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USMLE Step 2 CK Lecture Notes 2021: Internal Medicine, 1st Edition (2020)

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    K A P L A N MEDICAL USMLE Step 2 CK Lecture Notes 2021 Internal Medicine Obstetrics and Gynecology Pediatrics Psychiatry , Epidemiology , Ethics , Patient Safety Surgery USMLE ® is a joint program of the Federation of State Medical Boards ( FSMB ) and the National Board of Medical Examiners ( NBME ) , which neither sponsor nor endorse this product .

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    USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of Medical Examiners. USMLE ® Step 2 CK Lecture Notes 2021

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

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    K A P L A N MEDICAL USMLE Step 2 CK Lecture Notes 2021 Internal Medicine USMLE ® is a joint program of the Federation of State Medical Boards ( FSMB ) and the National Board of Medical Examiners ( NBME ) , which neither sponsor nor endorse this product .

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    USMLE ® Step 2 CK Lecture Notes 2021 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), which neither sponsor nor endorse 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. © 2020 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: 978-1-5062-6141-6 Course Kit ISBN: 978-1-5062-6135-5 Retail ISBN: 978-1-5062-6139- 3 Retail Kit ISBN: 978-1-5062-6137-9 Thekits come 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 Contributors Raj Dasgupta, MD, FACP, FCCP, FAASM Assistant Professor of Clinical Medicine Assistant Program Director of Internal Medicine Residency Associate Program Director of Sleep Medicine Fellowship Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine Keck School of Medicine of USC University of Southern California Los Angeles, CA The editors would also like to acknowledge Manuel A. Castro, MD, AAHIVS; 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 Table of Contents Chapter 1: Preventive Medicine 1 Chapter 2: Endocrinology 13 Chapter 3: Rheumatology 69 Chapter 4: Gastroenterology 95 Chapter 5: Cardiology 137 Chapter 6: Hematology 203 Chapter 7: Infectious Diseases 241 Chapter 8: Nephrology 305 Chapter 9: Pulmonology 353 Chapter 10: Emergency Medicine 399 Chapter 11: Neurology 443 Chapter 12: Dermatology 473 Chapter 13: Radiology/Imaging 497 Chapter 14: Ophthalmology 507 Medical Abbreviations 515 Index 523 Additional resources available at kaptest.com/usmlebookresources

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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 SCREENINGS For all diseases that have recommended screening: • Effective intervention must exist • After a positive test result, course of events must be acceptable to patient • Screening test must be valid, i.e., it must have proven in trials to decrease overall mortality For a screening test to be recommended for regular use, it has to be extensively studied to ensure that all of the above requirements are met. 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 disease. Preventive Medicine 1

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    2 USMLE Step 2 CK ● Internal Medicine However, even if a diagnostic test is available, that does not always mean it should be used to screen for a particular disease. That is because diagnostic tests may: • Have adverse (and possibly iatrogenic) effects (e.g., large bowel perforation secondary to a colonoscopy) • Be expensive, unpleasant, and/or inconvenient • Lead to ineffective or even harmful treatment The 4 malignancies for which regular screening is recommended are cancers of the colon, breast, cervix, and lung . Colon Cancer If there is no significant family history of colon cancer, screen everyone starting age 50. • Colonoscopy every 10 years ( preferred ) • Annual fecal occult blood test and sigmoidoscopy with barium enema every 5 years If there is a single first-degree relative diagnosed with colorectal cancer age <60 or multiple first-degree relatives with colon cancer at any age, screen with colonoscopy starting age 40 or 10 years before the age at which the youngest affected relative was diagnosed, whichever age occurs earlier. • Repeat colonoscopy every 5 years • Routine screening can stop age >75, as per the U.S. Preventive Services Task Force (USPSTF) Breast Cancer Mammography plus manual breast exam are used to screen for breast cancer. (Self-breast exam by itself is not recommended as a screening tool.) • Mammography with or without clinical breast exam every 1–2 years from age 50–74 • If there is a very strong family history of breast cancer (i.e., multiple first-degree relatives), consider prophylactic tamoxifen, which 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, screen as follows: • Starting age 21, screen with Pap (regardless of onset of sexual activity) every 3 years until age 65 • Alternatively, screen with Pap + HPV testing every 5 years, age 30–65 • Higher risk women, e.g., HIV, may require more frequent screening or screening age >65 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 Lung Cancer Current recommendations for lung cancer screening are as follows: • For adults age 55–80 with a 30-pack-year smoking history and currently smoke or have quit within 15 years, screen annually with low-dose CT. • For those who have not smoked for 15 years; age >80; or who have another medical problem which significantly limits life expectancy or the ability to undergo surgery, screening is not necessary. 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 Osteoporosis Screening A bone density test uses x-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone. The bones typically tested are the spine, hip, and forearm. • Screening with a DEXA bone density scan should be given to all women age >65. • Screening should begin at age 60 if there is low body weight or increased risk of fractures. Bone density test results are reported in 2 numbers. • The T-score compares the patient’s bone density with what is normally expected in a healthy young adult of the same sex. This score is the number of units—standard deviations—that bone density is above or below the average. – T-score >2.5 SD indicates the likelihood of osteoporosis and increased risk of fracture. – A diagnosis of osteoporosis by DEXA scan also means that treatment should be initiated with bisphosphonates, oral daily calcium supplementation, and vitamin D. Note A pack year is smoking an average of 1 pack of cigarettes per day for 1 year. A patient with a smoking history of 30 pack years is considered a heavy smoker.

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    4 USMLE Step 2 CK ● Internal Medicine • The Z-score compares the condition of the patient’s bones with those of an average person the same age and body size. It is the number of standard deviations above or below what is normally expected for someone of the same age, sex, weight, and ethnic or racial origin. – Z-score ≤-2 may suggest that something other than aging is causing abnormal bone loss (consider drugs causing osteoporosis such as corticosteroids). – The goal in this case is to identify the underlying problem. Hypertension, Diabetes Mellitus, and Hypercholesterolemia A 45-year-old man comes to the physician anxious about his health. Five years ago his mother was diagnosed with diabetes and high cholesterol. He is worried about his health and risk for heart disease. Physical examination is within normal limits. Cholesterol screening should commence at age 35 in men who have no risk factors for coronary artery disease. In both men and women with risk factors, screening should be done routinely after age 20. Management should not be determined by an isolated reading because cholesterol levels may fluctuate between measurements. Repeat in 5 years in low-risk individuals. Screening for diabetes mellitus should be considered only for patients with hypertension (>135/80 mm Hg). Diabetes mellitus is diagnosed in either of these situations: • Two fasting glucose measurements are >125 mg/dL, HbA1c >6.5% • Random glucose >200 mg/dL accompanied by symptoms There is insufficient evidence for or against routine screening. The strongest indication is for those with hypertension and hyperlipidemia. Screening is recommended for elevated blood pressure in those age >18, at every visit. Screening is not recommended for carotid artery stenosis with duplex. Abdominal Aortic Aneurysm U/S should be done once in men age >65 who have ever smoked. There are no screening recommendations for male nonsmokers and women, regardless of smoking history. TRAVEL MEDICINE A 44-year-old man comes to the clinic before traveling to Thailand for business. He has no significant past medical history and is here only because it is required by his company. 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 depar- ture. Note Low bone density is very common among older adults, so Z-score can be misleading. • Use Z-score (not T-score) for children/teens/women of childbearing age/ younger men. • In these younger age groups, routine bone density screening is not recommended, nor should a diagnosis of osteoporosis be based on bone density test alone.

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    Chapter 1 ● Preventive Medicine 5 Recommendations are as follows: • Hepatitis A vaccination: recommended for all travelers to less developed nations – If patient is departing within 2 weeks of being seen, give both the vaccine and immune serum globulin – Booster shot given 6 months post-initial vaccination provides immunity for approximately 10 yrs • Hepatitis B vaccination: recommended for patients who work closely with indigenous populations – If patient plans to engage in sexual intercourse with the local populace or to receive medical/dental care, vaccinate – If patient plans to remain abroad for >6 months, vaccinate • Malaria – Mefloquine is the agent of choice for malaria prophylaxis (given 1×/week); side effects include neuropsychiatric effects such as hallucinations, depression, and unusual behavior – Doxycycline is an acceptable alternative; side effects include photosensitivity – In pregnancy, chloroquine is the preferred regimen for prophylaxis • Rabies vaccination is recommended only for those traveling to areas where rabies is common among domesticated animals (India, Asia, Mexico). It is not considered a routine vaccine for most travelers. – Chloroquine can blunt the response to the intradermal form of rabies vaccine – Therefore, if both malaria prophylaxis and rabies prophylaxis are required, give the intramuscular form of the vaccine • Typhoid vaccination is recommended for those traveling to developing nations, who may have prolonged exposure to contaminated food and water; side effects include irritation at the injection site and rarely headache and fever – Live attenuated form: given orally (needs refrigeration; contraindicated for HIV patients) – Capsular polysaccharide form ( preferred ): given intramuscularly 1× (needs no refrigeration; safe for HIV patients; well-tolerated) Polio vaccination is recommended for those traveling to developing nations. • If patient has not previously received a polio vaccine, give 3 doses of the inactivated polio vaccine. • If patient has previously been immunized, give a one-time booster. • The live attenuated polio vaccine is no longer recommended because of the risk of vaccine-associated disease. 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. Note • The global health approach to disease prophylaxis is to provide treatment to travelers whose destination is an area where the disease is endemic. • Because disease distribution shifts over time, country- specific questions are not likely to be on the exam.

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    6 USMLE Step 2 CK ● Internal Medicine Other general travel recommendations are as follows: • Polysaccharide vaccination is recommended for those traveling to areas where meningococcal meningitis is endemic or epidemic (Nepal, sub-Saharan Africa, northern India). – Meningococcal vaccine is now routinely administered at age 11 – Saudi Arabia requires immunization for pilgrims to Mecca – Immunize those with functional (or actual) asplenia and those with terminal complement deficiencies • 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 fluoroqui- nolone or azithromycin 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 recommends that every patient’s immunization status be reviewed at age 50 ; evaluate risk factors for specific vaccinations at that time. • Most patients received a primary immunization against tetanus and diphtheria as children. • For those adults who were never vaccinated, give 3 doses. The principle is that adults require a total of 3 vaccinations against tetanus and diphtheria. – Give the first 2 doses 1−2 months apart – Give the third dose 6–12 months later – Give a booster vaccination every 10 years for life; one of the boosters should use Tdap instead of Td booster; if wound is dirty, revaccinate after 5 years

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