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

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K A P L A NMEDICALUSMLEStep2CKLectureNotes2021InternalMedicineObstetricsandGynecologyPediatricsPsychiatry,Epidemiology,Ethics,PatientSafetySurgeryUSMLE®isajointprogramoftheFederationofStateMedicalBoards(FSMB)andtheNationalBoardofMedicalExaminers(NBME),whichneithersponsornorendorsethisproduct.

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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 CKLecture Notes2021

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USMLETM*STEP 2 CKINTERNAL MEDICINEUSMLETM*STEP 2 CKOBSTETRICS AND GYNECOLOGYUSMLETM*STEP 2 CKPEDIATRICSUSMLETM*STEP 2 CKPSYCHIATRY, EPIDEMIOLOGY,ETHICS, PATIENT SAFETYUSMLETM*STEP 2 CKSURGERY

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K A P L A NMEDICALUSMLEStep2CKLectureNotes2021InternalMedicineUSMLE®isajointprogramoftheFederationofStateMedicalBoards(FSMB)andtheNationalBoardofMedicalExaminers(NBME),whichneithersponsornorendorsethisproduct.

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USMLE®Step 2 CKLecture Notes2021Internal 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), which neither sponsor nor endorse 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.© 2020 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: 978-1-5062-6141-6Course Kit ISBN: 978-1-5062-6135-5Retail ISBN: 978-1-5062-6139-3Retail Kit ISBN: 978-1-5062-6137-9Thekitscome 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 salespromotions, employee premiums, or educational purposes. For more information or to purchasebooks, please call 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, NYContributorsRaj Dasgupta, MD, FACP, FCCP, FAASMAssistant Professor of Clinical MedicineAssistant Program Director of Internal Medicine ResidencyAssociate Program Director of Sleep Medicine FellowshipDepartment of Medicine, Division of Pulmonary, Critical Care and Sleep MedicineKeck School of Medicine of USCUniversity of Southern CaliforniaLos Angeles, CAThe editors would also like to acknowledgeManuel A. Castro, MD,AAHIVS; 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 Title00vTable of ContentsChapter 1:Preventive Medicine1Chapter 2:Endocrinology13Chapter 3:Rheumatology69Chapter 4:Gastroenterology95Chapter 5:Cardiology137Chapter 6:Hematology203Chapter 7:Infectious Diseases241Chapter 8:Nephrology305Chapter 9:Pulmonology353Chapter 10:Emergency Medicine399Chapter 11:Neurology443Chapter 12:Dermatology473Chapter 13:Radiology/Imaging497Chapter 14:Ophthalmology507Medical Abbreviations515Index523Additional resources available atkaptest.com/usmlebookresources

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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 risksSCREENINGSFor 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 overallmortalityFor a screening test to be recommended for regular use, it has to be extensively studied toensure that all of the above requirements are met.Cancer 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 ofdisease.Preventive Medicine1

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2USMLE Step 2 CK●Internal MedicineHowever, even if a diagnostic test is available, that does not always mean it should be used toscreen for a particular disease. That is because diagnostic tests may:•Have adverse (and possibly iatrogenic) effects (e.g., large bowel perforation secondaryto a colonoscopy)•Be expensive, unpleasant, and/or inconvenient•Lead to ineffective or even harmful treatmentThe 4 malignancies for which regular screening is recommended arecancers of the colon,breast,cervix,andlung.Colon CancerIf 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 every5 yearsIf there is a single first-degree relative diagnosed with colorectal cancer age <60 or multiplefirst-degree relatives with colon cancer at any age, screen with colonoscopy starting age 40 or10 years before the age at which the youngest affected relative was diagnosed,whichever ageoccurs earlier.•Repeat colonoscopy every 5 years•Routine screening can stop age >75, as per the U.S. Preventive Services Task Force(USPSTF)Breast CancerMammography plus manual breast exam are used to screen for breast cancer. (Self-breastexam by itself is not recommended as a screening tool.)•Mammography with or without clinical breast exam every 1–2 years fromage 50–74•If there is a very strong family history of breast cancer (i.e., multiple first-degreerelatives), consider prophylactic tamoxifen, which prevents breast cancer in high-riskindividualsCervical CancerThe screening test of choice for the early detection of cervical cancer is the Papanicolaousmear (the “Pap” test). In average risk women, screen as follows:•Starting age 21, screen with Pap (regardless of onset of sexual activity) every 3 yearsuntil 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 screeningage >65NoteTamoxifen 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 prostate cancerscreening in men age <75. Itrecommends against screeningin men age >75.For USMLE, do not screen forprostate cancer.

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Chapter 1●Preventive Medicine3Lung CancerCurrent recommendations for lung cancer screening are as follows:•For adults age 55–80 with a 30-pack-year smoking history and currently smoke orhave 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 medicalproblem which significantly limits life expectancy or the ability to undergo surgery,screening is not necessary.Clinical 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: COsteoporosis ScreeningA bone density test uses x-rays to measure how many grams of calcium and other boneminerals 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 offractures.Bone density test results are reported in 2 numbers.•TheT-scorecompares the patient’s bone density with what is normally expected in ahealthy young adult of the same sex. This score is the number of units—standarddeviations—that bone density is above or below the average.–T-score >2.5 SD indicates the likelihood of osteoporosis and increased risk offracture.–A diagnosis of osteoporosis by DEXA scan also means that treatment should beinitiated with bisphosphonates, oral daily calcium supplementation, and vitamin D.NoteApack yearis smoking anaverage of 1 pack of cigarettesper day for 1 year. A patientwith a smoking history of30pack years is considered aheavy smoker.

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4USMLE Step 2 CK●Internal Medicine•TheZ-scorecompares the condition of the patient’s bones with those of an averageperson the same age and body size. It is the number of standard deviations above orbelow what is normally expected for someone of the same age, sex, weight, and ethnicor racial origin.–Z-score ≤-2 may suggest that something other than aging is causing abnormal boneloss (consider drugs causing osteoporosis such as corticosteroids).–The goal in this case is to identify the underlying problem.Hypertension, Diabetes Mellitus, and HypercholesterolemiaA 45-year-old man comes to the physician anxious about his health. Five years agohis mother was diagnosed with diabetes and high cholesterol. He is worried abouthis 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 forcoronary artery disease. In both men and women with risk factors, screening should be doneroutinely after age 20. Management should not be determined by an isolated reading becausecholesterol levels may fluctuate between measurements. Repeat in 5 years in low-riskindividuals.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 symptomsThere is insufficient evidence for or against routine screening. The strongest indication is forthose 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 AneurysmU/S should be done once in men age >65 who have ever smoked. There are no screeningrecommendations for male nonsmokers and women, regardless of smoking history.TRAVEL MEDICINEA 44-year-old man comes to the clinic before traveling to Thailand for business.Hehas no significant past medical history and is here only because it is requiredbyhiscompany. The patient appears agitated and demands the physician’srecommendation immediately.It is important to set up a pretravel counseling session 4–6 weeks before the patient’s depar-ture.NoteLow bone density is verycommon among older adults,soZ-scorecan be misleading.•Use Z-score (not T-score)for children/teens/womenof childbearing age/younger men.•In these younger agegroups, routine bonedensity screening is notrecommended, nor shoulda diagnosis of osteoporosisbe based on bone densitytest alone.

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Chapter 1●Preventive Medicine5Recommendations are as follows:•Hepatitis Avaccination: recommended for all travelers to less developed nations–If patient is departing within 2 weeks of being seen, give both the vaccine andimmune serum globulin–Booster shot given 6 months post-initial vaccination provides immunity forapproximately 10 yrs•Hepatitis Bvaccination: recommended for patients who work closely with indigenouspopulations–If patient plans to engage in sexual intercourse with the local populace or to receivemedical/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); sideeffects include neuropsychiatric effects such as hallucinations, depression, andunusual behavior–Doxycycline is an acceptable alternative; side effects include photosensitivity–In pregnancy, chloroquine is the preferred regimen for prophylaxis•Rabiesvaccination is recommended only for those traveling to areas where rabies iscommon among domesticated animals (India, Asia, Mexico). It is not considered aroutine vaccine for most travelers.–Chloroquine can blunt the response to theintradermalform of rabies vaccine–Therefore, if both malaria prophylaxis and rabies prophylaxis are required, give theintramuscular form of the vaccine•Typhoidvaccination is recommended for those traveling to developing nations, whomay have prolonged exposure to contaminated food and water; side effects includeirritation at the injection site and rarely headache and fever–Live attenuated form: given orally (needs refrigeration; contraindicated for HIVpatients)–Capsular polysaccharide form (preferred): given intramuscularly 1× (needs norefrigeration; safe for HIV patients; well-tolerated)Poliovaccination is recommended for those traveling to developing nations.•If patient has not previously received a polio vaccine, give 3 doses of the inactivatedpolio 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 ofvaccine-associated disease.NoteHepatitis A infection is the mostcommon vaccine-preventabledisease in travelers. It canoccur wherever there is fecalcontamination of food/drinking water.Note•The global health approachto disease prophylaxis is toprovide treatment totravelers whose destinationis an area where the diseaseis endemic.•Because disease distributionshifts over time, country-specific questions are notlikely to be on the exam.

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6USMLE Step 2 CK●Internal MedicineOther general travel recommendations are as follows:•Polysaccharide vaccinationis recommended for those traveling to areas wheremeningococcal 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 terminalcomplement deficiencies•To preventtraveler’s diarrhea, patients should be advised to avoid raw and streetvendor salads, unwashed fruit, and tap/ice water. Patients who experience mild loosestools without fever or blood can safely take loperamide. Treatment with a fluoroqui-nolone or azithromycin is 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. He wasdiagnosed 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 an indication for any vaccination, very fewactually receive it (pneumococcal vaccination 20%, influenza 40%, hepatitis B 10%). For thisreason, the American College of Physicians recommends thatevery patient’s immunizationstatus be reviewed at age 50; evaluate risk factors for specific vaccinations at that time.•Most patients received a primary immunization against tetanus and diphtheria aschildren.•For those adults who were never vaccinated, give 3 doses. The principle is that adultsrequire 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 useTdap instead of Td booster; if wound is dirty, revaccinate after 5 years

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