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USMLE Step 2 CK Lecture Notes 2020: Internal Medicine (2019)

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    USMLE ® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), neither of which sponsors nor endorses this product. USMLE ® Step 2 CK Lecture Notes 2020 Internal Medicine Obstetrics and Gynecology Pediatrics Psychiatry, Epidemiology, Ethics, Patient Safety Surgery

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    USMLE ® Step 2 LECTURE NOTES USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners.

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    Copyright © 2019 Kaplan, Inc. ISBN: 978-1-5062-5520-0 All rights reserved. No part of this book may be reproduced in any form, by photostat, microfilm, xerography, or any other means, or incorporated into any information retrieval system, electronic or mechanical, without the written permission of Kaplan, Inc. This book may not be duplicated or sold. USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), neither of which sponsors or endorses this product.

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    USMLE TM* STEP 2 INTERNAL MEDICINE USMLE TM* STEP 2 OBSTETRICS AND GYNECOLOGY USMLE TM* STEP 2 PEDIATRICS USMLE TM* STEP 2 PSYCHIATRY, EPIDEMIOLOGY, ETHICS, PATIENT SAFETY USMLE TM* STEP 2 SURGERY

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    USMLE ® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), neither of which sponsors nor endorses this product. USMLE ® Step 2 CK Lecture Notes 2020 Internal Medicine

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    USMLE ® Step 2 CK Lecture Notes 2020 Internal Medicine

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    USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), neither of which sponsors or endorses this product. This publication is designed to provide accurate information in regard to the subject matter covered as of its publication date, with the understanding that knowledge and best practice constantly evolve. The publisher is not engaged in rendering medical, legal, accounting, or other professional service. If medical or legal advice or other expert assistance is required, the services of a competent profes- sional should be sought. This publication is not intended for use in clinical practice or the delivery of medical care. To the fullest extent of the law, neither the Publisher nor the Editors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. © 2019 by Kaplan, Inc. Published by Kaplan Medical, a division of Kaplan, Inc. 750 Third Avenue New York, NY 10017 All rights reserved. The text of this publication, or any part thereof, may not be reproduced in any manner whatsoever without written permission from the publisher. 10 9 8 7 6 5 4 3 2 1 Course ISBN: 978-1-5062-5504-0 Retail Kit ISBN: 978-1-5062-5502-6 This item comes as a set and should not be broken out and sold separately. Kaplan Publishing print books are available at special quantity discounts to use for sales promotions, employee premiums, or educational purposes. For more information or to purchase books, please call the Simon & Schuster special sales department at 866-506-1949.

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    Editors Joseph J. Lieber, MD Director of Medicine Elmhurst Hospital Center Associate Professor of Medicine Associate Program Director of Medicine for Elmhurst Site Icahn School of Medicine at Mt. Sinai New York, NY Frank P. Noto, MD Assistant Professor of Internal Medicine Department of Hospital Medicine Associate Program Director of Education for Elmhurst Site Icahn School of Medicine at Mt. Sinai Internal Medicine Clerkship and Sub-Internship Site Director Icahn School of Medicine at Mt. Sinai New York, NY The editors would like to acknowledge Manuel A. Castro, MD, AAHIVS; Raj Dasgupta, MD, FACP, FCCP, FAASM; Amirtharaj Dhanaraja, MD; Aditya Patel, MD; Irfan Sheikh, MD; and Frazier Stevenson, MD for their contributions.

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    We want to hear what you think. What do you like or not like about the Notes? Please email us at medfeedback@kaplan.com .

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    Chapter Title 00 v Chapter 1: Preventive Medicine 1 Chapter 2: Endocrinology 11 Chapter 3: Rheumatology 61 Chapter 4: Gastroenterology 85 Chapter 5: Cardiology 125 Chapter 6: Hematology 193 Chapter 7: Infectious Diseases 225 Chapter 8: Nephrology 283 Chapter 9: Pulmonology 331 Chapter 10: Emergency Medicine 371 Chapter 11: Neurology 415 Chapter 12: Dermatology 443 Chapter 13: Radiology/Imaging 465 Chapter 14: Ophthalmology 475 Index 483 Additional resources available at www.kaptest.com/usmlebookresources Table of Contents

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    Chapter Title # 1 Learning Objectives ❏ Describe appropriate screening methods as they apply to neoplasms of the colon, breast, cervix, and lung ❏ Describe epidemiological data related to incidence and prevention of common infectious disease, chronic illness, trauma, smoking, and travel risks CANCER SCREENING A 39-year-old woman comes to the clinic very concerned about her risk of developing cancer. Her father was diagnosed with colon cancer at age 43, and her mother was diagnosed with breast cancer at age 52. She is sexually active with multiple partners and has not seen a physician since a car accident 15 years ago. She denies any symptoms at this time, and her physical examination is normal. She asks what is recommended for a woman her age. Screening tests are done on seemingly healthy people to identify those at increased risk of dis- ease. Even if a diagnostic test is available, however, that does not necessarily mean it should be used to screen for a particular disease. • Several harmful effects may potentially result from screening tests. • Any adverse outcome that occurs (large bowel perforation secondary to a colonoscopy) is iatrogenic. • Screening may be expensive, unpleasant, and/or inconvenient. • Screening may also lead to harmful treatment. Finally, there may be a stigma associated with incorrectly labeling a patient as “sick.” For all diseases for which screening is recommended, effective intervention must exist, and the course of events after a positive test result must be acceptable to the patient. Most important, the screening test must be valid, i.e., it must have been shown in trials to decrease overall mortality in the screened population. For a screening test to be recommended for regular use, it has to be extensively studied to ensure that all of the requirements are met. Preventive Medicine 1

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    2 USMLE Step 2 CK l Internal Medicine The 4 malignancies for which regular screening is recommended are cancers of the colon, breast , cervix, and lung . Colon Cancer In the patient with no significant family history of colon cancer, screening should begin at age 50. The preferred screening modality for colon cancer is colonoscopy every 10 years. Other choices include annual fecal occult blood testing and sigmoidoscopy with barium enema every 5 years. In the patient with a single first-degree relative diagnosed with colorectal cancer before age 60 or multiple first-degree relatives with colon cancer at any age, colonoscopy should begin at age 40 or 10 years before the age at which the youngest affected relative was diagnosed, whichever age occurs earlier. In these high-risk patients, colonoscopy should be repeated every 5 years. The U.S. Preventive Services Task Force (USPSTF) does not recommend routine screening in patients age >75. Breast Cancer The tests used to screen for breast cancer are mammography and manual breast exam. Mammography with or without clinical breast exam is recommended every 1–2 years from age 50–74. The American Cancer Society no longer recommends monthly self-breast examination alone as a screening tool. Patients with very strong family histories of breast cancer (defined as multiple first-degree relatives) should consider prophylactic tamoxifen, discussing risks and benefits with a physician. Tamoxifen prevents breast cancer in high-risk individuals. Cervical Cancer The screening test of choice for the early detection of cervical cancer is the Papanicolaou smear (the “Pap” test). In average risk women, Pap smear screening should be started at age 21, regardless of onset of sexual activity . It should be performed every 3 years until age 65. As an alternative, women age 30–65 who wish to lengthen the screening interval to every 5 years can do co-testing with Pap and HPV testing. In higher risk women, e.g., HIV, more frequent screening or screening after age 65 may be required. Lung Cancer Current recommendations for lung cancer screening are as follows: • Annual screening with low-dose CT in adults age 55–80 who have a 30-pack-year smoking history and currently smoke or have quit within past 15 years • Once a person has not smoked for 15 years or develops a health problem substantially limiting life expectancy or ability/willingness to have curative lung surgery, screening should be discontinued Note Tamoxifen prevents cancer by 50% in those with >1 family member with breast cancer. Note Prostate Screening USPSTF concludes that the current evidence is insufficient to assess the balance of benefits/risks of prostate cancer screening in men age <75. It recommends against screening in men age >75. For USMLE, do not screen for prostate cancer.

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    Chapter 1 ● Preventive Medicine 3 Clinical Recall Which of the following patients is undergoing an inappropriate method of screening as recommended by the USPSTF? A. A 50-year-old man gets his first screening for colon cancer via colonoscopy B. A 50-year-old woman gets her first screening for breast cancer via mammography C. A 17-year-old woman is screened for HPV via a Pap smear after her first sexual encounter D. A 65-year-old man with a 30-pack-year smoking history gets a low- dose CT E. A 21-year-old woman with a high risk of developing breast cancer is given tamoxifen Answer: C TRAVEL MEDICINE A 44-year-old executive comes to the clinic before traveling to Thailand for business. He has no significant past medical history and is here only because his company will not let him travel until he is seen by a physician. The patient appears agitated and demands the physician’s recommendation immediately. It is important to set up a pretravel counseling session 4–6 weeks before the patient’s departure. Hepatitis A vaccination is recommended for all travelers to less developed countries. If a patient is leaving within 2 weeks of being seen, both the vaccine and immune serum globulin are recommended. A booster shot given 6 months post-initial vaccination confers immunity for approximately 10 years. Hepatitis B vaccination is recommended for patients who work closely with indigenous popula- tions. Additionally, patients who plan to engage in sexual intercourse with the local populace, to receive medical or dental care, or to remain abroad for >6 months should be vaccinated. Malaria: Mefloquine is the agent of choice for malaria prophylaxis. It is given once per week; it may cause adverse neuropsychiatric effects such as hallucinations, depression, suicidal ideations, and unusual behavior. Doxycycline is an acceptable alternative to mefloquine, although photosensitivity can be problematic. For pregnant patients requiring chemoprophy- laxis for malaria, chloroquine is the preferred regimen. Note Hepatitis A infection is the most common vaccine- preventable disease in travelers. It can occur wherever there is fecal contamination of food/ drinking water.

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    4 USMLE Step 2 CK l Internal Medicine Rabies vaccination is recommended for patients traveling to areas where rabies is common among domesticated animals (India, Asia, Mexico). Chloroquine can blunt the response to the intradermal form of rabies vaccine. Therefore, in patients who require malaria prophylaxis, in addition to rabies prophylaxis the intramuscular form of the vaccine should be administered. Rabies vaccination is not considered a routine vaccination for most travelers. Typhoid vaccination is recommended for patients who are traveling to developing countries and will have prolonged exposure to contaminated food and water. Typhoid vaccination comes in 2 forms, an oral live attenuated form and a capsular polysaccharide vaccine given parenter- ally. The live attenuated form (1) needs to be refrigerated, and (2) is contraindicated in patients who are HIV-positive. The polysaccharide vaccine is given intramuscularly as a single injection. Side effects include irritation at the injection site. Fever and headache are rare adverse reactions to the vaccine. The polysaccharide vaccine is the preferred form for almost all subjects as it is well-tolerated and convenient (no need for refrigeration). It is safe for HIV patients. Polio: Adults who are traveling to developing countries and have never received a polio vaccine should receive 3 doses of the inactivated polio vaccine. Patients who have been previously immunized should receive a 1-time booster. The live attenuated polio vaccine is no longer recommended because of the risk of vaccine-associated disease. Patients traveling to areas where meningococcal meningitis is endemic or epidemic ( Nepal, sub-Saharan Africa, northern India) should be immunized with the polysaccharide vaccine. Additionally, Saudi Arabia requires immunization for pilgrims to Mecca. Patients with func- tional or actual asplenia and patients with terminal complement deficiencies should also receive the vaccine. Meningococcal vaccine is now routinely administered at age 11. To prevent traveler’s diarrhea , patients should be advised to avoid raw and street vendor salads, unwashed fruit, and tap/ice water. Patients who experience mild loose stools without fever or blood can safely take loperamide. Treatment with a fluoroquinolone or azithro mycin is reserved for patients with moderate to severe symptoms. IMMUNIZATIONS A 52-year-old man comes to the clinic for a health maintenance evaluation. His recent colonoscopy showed no evidence of carcinoma. Recent serum fasting glucose, serum cholesterol, and blood pressure are all within normal limits. The patient has a history of smoking and continues to smoke 2 packs per day. He was diagnosed with COPD 3 years ago. Immunization is the best method available for preventing serious infectious disease. Between 50,000–70,000 adults die every year from preventable infectious disease (influenza, invasive pneumococcal disease, and hepatitis B). Surveys have shown that among patients who have an indication for any vaccination, very few actually receive it (pneumococcal vaccination 20%, influenza 40%, hepatitis B 10%). For this reason, the American College of Physicians recom- mends that every patient’s immunization status be reviewed at age 50 ; evaluate risk factors for specific vaccinations at that time.

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