FIRST AID FOR THE® INTERNAL MEDICINE BOARDS Second Edition TAO LE, MD, MHS Assistant Clinical Professor of Medicine and Pediatrics Chief, Section of Allergy and Immunology Department of Medicine University of Louisville Louisville, Kentucky PETER CHIN-HONG, MD Assistant Professor, Division of Infectious Diseases Department of Medicine University of California at San Francisco San Francisco, California THOMAS E BAUDENDISTEL, MD, FACP Associate Director, Internal Medicine Residency Department of Medicine California Pacific Medical Center San Francisco, California New York / Chicago / San Francisco / Lisbon / London / Madrid / Mexico City Milan / New Delhi / San Juan / Seoul / Singapore / Sydney / Toronto Copyright © 2008 by Tao Le All rights reserved Manufactured in the United States of America Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher 0-07-164320-6 The material in this eBook also appears in the print version of this title: 0-07-149913-X All trademarks are trademarks of their respective owners Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark Where such designations appear in this book, they have been printed with initial caps McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs For more information, please contact George Hoare, Special Sales, at george_hoare@mcgraw-hill.com or (212) 904-4069 TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc (“McGraw-Hill”) and its licensors reserve all rights in and to the work Use of this work is subject to these terms Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not 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 DOI: 10.1036/007149913X Professional Want to learn more? We hope you enjoy this McGraw-Hill eBook! If you’d like more information about this book, its author, or related books and websites, please click here D E D I C AT I O N To the contributors to this and future editions, who took time to share their knowledge, insight, and humor for the benefit of residents and clinicians and To our families, friends, and loved ones, who endured and assisted in the task of assembling this guide Copyright © 2008 by Tao Le Click here for terms of use This page intentionally left blank For more information about this title, click here CONTENTS Authors vii Preface ix Acknowledgments xi How to Contribute xiii Introduction to the ABIM xv Chapter Allergy and Immunology Raffi Tachdjian, MD, MPH Marc Riedl, MD, MS Chapter Ambulatory Medicine 23 Deborah Lindes, MD Cindy J Lai, MD Chapter Cardiovascular Disease 83 Ankush Goel, MD Sanjiv Shah, MD Chapter Critical Care 149 Elliott Dasenbrook, MD Christian A Merlo, MD, MPH Chapter Dermatology 161 Tara Miller, MD Siegrid S Yu, MD Chapter Endocrinology 203 Melissa Weinberg, MD Diana M Antoniucci, MD Karen Earle, MD Chapter Gastroenterology and Hepatology 251 Ma Somsouk, MD Scott W Biggins, MD, MAS Chapter Geriatrics 313 Abigail Holley, MD Param Dedhia, MD Chapter Hematology 341 Andrea Harzstark, MD Thomas Chen, MD, PhD Chapter 10 Hospital Medicine 387 Jesse Liu, MD Robert L Trowbridge, MD v Chapter 11 Infectious Diseases 421 Brian S Schwartz, MD José M Eguía, MD Chapter 12 Nephrology 479 Carmen A Peralta, MD, MAS Alan C Pao, MD Chapter 13 Neurology 509 Joey English, MD, PhD S Andrew Josephson, MD Chapter 14 Oncology 549 Andrea Harzstark, MD Jonathan E Rosenberg, MD Chapter 15 Psychiatry 581 Demian Rose, MD, PhD Amin N Azzam, MD, MA Chapter 16 Pulmonary Medicine 599 Elliott Dasenbrook, MD Christian A Merlo, MD, MPH Chapter 17 Rheumatology 629 Mary E Margaretten, MD Jonathan Graf, MD Chapter 18 Women’s Health 665 Deborah Lindes, MD Linda Shiue, MD Appendix: Abbreviations and Symbols 689 Index 697 About the Authors 714 Color insert 715-734 AUTHORS ELLIOTT DASENBROOK, MD MARY E MARGARETTEN, MD Fellow, Division of Pulmonary and Critical Care Medicine Department of Medicine Johns Hopkins University Fellow, Division of Rheumatology Department of Medicine University of California, San Francisco JOEY ENGLISH, MD, PhD TARA MILLER, MD Assistant Professor Department of Neurology University of California, San Francisco Fellow, Dermatologic Surgery Department of Dermatology University of California, San Francisco ANKUSH GOEL, MD CARMEN A PERALTA, MD, MAS Fellow, Division of Cardiology Department of Medicine University of Chicago Fellow, Division of Nephrology Department of Medicine University of California, San Francisco ANDREA HARZSTARK, MD DEMIAN ROSE, MD, PhD Fellow, Division of Hematology and Oncology Department of Medicine University of California, San Francisco Clinical Instructor Department of Psychiatry University of California, San Francisco ABIGAIL HOLLEY, MD BRIAN S SCHWARTZ, MD Fellow, Section of Geriatrics Department of Medicine University of Chicago Fellow, Division of Infectious Diseases Department of Medicine University of California, San Francisco S ANDREW JOSEPHSON, MD MA SOMSOUK, MD Assistant Professor Department of Neurology University of California, San Francisco Fellow, Division of Gastroenterology Department of Medicine University of California, San Francisco DEBORAH LINDES, MD RAFFI TACHDJIAN, MD, MPH Associate Director, Family Health Center Department of Medicine California Pacific Medical Center Assistant Clinical Professor, Division of Allergy, Immunology and Rheumatology Department of Pediatrics UCLA School of Medicine JESSE LIU, MD Fellow, Division of Gastroenterology Department of Medicine MELISSA WEINBERG, MD Fellow, Division of Endocrinology, Diabetes, and Metabolism Department of Medicine University of California, San Francisco vii Copyright © 2008 by Tao Le Click here for terms of use SENIOR REVIEWERS DIANA M ANTONIUCCI, MD CHRISTIAN A MERLO, MD, MPH Assistant Professor, Division of Endocrinology and Metabolism Department of Medicine University of California, San Francisco Assistant Professor, Division of Pulmonary and Critical Care Medicine Department of Medicine Johns Hopkins University AMIN N AZZAM, MD, MA Assistant Professor Department of Psychiatry University of California, San Francisco SCOTT W BIGGINS, MD, MAS Assistant Professor, Division of Gastroenterology Department of Medicine University of California, San Francisco THOMAS CHEN, MD, PhD Staff Physician Associated Medical Specialists San Mateo Medical Center PARAM DEDHIA, MD Clinical Instructor Associate Director of Geriatric Education Committee Department of Medicine Johns Hopkins Bayview Medical Center ALAN C PAO, MD Assistant Professor, Division of Nephrology Department of Medicine University of California, San Francisco MARC RIEDL, MD, MS Assistant Professor, Division of Clinical Immunology and Allergy Department of Medicine University of California, Los Angeles JONATHAN E ROSENBERG, MD Assistant Professor, Division of Hematology and Oncology Department of Medicine University of California, San Francisco SANJIV SHAH, MD Assistant Professor, Division of Cardiology Department of Medicine Northwestern University KAREN EARLE, MD LINDA SHIUE, MD Medical Director, Center for Diabetes Services Department of Internal Medicine California Pacific Medical Center Physician, Palo Alto Medical Foundation Assistant Professor Department of Medicine University of California, San Francisco JOSÉ M EGUÍA, MD, MPH Associate Physician Positive Health Program Department of Medicine University of California, San Francisco JONATHAN GRAF, MD Assistant Professor, Division of Rheumatology Department of Medicine University of California, San Francisco CINDY J LAI, MD Assistant Professor Department of Medicine University of California, San Francisco viii Copyright © 2008 by Tao Le Click here for terms of use ROBERT L TROWBRIDGE, MD Assistant Professor University of Vermont College of Medicine Maine Hospitalist Service Maine Medical Center SIEGRID S YU, MD Assistant Professor Department of Dermatology University of California, San Francisco Cutaneous candidiasis: intertrigo Confluent bright red papules with “satellite” pustules are seen (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 719.) H IG H-YI E LD I MAG ES H IG H-YI E LD FACTS F I G U R E FIGURE 5.11 Symptomatic livedo reticularis A bluish, netlike, arborizing pattern is seen on the posterior thighs and buttocks (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 381.) FIGURE 5.12 Lichen planus Flat-topped, polygonal, sharply defined, shiny, violaceous papules are seen (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 125.) Pyoderma gangrenosum A painful ulcer is seen with a dusky-red peripheral rim and an undermined border (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 153.) FIGURE 5.14 Dermatomyositis Heliotrope (reddish-purple) erythema of the upper eyelids can be seen along with edema of the lower lids (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 373.) H IG H-YI E LD FACTS FIGURE 5.13 H IG H-YI E LD I MAG ES FIGURE 5.15 Acanthosis nigricans Note the velvety, dark brown epidermal thickening of the armpit (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 87.) FIGURE 5.16 Oral hairy leukoplakia Note the corrugated white plaque on the lateral tongue Essentially pathognomonic for HIV infection (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 943.) Erythema multiforme Targetoid lesions are seen on the palms (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 141.) FIGURE 5.22 Bullous pemphigoid Tense bullae with serous fluid are seen (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 108.) H IG H-YI E LD I MAG ES H IG H-YI E LD FACTS FIGURE 5.21 FIGURE 5.23 Pemphigus vulgaris Because of the fragility of the blisters, pemphigus vulgaris presents as erosions (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 104.) FIGURE 5.24 Stevens-Johnson syndrome Generalized eruption of initially targetlike lesions that become confluent, brightly erythematous, and bullous (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 145.) Toxic epidermal necrolysis Bulla formation with rapid desquamation (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 147.) H IG H-YI E LD FACTS FIGURE 5.25 H IG H-YI E LD I MAG ES FIGURE 5.26 Superficial spreading melanoma A highly characteristic lesion is seen with an irregular pigmentary pattern and scalloped borders (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 318.) F I G U R E Nodular basal cell carcinoma Note the smooth, pearly nodule with telangiectasias (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 283.) FIGURE 9.2 Iron deficiency anemia Note hypochromic cells (prominent central pallor) and microcytosis (RBCs smaller than the nucleus of the lymphocyte) There is also prominent thrombocytosis, a common finding associated with iron deficiency (Reproduced, with permission, from Tierney LM et al Current Medical Diagnosis & Treatment, 44th ed New York: McGraw-Hill, 2005.) FIGURE 9.3 Megaloblastic anemia Note the macro-ovalocytes and prominent hypersegmented neutrophil (Reproduced, with permission, from Kasper DL et al Harrison’s Principles of Internal Medicine, 16th ed New York: McGraw-Hill, 2005: 605.) H IG H-YI E LD I MAG ES H IG H-YI E LD FACTS H E MATO LO G Y FIGURE 9.5 Spherocytes Characteristic spherocytes (small, round RBCs without central pallor) are present in addition to signs of markedly ↑ RBC synthesis (polychromasia, nucleated RBCs) in a patient with extravascular immune hemolysis (Reproduced, with permission, from R.S Hillman, MD, and K.A Ault, MD, the American Society of Hematology Slide Bank Copyright © American Society of Hematology All rights reserved.) FIGURE 9.6 Schistocytes A large number of fragmented RBCs is characteristic of microangiopathic or intravascular hemolysis In this case, the patient had HUS (Courtesy of Lloyd Damon, MD.) Bite cells Several characteristic bite cells are present in this patient with G6PD deficiency with acute oxidative hemolysis (Courtesy of Lloyd Damon, MD.) FIGURE 9.8 β-thalassemia major Note the microcytic, hypochromic cells, target cells, and nucleated RBCs (Courtesy of Lloyd Damon, MD.) H IG H-YI E LD FACTS F I G U R E H IG H-YI E LD I MAG ES FIGURE 9.9 Sickle cell anemia Multiple sickle forms are characteristic (Courtesy of Lloyd Damon, MD.) FIGURE 9.10 Myelodysplasia Both neutrophils in this slide demonstrate hypogranulation and hypolobation (pseudo–Pelger-Huët anomaly), suggesting myelodysplasia (Courtesy of Lloyd Damon, MD.) H IG H-YI E LD FACTS FIGURE 9.11 Chronic myelogenous leukemia Note the large number of immature myeloid forms in the peripheral blood, including metamyelocytes, myelocytes, and promyelocytes, as well as a large number of eosinophils and basophils (Courtesy of Lloyd Damon, MD.) FIGURE 9.12 Myelofibrosis Note the large number of teardrop cells suggestive of bone marrow infiltrative disease (Courtesy of Lloyd Damon, MD.) H IG H-YI E LD I MAG ES H O S P I TAL M E D I C I N E FIGURE 10.3 Phlegmasia cerulea dolens of the left lower extremity Note the bluish discoloration and swelling (Courtesy of Daniel L Savitt, MD.) INFECTIOUS DISEASES Atypical lymphocytosis seen in infectious mononucleosis and other infections FIGURE 11.4 Babesiosis on a blood smear Note the parasites within RBCs resembling malaria (Reproduced, with permission, from Lichtman MA et al Williams Hematology, 7th ed New York: McGraw-Hill, 2005: Plate I-10.) These reactive T lymphocytes are large with eccentric nuclei and bluish-staining RNA in the cytoplasm (Reproduced, with permission, from Braunwald E et al Harrison’s Principles of Internal Medicine, 15th ed New York: McGraw-Hill, 2001.) H IG H-YI E LD FACTS FIGURE 11.1 H IG H-YI E LD I MAG ES FIGURE 11.5 Erythema chronicum migrans seen in Lyme disease The classic “bull’s eye” lesion consists of an outer ring where the spirochetes are found, an inner ring of clearing, and central erythema due to an allergic response at the site of the tick bite Note that some lesions may consist only of the outer annular erythema with central clearing (Reproduced, with permission, from Braunwald E et al Harrison’s Principles of Internal Medicine, 15th ed New York: McGraw-Hill, 2001.) FIGURE 11.6 Pneumococcal pneumonia This Gram-stained sputum sample shows many neutrophils and lancet-shaped gram-ᮍ cocci in pairs and chains, indicating infection with S pneumoniae (Reproduced, with permission, from Kasper DL et al Harrison’s Principles of Internal Medicine, 16th ed New York: McGraw-Hill, 2005: 810.) Gonococcal urethritis: Gram stain of Neisseria gonorrhoeae Multiple gram-ᮎ diplococci are seen within PMNs as well as in the extracellular areas of a smear from a urethral discharge (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 906.) Ecthyma gangrenosum with Pseudomonas in a neutropenic patient FIGURE 11.8 Note the red papule with a necrotic center (Reproduced, with permission, from Kasper DL et al Harrison’s Principles of Internal Medicine, 16th ed New York: McGraw-Hill, 2005: 890.) H IG H-YI E LD I MAG ES H IG H-YI E LD FACTS F I G U R E 1 FIGURE 11.10 FIGURE 11.9 Condylomata lata in 2° syphilis (Reproduced, with permission, from Kasper DL et al Harrison’s Principles of Internal Medicine, 16th ed New York: McGraw-Hill, 2005: 979.) Alopecia of 2° syphilis Hair loss may be one of the only cutaneous manifestations of 2° syphilis that may present either as patchy, “moth-eaten” alopecia or as generalized thinning (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Dermatology in General Medicine, 7th ed New York: McGraw-Hill, 2008.) Rocky Mountain spotted fever (Reproduced, with permission, from Braunwald E et al Harrison’s Principles of Internal Medicine, 15th ed New York: McGraw-Hill, 2001: Plate IID-45.) H IG H-YI E LD FACTS FIGURE 11.11 H IG H-YI E LD I MAG ES FIGURE 11.12 2° syphilis (Reproduced, with permission, from Kasper DL et al Harrison’s Principles of Internal Medicine, 16th ed New York: McGraw-Hill, 2005: 979.) FIGURE 11.13 Erythema multiforme (Courtesy of Michael Redman, PA-C.) Acute meningococcemia (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 643.) FIGURE 11.15 Janeway lesions in endocarditis (Reproduced, with permission, from Wolff K et al Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed New York: McGraw-Hill, 2005: 636.) H IG H-YI E LD I MAG ES H IG H-YI E LD FACTS FIGURE 11.14 FIGURE 11.16 Falciparum malaria on a thin blood smear F I G U R E 1 Vivax malaria on a thin blood smear Young signet-ring-shaped parasites are seen for all species of Plasmodium, but only P falciparum shows multiple parasites within a single RBC (Reproduced, with permission, from Lichtman MA et al Williams Hematology, 7th ed New York: McGraw-Hill, 2005.) Blood smear of Plasmodium vivax showing both a ring form and a female gametocyte (Reproduced, with permission, from Lichtman MA et al Lichtman’s Atlas of Hematology New York: McGraw-Hill, 2007: Figure III.A.20.) N E U R O LO G Y FIGURE 13.2 Papilledema H IG H-YI E LD FACTS This obese young women with pseudotumor cerebri was misdiagnosed as a migraineur until fundus examination was performed showing optic disk elevation, hemorrhages, and cottonwool spots (Reproduced, with permission, from Kasper DL et al Harrison’s Principles of Internal Medicine, 16th ed New York: McGraw-Hill, 2005: 169.) H IG H-YI E LD I MAG ES FIGURE 13.3 Parkinson’s disease Bilateral internuclear ophthalmoplegia due to multiple sclerosis FIGURE 13.5 Midbrain of a 45-year-old woman with Parkinson’s disease, showing depigmentation of the substantia nigra (arrow) (Reproduced, with permission, from Waxman S Clinical Neuroanatomy, 25th ed New York: McGraw-Hill, 2003: Figure 13-9.) (Reproduced, with permission, from Riordan-Eva P, Whitcher JP Vaughan & Asbury’s General Ophthalmology, 16th ed New York: McGraw-Hill, 2004: Figure 14-12.) H IG H-YI E LD FACTS FIGURE 13.6 MRI findings in multiple sclerosis (A) Axial image from T2-weighted sequence demonstrates multiple bright signal abnormalities in white matter, typical for MS (B) Sagittal T2-weighted FLAIR (fluid-attenuated inversion recovery) image in which the high signal of CSF has been suppressed CSF appears dark, while areas of brain edema or demyelination appear high in signal, as shown here in the corpus callosum (arrows) Lesions in the anterior corpus callosum are frequent in MS and rare in vascular disease (Reproduced, with permission, from Kasper DL et al Harrison’s Principles of Internal Medicine, 16th ed New York: McGraw-Hill, 2005: 2465.) H IG H-YI E LD I MAG ES R H E U MATO LO G Y F I G U R E Oral ulcer on hard palate of patient with SLE F I G U R E Tophaceous gout of the elbow H IG H-YI E LD I MAG ES Onycholysis in a psoriatic arthritis patient H IG H-YI E LD FACTS F I G U R E H IG H-YI E LD FACTS Gout crystals F I G U R E 7 Gottron’s papules in patient with dermatomyositis H IG H-YI E LD I MAG ES F I G U R E .. .FIRST AID FOR THE® INTERNAL MEDICINE BOARDS Second Edition TAO LE, MD, MHS Assistant Clinical Professor of Medicine and Pediatrics Chief, Section of Allergy and Immunology Department of Medicine. .. know” information for the boards Mnemonics throughout, making learning memorable and fun We invite you to share your thoughts and ideas to help us improve First Aid for the® Internal Medicine Boards. .. Department of Dermatology University of California, San Francisco PREFACE With this revised and expanded edition of First Aid for the® Internal Medicine Boards, we hope to provide residents and