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include behavioral habits of living, adapting, coping, and achieving. Lung cancer could be significantly reduced by changing just one behavioral habit—cigarette smoking. Since behavior that is learned also can be unlearned, behavioral theory and technology exists that could change smoking behavior and in turn significantly reduce the number of premature deaths from lung cancer. This is also true to a lesser degree for other types of premature death, such as unintentional injuries, violence, homicide, cardiac disease, diabetes, suicide, chronic obstructive pulmonary disease, obesity, and HIV infection. This assertion does not imply that most premature deaths are caused only by behavior, nor can they all be prevented by behavioral change, but it does illustrate the important role that behavior plays in the etiology, treatment, and prevention of modern diseases. Major known behavioral risk factors include cigarette smoking, poor dietary habits, reckless driving, violence, use of illicit drugs, excessive consumption of alcoholic beverages, insufficient exercise, nonadherence to medication and treatment regimens, maladaptive responses to personal and social pressures, and obesity.
In 1990, the United States Congress passed the Patient Self-Determination Act, which granted a patient several rights to determine his or her own medical care. One is the ability to grant to a specific individual the authority to make medical decisions if the patient is unable to make them. What is this process called?
A. Conservatorship
B. Durable power of attorney
C. Advance directive
D. Guardianship
E. Proxy
The answer is: B
The Patient Self-Determination Act was passed by Congress in 1990 and became effective December 1, 1991. It guarantees a patient the right to refuse medical care, to specify advance directives (the measures or procedures a patient would want or would refuse under a variety of potential circumstances), and to specify an individual who would have the authority to make medical decisions (durable power of attorney) if the patient was unable to do so. Thus, a patient could specify that a breathing respirator or even cardiopulmonary resuscitation (CPR) not be used in an emergency. Possible circumstances can be specified (e.g., irreversible coma) for which the patient wants no intervention through medical technology.
You are conducting a general internal medicine practice and seeing patients with a variety of chronic illnesses. In which of the diseases below would it be most relevant to evaluate the patient's ability to cope with psychological stress?
A. Breast cancer
B. Essential hypertension
C. Colon cancer
D. Diverticulitis
E. Rheumatoid arthritis
The answer is: B
Inability to cope with psychological stress has a direct physiologic effect and over time can cause damage to most systems of the body. The most frequently cited illnesses related to failure to cope with stress include coronary artery disease, hypertension, and gastrointestinal problems. Coping style and lifestyle are very important since they help determine the reaction to stress, and they lead people to adopt behaviors and habits that can predispose them to illness. Cancer can be aggravated by psychological stress but the initial pathogenesis appears to be more dependent on other factors. Stress is increasingly considered to be a major factor in the prognosis of cancer.
Which of the following is the best predictor of health and longevity?
A. Income level
B. Education level
C. Lifestyle
D. Marital status
E. Religious participation
The answer is: C
A remarkable number of studies have found that lifestyle, schooling, marital status, income level, and even religious participation are good predictors of health and longevity. While all of these factors are important, lifestyle represents a combination of all the behavioral factors upon which health risks and prevention are based and has a central role in the etiology and treatment of most diseases. Of course genetics is also a major factor, but one's lifestyle can have a direct effect on the expression of particular genes or predispositions. Education is associated with income, life changes, lifestyle, habits, knowledge, self-esteem, and other factors, all of which affect health. Marriage favors men, but both men and women gain significantly relative to unmarried or divorced persons. Religious participation generally is related to conventionality of lifestyle, and more positive health behaviors in respect to smoking, drinking, and other risks.
Which of the following is the fastest growing age group in the United States?
A. Adolescents
B. Young adults
C. Middle-aged persons
D. Persons 65 to 79 years of age
E. Persons 80 years of age and older
The answer is: E
The fastest growing age group in the United States is the group 80 years old and older. This is attributed to increased health concerns and better medical care. The number of persons over 65 years of age now exceeds the number of persons aged 25 years or younger. A significant problem for medicine is that this group requires more medical care and greater costs primarily for chronic illnesses. Women outlive men by a ratio of 1.5:1 and they also have a greater utilization of health care than men.
A 45-year-old male presents with weight loss, steatorrhea, and malabsorption. A CT scan of the abdomen reveals a questionable mass in the head of the pancreas. A biopsy specimen microscopically reveals chronic inflammation and atrophy of the pancreatic acini with marked fibrosis. No malignancy is identified. What is the most common cause of this patient's disease in adults in the United States?
A. Abdominal trauma
B. Chronic alcoholism
C. Cystic fibrosis
D. Gallstones
E. Hyperlipidemia
The answer is: B
Chronic pancreatitis is characterized histologically by chronic inflammation and irregular fibrosis of the pancreas. The major cause of chronic pancreatitis in adults is chronic alcoholism, while in children the major cause is cystic fibrosis. Recurrent attacks of acute pancreatitis also result in the changes of chronic pancreatitis. Hypercalcemia and hyperlipidemia also predispose to chronic pancreatitis (since they are causes of acute pancreatitis), while in as many as 10% of patients, recurrent pancreatitis is associated with pancreas divisum. This condition refers to the finding of the accessory duct being the major excretory duct of the pancreas. Chronic ductal obstruction may be a cause of chronic pancreatitis and may be associated with gallstones, but it is more appropriate to relate gallstones with acute ductal obstruction and resultant acute pancreatitis. Complications of chronic pancreatitis include pancreatic calcifications, pancreatic cysts and pseudocysts, stones within the pancreatic ducts, diabetes, and fat malabsorption, which results in steatorrhea and decreased vitamin K levels.
A 50-year-old patient has just lost his wife of 30 years and is suffering from the acute stress of bereavement. Without medical intervention such as supervision of factors affecting his mental and physical health, recommendation of support groups, and the scheduling of regular visits over the next six months, the patient will be subject to an increased mortality risk of what percent?

A. 10%
B. 20%
C. 30%
D. 40%
E. 50%
The answer is: D
The health risk to individuals who are in bereavement from the loss of a loved one is often ignored. Prospective studies have shown that the stressful effects of severe life crises are a real risk factor to general health and to the immune system. A large cohort of middle-aged widowers demonstrated a 40% increase in their mortality rate in the first six months of bereavement following the death of their spouse. Furthermore, over one-half of the deaths were from cardiovascular causes. Other factors that may contribute to the increased mortality rate include sudden changes in lifestyle or environment and feelings of isolation or lack of support.
Which of the following is the leading cause of death for African American male adolescents?
A. Motor vehicle accidents
B. Homicide
C. Suicide
D. Genetic and developmental cardiovascular disease
E. Alcohol and substance abuse
The answer is: B
African American males 15 to 19 years of age have the lowest life expectancy of all adolescents. They have a fivefold greater rate of death from homicide than white males. Homicide accounts for 58% of the deaths in late adolescence and 54% in young adults. Living in impoverished metropolitan areas increases the risk tremendously for African American adolescents. Rates of suicide are lower for African American than Native American or white adolescents. The rate of death by motor vehicle accident is lower for African American males than for whites, as is death from alcohol and substance abuse. Death from cardiovascular disease is infrequent in adolescents.
Between 1990 and 1995, which disease accounted for the greatest percent increase in years of potential lives lost before the age of 75?

A. Diabetes
B. Breast cancer
C. Prostate cancer
D. Ischemic heart disease
E. Chronic obstructive pulmonary disease
The answer is: A
Mortality rates are calculated from the number of deaths per 100,000 population each year. To add a new perspective of the humanitarian loss to society and to the life of an individual, the concept of years of potential life lost was developed. Of the diseases listed in the question, diabetes has had the greatest percent increase between 1990 and 1995. Diabetes showed a 15% increase in years of potential lives lost before the age of 75 (from 147.0 to 169.6 per 100,000 population). This increase represents a very costly price and sacrifice, considering the efficacy of treatments for the diagnosis and control of diabetes. Chronic obstructive pulmonary disease (COPD) also had an increase in years of potential life lost between 1990 and 1995 (182.5 to 188.0 per 100,000), a 3% increase. As might be expected, the greatest increase of all was from human immunodeficiency virus (HIV) infection. The years of potential life lost increased from 391.2 to 615.0 per 100,000, a 57% increase. This dramatic increase can be explained by HIV's occurrence in a younger age group and failed prevention. The diabetes increase is not as easily explained, unless treatment compliance and lifestyle factors are questionable. The COPD increase can be explained by the fact that the COPD mortality rate for females doubled between 1980 and 1995, a delayed consequence of an earlier increase in smoking by females.
All of the other diseases listed decreased in years of potential life lost: breast cancer (7% decrease), prostate cancer (15% decrease), and ischemic heart disease (12% decrease). Other decreases include cerebrovascular diseases, all major malignant neoplasms including respiratory and colorectal, pneumonia, influenza, chronic liver disease, cirrhosis, all unintentional injuries, suicide, and homicide. Explanations for these decreases could include early diagnosis, treatment, and relevant changes in lifestyle and environment.
In the U.S., which of the following is the leading cause of death among women?
A. Breast cancer
B. Lung cancer
C. Motor vehicle accidents
D. Cerebrovascular disease
E. Ischemic heart disease
The answer is: E
Ischemic heart disease (IHD) is the leading cause of death among women (nearly 400,000 deaths annually). The death rate is 5 to 6 times that for lung or breast cancer. Because men develop IHD 10 years earlier than women and die of IHD 20 years earlier, many persons think of IHD as primarily a problem of men. High-density lipoprotein (HDL) cholesterol levels are about 10 mg/dL higher in women in all age groups, and there is some evidence that HDL may be more related to IHD among women than low-density lipoprotein (LDL). The relative power of various risk factors and the extent to which interventions prescribed for men can change a woman's risk need more study. Obesity, smoking, hypertension, and oral contraceptives are risk factors for IHD in women.
Specificity of a test is defined by which one of the following expressions?

A. True negatives/(true negatives + false negatives)
B. True negatives/(true negatives + false positives)
C. True positives/(true positives + false negatives)
D. True positives/(true positives + false positives)
E. (True positives + false negatives)/(true negatives + false positives)
The answer is: B
Diagnostic specificity is defined as the probability of a negative diagnostic test (true negatives) in the absence of the disease (true negatives and false positives), or simply, it is the ability of a test to correctly identify a person who is free of the specific disease. Specificity can be calculated using the formula true negatives/(true negatives + false positives). Diagnostic sensitivity is defined as the probability of a positive diagnosis (true positives) in patients with the disease the test is designed to detect (true positives and false negatives). Sensitivity can be calculated using the formula true positives/(true positives + false negatives). The best information from laboratory tests comes from their positive and negative predictive values (PVs) relating the results to the prevalence of the disease in the population being studied. Positive predictive value equals true positives/(true positives + false positives), while predictive negative value equals true negatives/(true negatives + false negatives).
Which of the following is the usual cause of death in cases of anorexia nervosa?
A. Suicide
B. Cardiac arrhythmia
C. Acute pancreatitis
D. Episodic bulemia
E. Onset of depression
The answer is: B
When body weight drops 35% below the minimum normal for age and height, electrolytes are apt to become severely imbalanced. Ventricular tachycardia and arrhythmia occur and the patient with anorexia nervosa becomes vulnerable to sudden death. These characteristics develop due to prolonged starvation. Suicide can occur in instances when the patient becomes depressed and loses all hope. Antidepressants have little positive effect. Supportive care by an understanding physician may accomplish as much as formal psychotherapy. Behavior modification techniques and group and family therapy (family interrelationships appear to be significant) are sometimes helpful. Explicit contracts for a weight-goal diet and a healthy exercise pattern can also be beneficial. Realistic reviews of the dangers of starvation and sincere assurance from the physician that "we will not let you get fat" can also be helpful. The physician should be perceived as an advisor and partner, not as an enemy or parental surrogate. Hospitalization may be lifesaving if hypokalemia, hypotension, and prerenal azotemia are present. The prognosis is variable with approximately half of the anorectic patients achieving normal weight, 20% improve but remain underweight, 20% are not cured and remain anorectic, 5% become obese, and 6% die. Even of those who reach normal weight or improve, two-thirds will continue binge eating, vomiting, and laxative use, making treatment and monitoring a lifelong endeavor.
Which of the following is the most common mental disorder in the U.S. population?
A. Phobic disorder
B. Anxiety disorder
C. Schizophrenia
D. Mood disorder
E. Obsessive-compulsive disorder
The answer is: B
Anxiety disorders are the most common mental disorders in the U.S.; 4 to 14% of general medical patients suffer from anxiety states. Patients with anxiety disorders are more apt to seek help from general physicians or to use the emergency room than are patients with other psychiatric disorders. Mood disorders are the second most common mental disorders in the U.S.; they afflict 5% at any point in time, with a 1-year prevalence of 9.5% for all mood disorders. Prevalence of mood disorders among patients seeking help in a primary care outpatient setting ranges from 4.8 to 8.6% for major depressive disorder to 2.1 to 8.7% for dysthymic disorder. That adds up to 10.2 to 21% of primary care outpatients who suffer from clinically significant mood disorders. They are also high users of nonpsychiatric medical and primary care and of emergency services. Anxiety disorders and mood disorders should be a part of the differential diagnosis when a patient seeks help for depressive symptoms.
Which of the following is the most common cause of goiter in developing nations?


A. Iodine deficiency
B. Lithium
C. Hashimoto's thyroiditis
D. Propylthiouracil
E. Toxic multinodular goiter
The answer is: A

World-wide, iodine deficiency (endemic) goiter is very common. It is not common in the United States or other countries where salt is fortified with iodine.
Most mental health care authorities agree that the trend toward community-based treatment of patients who have emotional disorders, as opposed to their incarceration in public mental institutions, can be ascribed principally to which of the following?

A. Improved therapeutic results when treatment is available within a patient's community
B. The development of preventive measures for various mental illnesses
C. The use of new drugs that allow many emotionally disturbed patients to function outside an institution
D. An increasing willingness by general hospitals to accept mentally disturbed patients
E. The 1961 report of the Joint Commission on Mental Illness and Health, which strongly recommended community mental health programs
The answer is: C

The old approach of treating mentally ill people in large, isolated institutions is becoming outmoded largely because of the effectiveness of new psychotropic drugs that enable many disturbed persons to function normally. The success of these drugs resulted in the recommendations in 1961 of the Joint Commission on Mental Illness and Health to increase the use of community facilities in treating mental illness. Congress passed the Community Mental Health Centers Act in 1963 to provide funds for the construction of community mental health centers. As a result, general hospitals became more active in mental health therapy and community mental health centers developed to support mental patients in a functional atmosphere, in addition to taking steps at a local level to prevent mental illness. Cuts in the federal budget over the past 10 years have significantly restricted the programs and reduced the number of community health centers. As a result many of the patients who have regressed while in the community are not receiving the much needed drugs, social support, vocational counseling and training, a paying job, or psychiatric treatment. Thus, the potential benefits from new medications have been lost because of a failed public policy of deinstitutionalization.
Which of the following is the most reported form of child abuse for children 18 years of age or less?
A. Neglect
B. Physical abuse
C. Sexual abuse
D. Emotional abuse
E. Medical neglect
The answer is: A
Over 1 million children who are 18 years of age and younger are victims of reported abuse and neglect each year. In 1994, 1111 children died as a result of abuse or neglect. More than half of the cases involved neglect, even though financial and other resources were available. Of the other victims, approximately 25% were physically abused, 14% sexually abused, 5% emotionally abused, and 2% medically abused. Another 15% were involved with abandonment, drug addiction, and threats of harm. Twenty-seven percent of the victims were younger than 4 years of age and 52% were female. Between 1990 and 1994 there was an increase of 27% in reported cases of child abuse. Forty-seven states and the District of Columbia now require all cases of child abuse to be reported
When a code call for cardiopulmonary resuscitation (CPR) occurs on a general hospital service, what is the chance that the patient will survive to discharge?

A. 15%
B. 20%
C. 25%
D. 30%
E. 35%
The answer is: A

On a general hospital service, only about 15% of patients given cardiopulmonary resuscitation (CPR) survive to discharge. Hospital patients are increasingly concerned that they will be subjected to abusive modern technology. While CPR has a definite role in some emergency situations, in a hospital setting it should be discussed in advance. In general, it will be attempted unless a do not resuscitate (DNR) order has been made. DNR orders are appropriate if requested, especially if CPR would most likely be futile. "Slow" or "show" codes that merely appear to provide CPR are deceptive and should be questioned on an ethical basis. Sometimes patients may need to be reassured that DNR signifies that only CPR will be withheld and does not mean that other appropriate care or procedures will be withheld.