movements are full and intact. There is no ortho-static hypotension. A brain MRI with gadolinium shows no evidence of mass lesions, hydrocephalus, or vascular disease. You diagnose the patient with Parkinson’s disease. The patient asks about his prognosis and likelihood of disability. Which of the following is correct about the clinical course and treatment of Parkinson’s disease?

A.  Early initiation of therapy with levodopa predisposes an individual to a higher likelihood of dyskinesias early in the disease.

B.  Early therapy with bilateral deep-brain stimulation of the subthalamic nuclei slows the progression of Parkinson’s disease.

C.  Initial treatment with a dopamine agonist such as pramipexole is likely to be effective in controlling his motor symptoms for 1–3 years before the addition of levodopa or another agent is necessary.

D.  Levodopa should be started immediately to prevent the development of disabling rigidity.

E.  MAO inhibitors are contraindicated once the diagnosis of Parkinson’s disease is established.

XI-26. All of the following statements regarding restless legs syndrome (RLS) are true EXCEPT:

A.  Dopamine antagonists are effective therapy.

B.  Most patients develop symptoms before the age of 30 years old.

C.  RLS may cause sleep disorder and daytime hyper-somnolence.

D.  RLS is more common in Asians than in the general U.S. population.

E.  Symptoms may involve the upper extremity.

XI-27. A 63-year-old man seeks medical attention because of progressive weakness of the left foot and lower leg over the last 6 months. The progression has been gradual, and he only noticed it initially because of cramping and tripping while playing squash. He denies back pain. His only medication is atorvastatin. On physical examination, vital signs are normal and the only abnormalities are on neurologic examination. His left leg strength is notably diminished in the hip flexors, hip adductors, quadriceps, and calf muscles. There is atrophy of the quadriceps and calf. His ankle and knee reflexes are increased on the left. He has subtle weakness on the right quadriceps. There are no sensory abnormalities in light touch, pinprick, temperature, or proprioception. There are occasional fasciculations of the abdominal muscles. Before diagnosing the patient with amyotrophic lateral sclerosis (ALS), all of the following alternative diagnoses should be ruled out EXCEPT:

A.  Cervical spondylosis

B.  Foramen magnum tumor

C.  Lead poisoning

D.  Multifocal motor neuropathy with conduction block

E.  Vitamin C deficiency

XI-28. A 42-year-old woman seeks medical attention for a 5- to 6-week history of marked fatigue that is affecting her work. She reports that she has felt some general fatigue but her symptoms are most notable when she starts moving around during the day. She has taken her pulse and it feels fast to her. She reports no loss of consciousness, but does say that she feels lightheaded and has blurred vision after arising. Sitting or lying down improves the symptoms. She has no notable past medical history and takes no medications other than a calcium/vitamin supplement. On physical examination, her supine heart rate is 90 beats/min with blood pressure of 110/70 mmHg. Upon standing her heart rate increases to 130 beats/min and is regular, and her blood pressure standing is 115/75 mmHg. She reports lightheadedness during the episode. An ECG while symptomatic shows sinus tachycardia without any conduction abnormalities. Which of the following is the most likely diagnosis?

A.  Addison’s disease

B.  Autoimmune autonomic neuropathy

C.  Diabetic neuropathy

D.  Multisystem atrophy

E.  Postural orthostatic tachycardia syndrome

XI-29. A 45-year-old male complains of severe right arm pain. He gives a history of having slipped on the ice and severely contusing his right shoulder approximately 6 months ago. Soon thereafter, he developed sharp, knifelike pain in the right arm and forearm that lasted for a few months. There was some arm swelling and warmth. He was evaluated in an urgent care setting. There were no radiographic abnormalities and he was not treated. Since the injury, the pain and swelling have persisted. Physical examination reveals a right arm that is more moist and hairy than the left arm. There is no specific weakness or sensory change. However, the right arm is clearly more edematous than the left, and the skin appears shiny and cool. The patient’s pain most likely is due to:

A.  Acromioclavicular separation

B.  Brachial plexus injury

C.  Cervical radiculopathy

D.  Complex regional pain syndrome

E.  Subclavian vein thrombosis

XI-30. Which of the following criteria suggests the diagnosis of trigeminal neuralgia?

A.  Deep-seated, steady facial pain

B.  Elevated erythrocyte sedimentation rate (ESR)

C.  Objective signs of sensory loss on physical examination

D.  Response to gabapentin therapy

E.  None of the above

XI-31. A 72-year-old woman presents with recurrent episodes of incapacitating facial pain lasting from second to minutes and then dissipating. The episodes occur usually twice per day, usually without warning, but are also occasionally provoked by brushing of her teeth. On physical examination, she appears well with normal vital signs. Detailed cranial nerve examination reveals no sensory or motor abnormalities. The remainder of her neurologic examination is normal. What is the next step in her management?

A.  Brain MRI

B.  Brain MRI plus carbamazepine therapy

C.  Carbamazepine therapy

D.  Glucocorticoid therapy

E.  Referral to Otolaryngology for surgical cure

XI-32. A 72-year-old female presents with brief, intermittent excruciating episodes of lancinating pain in the lips, gums, and cheek. Touching the lips or moving the tongue can initiate these intense spasms of pain. The results of a physical examination are normal. MRI of the head is also normal. The most likely cause of this patient’s pain is:

A.  Acoustic neuroma

B.  Amyotrophic lateral sclerosis

C.  Meningioma

D.  Trigeminal neuralgia

E.  Facial nerve palsy

XI-33. A 33-year-old woman presents with rapidly worsening pain at the top of the back over the last 3 days. The pain is not relieved by lying down or by wearing a soft neck collar. She notes that the pain is much worse with movement and has woken her from sleep. The pain is severe and is impeding her daily activities. She denies any arm pain or weakness. There is no history of prior back or neck pain, trauma, or arthritis. She works as a postal delivery agent and her only physical activity is walking. She is monogamous with her husband and has no illicit activities. Her family history is notable for an aunt and mother with breast cancer. Her MRI is shown in Figure XI-33. Which is the most likely diagnosis?

image

FIGURE XI-33

A.  Cervical spondylosis

B.  Hematomyelia

C.  Metastatic breast cancer

D.  Spinal epidural abscess

E.  Spinal epidural hematoma

XI-34. A 34-year-old female complains of lower extremity weakness for the last 3 days. She has noted progressive weakness in the lower extremities with loss of sensation “below the belly button” and incontinence. She had had some low-grade fevers for the last week. She denies recent travel. Past medical history is unremarkable. Physical examination is notable for a sensory level at the level of the umbilicus. The lower extremities show +3/5 strength bilaterally proximally and distally. Reflexes, cerebellar examination, and mental status are normal. All of the following are appropriate steps in evaluating this patient EXCEPT:

A.  Antinuclear antibodies

B.  Electromyography

C.  Lumbar puncture

D.  MRI of the spine

E.  Viral serologies

XI-35. Which of the following statements about syringomyelia is true?

A.  More than half the cases are associated with Chiari malformations.

B.  Symptoms typically begin in middle age.

C.  Vibration and position sensation are usually diminished.

D.  Syrinx cavities are always congenital.

E.  Neurosurgical decompression is usually effective in relieving the symptoms.

XI-36. A 17-year-old adolescent is seen in the clinic several weeks after he suffered a concussion during a high-school football game. At the time of the event, paramedics reported that he experienced no loss of consciousness but was confused for a period of about 10 minutes. Head imaging was normal. He describes a generalized headache that is present all the time since his trauma, and he occasionally feels dizzy. His mother is concerned that he is having a hard time concentrating in school and seems depressed to her lately; she describes him as being very energetic prior to his concussion. The patient’s physical examination is entirely normal except for a somewhat flattened affect. Which of the following statements regarding his condition is true?

A.  He has an excellent prognosis.

B.  He meets the criteria for postconcussive syndrome and should improve over 1–2 months.

C.  He should avoid contact sports for 2 weeks.

D.  He is most likely malingering.

E.  Low-dose narcotics should be started for headache.

XI-37. A 68-year-old man is brought to the clinic by his wife for evaluation. She has noticed that over past 2–3 months her husband has had increasingly slowed thinking and a change in his personality in that he has become very withdrawn. His only complaint is a mild but persistent, diffuse headache. There is no history of head trauma, prior neurologic or psychiatric disease, or family history of dementia. Physical examination is only notable for a moderate cognitive deficit with a mini-mental examination of 19/30. His head CT is shown in Figure XI-37. What is the most likely diagnosis?

image

FIGURE XI-37

A.  Acute epidural hematoma

B.  Acute subarachnoid hemorrhage

C.  Alzheimer’s disease

D.  Chronic subdural hematomas

E.  Normal-pressure hydrocephalus

XI-38. A 76-year-old nursing home resident is brought to the local emergency department after falling out of bed. The fall was not witnessed; however, she was suspected to have hit her head. She is not responsive to verbal or light tactile stimuli. At baseline she is able to converse but is frequently disoriented to place and time. She has a medical history that includes stable coronary disease, mild emphysema, and multi-infarct dementia. Immediately after triage she is taken for a CT scan of the head. Which of the following is true regarding head injury and hematomas?

A.  More than 80% of patients with subdural hematomas will experience a lucid interval prior to loss of consciousness.

B.  Epidural hematomas generally arise from venous sources.

C.  Epidural hematomas are common among the elderly with minor head trauma.

D.  Most patients presenting with epidural hematomas are unconscious.

E.  Subdural hematomas lead to rapid increases in intracranial pressure and can require arterial ligation.

XI-39. A 49-year-old man is admitted to the hospital with a seizure. He does not have a history of seizures and he currently takes no medications. He has AIDS and is not under any care at this time. His physical examination is most notable for small, shoddy lymphadenopathy in the cervical region. A head CT shows a ring-enhancing lesion in the right temporal lobe, with edema but no mass effect. A lumbar puncture shows no white or red blood cells, and the Gram stain is negative. His serum Toxoplasma IgG is positive. He is treated with pyrimethamine, sulfadiazine, and levetiracetam. After 2 weeks of therapy the central nervous system (CNS) lesion has not changed in size and he has not had any more seizures. All microbiologic cultures and viral studies, including Epstein-Barr virus DNA from the cerebrospinal fluid, are negative. What is the best course of action for this patient at this time?

A.  Continue treatment for CNS toxoplasmosis.

B.  Dexamethasone.

C.  IV acyclovir.

D.  Stereotactic brain biopsy.

E.  Whole-brain radiation therapy.

XI-40. A young man with a history of a low-grade astrocytoma comes into your office complaining of weight gain and low energy. He is status post resection of his low-grade astrocytoma and had a course of whole-brain radiation therapy (WBRT) 1 year ago. A laboratory workup reveals a decreased morning cortisol level of 1.9 μg/dL. In addition to depressed adrenocorticotropic hormone (ACTH) function, which of the following hormones is most sensitive to damage from whole-brain radiation therapy?

A.  Growth hormone

B.  Follicle-stimulating hormone

C.  Prolactin

D.  Thyroid-stimulating hormone

XI-41. A 37-year-old woman with a history of 6 months of worsening headache is admitted to the hospital after a tonic-clonic seizure that occurred at work. The seizure lasted a short time and terminated spontaneously. On examination her vital signs are normal, she is somnolent but awake, and there are no focal abnormalities. Her initial CT scan showed no acute hemorrhage but was abnormal. An MRI is obtained and is shown in Figure XI-41. What is the most likely diagnosis in this patient?

image

FIGURE XI-41

A.  Brain abscess

B.  Glioblastoma

C.  Low-grade astrocytoma

D.  Meningioma

E.  Oligodendroglioma

XI-42. All of the following are frequent initial symptoms of multiple sclerosis EXCEPT:

A.  Optic neuritis

B.  Paresthesias

C.  Sensory loss

D.  Visual loss

E.  Weakness

XI-43. Which of the following is the most common clinical classification of multiple sclerosis?

A.  Autoimmune autonomic neuropathy

B.  Primary progressive

C.  Progressive relapsing

D.  Relapsing/remitting

E.  Secondary progressive

XI-44. Lumbar puncture should be preceded by CT or MRI in all of the following subsets of patients suspected of having meningitis EXCEPT those with:

A.  Depressed consciousness

B.  Focal neurologic abnormality

C.  Known central nervous system (CNS) mass lesion

D.  Positive Kernig’s sign

E.  Recent head trauma

XI-45. A 78-year-old man with diabetes mellitus presents with fever, headache, and altered sensorium. On physical exam his temperature is 40.2°C (104.4°F), heart rate is 103 beats/min, and blood pressure is 84/52 mmHg. His neck is stiff and he has photophobia. His cerebrospinal fluid (CSF) examination shows 2100 cells/μL, with 100% neutrophils, glucose 10 mg/dL, and protein 78 mg/dL. CSF Gram stain is negative. In addition to empiric antibacterial antibiotics, initial therapy should include which of the following?

A.  Acyclovir

B.  Dexamethasone after antibiotics

C.  Dexamethasone prior to antibiotics

D.  IV γ globulin

E.  Valacyclovir

XI-46. Which of the following groups of patients should receive empirical antibiotic therapy that includes coverage of Listeria monocytogenes in cases of presumed meningitis?

A.  Immunocompromised patients

B.  Elderly patients

C.  Infants

D.  All of the above

XI-47. Which of the following medicines has been most commonly implicated in the development of noninfectious chronic meningitis?

A.  Acetaminophen

B.  Acyclovir

C.  β-lactam antibiotics

D.  Ibuprofen

E.  Phenobarbital

XI-48. Variant Creutzfeldt-Jakob disease (vCJD) has been diagnosed in which of the following populations?

A.  Family members with well-defined germ-line mutations leading to autosomal dominant inheritance of a fatal neurodegenerative disease

B.  New Guinea natives practicing cannibalism

C.  Patients accidentally inoculated with infected material during surgical procedures

D.  Worldwide, in sporadic cases, mostly during the fifth and sixth decades of life

E.  Young adults in Europe thought to have been exposed to tainted beef products

XI-49. The presence of startle myoclonus in a 60-year-old man with rapidly progressive deficits in cortical dysfunction is which of the following?

A.  Neither sensitive nor specific for Creutzfeldt-Jacob disease (CJD) but does represent grounds to explore further for this condition with an electroencephalogram (EEG)

B.  Neither sensitive nor specific for CJD but does represent grounds to explore further for this condition with an EEG and brain MRI

C.  Sensitive but not specific for CJD and is not enough to prompt a further workup for this condition unless other clinical criteria are met

D.  Specific but not sensitive for CJD and should therefore prompt immediate referral for brain biopsy to confirm the diagnosis

E.  Virtually diagnostic for CJD, and further workup including EEG, brain MRI, and perhaps brain biopsy serves only a prognostic purpose

XI-50. A 24-year-old man presents for evaluation of foot-drop. He has noted that for the last several months, he has had difficulty picking his feet up to walk up stairs and over thresholds. His right leg is more affected than his left leg. He has not noted any sensory changes. He has several family members with similar complaints. His exam is notable for distal leg weakness with reduced sensation to light touch in both lower extremities. Knee and ankle jerk reflexes are unobtainable. Calves are reduced in size bilaterally. Upper extremity examination is normal. Which of the following is the most likely diagnosis?

A.  Charcot-Marie-Tooth syndrome

B.  Fabry disease

C.  Guillain-Barré syndrome

D.  Hereditary neuralgic amyotrophy

E.  Hereditary sensory and autonomic neuropathy

XI-51. A 57-year-old immigrant from Vietnam is evaluated by his primary caregiver for dysesthesias that have been present in his hands and feet for the past several weeks. He also reports some difficulty walking. His past medical history is notable for hypertriglyceridemia, tobacco abuse, and a recently discovered positive PPD with sputum that is smear-negative for Mycobacterium tuberculosis. His medications include niacin, aspirin, and isoniazid. Which of the following is likely to reverse his symptoms?

A.  Cobalamin

B.  Levothyroxine

C.  Neurontin

D.  Pregabalin

E.  Pyridoxine

XI-52. A 52-year-old woman with long-standing, poorly controlled type 2 diabetes mellitus is evaluated for a sensation of numbness in her fingers and toes, as if she is wearing gloves and socks all the time. She also reports tingling and burning in the same location, but no weakness. Her symptoms have been intermittently present for the last several months. After a thorough evaluation, nerve biopsy is obtained and demonstrates axonal degeneration, endothelial hyperplasia, and perivascular inflammation. Which of the following statements regarding this condition is true?

A.  Autonomic neuropathy is rarely seen in combination with sensory neuropathy.

B.  The presence of retinopathy or nephropathy does not portend increased risk for diabetic neuropathy.

C.  This is the most common cause of peripheral neuropathy in developed countries.

D.  Tight glucose control from now on will reverse her neuropathy.

E.  None of the above is true.

XI-53. All the following cause primarily a sensory neuropathy EXCEPT:

A.  Acromegaly

B.  Critical illness

C.  HIV infection

D.  Hypothyroidism

E.  Vitamin B12 deficiency

XI-54. A 50-year-old male complains of weakness and numbness in the hands for the last month. He describes paresthesias in the thumb and the index and middle fingers. The symptoms are worse at night. He also describes decreased grip strength bilaterally. He works as a mechanical engineer. The patient denies fevers, chills, or weight loss. The examination is notable for atrophy of the thenar eminences bilaterally and decreased sensation in a median nerve distribution. You consider the diagnosis of carpal tunnel syndrome. All the following are causes of carpal tunnel syndrome EXCEPT:

A.  Amyloidosis

B.  Chronic lymphocytic leukemia

C.  Diabetes mellitus

D.  Hypothyroidism

E.  Rheumatoid arthritis

XI-55. A 27-year-old woman is diagnosed with Guillain-Barré syndrome after presenting with flaccid paralysis and sensory disturbance several weeks after a diarrheal illness. Which of the following bacteria have been implicated in cases of Guillain-Barré syndrome?

A.  Bartonella henselae

B.  Campylobacter jejuni

C.  Escherichia coli

D.  Proteus mirabilis

E.  Tropheryma whippelii

XI-56. A 34-year-old female complains of weakness and double vision for the last 3 weeks. She has also noted a change in her speech, and her friends tell her that she is “more nasal.” She has noticed decreased exercise tolerance and difficulty lifting objects and getting out of a chair. The patient denies pain. The symptoms are worse at the end of the day and with repeated muscle use. You suspect myasthenia gravis. All the following are useful in the diagnosis of myasthenia gravis EXCEPT:

A.  Acetylcholine receptor (AChR) antibodies

B.  Edrophonium

C.  Electrodiagnostic testing

D.  Muscle-specific kinase (MuSK) antibodies

E.  Voltage-gated calcium channel antibodies

XI-57. A 38-year-old female patient with facial and ocular weakness has just been diagnosed with myasthenia gravis. You intend to initiate therapy with anticholinesterase medications and glucocorticoids. All of the following tests are necessary before instituting this therapy EXCEPT:

A.  MRI of mediastinum

B.  Purified protein derivative skin test

C.  Lumbar puncture

D.  Pulmonary function tests

E.  Thyroid-stimulating hormone

XI-58. All of the following lipid-lowering agents are associated with muscle toxicity EXCEPT:

A.  Atorvastatin.

B.  Ezetimibe.

C.  Gemfibrozil.

D.  Niacin.

E.  All of the above are associated with muscle toxicity.

XI-59. All of the following endocrine conditions are associated with myopathy EXCEPT:

A.  Hypothyroidism.

B.  Hyperparathyroidism.

C.  Hyperthyroidism.

D.  Acromegaly.

E.  All of the above are associated with myopathy.

XI-60. A 34-year-old woman seeks evaluation for weakness. She has noted tripping when walking, particularly in her left foot, for the past 2 years. She recently also began to drop things, once allowing a full cup of coffee to spill onto her legs. In this setting, she also feels as if the appearance of her face has changed over the course of many years, stating that she feels as if her face is becoming more hollow and elongated, although she hasn’t lost any weight recently. She has not seen a physician in many years and has no past medical history. Her only medications are a multivitamin and calcium with vitamin D. Her family history is significant for similar symptoms of weakness in her brother who is 2 years older. Her mother, who is 58 years old, was diagnosed with mild weakness after her brother was evaluated, but is not symptomatic. On physical examination, the patient’s face appears long and narrow with wasting of the temporalis and masseter muscles. Her speech is mildly dysarthric, and the palate is high and arched. Strength is 4/5 in the intrinsic muscles of the hand, wrist extensors, and ankle dorsiflexors. After testing handgrip strength, you notice that there is a delayed relaxation of the muscles of the hand. What is the most likely diagnosis?

A.  Acid maltase deficiency (Pompe’s disease)

B.  Becker muscular dystrophy

C.  Duchenne muscular dystrophy

D.  Myotonic dystrophy

E.  Nemaline myopathy

XI-61. An elevation in which of the following serum enzymes is the most sensitive indicator of myositis?

A.  Aldolase

B.  Creatinine kinase

C.  Glutamic-oxaloacetic transaminase

D.  Glutamate pyruvate transaminase

E.  Lactate dehydrogenase

XI-62. A 64-year-old woman is evaluated for weakness. For several weeks she has had difficulty brushing her teeth and combing her hair. She has also noted a rash on her face. Examination is notable for a heliotrope rash and proximal muscle weakness. Serum creatine kinase (CK) is elevated and she is diagnosed with dermatomyositis. After evaluation by a rheumatologist, she is found to have anti-Jo-1 antibodies. She is also likely to have which of the following findings?

A.  Ankylosing spondylitis

B.  Inflammatory bowel disease

C.  Interstitial lung disease

D.  Primary biliary cirrhosis

E.  Psoriasis

XI-63. A 63-year-old woman is evaluated for a rash on her eyes and fatigue for 1 month. She reports difficulty with arm and leg strength and constant fatigue, but no fevers or sweats. She also notes that she has a red discoloration around her eyes. She has hypothyroidism but is otherwise well. On examination she has a heliotrope rash and proximal muscle weakness. A diagnosis of dermatomyositis is made after demonstration of elevated serum creatinine kinase and confirmatory EMGs. Which of the following studies should be performed as well to look for associated conditions?

A.  Mammogram

B.  Serum antinuclear antibody measurement

C.  Stool examination for ova and parasites

D.  Thyroid-stimulating immunoglobulins

E.  Titers of antibodies to varicella zoster

XI-64. You are seeing your patient with polymyositis for follow-up. He has been taking prednisone at high doses for 2 months, and you initiated mycophenolate mofetil at the last clinic visit for a steroid-sparing effect. He began a steroid taper 2 weeks ago. His symptoms were predominantly in the lower extremities and face, and he has improved considerably. He no longer needs a cane and his voice has returned to normal. Laboratory data show a creatine kinase (CK) of 1300 U/L, which is unchanged from 2 months ago. What is the most appropriate next step in this patient’s management?

A.  Continue current management.

B.  Continue high-dose steroids with no taper.

C.  Switch mycophenolate to methotrexate.

D.  Repeat muscle biopsy.

XI-65. A 45-year-old woman who is 6 months post–liver transplant is admitted to the hospital after two grand mal seizures in the last 45 minutes. For the last day she has complained about headache and confusion. Her medications include diltiazem, cyclosporine, prednisone, and mycophenolate mofetil. She is now awake but somnolent. Her vital signs are normal except a blood pressure of 150/90 mmHg. There is bilateral afferent pupillary defect, and she reports she cannot see out of either eye. Hearing is intact. There is no nuchal rigidity. Her cyclosporine level is therapeutic. The FLAIR image of her MRI is shown in Figure XI-65. Which of the following is the most likely diagnosis?

image

FIGURE XI-65

A.  Acoustic neuroma

B.  Calcineurin-inhibitor toxicity

C.  Panhypopituitarism

D.  Streptococcal meningitis

E.  Tuberculous meningitis

XI-66. A 77-year-old man undergoes coronary artery bypass grafting for refractory angina and three-vessel disease. Prior to surgery he still worked as a classics professor at a university teaching a renowned course on Dante’s “Inferno.” One month after surgery, his cardiac status is normal and his exercise tolerance is better than presurgery. However, his wife reports that he seems depressed and is often confused. His short-term memory is poor and he exhibits no enthusiasm for teaching. He has no fever or night sweats. Current medications include lovastatin and lisinopril. His physical examination is normal except for poor performance on serial 7 subtraction and only recalling 1 or 3 objects at 15 minutes. Which of the following is the most likely diagnosis?

A.  Multiple sclerosis

B.  Post–cardiac bypass brain injury

C.  Streptococcal meningitis

D.  Variant Creutzfeldt-Jacob disease

E.  West Nile virus encephalitis

XI-67. A 24-year-old man is recovering from ARDS due to severe influenza A infection. During his complicated 3-week course of respiratory failure, he was placed on high-frequency ventilation and prone positioning necessitating paralysis and heavy sedation. Passive splints were placed on his upper and lower extremities. He is now extubated and awake, requiring only nasal oxygen. While starting his physical therapy, it is noted that he has right footdrop and numbness on the lateral leg. Additional examination reveals a unilateral right motor defect in foot dorsiflexion with intact inversion. There is sensory loss of the lateral aspect of the leg below the knee extending to the dorsum of the foot. The rest of the neurologic examination of the right leg and foot appears normal. Which of the following is the most likely etiology of his defects?

A.  Cauda equina syndrome

B.  Femoral nerve injury

C.  L4 radiculopathy

D.  L5 radiculopathy

E.  Peroneal nerve injury

XI-68. In the CDC diagnostic criteria for chronic fatigue syndrome, in addition to clearly delineated findings of fatigue, all of the following symptoms or findings must be concurrently present for at least 6 months EXCEPT:

A.  Delusional disorder

B.  Impaired memory or concentration

C.  Muscle pain

D.  Sore throat

E.  Tender cervical or axillary lymph nodes

XI-69. Which of the following is a beneficial therapy for chronic fatigue syndrome?

A.  Bupropion

B.  Cognitive behavioral therapy

C.  Doxycycline

D.  Fluoxetine

E.  Olanzapine

XI-70. A 26-year-old woman presents to the emergency department complaining of shortness of breath and chest pain. These symptoms began abruptly and became progressively worse over 10 minutes, prompting her to call 911. Over this same period, the patient describes feeling her heart pounding and states that she felt like she was dying. She feels lightheaded and dizzy. It is currently about 20 minutes since the onset of symptoms and the severity has abated, although she continues to feel not back to her baseline. She denies any immediate precipitating cause, although she has been under increased stress as her mother has been hospitalized recently with advanced breast cancer. She does not take any medications and has no medical history. She denies tobacco, alcohol, or drug use. On initial examination, she appears somewhat anxious and diaphoretic. Her initial vital signs show a heart rate of 108 beats/min, blood pressure 122/68 mmHg, and respiratory rate 20 breaths/min. She is afebrile. Her examination is normal. Her arterial blood gas shows a pH of 7.52, PaCO2 of 28 mmHg, and PaO2 of 116 mmHg. The ECG is normal as is a chest radiograph. What is the next best step in the management of this patient?

A.  Initiate therapy with alprazolam 0.5 mg four times daily.

B.  Initiate therapy with fluoxetine 20 mg daily.

C.  Perform a CT pulmonary angiogram.

D.  Reassure the patient and suggest medical and/or psychological therapy if symptoms recur on a frequent basis.

E.  Refer for cognitive behavioral therapy.

XI-71. All of the following antidepressant medications are correctly paired with their class of medication EXCEPT:

A.  Duloxetine—Selective serotonin reuptake inhibitor

B.  Fluoxetine—Selective serotonin reuptake inhibitor

C.  Nortriptyline—Tricyclic antidepressant

D.  Phenelzine—Monoamine oxidase inhibitor

E.  Venlafaxine—Mixed norepinephrine/serotonin reuptake inhibitor and receptor blocker

XI-72. A 42-year-old woman seeks your advice regarding symptoms concerning for post-traumatic stress disorder. She was the victim of a home invasion 6 months previously where she was robbed and beaten by a man at gunpoint. She thought she was going to die and was hospitalized with multiple blunt force injuries including a broken nose and zygomatic arch. She now states that she is unable to be alone in her home and frequently awakens with dreams of the event. She is irritable with her husband and children and cries frequently. She has worsening insomnia and often stays awake most of the night watching out her window because she is afraid her assailant will return. She has begun drinking a bottle of wine nightly to help her fall asleep, although she notes that this has worsened her nightmares in the early morning hours. You concur that post-traumatic stress disorder is likely. What treatment do you recommend for this patient?

A.  Avoidance of alcohol

B.  Cognitive behavioral therapy

C.  Paroxetine 20 mg daily

D.  Trazodone 50 mg nightly

E.  All of the above

XI-73. A 36-year-old man is being treated with venlafaxine 150 mg twice daily for major depression. He has currently been on the medication for 4 months. After 2 months, his symptoms were inadequately controlled, necessitating an increase in the dose of venlafaxine from 75 mg twice daily. He has had one prior episode of major depression when he was 25. At that time, he was treated with fluoxetine 80 mg daily for 12 months, but found the sexual side effects difficult to tolerate. He asks when he can safely discontinue his medication. What is your advice to the patient?

A.  He should continue on the medication indefinitely as his depression is likely to recur.

B.  The current medication should be continued for a minimum of 6–9 months following control of his symptoms.

C.  The medication can be discontinued safely if he establishes a relationship with a psychotherapist who will monitor his progress and symptoms.

D.  The medication can be discontinued safely now as his symptoms are well controlled.

E.  The medication should be switched to fluoxetine to complete 12 months of therapy, as this was previously effective for him.

XI-74. Which of the following will lead to a faster rate of absorption of alcohol from the gut into the blood?

A.  Coadministration with a carbonated beverage

B.  Concentration of alcohol of more than 20% by volume

C.  Concurrent intake of a high-carbohydrate meal

D.  Concurrent intake of a high-fat meal

E.  Concurrent intake of a high-protein meal

XI-75. Which of the following best reflects the effect of alcohol on neurotransmitters in the brain?

A.  Decreases dopamine activity

B.  Decreases serotonin activity

C.  Increases γ-aminobutyric acid activity

D.  Stimulates muscarinic acetylcholine receptors

E.  Stimulates N-methyl-D-aspartate excitatory glutamate receptors

XI-76. In an individual without any prior history of alcohol intake, what serum concentration of ethanol (in grams per deciliter) would likely result in death?

A.  0.02

B.  0.08

C.  0.28

D.  0.40

E.  0.60

XI-77. All of the following statements regarding the epidemiology and genetics of alcoholism are true EXCEPT:

A.  Among individuals who have demonstrated alcohol abuse, about 10% will develop true alcohol dependence.

B.  Approximately 60% of the risk for alcohol abuse disorders is attributed to genetics.

C.  Children of alcoholics have a 10-fold higher risk of alcohol abuse and dependence.

D.  The presence of a mutation of aldehyde dehydrogenase that results in intense flushing with alcohol consumption confers a decreased risk of alcohol dependence.

E.  The lifetime risk of alcohol dependence in most Western countries is about 10–15% for men and 5–8% for women.

XI-78. A 42-year-old man with alcohol dependence is admitted to the hospital for acute pancreatitis. Upon admission, he has an abdominal CT scan that shows edema without necrosis or hemorrhage of the pancreas. He is treated with IV fluids with dextrose, multivitamins, thiamine 50 mg daily, pain control, and bowel rest. He typically drinks 24 12-ounce beers daily. Forty-eight hours after admission, you are called because the patient is febrile and combative with the nursing staff. His vital signs demonstrate a heart rate of 132 beats/min, blood pressure of 184/96 mmHg, respiratory rate of 32 breaths/min, temperature of 38.7°C (101.7°F), and oxygen saturation of 94% on room air. He is agitated, diaphoretic, and pacing his room. He is oriented to person only. His neurologic examination appears non-focal, although he does not cooperate. He is tremulous. What is the next step in the management of this patient?

A.  Administer a bolus of 1 L of normal saline and thiamine 100 mg IV.

B.  Administer diazepam 10–20 mg IV followed by bolus doses of 5–10 mg as needed until the patient is calm but able to be aroused.

C.  Perform an emergent head CT.

D.  Perform two peripheral blood cultures and begin treatment with imipenem 1 g IV every 8 hours.

E.  Place the patient in four-point restraints and treat with haloperidol 5 mg IV.

XI-79. A 48-year-old woman is recovering from alcohol dependence and requests medication to help prevent relapse. She has a medical history of stroke occurring during a hypertensive crisis. Which of the following medications could be considered?

A.  Acamprosate

B.  Disulfiram

C.  Naltrexone

D.  A and C

E.  All of the above

XI-80. What is the most common initial illicit drug of abuse among U.S. adolescents?

A.  Benzodiazepines

B.  Heroin

C.  Marijuana

D.  Methamphetamines

E.  Prescription narcotics

XI-81. A 32-year-old woman is admitted to the hospital for drainage and treatment of a soft tissue abscess of her left forearm. She uses IV heroin on a daily basis, often spending $100 or more per day on drugs. Upon admission, she has a 4 × 2-cm fluctuant mass in the left forearm associated with fevers to 39.3°C (102.7°F) and tachycardia. The abscess is drained and packed, and the patient is initiated on therapy with IV clindamycin. About 10 hours after admission, you are called to the patient’s bedside for a change in the patient’s condition. You are suspecting narcotic withdrawal. All of the following symptoms are consistent with this diagnosis EXCEPT:

A.  Hyperthermia

B.  Hypotension

C.  Piloerection

D.  Sweating

E.  Vomiting

XI-82. A 24-year-old man is brought to the emergency department by emergency medical services (EMS) about 2 hours after an intentional overdose of sustained-release oxycodone that was taken in conjunction with alcohol. Upon arrival at the scene, emergency medical technicians found an empty bottle of sustained-release oxycodone tablets with a dose of 20 mg. It is unknown how many pills the patient ingested, but the prescription was written for 60 tablets. The patient was unresponsive with a respiratory rate of 4 breaths/min, blood pressure of 80/56 mmHg, heart rate of 65 beats/min, and oxygen saturation of 86% on room air. The patient was intubated in the field and naloxone 2 mg IM was administered. He is currently intubated and unresponsive without spontaneous respiration above the set ventilator rate. His blood pressure is 82/50 mmHg and heart rate is 70 beats/min. Which of the following is most appropriate at the present time in the evaluation and treatment of this patient?

A.  Activated charcoal

B.  IV saline bolus 1 L followed by repeated 500–1000 mL boluses to maintain adequate blood pressure

C.  Naloxone continuous infusion at a rate of 0.4 mg/h

D.  Urine drug screen, acetaminophen levels, and blood alcohol content

E.  All of the above

XI-83. Which of the following statements is TRUE with regard to the chronic effects of marijuana use?

A.  Chronic use of marijuana is associated with low testosterone levels.

B.  Chronic use of marijuana is the primary cause of amotivational syndrome.

C.  Marijuana use is associated with an increased risk of psychotic symptoms in individuals with a past history of schizophrenia.

D.  Physical and psychological tolerance does not develop in chronic users of marijuana.

E.  There is no withdrawal syndrome associated with cessation of marijuana use.

XI-84. All of the following malignancies are associated with cigarette smoking EXCEPT:

A.  Acute myeloid leukemia

B.  Bladder

C.  Cervix

D.  Pancreas

E.  Postmenopausal breast cancer

XI-85. A 42-year-old woman seeks advice from you regarding smoking cessation. She began smoking at age 15. On average, she has smoked about 1.5 packs of tobacco daily and is currently smoking 1 pack daily. She was able to successfully quit for a period of 8 months when she was pregnant with her child at the age of 28, but quickly began smoking again shortly after the baby’s birth. Her past medical history is significant for depression, but she is not currently on any medication. She does admit to ongoing symptoms of depression that contribute to her perceived need for ongoing cigarette use. Which of the following would you recommend for this patient?

A.  Bupropion titrated to a dose of 150 mg twice daily

B.  Bupropion titrated to a dose of 150 mg twice daily in combination with nicotine replacement therapy

C.  In-office counseling alone with a negotiated quit date

D.  Varenicline titrated to a dose of 1 mg twice daily

E.  Varenicline titrated to a dose of 1 mg twice daily in combination with nicotine replacement therapy

XI-86. What percentage of cigarette smokers will die prematurely if they are unable to quit?

A.  2%

B.  10%

C.  25%

D.  40%

E.  70%

XI-87. You are counseling your patient on the need to quit smoking cigarettes. She has been smoking for over two decades and wants to quit in order to avoid the harmful physical effects of smoking. Wanting to take “baby steps,” she has switched to low-tar, low-nicotine cigarettes. Which of the following statements is TRUE about the potential benefit of switching to these low-yield cigarettes?

A.  Fewer smoking-drug interactions are found among smokers of low-yield cigarettes.

B.  Most smokers inhale the same amount of nicotine and tar even if they switch to low-yield cigarettes.

C.  Smokers of low-yield cigarettes tend to inhale less deeply and smoke fewer cigarettes daily.

D.  Smoking low-yield cigarettes decreases the harmful cardiovascular effects of cigarette smoking.

E.  Smoking low-yield cigarettes is a reasonable alternative to complete smoking cessation for chronic smokers.