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QUYỂN HARRISON TỰ ĐÁNH GIÁ bao gồm những câu hỏi kiến thức sinh lý bệnh và case lâm sàng, đáp án có giải thích và chỉ điểm cụ thể trong quyển Harrison. Chắc chắn một điều quyển sách rất bổ ích để vượt qua các kỳ thi chuyên khoa nội cho các đối tượng: sinh viên, nội trú, cao học, chuyên khoa I, chuyên khoa II
18th Edition Principles of HARRISON’S ® INTERNAL MEDICINE SELF-ASSESSMENT AND BOARD REVIEW Editorial Board DAN L LONGO, md Professor of Medicine, Harvard Medical School Senior Physician, Brigham and Women’s Hospital Deputy Editor, New England Journal of Medicine Boston, Massachusetts ANTHONY S FAUCI, md Chief, Laboratory of Immunoregulation Director, National Institute of Allergy and Infectious Diseases National Institutes of Health Bethesda, Maryland 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, Massachusetts STEPHEN L HAUSER, md Robert A Fishman Distinguished Professor and Chairman Department of Neurology, University of California San Francisco, California J LARRY JAMESON, md, phd Robert G Dunlop Professor of Medicine Dean, University of Pennsylvania School of Medicine Executive Vice-President of the University of Pennsylvania for the Health System Philadelphia, Pennsylvania 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, Massachusetts 18th Edition HARRISON’S INTERNAL MEDICINE Principles of ® SELF-ASSESSMENT AND BOARD REVIEW For use with the 18th edition of HARRISON’S PRINCIPLES OF INTERNAL MEDICINE EDITED BY CHARLES M WIENER, MD Dean/CEO Perdana University Graduate School of Medicine Selangor, Malaysia Professor of Medicine and Physiology Johns Hopkins University School of Medicine Baltimore, Maryland CYNTHIA D BROWN, MD Assistant Professor of Medicine Division of Pulmonary and Critical Care Medicine University of Virginia Charlottesville, Virginia ANNA R HEMNES, MD Assistant Professor, Division of Allergy, Pulmonary, and Critical Care Medicine Vanderbilt University Medical Center Nashville, Tennessee New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2012, 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc All rights reserved Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher ISBN: 978-0-07-177196-2 MHID: 0-07-177196-4 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-177195-5, MHID: 0-07-177195-6 All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs To contact a representative please e-mail us at bulksales@mcgraw-hill.com International Edition ISBN 978-0-07-178847-2; MHID 0-07-178847-6 Copyright © 2012 Exclusive rights by The McGraw-Hill Companies, Inc., for manufacture and export This book cannot be re-exported from the country to which it is consigned by McGraw-Hill The International Edition is not available in North America Notice Medicine is an ever-changing science As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work Readers are encouraged to confirm the information contained herein with other sources For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration This recommendation is of particular importance in connection with new or infrequently used drugs TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc (“McGraw-Hill”) and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited Your right to use the work may be terminated if you fail to comply with these terms THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE McGraw-Hill and its licensors not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom McGraw-Hill has no responsibility for the content of any information accessed through the work Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise CONTENTS Preface Introduction to Clinical Medicine SECTION II Nutrition SECTION III Oncology and Hematology SECTION IV Infectious Diseases SECTION V Disorders of the Cardiovascular System SECTION VI Disorders of the Respiratory System SECTION VII Disorders of the Kidney and Urinary Tract SECTION VIII Disorders of the Gastrointestinal System SECTION IX Rheumatology and Immunology SECTION X Endocrinology and Metabolism SECTION XI Neurologic Disorders SECTION XII Dermatology Questions Answers Questions Answers Questions Answers Questions Answers Questions Answers Questions Answers Questions Answers Questions Answers Questions Answers Questions Answers Questions Answers Questions Answers Color Atlas 25 83 87 97 114 153 193 CONTENTS SECTION I vi 265 280 299 310 331 336 343 355 377 388 409 424 453 466 497 501 507 v SECTION I PREFACE This is the third edition of Harrison’s Self-Assessment and Board Review that we have had the honor of working on We thank the editors of the 18th edition of Harrison’s Principles of Internal Medicine for their continued confidence in our ability to produce a worthwhile companion to their exceptional textbook It is truly inspirational to remind ourselves why we love medicine broadly, and internal medicine specifically The care of patients is a privilege As physicians, we owe it to our patients to be intelligent, contemporary, and curious Continuing education takes many forms; many of us enjoy the intellectual stimulation and active learning challenge of the question-answer format It is in that spirit that we offer the 18th edition of the Self-Assessment and Board Review to students, housestaff, and practitioners We hope that from it you will learn, read, investigate, and question The questions and answers are particularly conducive to collaboration and discussion with colleagues This edition contains over 1100 questions that, whenever possible, utilize realistic patient scenarios including radiographic or pathologic images Similarly, our answers attempt to explain the correct or best choice, often supported with figures from the 18th edition of Harrison’s Principles of Internal Medicine to stimulate learning All of the authors have physically left the Osler Medical Service at Johns Hopkins Hospital However, our experiences with colleagues and patients at Hopkins have defined our professional lives In the words of William Osler, “We are here to add what we can to life, not to get what we can from life.” We hope this addition to your life stimulates your mind, challenges your thinking, and translates to your patients Of course, none of this would be possible without the loving support of our families, for which we are truly thankful They were patient and encouraging as we transformed (often not quietly) a mountain of page proofs into this book PREFACE SECTION I Introduction to Clinical Medicine QUESTIONS DIRECTIONS: Choose the one best response to each question I-1. Which of the following is the best definition of evidencebased medicine? A A summary of existing data from existing clinical trials with a critical methodological review and statistical analysis of summative data B A type of research that compares the results of one approach to treating a disease with another approach to treating the same disease C Clinical decision making support tools developed by professional organizations that include expert opinions and data from clinical trials D Clinical decision making supported by data, preferably from randomized controlled clinical trials E One physician’s clinical experience in caring for multiple patients with a specific disorder over many years I-2. All of the following are part of the informed consent process EXCEPT: A Alternatives and likely consequences of the alternatives to the procedure B Ascertainment of understanding by the patient C Discussion of the details of the procedure D Outlining the patient’s wishes if he or she becomes unable to make decisions E Risks and benefits of the procedure I-4. In high-income countries, what category of disease accounts for the greatest percentage of disability-adjusted life years lost? A B C D E Alcohol abuse Chronic obstructive pulmonary disease Diabetes mellitus Ischemic heart disease Unipolar depressive disorders I-5. What is the leading cause of death in low-income countries? A B D D E Diarrheal diseases Human immunodeficiency virus Ischemic heart disease Lower respiratory disease Malaria I-6. You are working with the public health minister of Malawi in a project to decrease malarial deaths in children younger than years of age All of the following strategies are part of the World Health Organization Roll Back Malaria plan EXCEPT: A B C D E Artemisinin-based combination therapy Early treatment with chloroquine alone Indoor residual spraying Insecticide-treated bed nets Intermittent preventive treatment during pregnancy I-3. Which of the following is the standard measure for determining the impact of a health condition on a population? A B C D E Disability-adjusted life years Infant mortality Life expectancy Standardized mortality ratio Years of life lost SECTION I I-7. A 38-year-old woman is evaluated for chest pain She has no risk factors for coronary artery disease, but a stress test is ordered by a physician in the emergency department You are called for a cardiology consult when an exercise ECG stress test result is positive You estimate that the pretest probability of coronary artery disease is 10% and determine that this is most likely a false-positive stress test with a low posttest probability of coronary artery disease This is an example of which of the following principles used in medical decision making? Introduction to Clinical Medicine A B C D E Bayes’ theorem High positive predictive value High specificity Low negative predictive value Low sensitivity I-8. A new diagnostic test for predicting latent tuberculosis is introduced into clinical practice In clinical trials, it was determined to have a sensitivity of 90% and a specificity of 80% A specific clinical population of 1000 individuals has a prevalence of tuberculosis of 10% How many individuals with latent tuberculosis would be correctly identified in this population? A B C D E 10 80 90 100 180 I-9. In the above scenario, how many individuals would be erroneously told they have latent tuberculosis? A B C D E 10 90 180 720 900 I-10. A receiver operating characteristic (ROC) curve is constructed for a new test for disease X All of the following statements regarding the ROC curve are true EXCEPT: A One criticism of the ROC curve is that it is developed for testing only one test or clinical parameter with exclusion of other potentially relevant data B The ROC curve allows the selection of a threshold value for a test that yields the best sensitivity with the fewest false-positive test results C The axes of the ROC curve are sensitivity versus - specificity D The ideal ROC curve would have a value of 0.5 E The value of the ROC curve is calculated as the area under the curve generated from the true-positive rate versus the false-positive rate I-11. Which of the following values is affected by the disease prevalence in a population? A B C D E Number needed to treat Positive likelihood ratio Positive predictive value Sensitivity Specificity I-12. Drug X is investigated in a meta-analysis for its effect on mortality after a myocardial infarction It is found that mortality drops from 10 to 2% when this drug is administered What is the absolute risk reduction conferred by drug X? A B C D E 2% 8% 20% 200% None of the above I-13. How many patients will have to be treated with drug X to prevent one death? A B C D E 12.5 50 93 I-14. When considering a potential screening test, what endpoints should be considered to assess the potential gain from a proposed intervention? A Absolute and relative impact of screening on the disease outcome B Cost per life year saved C Increase in the average life expectancy for the entire population D Number of subjects screened to alter the outcome in one individual E All of the above I-15. A 55-year-old man who smokes cigarettes is enrolled in a lung cancer screening trial based on performance of yearly CT scans over a period of years At year 2, he is found to have a 2-cm right lower lobe lung nodule that is a non–small cell lung cancer upon surgical removal At that time, there were no positive lymph nodes The cancer recurs, and the patient subsequently dies from lung cancer years after his initial diagnosis A person with a similar smoking history who is not participating in the trial is discovered to have a 3-cm lung nodule that is also non–small cell lung cancer Upon surgical resection, one lymph node is positive This person also dies from lung cancer after a period of years What conclusion can be made about the use of the CT screening for lung cancer in these patients? A CT screening for lung cancer improves mortality in smokers B It is unable to be determined if CT screening for lung cancer led to any difference in survival because one cannot determine if lag time bias is present C It is unable to be determined if CT screening for lung cancer led to any difference in survival because one cannot determine if lead time bias is present D Selection bias may cause apparent differences in survival in this trial, and one should be cautious in making conclusions with regards to CT screening for lung cancer E The radiation received as part of the CT scan screening led to lung cancer in the initial patient and contributed to the first patient’s overall mortality I-17. Which preventative intervention leads to the largest average increase in life expectancy for a target population? A regular exercise program for a 40-year-old man Getting a 35-year-old smoker to quit smoking Mammography in women age 50–70 years Pap smears in women age 18–65 years Prostate-specific antigen (PSA) and digital rectal examination for a man older than 50 years old A Digitalis-specific antibody (Fab) fragments alone B Digitalis-specific antibody fragments plus hemodialysis C Digitalis-specific antibody fragments plus hemoperfusion D Plasmapheresis alone E Volume resuscitation and observation I-18. All of the following patients should receive a lipid screening profile EXCEPT: I-22. A 48-year-old woman with a generalized seizure disorder has been taking phenytoin for the past 10 years with good control of her disease She also has a history of hepatitis C virus infection acquired via a blood transfusion received after an automobile accident in her teens She currently takes phenytoin 100 mg tid, lactulose 30 g tid, and spironolactone 25 mg daily She is brought to the emergency department by her husband, who reports that she has had increasing lethargy for the past week On examination, her blood pressure is 100/60 mmHg, heart rate is 88 beats/min, respiratory rate is 20 breaths/ min, and oxygen saturation is 98% on room air She is afebrile She is minimally responsive to voice and follows no commands There is no nuchal rigidity Her abdomen is distended with a positive fluid wave but without tenderness She has spider angiomata, caput medusa, and palmar erythema She does not appear to have asterixis She does have horizontal nystagmus on examination Her laboratory values include Na, 134 meq/L; potassium, 3.9 meq/L; chloride, 104 meq/L; and bicarbonate, 20 meq/L Creatinine is 1.0 mg/dL The white blood cell count is 10,000/μL with a normal differential Her liver function tests are unchanged from baseline with the exception of an albumin that is now 2.1 g/dL compared with months ago when her level was 2.9 g/dL Ammonia level is 15 μmol/L, and her phenytoin level is 17 mg/L A paracentesis shows a white blood cell count of 100/μL that is 80% neutrophils What test would be most likely to demonstrate the cause of the patient’s change in mental status? A B C D E A A 16-year-old boy with type diabetes B A 17-year-old female teen who recently began smoking C A 23-year-old healthy man who is starting his first job D A 48-year-old woman beginning menopause E A 62-year-old man with no past medical history I-19. A 43-year-old woman is diagnosed with pulmonary blastomycosis and is initiated on therapy with oral itraconazole therapy All of the following could affect the bioavailability of this drug EXCEPT: A B C D E Coadministration with a cola beverage Coadministration with oral contraceptive pills Formulation of the drug (liquid vs capsule) pH of the stomach Presence of food in the stomach I-20. A 24-year-old woman with cystic fibrosis is admitted to the hospital with an exacerbation She is known to be colonized with Pseudomonas aeruginosa and is started on intravenous therapy with cefepime g IV every hours and tobramycin 10 mg/kg IV once daily You want to ensure that the risk of nephrotoxicity is low When should the tobramycin level be checked? A B C D E 30 minutes after the first dose hours after the first dose hours before second dose Immediately before the fourth dose There is no need to check drug levels if the patient has normal renal function A B C D E QUESTIONS A Every years beginning at age 30 years B Once at age 30 years C Once at age 30 years and again in 10 years if the test result is normal D Periodically E There is no recommended screening for thyroid disease recommended by the U.S Preventive Services Task Force I-21. A 68-year-old man with ischemic cardiomyopathy has been treated with digoxin 250 μg daily for the past year He has chronic kidney disease with a stable baseline creatinine of 2.1 mg/dL He is initiated on an oral amiodarone load for new-onset atrial fibrillation with rapid ventricular response Over week, he develops increasing nausea, vomiting, and fatigue On presentation to the emergency department, he is lethargic and difficult to arouse with a heart rate of 45 beats/min and a blood pressure of 88/50 mmHg His laboratory values demonstrate a potassium of 5.2 meq/L, creatinine of 3.0 mg/dL, and a digoxin level of 13 ng/mL His ECG shows complete heart block What is the most appropriate treatment for this patient? SECTION I I-16. According to the U.S Preventive Services Task Force, what is the recommended screening interval for thyroid disease in women older than the age of 30 years? CT scan of the head Electroencephalogram (EEG) Free phenytoin level Gram stain of ascites fluid Gram stain of cerebrospinal fluid (CSF) SECTION XII Dermatology XII-13 While on a medical mission to the Ivory Coast, you are asked to see a 17-year-old boy with a large skin lesion on his forearm (see Figure XII-13) The lesion began as a small bump about weeks ago and has grown to the size of a raspberry He has tender axillary adenopathy on the ipsilateral side but no other physical findings His siblings report similar lesions that healed after about 6 months Which of the following is the most appropriate therapy? XII-15 A 36-year-old man with HIV/AIDS (CD4+ lymphocyte count = 112/μL) develops a scaly, waxy, yellowish, patchy, crusty, pruritic rash on and around his nose The rest of his skin examination is normal Which of the following is the most likely diagnosis? A B C D E Molluscum contagiosum Kaposi’s sarcoma Psoriasis Reactivation herpes zoster Seborrheic dermatitis XII-16 A 34-year-old man seeks the advice of his primary care physician because of an asymptomatic rash on his chest There are coalescing light-brown to salmon-colored macules present on the chest A scraping of the lesions is viewed after a wet preparation with 10% potassium hydroxide solution There are both hyphal and spore forms present, giving the slide an appearance of “spaghetti and meatballs.” In addition, the lesions fluoresce to a yellowgreen appearance under a Wood’s lamp Tinea versicolor is diagnosed Which of the following microorganisms is responsible for this skin infection? FIGURE XII-13 (see Color Atlas) A B C D E Albendazole Ivermectin Penicillin Praziquantel Vancomycin XII-14 Infection by what organism causes the rash shown in Figure XII-14? A B C D E Fusarium solani Malassezia furfur Penicillium marneffei Sporothrix schenckii Trichophyton rubrum XII-17 A 19-year-old college freshman comes to the clinic complaining of blistering skin lesions on the back of his hands and arms that are painful He’s noticed these occasionally during his childhood, and they were often precipitated by sunlight and healed with scarring He now notices that since starting college they are more frequent, and often occur after drunken parties His hands and forearms have numerous hypopigmented scars that he says are from previous episodes The skin over the back of his hands appears thick and coarse Otherwise his review of systems and physical examination is normal The lesions on his hands are shown in Figure XII-17 Which of the following tests will most likely yield the correct diagnosis? FIGURE XII-14 (see Color Atlas) (Courtesy of Vijay K Sikand, MD; with permission.) A B C D E 500 Anaplasma phagocytophilum Bartonella henselae Borrelia burgdorferi Ehrlichia chaffeensis Rickettsia rickettsii FIGURE XII-17 (see Color Atlas) (Courtesy of Dr Karl E Anderson; with permission.) ANA Anti-SCL-70 Plasma cortisol Plasma porphyrin Urine porphobilinogen SECTION XII A B C D E A B C D E ANSWERS XII-18 A 22-year-old male comes to the clinic reporting severe penile itching and new skin lesions His last sexual encounter was unprotected sex weeks prior with a new female partner in her bed He has not seen her since Over the last days he’s noticed new lesions on his penis and scrotum The lesions are extremely pruritic, particularly at night and after a shower His physical examination is shown in Figure XII-18 Which of the following is the best therapy? Ceftriaxone plus azithromycin Metronidazole Penicillin G Permethrin Vancomycin FIGURE XII-18 (see Color Atlas) ANSWERS XII-1 The answer is D (Chap 51) Rashes and skin lesions are the most common reasons for visits to primary care physicians Accurately characterizing a skin lesion is important for determining the underlying cause of the disease Four basic features that are important when describing a skin lesion are the distribution, types of primary and secondary lesions, shape, and arrangement of lesions The primary description of a skin lesion takes into account size, whether the lesion is raised or flat, and whether the lesion is fluid filled Raised lesions can be papules, nodules, tumors, or plaques A plaque is a raised lesion with a flat top that measures more than cm in diameter The edges may be distinct or gradually blend in with the surrounding skin Papules, nodules, and tumors are similar raised solid lesions of the skin These lesions differ only by size, with papules being smaller than 0.5 cm, nodules measuring 0.5–5.0 cm, and tumors measuring more than cm Macules and patches are not raised and also differ only by size, with macules being less than cm and patches being greater than cm Vesicles are small ([...]... another endpoint) between the treatment and the placebo arms In this case, the absolute risk reduction is 10% − 2% = 8% From this number, one can calculate the number needed to treat (NNT), which is 1/ ARR The NNT is the number of patients who must receive the intervention to prevent one death (or another outcome assessed in the study) In this case, the NNT is 1/8% = 12.5 patients 28 I-14 The answer is E... Transfusion of 2 units of packed red blood cells I-151. All of the following statements about the pathogenesis of sepsis and septic shock are true EXCEPT: A Blood cultures are positive in only 20–40% of cases of severe sepsis B Microbial invasion of the bloodstream is not necessary for the development of severe sepsis C Serum levels of TNF-alpha are typically reduced in patients with severe sepsis or... as an advantage over therapy with infused vasopressors or inotropes in a patient with acute ST-segment elevation myocardial infarction and cardiogenic shock? A B C D E SECTION I A Approximately 80% of cases of cardiogenic shock complicating acute myocardial infarction are attributable to acute severe mitral regurgitation B Cardiogenic shock is more common in ST-segment elevation than non–ST-segment... gleaned from randomized controlled clinical trials Clearly, in some situations, it is impossible or unethical to perform randomized controlled trials, and data from observational studies such as cohort or case- control studies supply important information regarding disease associations Professional organizations and government agencies use EBM to develop clinical practice guidelines These guidelines combine... two-by-two table, as shown below This table is used to generate the total number of patients in each group of the population The sensitivity of the test is TP/(TP + FN) The specificity is TN/(TN + FP) In this case, the disease prevalence is 10% In a population of 1000 individuals, 100 would truly have latent tuberculosis, and the table is filled in as follows: Latent Tuberculosis Test + − + 90 10 − 180 720... because of recent falls He reports gait difficulties with a sensation of being off balance at times One recent fall caused a shoulder injury requiring surgery to repair a torn rotation cuff In epidemiologic case series, what is the most common cause of gait disorders? A B C D E Cerebellar degeneration Cerebrovascular disease with multiple infarcts Cervical myelopathy Parkinson’s disease Sensory deficits... bias refers to the bias that occurs when one finds a tumor at an earlier clinical stage than would be expected from usual care but ultimately does not lead to an overall change in the outcome In this case, the apparent difference in time to diagnosis and death likely represents lead time bias To fully determine this, one would The answer is E (Chap 4) The U.S Preventive Services Task Force (USPSTF)... azole antifungals (including itraconazole) inhibit CYP450 3A4 and may increase the serum levels of estrogens and progestins ANSWERS I-16 SECTION I need to know outcome data for the entire trial In the case of lead time bias, one would find that although the number of tumors diagnosed at early stages was increased, the overall mortality would be the same The recently published Lung Cancer Screening Trial ... Hospital Boston, Massachusetts 18th Edition HARRISON S INTERNAL MEDICINE Principles of ® SELF-ASSESSMENT AND BOARD REVIEW For use with the 18th edition of HARRISON S PRINCIPLES OF INTERNAL MEDICINE... PREFACE This is the third edition of Harrison s Self-Assessment and Board Review that we have had the honor of working on We thank the editors of the 18th edition of Harrison s Principles of Internal... 30 μg/mL However, in the case of hypoalbuminemia, the total level can substantially misrepresent the free level of drug When the free phenytoin level was checked in this case, it was elevated at