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 Boardof Medical Examiners (NBME), neither of which sponsors nor endorses this product.USMLE®Step 2 CKLecture Notes2020Internal MedicineObstetrics and GynecologyPediatricsPsychiatry, Epidemiology,Ethics, Patient SafetySurgery

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USMLE®Step 2LECTURE NOTESUSMLE® 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: 978-1-5062-5520-0All rights reserved. No part of this book may be reproduced in any form, by photostat, microfilm, xerography, or any othermeans, or incorporated into any information retrieval system, electronic or mechanical, without the written permission ofKaplan, Inc. This book may not be duplicated or sold.USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the NationalBoard of Medical Examiners (NBME), neither of which sponsors or endorses this product.

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USMLETM*STEP 2INTERNAL MEDICINEUSMLETM*STEP 2OBSTETRICS AND GYNECOLOGYUSMLETM*STEP 2PEDIATRICSUSMLETM*STEP 2PSYCHIATRY, EPIDEMIOLOGY,ETHICS, PATIENT SAFETYUSMLETM*STEP 2SURGERY

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USMLE®Step 2 CKLecture Notes2020Internal Medicine

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USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the NationalBoard 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 coveredas 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 deliveryof medical care. To the fullest extent of the law, neither the Publisher nor the Editors assume anyliability for any injury and/or damage to persons or property arising out of or related to any use ofthe material contained in this book.© 2019 by Kaplan, Inc.Published by Kaplan Medical, a division of Kaplan, Inc.750 Third AvenueNew York, NY 10017All rights reserved. The text of this publication, or any part thereof, may not be reproduced in anymanner whatsoever without written permission from the publisher.10 9 8 7 6 5 4 3 2 1Course ISBN: 978-1-5062-5504-0Retail Kit ISBN: 978-1-5062-5502-6This 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, pleasecall the Simon & Schuster special sales department at 866-506-1949.

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EditorsJoseph J. Lieber, MDDirector of MedicineElmhurst Hospital CenterAssociate Professor of MedicineAssociate Program Director of Medicine for Elmhurst SiteIcahn School of Medicine at Mt. SinaiNew York, NYFrank P. Noto, MDAssistant Professor of Internal MedicineDepartment of Hospital MedicineAssociate Program Director of Education for Elmhurst SiteIcahn School of Medicine at Mt. SinaiInternal Medicine Clerkship and Sub-Internship Site DirectorIcahn School of Medicine at Mt. SinaiNew York, NYThe editors would like to acknowledgeManuel A. Castro, MD, AAHIVS; Raj Dasgupta, MD, FACP, FCCP, FAASM; Amirtharaj Dhanaraja,MD; Aditya Patel, MD; Irfan Sheikh, MD;andFrazier Stevenson, MDfor 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 atmedfeedback@kaplan.com.

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Chapter Title00vChapter 1:Preventive Medicine1Chapter 2:Endocrinology11Chapter 3:Rheumatology61Chapter 4:Gastroenterology85Chapter 5:Cardiology125Chapter 6:Hematology193Chapter 7:Infectious Diseases225Chapter 8:Nephrology283Chapter 9:Pulmonology331Chapter 10:Emergency Medicine371Chapter 11:Neurology415Chapter 12:Dermatology443Chapter 13:Radiology/Imaging465Chapter 14:Ophthalmology475Index483Additional resources available atwww.kaptest.com/usmlebookresourcesTable of Contents

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Chapter Title#1Learning 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 commoninfectious disease, chronic illness, trauma, smoking, and travel risksCANCER SCREENINGA 39-year-old woman comes to the clinic very concerned about her risk of developingcancer. Her father was diagnosed with colon cancer at age 43, and her mother wasdiagnosed with breast cancer at age 52. She is sexually active with multiple partnersand has not seen a physician since a car accident 15 years ago. She denies anysymptoms at this time, and her physical examination is normal. She asks what isrecommended 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 beused 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) isiatrogenic.•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 thecourse of events after a positive test result must be acceptable to the patient. Most important, thescreening test must be valid, i.e., it must have been shown in trials to decrease overall mortality inthe screened population. For a screening test to be recommended for regular use, it has to beextensively studied to ensure that all of the requirements are met.Preventive Medicine1

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2USMLE Step 2 CKlInternal MedicineThe 4 malignancies for which regular screening is recommended arecancers of the colon,breast,cervix,andlung.Colon CancerIn the patient with no significant family history of colon cancer, screening should begin at age50. The preferred screening modality for colon cancer is colonoscopy every 10 years. Otherchoices include annual fecal occult blood testing and sigmoidoscopy with barium enema every5 years.In the patient with a single first-degree relative diagnosed with colorectal cancer beforeage60 or multiple first-degree relatives with colon cancer at any age, colonoscopy shouldbegin atage 40 or 10 years before the age at which the youngest affected relative wasdiagnosed,whichever age occurs earlier.In these high-risk patients, colonoscopy shouldbe repeated every 5 years. The U.S. Preventive Services Task Force (USPSTF) does notrecommend routine screening in patients age >75.Breast CancerThe 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 age50–74. The American Cancer Society no longer recommends monthly self-breastexaminationalone as a screening tool. Patients with very strong family histories of breast cancer (defined asmultiple first-degree relatives) should consider prophylactic tamoxifen, discussing risks andbenefits with a physician. Tamoxifen prevents breast cancer in high-risk individuals.Cervical CancerThe 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 every5 years can do co-testing with Pap and HPV testing. In higher risk women, e.g., HIV, morefrequent screening or screening after age 65 may be required.Lung CancerCurrent recommendations for lung cancer screening are as follows:•Annual screening with low-dose CT in adults age 55–80 who have a 30-pack-yearsmoking 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 substantiallylimiting life expectancy or ability/willingness to have curative lung surgery, screeningshould be discontinuedNoteTamoxifen prevents cancer by50% in those with >1 familymember with breast cancer.NoteProstate ScreeningUSPSTF concludes that thecurrent evidence is insufficientto assess the balance ofbenefits/risks of prostatecancer screening in men age<75. It recommends againstscreening in men age >75.For USMLE, do not screen forprostate cancer.

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Chapter 1●Preventive Medicine3Clinical RecallWhich of the following patients is undergoing an inappropriate method ofscreening as recommended by the USPSTF?A.A 50-year-old man gets his first screening for colon cancer viacolonoscopyB.A 50-year-old woman gets her first screening for breast cancer viamammographyC.A 17-year-old woman is screened for HPV via a Pap smear after herfirst sexual encounterD.A 65-year-old man with a 30-pack-year smoking history gets a low-dose CTE.A 21-year-old woman with a high risk of developing breast cancer isgiven tamoxifenAnswer: CTRAVEL MEDICINEA 44-year-old executive comes to the clinic before traveling to Thailand forbusiness. He has no significant past medical history and is here only because hiscompany will not let him travel until he is seen by a physician. The patientappears 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 Avaccination is recommended for all travelers to less developed countries. If apatient is leaving within 2 weeks of being seen, both the vaccine and immune serum globulinare recommended.A booster shot given 6 months post-initial vaccination confers immunity for approximately10 years.Hepatitis Bvaccination is recommended for patients who work closely with indigenous popula-tions. Additionally, patients who plan to engage in sexual intercourse with the local populace, toreceive 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; itmay cause adverse neuropsychiatric effects such as hallucinations, depression,suicidalideations, and unusual behavior. Doxycycline is an acceptable alternative tomefloquine,although photosensitivity can be problematic. For pregnant patients requiring chemoprophy-laxis for malaria, chloroquine is the preferred regimen.NoteHepatitis A infection is themost common vaccine-preventable disease in travelers.It can occur wherever there isfecal contamination of food/drinking water.

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4USMLE Step 2 CKlInternal MedicineRabiesvaccination is recommended for patients traveling to areas where rabies is commonamong domesticated animals (India, Asia, Mexico). Chloroquine can blunt the response to theintradermalform of rabies vaccine. Therefore, in patients who require malaria prophylaxis, inaddition to rabies prophylaxis theintramuscularform of the vaccine should be administered.Rabies vaccination is not considered a routine vaccination for most travelers.Typhoidvaccination is recommended for patients who are traveling to developing countriesand will have prolonged exposure to contaminated food and water. Typhoid vaccination comesin 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 patientswho 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 reactionsto the vaccine. The polysaccharide vaccine is the preferred form for almost all subjects as it iswell-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 poliovaccine should receive 3 doses of the inactivated polio vaccine. Patients who have beenpreviously immunized should receive a 1-time booster. The live attenuated polio vaccine is nolonger recommended because of the risk of vaccine-associated disease.Patients traveling to areas wheremeningococcal meningitisis 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 alsoreceive the vaccine. Meningococcal vaccine is now routinely administered at age 11.To preventtraveler’s diarrhea, patients should be advised to avoid raw and street vendorsalads, unwashed fruit, and tap/ice water. Patients who experience mild loose stools withoutfever or blood can safely take loperamide. Treatment with a fluoroquinolone or azithromycinis reserved for patients with moderate to severe symptoms.IMMUNIZATIONSA 52-year-old man comes to the clinic for a health maintenance evaluation. Hisrecent colonoscopy showed no evidence of carcinoma. Recent serum fastingglucose, serum cholesterol, and blood pressure are all within normal limits.Thepatient has a history of smoking and continues to smoke 2 packs per day. Hewas diagnosed with COPD 3 years ago.Immunization is the best method available for preventing serious infectious disease.Between50,000–70,000 adults die every year from preventable infectious disease (influenza, invasivepneumococcal disease, and hepatitis B). Surveys have shown that among patients who have anindication 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 thatevery patient’s immunization status be reviewed at age 50; evaluate risk factorsfor specific vaccinations at that time.

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