Mayo Clinic Internal Medicine Review EIGHTH EDITION pptx

• NEW—chapter on HOSPITAL MEDICINE • QUESTION-AND-ANSWER segments and expertly written explanatory notes at the end of each chapter • STRATEGIES AND RECOMMENDATIONS on how to approach th

Mayo Clinic Internal Medicine Review

Editor-in-Chief Amit K Ghosh, MD

MAYO CLINIC SCIENTIFIC PRESS

EIGHTH EDITION

Master the Internal Medicine Boards

Written by experienced faculty at Mayo Clinic, this EIGHTH EDITION is

a completely revised and updated study tool that has proved invaluable

for the American Board of Internal Medicine certification or maintenance

of certification as well as general practice review by physicians around

the world

Using this source, physicians will access a virtual blueprint for exam

preparation and acquire clear guidance on question format, types of

questions, and hints on topics commonly encountered on the test

Providing more than 350 MULTIPLE-CHOICE QUESTIONS that simulate the current exam format, this

must-have guide will equip readers with the resources they need to anticipate testing challenges and pass

the exam Here are just a few of the great features found in the EIGHTH EDITION.

• NEW—chapter on HOSPITAL MEDICINE

• QUESTION-AND-ANSWER segments and expertly written explanatory notes at the end of each chapter

• STRATEGIES AND RECOMMENDATIONS on how to approach the board exam

• CURRENT PHARMACY TABLES that highlight indications, toxic effects, and drug interactions

• TYPICAL CLINICAL SCENARIOS

• EXTENSIVELY EDITED CHAPTERS on cardiology, pulmonology, nephrology, critical care, geriatrics,

preventive medicine, hematology, infectious diseases, women’s and men’s health

• DETAILED INDEX for quick retrieval of information

• GREAT ILLUSTRATIVE TOOLS—lucid images, algorithms, and summary tables that reflect major

practices, therapies, and medications utilized in the field

ABOUT THE EDITOR

Internal Medicine, Mayo Clinic, Rochester, Minnesota; and

Associate Professor of Medicine, College of Medicine, Mayo Clinic

• Gastroenterology and Hepatology

• General Internal Medicine

Ghosh

Mayo Clinic Internal Medicine Review

EIGHTH EDITION

Mayo Clinic Internal Medicine Review

EIGHTH EDITION

MAYO CLINIC SCIENTIFIC PRESS

INFORMA HEALTHCARE

The triple-shield Mayo logo and the words MAYO, MAYO CLINIC, and MAYO CLINIC SCIENTIFIC PRESS are marks of Mayo Foundation for Medical Education and Research.

©1994, 1996, 1998, 2000, 2002, 2004, 2006, 2008 Mayo Foundation for Medical Education and Research.

All rights reserved This book is protected by copyright No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise— without the prior written consent of the copyright holder, except for brief quo- tations embodied in critical articles and reviews Inquiries should be addressed

to Scientific Publications, Plummer 10, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

For order inquiries, contact Informa Healthcare, Kentucky Distribution Center,

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E-mail: orders@taylorandfrancis.com.

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Catalog record is available from the Library of Congress

Care has been taken to confirm the accuracy of the information presented and

to describe generally accepted practices However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication This book should not

be relied on apart from the advice of a qualified health care provider The authors, editors, and publisher have exerted efforts to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication However, in view

of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions This is particularly impor- tant when the recommended agent is a new or infrequently employed drug Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings It is the responsibility of the health care providers to ascertain the FDA status of each drug or device planned for use in their clinical practice Printed in Canada

edical advances have been occurring at breathtaking speed, with diagnostic and treatmentoptions becoming available for conditions for which none previously existed However, severalaspects of health care remain the same Patients continue to rely heavily on clinicians for help inunderstanding the burgeoning evidence in medical research and for providing optimal healthcare Clinicians remain steadfast in their quest to meet the needs of their patients and to encourageinnovation in meeting those needs The focus on patient safety and quality of care remains a key-stone of medical practice, and multidisciplinary care with a system-based approach is increas-ingly being adopted to manage chronic disorders The associated demands and challenges mandatethat physicians remain abreast of the latest developments in medicine To assist physicians in thisendeavor, the Department of Internal Medicine at Mayo Clinic provides continuing medical

education updates and resources in a timely manner This book, Mayo Clinic Internal Medicine

Review, is designed to meet the needs of practicing clinicians and physicians-in-training by updating

their knowledge of internal medicine and helping to prepare them for the internal medicine tification and maintenance of certification examinations administered by the American Board

cer-of Internal Medicine (ABIM)

The success of the earlier editions of this textbook is exemplified by the number of books lished The positive reaction to and the success enjoyed by the earlier editions prompted theDepartment of Internal Medicine to proceed with the publication of the eighth edition Eachchapter has been thoroughly updated, and a new chapter on hospital medicine has been added.The goal is to provide an update in internal medicine that is readable and easy to study This book is divided into chapters based on subspecialty topics and written by authors withexpertise in the respective fields of medicine Bulleted items highlight elements that are impor-tant concepts The repetition of important points in the chapters reinforces the essential aspects

pub-of the topics and serves as an additional aid in review pub-of the subjects Multiple-choice tions appear at the end of each chapter; there are more than 350 multiple-choice questions inthis edition Correct answers and detailed explanations follow the questions

ques-I am grateful to all the individuals who contributed ideas and suggestions for improvementduring the development of this book I thank the esteemed authors of the previous editions fortheir input into this edition and for permitting the use of some of the materials from previouseditions I am indebted to all authors for their immense effort and contributions to this edi-tion I thank the staffs of the Section of Scientific Publications, Department of Medicine, andDivision of Media Support Services at Mayo Clinic for their contributions to this edition Thesupport and cooperation of the publisher, Informa Healthcare, are also gratefully acknowledged

I trust that the eighth edition of Mayo Clinic Internal Medicine Review will continue to update

and advance the reader’s knowledge of internal medicine

Amit K Ghosh, MD

Editor-in-Chief

ix

M

All students of medicine, whatever their level of experience

and whatever their needs

v

he eighth edition of Mayo Clinic Internal Medicine Review is a reflection of the continued

com-mitment by the faculty of the Department of Internal Medicine to its mission to “serve the patientand advance the science.” There are substantial differences from the previous edition as a result

of extensive revisions All chapters were updated, 12 new authors and 2 new associate editorswere recruited, a new chapter on hospital medicine was added, and new tables, figures, and ques-tions and answers were included These changes and improvements are consistent with the themeeloquently articulated by William J Mayo, MD, in 1928: “The glory of medicine is that it isconstantly moving forward, that there is always more to learn.”*My hope is that the reader willfind the contents of this book informative, enjoyable, and, most of all, useful in our shared objective

of understanding, preventing, diagnosing, and treating the diseases that still plague the human race

Nicholas F LaRusso, MD

Chair, Department of Internal Medicine Mayo Clinic, Rochester, Minnesota

*Mayo WJ The aims and ideals of the American Medical Association Proceedings of the 66th Annual Meeting

of the National Education Association of the United States, 1928 p 158-63.

vii

T

PREFACE TO THE FIRST EDITION

or more than 2 decades, the staff of the Mayo Clinic and faculty of the Mayo Graduate School

of Medicine have provided in-house didactic presentations for residents and fellows preparingfor the internal medicine certifying examination administered by the American Board of InternalMedicine (ABIM) The extreme popularity of the Mayo “board reviews” among the residentsand fellows and other physicians prompted the initiation of “Mayo Internal Medicine BoardReview” courses in August 1992 to all physicians Nearly 200 physicians in 1992 and twice thatnumber in August 1993 attended the courses offered in Rochester, Minnesota The popularityand the great demand for the course syllabus inspired us to write this book for candidates preparing

for the ABIM examinations in internal medicine This book, Mayo Internal Medicine Board

Review 1994-95, will be used as the course syllabus for the “Mayo Internal Medicine Board

Review” courses to be held in 1994 (July 24-30) and 1995 (July 23-29) in Rochester, Minnesota.This is not a comprehensive textbook of medicine It is rather analogous to a guide or a note-book containing selected topics deemed important for candidates preparing for the certifying orrecertifying examinations offered by the ABIM in 1994 and 1995 The authors of this bookassume that the candidates preparing for the board examinations will have studied at length astandard textbook of medicine before reading this review The chapters are divided by subspecialtytopics As a means of underscoring the important clinical points for the boards, many paragraphsare followed by selected “pearls.” Some of these pearls may seem repetitious, but this approach

is intentional We hope this format will aid readers in recapitulating the salient points of the topicunder discussion The questions at the end of each chapter are intended to familiarize the can-didates with the format of the ABIM examination Answers to these questions and their expla-nations are at the end of the book

My coauthors and I are truly pleased to present this book and anticipate that it will be valuable

to anyone preparing for the certifying and recertifying examinations in internal medicine of theABIM We look forward to hearing comments and suggestions from readers

Udaya B S Prakash, MD

January 1994

xi

F

PRODUCTION STAFF

xiii

Mayo Clinic Section of Scientific Publications

Randall J Fritz, DVM Editor

LeAnn M Stee Editor

Roberta J Schwartz Production editor

Traci J H Post Scientific publications specialistAlissa K Baumgartner Copy editor/proofreaderJohn P Hedlund Copy editor/proofreader

Mayo Clinic Section of Illustration and Design

Jonathan Goebel Designer

James E Rownd Cover illustrator

Deborah A Veerkamp Production designer

Jonalle M Sauer Production designer

CONTRIBUTORS FOR PHARMACY REVIEW

Alma N Adrover, PharmD, MS

Scott E Apelgren, MS, BCPS, BCOP, BCNSP

Jeffrey J Armon, PharmDSansana Donna Boontaveekul, PharmD, MS

Lisa K Buss, PharmDSarah L Clark, PharmDJulie L Cunningham, PharmD, BCPP

Magali P Disdier, PharmD, PhD

Lynn L Estes, PharmDAnna C Gunderson, PharmDHeidi D Gunderson, PharmDRobert W Hoel, RPh, PharmD

Todd M Johnson, PharmDPhilip J Kuper, PharmD, BCPS

Scott Luther Larson, PharmD, BCPS

Jennifer D Lynch, PharmDKari L B Matzek, PharmDKevin W Odell, PharmDJohn G O’Meara, PharmDNarith N Ou, PharmDLance J Oyen, PharmDVirginia H Thompson, RPhRoger A Warndahl, RPhChristopher M Wittich, MD, PharmD

Robert C Wolf, PharmD

Haitham S Abu-Lebdeh, MD

Consultant, Division of General Internal Medicine, Mayo

Clinic, Rochester, Minnesota; Assistant Professor of Medicine,

College of Medicine, Mayo Clinic

Timothy R Aksamit, MD

Consultant, Division of Pulmonary and Critical Care Medicine,

Mayo Clinic, Rochester, Minnesota; Assistant Professor of

Medicine, College of Medicine, Mayo Clinic

Robert C Albright, Jr., DO

Consultant, Division of Nephrology and Hypertension, Mayo

Clinic, Rochester, Minnesota; Assistant Professor of Medicine,

College of Medicine, Mayo Clinic

Thomas J Beckman, MD

Consultant, Division of General Internal Medicine, Mayo

Clinic, Rochester, Minnesota; Associate Professor of Medicine,

College of Medicine, Mayo Clinic

Margaret Beliveau Ficalora, MD

Consultant, Division of General Internal Medicine, Mayo

Clinic, Rochester, Minnesota; Instructor in Medicine, College

of Medicine, Mayo Clinic

Eduardo E Benarroch, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester,

Minnesota; Professor of Neurology, College of Medicine, Mayo

Clinic

Peter A Brady, MB,ChB, MD

Consultant, Division of Cardiovascular Diseases, Mayo Clinic,

Rochester, Minnesota; Assistant Professor of Medicine, College

of Medicine, Mayo Clinic

Robert D Brown, Jr., MD

Chair, Department of Neurology, Mayo Clinic, Rochester,

Minnesota; Professor of Neurology, College of Medicine, Mayo

Clinic

Sean M Caples, DO

Senior Associate Consultant, Division of Pulmonary and Critical

Care Medicine, Mayo Clinic, Rochester, Minnesota; Assistant

Professor of Medicine, College of Medicine, Mayo Clinic

Brian A Crum, MD

Consultant, Department of Neurology, Mayo Clinic, Rochester,Minnesota; Assistant Professor of Neurology, College ofMedicine, Mayo Clinic

Lisa A Drage, MD

Consultant, Department of Dermatology, Mayo Clinic,Rochester, Minnesota; Assistant Professor of Dermatology,College of Medicine, Mayo Clinic

Stephen B Erickson, MD

Consultant, Division of Nephrology and Hypertension, MayoClinic, Rochester, Minnesota; Assistant Professor of Medicine,College of Medicine, Mayo Clinic

Lynn L Estes, PharmD

Infectious Diseases Pharmacy Specialist, Mayo Clinic, Rochester,Minnesota; Assistant Professor of Pharmacy, College ofMedicine, Mayo Clinic

Fernando C Fervenza, MD, PhD

Consultant, Division of Nephrology and Hypertension, MayoClinic, Rochester, Minnesota; Associate Professor of Medicine,College of Medicine, Mayo Clinic

Amit K Ghosh, MD

Consultant, Division of General Internal Medicine, MayoClinic, Rochester, Minnesota; Associate Professor of Medicine,College of Medicine, Mayo Clinic

Kyle W Klarich, MD

Consultant, Division of Cardiovascular Diseases, Mayo Clinic,

Rochester, Minnesota; Assistant Professor of Medicine, College

of Medicine, Mayo Clinic

Scott C Litin, MD

Consultant, Division of General Internal Medicine, Mayo

Clinic, Rochester, Minnesota; Professor of Medicine, College

of Medicine, Mayo Clinic

Conor G Loftus, MD

Consultant, Division of Gastroenterology and Hepatology,

Mayo Clinic, Rochester, Minnesota; Assistant Professor of

Medicine, College of Medicine, Mayo Clinic

Karen F Mauk, MD, MSc

Consultant, Division of General Internal Medicine, Mayo

Clinic, Rochester, Minnesota; Assistant Professor of Medicine,

College of Medicine, Mayo Clinic

Bryan McIver, MB,ChB, PhD

Consultant, Division of Endocrinology, Diabetes, Metabolism,

Nutrition, Mayo Clinic, Rochester, Minnesota

Virginia V Michels, MD

Emeritus Consultant, Department of Medical Genetics, Mayo

Clinic, Rochester, Minnesota; Professor of Medical Genetics,

College of Medicine, Mayo Clinic

Clement J Michet, Jr., MD

Consultant, Division of Rheumatology, Mayo Clinic, Rochester,

Minnesota; Associate Professor of Medicine, College of

Medicine, Mayo Clinic

Martha P Millman, MD, MPH

Consultant, Division of Preventive, Occupational and

Aerospace Medicine, Mayo Clinic, Rochester, Minnesota;

Instructor in Preventive Medicine, College of Medicine, Mayo

Clinic

Kevin G Moder, MD

Consultant, Division of Rheumatology, Mayo Clinic, Rochester,

Minnesota; Associate Professor of Medicine, College of

Medicine, Mayo Clinic

Timothy J Moynihan, MD

Consultant, Division of Medical Oncology, Mayo Clinic,

Rochester, Minnesota; Assistant Professor of Oncology, College

of Medicine, Mayo Clinic

Paul S Mueller, MD

Consultant, Division of General Internal Medicine, MayoClinic, Rochester, Minnesota; Associate Professor of Medicine,College of Medicine, Mayo Clinic

James S Newman, MD

Consultant, Division of Hospital Internal Medicine, MayoClinic, Rochester, Minnesota; Assistant Professor of History ofMedicine, College of Medicine, Mayo Clinic

John J Poterucha, MD

Consultant, Division of Gastroenterology and Hepatology,Mayo Clinic, Rochester, Minnesota; Associate Professor ofMedicine, College of Medicine, Mayo Clinic

David J Rosenman, MD

Consultant, Division of Hospital Internal Medicine, MayoClinic, Rochester, Minnesota; Assistant Professor of Medicine,College of Medicine, Mayo Clinic

xvi

Clinic, Rochester, Minnesota; Associate Professor of Medicine,

College of Medicine, Mayo Clinic

Gary L Schwartz, MD

Consultant, Division of Nephrology and Hypertension, Mayo

Clinic, Rochester, Minnesota; Associate Professor of Medicine,

College of Medicine, Mayo Clinic

Robert E Sedlack, MD, MHPE

Consultant, Division of Gastroenterology and Hepatology,

Mayo Clinic, Rochester, Minnesota; Assistant Professor of

Medicine and of Medical Education, College of Medicine,

Mayo Clinic

Lynne T Shuster, MD

Consultant, Division of General Internal Medicine, Mayo

Clinic, Rochester, Minnesota; Assistant Professor of Medicine,

College of Medicine, Mayo Clinic

Peter C Spittell, MD

Consultant, Division of Cardiovascular Diseases, Mayo Clinic,

Rochester, Minnesota; Assistant Professor of Medicine, College

of Medicine, Mayo Clinic

David P Steensma, MD

Consultant, Division of Hematology, Mayo Clinic, Rochester,

Minnesota; Associate Professor of Medicine and of Oncology,

College of Medicine, Mayo Clinic

Bruce Sutor, MD

Consultant, Division of Assessment and Consultation, Mayo

Clinic, Rochester, Minnesota; Assistant Professor of Psychiatry,

College of Medicine, Mayo Clinic

Karen L Swanson, DO

Consultant, Division of Pulmonary and Critical Care Medicine,

Mayo Clinic, Rochester, Minnesota; Assistant Professor of

Medicine, College of Medicine, Mayo Clinic

Rochester, Minnesota; Associate Professor of Medicine, College

of Medicine, Mayo Clinic

Charles F Thomas, Jr., MD

Consultant, Division of Pulmonary and Critical Care Medicine,Mayo Clinic, Rochester, Minnesota; Associate Professor ofMedicine, College of Medicine, Mayo Clinic

Prathibha Varkey, MD, MPH

Consultant, Division of Preventive, Occupational and AerospaceMedicine, Mayo Clinic, Rochester, Minnesota; AssociateProfessor of Medical Education, of Medicine, and of PreventiveMedicine, College of Medicine, Mayo Clinic

Thomas R Viggiano, MD

Consultant, Division of Gastroenterology and Hepatology,Mayo Clinic, Rochester, Minnesota; Professor of Medicine,College of Medicine, Mayo Clinic

1 The Board Examination 1

Amit K Ghosh, MD

2 Allergy 11

Gerald W Volcheck, MD

3 Cardiology 37

Kyle W Klarich, MD, Peter A Brady, MB,ChB, MD, Abhiram Prasad, MD, Barry L Karon, MD

4 Critical Care Medicine 149

7 Gastroenterology and Hepatology 257

Robert E Sedlack, MD, MHPE, Conor G Loftus, MD, Thomas R Viggiano, MD, John J Poterucha, MD

8 General Internal Medicine 329

Scott C Litin, MD, Karen F Mauk, MD, MSc

Mayo Clinic Internal Medicine Review

EIGHTH EDITION

Many physicians take the American Board of Internal Medicine

(ABIM) certifying examination in internal medicine (IM)

annual-ly The total number of candidates who took the ABIM certifying

examination for the first time in 2005 was 7,051 Of these, 92%

passed the examination Currently, greater importance is being

placed on achieving board certification In a 2003 Gallup poll of

1,001 US adults aged 18 years or older, 98% wanted their physicians

to be board-certified, and 79% thought that the recertification

process was very important Moreover, 54% would choose a new

internist if their physicians’ board certification had expired, and

75% said that they would choose a new specialist in a similar event

Many managed-care organizations now require board certification

before employment

This chapter is aimed primarily at candidates preparing for the

ABIM’s certifying or maintenance of certification examination in

IM However, candidates preparing for non-ABIM examinations

also may benefit from the information, which covers various aspects

of preparation for an examination, strategies to answer the

ques-tions effectively, and avoidance of pitfalls

Aim of the Examination

The ABIM has stated that the certifying examination tests the breadth

and depth of a candidate’s knowledge in IM to ensure that the

candidate has attained the necessary proficiency required for the

practice of IM According to the ABIM, the examination has 2 goals:

the first is to ensure competence in the diagnosis and treatment of

common disorders that have important consequences for patients,

and the second is to ensure excellence in the broad domain of IM

Examination Format

The examination for ABIM certification in IM is 1 day in duration

and consists of 4 sections; there are 60 questions in each section, and

each section is 2 hours in duration These examinations are all

com-puter-based and allow considerable flexibility to candidates to decide

on the duration of the breaks between sessions Details regarding

the examination, training requirements, eligibility requirements,

application forms, and other related information can be obtainedfrom the ABIM, 510 Walnut Street, Suite 1700, Philadelphia, PA19106-3699; telephone numbers: 215-446-3500 or 800-441-2246;fax number: 215-446-3590; e-mail address: request@abim.org;Internet address: http://www.abim.org

Almost all of the questions are clinical and based on correctdiagnosis and management Because there is no penalty for guessing

the answers, candidates should answer every question Most

ques-tions are based on the presentaques-tions of patients Among these, 75%are in the setting of outpatient or emergency department situations,and the remaining 25% are in the inpatient setting, including thecritical care unit and nursing home The ability to answer these ques-tions requires integration of information provided from several sources(such as history, physical examination, laboratory test results, and con-sultations), prioritization of alternatives, or use of clinical judgment.Candidates should know that a portion of questions are known as fieldquestions, or pretest questions, and are included for experimentalpurposes only and to test the question quality Although field ques-tions are not scored, they cannot be identified during the examina-tion The overall ability to manage a patient in a cost-effective,evidence-based fashion is stressed Questions that require simplerecall of medical facts have essentially been eliminated The examina-tion is reviewed by practicing internists to ensure the questions arerelevant to a general internal medicine practice

• Candidates should answer every question; there is no penaltyfor guessing

• Most questions are based on presentations of patients

• Questions that require simple recall of medical facts are in theminority

A list of normal laboratory values and illustrative materials cardiograms, blood smears, Gram stains, urine sediments, chestradiographs, and photomicrographs) necessary to answer questionsare provided Candidates should interpret the abnormal values onthe basis of the normal values provided and not on the basis of thenormal values to which they are accustomed in their practice or train-ing Candidates for the certifying examination receive an e-mail

(electro-1

1

The Board Examination

Amit K Ghosh, MD

communication from the ABIM highlighting several aspects of the

computer-based testing and examination instructions several weeks

before the examination Although much of the information

con-tained in this chapter is available on the ABIM Web site, candidates

for ABIM examinations should read information that is sent to them

because the ABIM may change various components of the format

of the examination

• A list of normal laboratory values and illustrative materials

nec-essary to answer questions are provided

• An e-mail with all examination information is sent by the ABIM

several weeks before the examination and should be read by

candidates

Scoring

The passing scores reflect predetermined standards set by the ABIM

Passing scores are determined before the examination and therefore

are not dependent on the performance of any group of candidates

taking the examination

• Passing scores are set before the examination

The Content

The questions in the examination cover a broad area of IM They are

divided into primary and cross-content groups The subspecialties in

the primary content areas have included cardiovascular diseases,

gastroenterology, pulmonary diseases, infectious diseases,

rheumatol-ogy/orthopedics, endocrinology/metabolism, oncology, hematology,

nephrology/urology, neurology, psychiatry, allergy/immunology,

dermatology, obstetrics/gynecology, ophthalmology, otolaryngology,

and miscellaneous The specialties in the cross-content group have

included adolescent medicine, critical care medicine, clinical

epi-demiology, ethics, geriatrics, nutrition, palliative/end-of-life care,

occu-pational/environmental medicine, preventive medicine, women’s

health, patient safety, and substance abuse Approximately 75% of

the questions test knowledge in the following major specialties in IM:

cardiology, endocrinology, gastroenterology, hematology, infectious

dis-eases, nephrology, oncology, pulmonary disdis-eases, and rheumatology

The remaining 25% of questions cover allergy/immunology,

derma-tology, gynecology, neurology, urology, ophthalmology, and

psychi-atry Independent of primary content, about 50% of the questions

encompass the cross-content topics Table 1-1 shows the distribution

of the contents for a recent ABIM certifying examination in IM

• About 75% of the questions test knowledge in the major specialties

• About 25% of the questions cover allergy/immunology,

der-matology, gynecology, neurology, urology, ophthalmology, and

psychiatry

• About 50% of all questions encompass the cross-content

top-ics: geriatrics, critical care medicine, adolescent medicine, clinical

epidemiology, medical ethics, nutrition, occupational

medi-cine, preventive medimedi-cine, substance abuse, patient safety, and

women’s health

Question Format

Each session contains 60 multiple-choice, single-best–answer questions.The question may include a case history, a brief statement, a radio-graph, a graph, or a picture (such as a blood smear or Gram stain).Each question has 5 possible answers, and the candidates should

identify the single-best answer More than 1 answer may appear

cor-rect or partially corcor-rect for a question Also, the traditionally corcor-rectanswer may not be listed as an option In that situation, the oneanswer that is better than the others should be selected As notedabove, most questions are based on interactions with patients

Table 1-1 Contents of the Certification Examination of the

American Board of Internal Medicine

The examples in this chapter, the questions at the end of each

chapter in this book, and the examples included on the ABIM’s Web

site (https://www.abim.org/cert/im.shtm) should help candidates become

familiar with the question format Furthermore, the national

in-train-ing examination taken by most second-year residents in IM provides

ample opportunity to become familiar with the question format

• All questions are of the single-best–answer type

• Various study guides should be used to become familiar with the

question format

Examples

Select the best answer for each of the following questions.

1 A 55-year-old woman presents with a history of having noticed

a blood stain from her left breast on her nightgown She has a

past history of hyperprolactinemia, treated with bromocriptine

She has no family history of breast cancer No masses are found

on clinical examination On manual expression there is a drop

of bright red blood from a solitary duct at the 2-o’clock position

of the left breast Breast imaging with mammography and

ultra-sonography is negative for worrisome lesions What is the most

appropriate next step in her management?

a Advise reassessment in 6 months with mammography and

ultrasonography

b Reassure the patient, because the breast imaging was negative

c Surgically excise the duct

d Do an endocrine work-up in view of the history of

hyper-prolactinemia

e Have the patient undergo MRI of the breast

2 A 20-year-old male military recruit returns home from several

weeks of summer training in boot camp He comes to your

office the following day with a 12-day history of fever (38°C),

coryza, pharyngitis, and cough Physical examination discloses

a bullous lesion over the right tympanic membrane and

scat-tered crackles in both lung fields Blood cell count shows mild

thrombocytopenia A chest radiograph shows patchy

alveolar-interstitial infiltrates in both lungs Which of the following is

the best treatment for this patient?

3 A 56-year-old man presents with a 1-year history of abnormal

results of liver function tests He has a history of hypertension

He has no risk factors for viral hepatitis or a family history of liver

disease He drinks a glass of wine 2 or 3 times a week On

exam-ination, his body mass index is 36, blood pressure 154/90 mm

Hg, pulse 80 beats per minute Results of the rest of the

exam-ination are normal Laboratory study results include aspartate

aminotransferase, 88 U/L; alanine aminotransferase, 90 U/L;bilirubin, 1.2 mg/dL; albumin, 4.0 g/dL; prothrombin time,normal Total cholesterol was 260 mg/dL, and low-densitylipoprotein cholesterol was 158 mg/dL The patient wants toknow more about the significance of the increased laboratory val-ues Which of the following statements about this patient’scondition is true?

a The chance of cirrhosis developing is more than 40%

b His estimated survival is lower than expected survival for thegeneral population

c Statins are absolutely contraindicated in this case

d The patient is underreporting his alcohol intake

e The patient needs to have a liver biopsy for diagnosis

4 A 50-year-old woman is admitted for abdominal pain and iting At operation, a ruptured appendix is removed That evening,fever, hypotension, and oliguria develop After a 2-L infusion of0.9% saline, blood pressure was 80/60 mm Hg, and heart ratewas 120 beats per minute Laboratory study results were hemo-globin 9.0 g/dL and leukocytes 18 × 109/L Findings on pul-monary catheterization include right atrial pressure 8 mm Hg,pulmonary artery pressure 28/10 mm Hg, wedge pressure 12

vom-mm Hg, and cardiac output 9.0 L/min Which of the following

is the most appropriate intervention?

a Additional saline infusion

a Enoxaparin 30 mg every 12 hours for 7 days postoperatively

b Enoxaparin 30 mg every 12 hours for 30 days postoperatively

c Aspirin and pneumatic compression boots during the diate postoperative period, aspirin continued on dismissalindefinitely

imme-d Enoxaparin 30 mg every 12 hours for 14 days postoperatively

e Warfarin therapy to keep the international normalized ratio

at 2 to 3 for 14 days postoperatively

6 A 65-year-old man is referred to your practice for a 4-monthhistory of swallowing difficulties His wife reports that the patientstarts coughing and choking immediately after he drinks anyfluid and that he has lost 2.3 kg He denies any hematemesis

Chapter 1 The Board Examination 3

or melena He denies any history of food “sticking” in the

suprasternal region His past medical history includes a

cere-brovascular accident with a right-sided hemiplegia 8 months

ago, diabetes mellitus, gastroesophageal reflux, and hypertension

On physical examination, the patient is alert and cooperative

and has right-sided hemiparesis His hematocrit value is 42% and

blood glucose 122 mg/dL What is the next best step in the

evaluation of his symptoms?

7 A 68-year-old woman was recently admitted to another hospital

with severe back pain At that time, MRI of the spine showed

moderate bulging disks at L3-4 and L4-5 causing moderate

compression of the L4 nerve root Her other medical problems

included hypertension and diet-controlled diabetes mellitus

Medications included hydrochlorothiazide 25 mg once daily

On physical examination, the blood pressure was 148/96 mm

Hg, and the pulse rate was 78 beats per minute On

neurolog-ic examination, there was an antalgneurolog-ic gait and the straight leg

raising test was negative Results of the remainder of the

exam-ination were normal Laboratory values were hematocrit 30%,

platelet count 110 × 109/L, blood urea nitrogen 60 mg/dL,

cre-atinine 4.0 mg/dL, serum sodium 132 mEq/L, serum chloride

112 mEq/L, serum bicarbonate 15 mEq/L, serum calcium 12.5

mg/dL, and serum glucose 120 mg/dL On urinalysis, there

was trace proteinuria, no ketonuria or glucosuria, and no casts

Arterial pH was 7.32, and PCO2was 30 mm Hg What is the

most likely diagnosis?

8 A patient who is positive for human immunodeficiency virus and

has low CD4 counts is receiving multidrug treatment He

com-plains of colicky flank pain, and many crystals are

subsequent-ly noted on urinasubsequent-lysis Which of the following drugs is most

9 A 34-year-old woman comes to your office with a 4-week

his-tory of hemoptysis, intermittent wheeze, and generalized

weak-ness On examination, her blood pressure is 186/112 mm Hg

She appears cushingoid and has noted these changes takingplace during the past 12 weeks Auscultation discloses localizedwheezing in the left mid lung area The chest radiograph indi-cates partial atelectasis of the left upper lobe The patient isreferred to you for further evaluations Which of the following

is least likely to provide useful information for diagnosis and

treatment?

a Serum adrenocorticotropic hormone level

b 24-Hour urine test for 5-hydroxyindoleacetic acid level

c Bronchoscopy

d CT of the chest

e Serum potassium level

10 A 62-year-old woman presents with the onset of eye discomfortand diplopia She has not noted any other new neurologicsymptoms Neurologic examination shows a normal mentalstatus and neurovascular findings Reflexes are slightly decreased

in the lower extremities Gait and coordination are normal.Cranial nerves show an inability to adduct, elevate, and depressthe eye Pupillary reaction is normal Motor strength testing isnegative Sensation is normal, except there is decreased vibratoryand joint position sensation in the feet What abnormality would

be expected?

a Saccular aneurysm of the cavernous sinus on CT

b Brainstem neoplasm on MRI

c Left temporal sharp waves on electroencephalography

d Increased fasting blood glucose level

e Increased erythrocyte sedimentation rate

11 A 45-year-old woman presents with symptoms of fatigue, coldintolerance, and constipation Hypothyroidism was diagnosed

7 years ago, and the patient remains euthyroid while receivinglevothyroxine 0.125 mg daily She is compliant with her med-ications and has not received any new prescription medica-tions Physical examination shows a pulse rate of 55 beats perminute Blood pressure is 140/80 mm Hg The deep tendonreflexes are delayed Investigations show a hemoglobin level of12.1 g/dL, thyroid-stimulating hormone 12.1 mIU/L, andfree thyroxine 0.75 ng/dL All of the following drugs could

affect levothyroxine metabolism except:

cephalosporin (ceftazidime) Which of the following is the most

appropriate therapy for this patient?

The patient has a history consistent with nonalcoholic

steato-hepatitis (NASH) A population-based study in the United

States showed that patients with NASH had a slightly lower

survival rate than expected for the general population

(stan-dard mortality ratio of 1.34) In patients with NASH, the

progression to cirrhosis over a 7-year period is 8% to 26%

(compared with 38%-50% in alcoholic hepatitis over a

sim-ilar period) (Gastroenterology 2005;129:113-21)

4 Answer a.

The patient has a history consistent with septic shock The

man-agement of septic shock includes resuscitation with rapid

infu-sion of large volumes of intravenous fluids to correct intravascular

hypovolemia, supportive care, monitoring, and treatment of

infection with antimicrobial therapy and surgical drainage (if

necessary) Colloids have not been shown to be more

benefi-cial than crystalloids in the management of shock Vasopressors

(norepinephrine or dopamine) are second-line agents and should

be used in patients who remain hypotensive after adequate fluid

resuscitation or in patients in whom pulmonary edema has

developed

5 Answer b.

Recent recommendations suggest anticoagulation for

prophy-laxis in venous thromboembolism (VTE) for 30 days after hip

replacement The choices of anticoagulants (duration 30 days)

include enoxaparin 30 mg every 12 hours, dalteparin 5,000

international units every 12 hours, fondaparinux 2.5 mg daily,

or warfarin with a target international normalized ratio between

2.0 and 3.0

The recommended duration of prophylaxis for knee

replace-ment is 2 weeks The 2004 guidelines of the American College

of Chest Physicians recommend that aspirin should not be used

for prophylaxis against VTE in any patient group (Chest

The following drugs decrease absorption of levothyroxine:

cal-cium carbonate, iron, sucralfate, bile-acid binding resins, and

aluminum hydroxide Patients should be instructed to takelevothyroxine at least 2 hours apart from these medications.Drugs that increase the metabolism of levothyroxine includesertraline, phenytoin, and phenobarbiturate

12 Answer d (disseminated aspergillosis in a leukopenic patient).

Questions 1 through 3 are examples of questions that are aimed

at evaluating knowledge and judgment about problems that arefrequent in clinical practice and for which physician interventionmakes a considerable difference These questions judge the candi-date’s minimal level of clinical competence These questions includedescriptions of the work-up of a patient with bloody nipple dischargedespite a negative physical examination and mammography, typical

clinical features of Mycoplasma pneumonia, and recognition of

slight-ly lower than normal survival in patients with nonalcoholic hepatitis Therefore, the decision making is relatively easy andstraightforward and requires knowledge of disease patterns and prog-nosis Questions 4 through 12 are more difficult to answer becausethey are structured to reflect excellence in clinical competence ratherthan just minimal competence In other words, they require moreextensive knowledge (ie, knowledge beyond that required for min-imal competence) in IM and its subspecialties Although most ofthe questions on the examination are based on encounters withpatients, some require recall of well-known medical facts

steato-Preparation for the Test

Training during medical school forms the foundation on whichadvanced clinical knowledge is accumulated during residency training.However, the serious preparation for the examination actually starts

at the beginning of the residency training in IM Most candidateswill require a minimum of 6 to 8 months of intense preparationfor the examination Cramming just before the examination is coun-terproductive and is unlikely to be successful Some of the meth-ods of preparation for the board examination are described below.Additionally, each candidate may develop her or his own system

• Preparation for the ABIM examination should start at the ning of the residency training in IM

begin-Each candidate should use a standard textbook of IM Any of thoseavailable should provide good basic knowledge in all areas of IM.Ideally, the candidate should use 1 good textbook and not jumpfrom 1 to another, except for reading certain chapters that are out-standing in a particular textbook The most effective way to use thetextbook is with patient-centered reading; this should occur through-out the residency program The candidate should read the descrip-tions of the symptoms and signs carefully because often they arepart of the questions in the examination Table 1-2 provides sever-

al examples of the common descriptions of symptoms and signsthat could be part of the examination Rather than reading chapters

at random, candidates are encouraged to read the literature in astructured manner to assist in future recall of facts This book andsimilar board review syllabi are excellent tools for brushing up onimportant board-relevant information several weeks to months

Chapter 1 The Board Examination 5

Table 1-2 Common Descriptions of Signs and Symptoms in Examination Questions

Cardiology

Shortness of breath or asymptomatic Late peaking systolic murmur, intensity decreases Hypertrophic obstructive

with handgrip & increases with squatting cardiomyopathyAsymptomatic, headache Hypertension, diminished or absent lower Coarctation of aorta

extremity pulses, systolic murmur, bruit overchest wall

Neurology

Gait impairment, falls, dysphagia, dysarthria Inability to look up & side to side Progressive supranuclear palsyDiplopia, oscillating images, reading fatigue, Impaired adduction on lateral gaze, with Internuclear ophthalmoplegialoss of depth perception nystagmus in the contralateral abducting eye (consider multiple sclerosis,

cerebrovascular disease)Fluctuating memory, confusion, visual Mild parkinsonism, dementia Lewy body dementia

hallucinations

Inappropriate behavior, dementia, poor social Dementia Frontotemporal dementiaskills

Paroxysmal pain affecting the side of the face Usually normal Trigeminal neuralgia affecting

1 of the branches of cranialnerve V

Muscle stiffness, clumsiness, occasional Brisk reflexes, spasticity (upper motor neuron Amyotrophic lateral sclerosisemotional lability signs), atrophy, fasciculation (lower motor

neuron signs)Altered mental status, fever, headache Flaccid paralysis, neck rigidity ±, altered mental West Nile virus encephalitis

status

Infectious disease

Recurrent sinusitis, skin, or pulmonary Sinus tenderness, abnormal lung sounds Chronic granulomatous disorder

infections due to Staphylococcus aureus

Recurrent Neisseria infections Neck rigidity ±, altered mental status Inherited deficiencies of

complement (C5, 6, 7, 8, 9),factor D, or properdinRecurrent episodes of bacterial pneumonia, Malnourished, abnormal lung sounds Common variable immuno-

pneumoniae

Gastroenterology

Cirrhosis of liver, ingestion of raw oysters Fever, hypotension, hemorrhagic bullae, signs Vibrio vulnificus

of cirrhosis of liverDiarrhea Pruritus, grouped vesicles over the elbow, knee, Dermatitis herpetiformis due to

scalp, or back of neck celiac sprueHepatitis C, photosensitivity Skin fragility, erosions, blisters on dorsum of Porphyria cutanea tarda

hand, hyperpigmentation

Dermatology

Facial rash, photosensitivity Papules & pustules on bridge of nose, face, Rosacea

telangiectasiaRash Sharply demarcated erythematous papules, Psoriasis

silvery white scales over scalp, extensorsurfaces of extremities, & nailsCough with sore throat Tender, erythematous pretibial nodules Erythema nodosum

Ulcerative colitis Irregular, undermined ulcer with violaceous Pyoderma gangrenosum

border or scarring in lower extremitiesFlushing, diarrhea, rapid heart rate Brown-red macules, urticaria on stroking skin Systemic mastocytosis

before the examination They, however, cannot take the place of

comprehensive textbooks of internal medicine This book is designed

as a study guide rather than a comprehensive textbook of medicine

Therefore, it should not be used as the sole source of medical

infor-mation for the examination

• Candidates should thoroughly study a standard textbook of IM

• This book is designed as a study guide and should not be used as

the sole source of information for preparation for the examination

• Candidates should pay considerable attention to the descriptions

of signs and symptoms

The Medical Knowledge Self-assessment Program (MKSAP) prepared

by the American College of Physicians is extremely valuable for

obtaining practice in answering multiple-choice questions The

questions and answers from the MKSAP are very useful to learn the

type of questions asked and the depth of knowledge expected for

various subjects

Some candidates find it helpful to prepare for the examination

in study groups Formation of 2 to 5 candidates per group permits

study of different textbooks and review articles in journals The group

should meet regularly as each candidate is assigned reading

materi-als Selected review articles on common and important topics in IM

should be included in the study materials Indiscriminate reading

of articles from many journals should be avoided In any case, most

candidates who begin preparation 6 to 8 months before the

exami-nation will not find time for extensive study of journal materials

The newer information in the recent (within 6-9 months of the

examination) medical journals is unlikely to be included in the

exam-ination Notes and other materials the candidates have gathered

during their residency training are also good sources of information

These clinical “pearls” gathered from mentors will be of help in

remembering certain important points

• Study groups may help cover large amounts of information

• Indiscriminate reading of articles from many journals should be

avoided

• Information in the recent (within 6-9 months of the examination)

medical journals is unlikely to be included in the examination

Candidates should try to remember some of the uncommon

man-ifestations of the most common diseases (such as polycythemia in

common obstructive pulmonary disease) and common

manifesta-tions of uncommon diseases (such as pneumothorax in eosinophilic

granuloma) The large majority of the questions on the examination

involve conditions most commonly encountered in clinical practice

Several formulas and points should be memorized (such as the anion

gap equation) The clinical training obtained and the regular study

habits formed during residency training are the most important

aspects of preparation for the examination

In general, the examination rarely has questions about specific

drug dosages or specific chemotherapy regimens used in oncology

Rather, questions are geared toward concepts regarding the treatment

of patients Questions regarding adverse effects of medications are

common on the examination, especially when the adverse effect

occurs frequently or is potentially serious The candidate is also

expect-ed to recognize when a clinical condition is a drug-relatexpect-ed event

• Study as much as possible about board-eligible topics

• Learn about the uncommon manifestations of common diseasesand the common manifestations of uncommon diseases

Day of the Examination

Adequate time is allowed to read and answer all the questions; fore, there is no need to rush or become anxious You should watchthe time to ensure that you are at least halfway through the exami-nation when half of the time has elapsed Start by answering the firstquestion and continue sequentially Almost all of the questions follow

there-a cthere-ase presentthere-ation formthere-at At times, subsequent questions will giveyou information that may help you answer a previous question Donot be alarmed by lengthy questions; look for the question’s salientpoints When faced with a confusing question, do not becomedistracted by that question Mark it so you can find it later, then go

to the next question and come back to the unanswered ones at theend Extremely lengthy stem statements or case presentations areapparently intended to test the candidate’s ability to separate theessential from the unnecessary or unimportant information Youmay want to highlight important information presented in the ques-tion in order to review this information after reading the entire ques-tion and the answer options

• Look for the salient points in each question

• If a question is confusing, mark it to find it and come back tothe unanswered questions at the end

Some candidates may fail the examination despite the possession of

an immense amount of knowledge and the clinical competence essary to pass the examination Their failure to pass the examinationmay be caused by the lack of ability to understand or interpret thequestions properly The ability to understand the nuances of the

nec-question format is sometimes referred to as boardsmanship Intelligent

interpretation of the questions is very important for candidateswho are not well versed in the format of multiple-choice questions.Tips on boardsmanship include the following:

• All questions whose answers are known should be answered first

• Spend adequate time on questions for which you are certain of theanswers to ensure that they are answered correctly It is easy tobecome overconfident with such questions and thus you may fail

to read the questions or the answer options carefully Make sureyou never make mistakes on easy questions

• Read the final sentence (that appears just before the multipleanswers) several times to understand how an answer should beselected Recheck the question format before selecting the correctanswer Read each answer option completely Occasionally aresponse may be only partially correct At times, the traditionallycorrect answer is not listed In these situations, select the best

alternative listed Watch for qualifiers such as next, immediately,

or initially.

Chapter 1 The Board Examination 7

• Avoid answers that contain absolute or very restrictive words such

as always, never, or must Answer options that contain absolutes

are likely incorrect

• Try to think of the correct answer to the question before

look-ing at the list of potential answers Assume you have been given

all the necessary information to answer the question If the answer

you had formulated is not among the list of answers provided,

you may have interpreted the question incorrectly When a

patient’s case is presented, think of the diagnosis before looking

at the list of answers It will be reassuring to realize (particularly

if your diagnosis is supported by the answers) that you are on

the right track

• Abnormalities on, for example, the photographs, radiographs,

and electrocardiograms will be obvious

• If you do not know the answer to a question, very often you are

able to rule out 1 or several answer options and improve your

odds at guessing

• Occasionally you can use information presented in 1 question

to help you answer other difficult questions

Candidates are well advised to use the basic fund of knowledge

accu-mulated from clinical experience and reading to solve the questions

Approaching the questions as real-life encounters with patients is far

better than trying to second-guess the examiners or trying to analyze

whether the question is tricky As indicated above, the questions are

never tricky, and there is no reason for the ABIM to trick the

can-didates into choosing wrong answers

It is better not to discuss the questions or answers (after the

exam-ination) with other candidates Such discussions usually cause more

consternation, although some candidates may derive a false sense of

having performed well in the examination In any case, the

candi-dates are bound by their oath to the ABIM not to discuss or

dis-seminate the questions Do not study between examination sessions

• Approach questions as real-life encounters with a patient

• There are no trick questions

Connections

Associations, causes, complications, and other relationships between

a phenomenon or disease and clinical features are important to

remember and recognize For example, Table 1-3 lists some of the

connections in infectious and occupational entities in pulmonary

medicine Each subspecialty has many similar connections, and

candidates for the ABIM and other examinations may want to

prepare lists like this for different areas

Computer-based Testing

Candidates currently can take the computer-based test for the

certifi-cation test examination The computer-based test provides a more

flexible, quiet, and professional environment for examination The

computer-based test is administered by Pearson VUE, a company with

around 200 centers in the United States Candidates are encouraged

to schedule their examination date by calling Pearson VUE

(800-601-3549) as soon as possible Candidates can now select to take their test

on any 1 of the 8 available days in the month of August

Candidates are encouraged to access the online tutorial atwww.abim.org/cert/cbt.shtm This tutorial allows the candidate tobecome familiar with answering questions, changing answers, makingnotes electronically, accessing the table of normal laboratory values,and marking questions for review

Maintenance of Certification

The diplomate certificates issued to candidates who have passed theABIM examination in IM since 1990 are valid for 10 years Thetotal number of candidates who took the ABIM maintenance ofcertification examination for the first time in 2005 was 4,242 Ofthese, 82% passed the examination

Enhancements to Maintenance of Certification Program

In January 2006, the ABIM enhanced the maintenance of cation program to increase flexibility, incorporate programs developed

certifi-by other organizations, and assess performance in clinical practice.The 3 general components (credentialing, self-evaluation, and secureexamination) were retained, and all self-evaluation modules nowhave a points value

Every candidate needs to complete a total of 100 points inself-evaluation modules Unlike the previous system, renewal ofmore than 1 certificate does not necessitate taking additional self-evaluation modules (ie, the same number of points, 100, satisfiesthe requirement to sit for these examinations) Candidates have tocomplete at least 20 points in medical knowledge and at least 20points in practice performance The remaining 60 points may beobtained from completion of modules developed by ABIM andother organizations that meet the ABIM standards Thus, one couldcombine an ABIM knowledge module (20 points) and an ABIMpractice improvement module (20 points) with the American College

of Physicians MKSAP (3 modules, 60 points), or one could bine an ABIM practice improvement module (20 points) with 3ABIM knowledge modules (60 points) and the ABIM peer andpatient feedback module (20 points) In 2007, the ABIM intro-duced annual updates of topics consisting of 25-question modules(10 points) and a structured phaseout of the 60-question medicalknowledge modules (Table 1-4) All points are valid for 10 years.The all-inclusive fee structure started in 2006 allows unlimitedaccess to ABIM self-evaluation modules and 1 examination Thus,continuous medical education credits can be earned without anyadditional fees for 10 years

com-The self-evaluation modules evaluate performance in clinicalskills, preventive services, practice performance, fund of medicalknowledge, and feedback from patients and colleagues Successfullycompleted self-evaluation modules are valid for 10 years Candidatesmay apply to begin the maintenance of certification process any timeafter initial certification The ABIM recommends that completion ofthe self-evaluation modules be spread out over time It is anticipatedthat a candidate will complete 1 self-assessment module every 1 to 2years The ABIM encourages candidates to enroll within 4 years ofcertification in order to have adequate time to complete the program

• Candidates who passed the ABIM certification examination in IM

in 1990 and thereafter have certificates that are valid for 10 years

• The maintenance of certification process is called continuous

professional development and consists of a 3-step process

Medical Knowledge and Clinical Skills Self-evaluation Modules

The medical knowledge module is an open-book examination

con-taining 60 single-best–answer multiple-choice questions regarding

recent clinical advances in IM As mentioned previously, ABIM has

introduced the 25-question annual update modules, and a phase-in

schedule is in place to replace the existing modules by 2010 Thismodule tests the candidate’s knowledge of IM and clinical judgment.The questions are written by board members and ABIM diplomates.Candidates may choose a module in IM or a subspecialty (focusedcontent) The module is available on paper (it is being phased out),CD-ROM, or the Internet Candidates must achieve a predeterminedpassing score to establish credit for the module The module may berepeated as often as necessary to achieve a passing score

The clinical skills self-evaluation module consists of an open-bookexamination containing audio and visual information pertaining to

Chapter 1 The Board Examination 9 Table 1-3 Example of Connections Between Etiologic Factors and Diseases

Cattle, swine, horses, wool, hide Anthrax

Travel to Southeast Asia, South America Melioidosis

Squirrels, chipmunks, rabbits, rats Plague

Rabbits, squirrels, infected flies, or ticks Tularemia

Rats, dogs, cats, cattle, swine Leptospirosis

Chicken coops, starling roosts, caves Histoplasmosis

Travel in southwestern United States Coccidioidomycosis

Ohio and Mississippi river valleys Histoplasmosis

Gardeners, florists, straw, plants Sporotrichosis

Progressive, massive fibrosis Silicosis, coal, hematite, kaolin, graphite, asbestosisAutoimmune mechanism Silicosis, asbestosis, berylliosis

Monday morning sickness Byssinosis, bagassosis, metal fume fever

Metals and fumes producing asthma Baker’s asthma, meat wrapper’s asthma, printer’s asthma,

nickel, platinum, toluene diisocyanate (TDI), cigarette cutter’s asthma

Increased incidence of tuberculosis Silicosis, hematite lung

Increased incidence of carcinoma Asbestos, hematite, arsenic, nickel, uranium, chromate

Asbestos exposure Mesothelioma, bronchogenic carcinoma, gastrointestinal

cancer

Diaphragmatic calcification Asbestosis (also ankylosing spondylitis)

Nonfibrogenic pneumoconioses Tin, emery, antimony, titanium, barium

Minimal pathology in lungs Siderosis, baritosis, stannosis

physical examination and physical diagnosis and physician-patient

communication skills The module contains 60 single-best–answer

multiple-choice questions It is available on a CD-ROM with Web

access Candidates must achieve a predetermined passing score to

establish credit for the module The module may be repeated as often

as necessary to achieve a passing score

Performance-based Practice Improvement Module

This module is a computer-based instrument to help candidates

assess the care they provide to patients and to help them develop a

plan for improvement Areas of the practice that have potential for

quality improvement are identified Completion of this module

involves review of patient charts and comparing them with national

guidelines Data are submitted electronically to the ABIM to provide

feedback Candidates can implement the changes and measure their

impact over a 2-week to 2-year period

Patient- and Peer-Feedback Module

Confidential and anonymous feedback regarding the candidate’s

professionalism, physician-patient communication skills, and

overall patient care skills is obtained from colleagues and patients of

the candidate by an automated telephone survey The candidate

selects 10 colleagues and 25 patients, who are asked to complete a brief,

anonymous telephone survey The candidate receives a summary ofthe survey findings

Secure Examination

A comprehensive, secure, computer-based examination is offered

2 times yearly, currently in May and November The examinationconsists of 3 modules of 60 single-best–answer multiple-choicequestions Each module is 2 hours in duration, although the can-didate might finish early and choose to take the next module imme-diately or after a brief break (recommended) Successful completion

of the self-evaluation modules is not required before taking thisexamination Questions are based on well-established informationand assess clinical judgment more than pure recall of medical infor-mation The examination contains clinically relevant questions Topass the final examination, the candidate must achieve a predeter-mined passing score The examination may be repeated as often as

it takes to achieve a passing score The blueprint of the number ofquestions for the maintenance of certification examination isdescribed at http://www.abim.org/moc/im.shtm

Details of the maintenance of certification program can beobtained from the ABIM, 510 Walnut Street, Suite 1700,Philadelphia, PA 19106-3699; telephone number: 800-441-2246;fax number: 215-446-3590; Internet address: http://www.abim.org

Table 1-4 Annual Update Medical Knowledge Modules, 3-Year Phase-In

2007 2007 annual update Recent advances, general A General B

2008 2008 annual update 2007 annual update, recent advances General A

2009 2009 annual update 2008 annual update, 2007 annual update Recent advances

2010 2010 annual update 2009 annual update, 2008 annual update 2007 annual update

Abbreviation: ABIM, American Board of Internal Medicine.

Allergy Testing

Standard allergy testing relies on identifying the IgE antibody specific

for the allergen in question Two classic methods of doing this are the

immediate wheal-and-flare skin prick tests (a small amount of antigen

is introduced into the skin and evaluated at 15 minutes for the

pres-ence of an immediate wheal-and-flare reaction) and in vitro testing

Allergy testing that does not have a clear scientific basis includes

cytotoxic testing, provocation-neutralization testing or treatment,

and “yeast allergy” testing

Patch Tests and Prick (Cutaneous) Tests

Many seem confused about the concept of patch testing of skin as

opposed to immediate wheal-and-flare skin testing Patch testing is

used only to investigate contact dermatitis, a type IV hypersensitivity

reaction Patch tests require about 96 hours for complete evaluation

(similar to tuberculin skin reactivity, which requires 72 hours) Most

substances that cause contact dermatitis are small organic molecules

that can penetrate various barriers inherent in the skin surface The

mechanisms of hypersensitivity postulated to explain these reactions

usu-ally involve the formation of haptens of endogenous dermal proteins

Inhalant allergens, in comparison, generally are sizable intact

proteins in which each molecule can be multivalent with respect to

IgE binding These molecules penetrate the skin poorly and are

seldom involved in cutaneous type IV hypersensitivity reactions

They cause respiratory symptoms, such as allergic rhinitis and

asth-ma, and are identified by skin prick testing Their sources include dust

mites, cats, dogs, cockroaches, molds, and tree, grass, and weed pollens

• Patch testing is used to investigate contact dermatitis

• Skin prick (immediate) testing is used to investigate respiratory

allergy to airborne allergens

Prick, scratch, and intradermal testing involve introducing allergen

to the skin layers below the external keratin layer The deeper

tech-niques are more sensitive but less specific With the deeper,

intra-dermal tests, allergen is introduced closer to responding cells and

at higher doses Allergen skin tests performed by the prick technique

adequately identify patients who have important clinical sensitivitieswithout identifying a large number of those who have minimal levels

of IgE antibody and no clinical sensitivity Intradermal testing is used

in selected cases, including evaluating allergy to stinging insect oms and to penicillin Drugs with antihistamine properties, such as

ven-H1receptor antagonists, and many anticholinergic and tricyclicantidepressant drugs can suppress immediate allergy skin test respons-

es The H2receptor antagonists have a small suppressive effect.Corticosteroids can suppress the delayed-type hypersensitivity responsebut not the immediate response

• Intradermal skin tests are more sensitive but less specific thanprick skin tests

• Intradermal skin testing is used to investigate allergy to insectvenoms and penicillin

In Vitro Allergy Testing

In vitro allergy testing initially involves chemically coupling allergenprotein molecules to a solid-phase substance The test is then con-ducted by incubating serum (from the patient) that may containIgE antibody specific for the allergen that has been immobilized tothe membrane for a standard time The solid phase is then washedfree of nonbinding materials from the serum and incubated in asecond solution containing a reagent (eg, radiolabeled anti-IgE anti-body) The various wells are counted, and the radioactivity is corre-lated directly with the preparation of a standard curve in whichknown amounts of allergen-specific IgE antibody were incubated with

a set of standard preparations of a solid phase In vitro allergy testinguses the principles of radioimmunoassay or chromogen activation

It is important to understand that this test only identifies thepresence of allergen-specific IgE antibody in the same way that theallergen skin test does Generally, in vitro allergy testing is not assensitive as any form of skin testing and has some limitations because

of the potential for chemical modification of the allergen proteinwhile it is being coupled to the solid phase by means of covalentreaction Generally, it is more expensive than allergen skin tests and has

no advantage in routine clinical work In vitro allergy testing may

be useful clinically for patients who have been taking antihistamines

11

2

Allergy Gerald W Volcheck, MD

and are unable to discontinue their use or for patients who have

pri-mary cutaneous diseases that make allergen skin testing impractical

or inaccurate (eg, severe atopic eczema with most of the skin involved

The pathologic features of asthma have been studied chiefly in fatal

cases; some bronchoscopic data are available for mild and moderate

asthma The histologic hallmarks of asthma are listed in Table 2-1

• The histologic hallmarks of asthma include mucous gland

hyper-trophy, mucus hypersecretion, epithelial desquamation, widening

of the basement membrane, and infiltration by eosinophils

Pathophysiology

Bronchial hyperresponsiveness is common to all forms of asthma

It is measured by assessing pulmonary function before and after

exposure to methacholine, histamine, cold air, or exercise Prolonged

aerosol corticosteroid therapy reduces bronchial hyperresponsiveness

Prolonged therapy with certain other anti-inflammatory drugs (eg,

cromolyn sodium, nedocromil) also reduces bronchial

hyperre-sponsiveness Note that although both cromolyn and nedocromil

were originally touted as “antiallergic” (they inhibit mast cell

activa-tion), they affect most cells involved in inflammation; also, the effects

on these cells occur at lower doses than those that inhibit mast cell

Persons who have allergic asthma generate mast cell and basophil

mediators that have important roles in the development of bronchial inflammation and smooth muscle changes that occur afteracute exposure to allergen Mast cells and basophils are prominentduring the immediate-phase reaction

endo-• In the immediate-phase reaction, mast cells and basophils areimportant

In the so-called late-phase reaction to allergen exposure, the bronchidisplay histologic features of chronic inflammation and eosinophilsbecome prominent in the reaction

• In the late-phase reaction, eosinophils become prominent Patients who have chronic asthma and negative results on allergyskin tests seem to have an inflammatory infiltrate in the bronchi andhistologic findings dominated by eosinophils when asthma is active.Patients with sudden asphyxic asthma may have a neutrophilic ratherthan an eosinophilic infiltration of the airway

Various hypotheses explain the development of nonallergicasthma One proposal is that the initial inflammation represents anautoimmune reaction arising from a viral or other microbial infec-tion in the lung and, for reasons unknown, inflammation becomeschronic and characterized by a lymphocyte cytokine profile in whichinterleukin (IL)-5 is prominent The intense eosinophilic inflam-mation is thought to come from the IL-5 influence of T cells in thechronic inflammatory infiltrate

• IL-5 stimulates eosinophils

The 2 types of helper T cells are TH1 and TH2 In general, TH1cells produce interferon-γ and IL-2, and TH2 cells produce IL-4 andIL-5 IL-4 stimulates IgE synthesis Hence, many clinical scientistsbelieve that atopic asthma is caused by a preferential activation ofTH2 lymphocytes

• IL-4 stimulates IgE synthesis

• TH2 lymphocytes produce IL-4 and IL-5

Important characteristics of cytokines are summarized in Table 2-2.IL-1, IL-6, and tumor necrosis factor are produced by antigen-pre-senting cells and start the acute inflammatory reaction against aninvader; IL-4 and IL-13 stimulate IgE synthesis; IL-2 and interfer-on-γ stimulate a cell-mediated response; and IL-10 is the primaryanti-inflammatory cytokine

of the β2-adrenergic receptor are linked to bronchial hyperreactivity.The gene for IL-4 is located on chromosome 5q31 and is linked

to total IgE

Table 2-1 Histologic Hallmarks of Asthma

Mucous gland hypertrophy

Mucus hypersecretion

Alteration of tinctorial & viscoelastic properties of mucus

Widening of basement membrane zone of bronchial epithelial

membrane

Increased number of intraepithelial leukocytes & mast cells

Round cell infiltration of bronchial submucosa

Intense eosinophilic infiltration of submucosa

Widespread damage to bronchial epithelium

Large areas of complete desquamation of epithelium into

airway lumen

Mucous plugs filled with eosinophils & their products

Occupational Asthma

Every patient interviewed about a history of allergy or asthma must

be asked to provide a detailed occupational history A large fraction

of occupational asthma escapes diagnosis because physicians obtain

an inadequate occupational history An enormous range of possible

industrial circumstances may lead to exposure and resultant disease

The most widely recognized types of occupational asthma are listed

in Table 2-3

• Inquiry into a possible occupational cause of asthma is important

for all patients with asthma

As new industrial processes and products evolve, occupational

asthma may become more common An example of this is

latex-induced asthma among medical workers, associated with the

widespread use of latex gloves The incidence of occupational

asthma is estimated to be 6% to 15% of all cases of adult-onset

asthma

• Allergy to latex is an important cause of occupational asthma

Gastroesophageal Reflux and Asthma

The role of gastroesophageal reflux in asthma is not known Twomechanistic hypotheses involve 1) reflex bronchospasm from acid

in the distal esophagus and 2) recurrent aspiration of gastric contents.Although a well-documented reflex in dogs links acid in the distalesophagus to vagally mediated bronchospasm, this reflex has notbeen demonstrated consistently in humans The other hypothesis

is that gastric contents reach the tracheobronchial tree by ascending

to the hypopharynx

Asthma-Provoking Drugs

It is important to recognize the potentially severe adverse response thatpatients with asthma may show to β-blocking drugs (β1- and β2-blockers), including β1-selective β-blocking agents Patients withasthma who have glaucoma treated with ophthalmic preparations

of timolol or betaxolol (betaxolol is less likely to cause problems)may experience bronchospasm

• β-Blocking drugs, including eyedrops, can cause severe adverseresponses

Chapter 2 Allergy 13 Table 2-2 Characteristics of Cytokines

Neutrophil, macrophage maturation Mast cells

IL-5 Eosinophil proliferation & differentiation T cells (TH2)

Endothelial cellsMonocytes

Macrophages

Stimulates MHC expressionInhibits TH2 activity

Macrophages

GM-CSF Stimulates mast cells, granulocytes, macrophages Lymphocytes

Mast cellsMacrophages

Abbreviations: GM-CSF, granulocyte-macrophage colony-stimulating factor; IFN, interferon; IL, interleukin; MHC, major histocompatibility complex; TH, helper T cell; TNF, tumor necrosis factor.

• So-called β1-selective β-blocking agents such as atenolol may

also provoke asthma

Persons taking angiotensin-converting enzyme inhibitor drugs may

develop a chronic cough that can mimic asthma This cough may

not be accompanied by additional bronchospasm

• Angiotensin-converting enzyme inhibitors can cause coughing

Aspirin ingestion can cause acute, severe, and fatal asthma in a

small subset of patients with asthma The cause of the reaction is

unknown but probably involves the generation of leukotrienes

Most of the affected patients have nasal polyposis and

hyperplas-tic pansinus mucosal disease and are steroid-dependent for

con-trol of asthma However, not all asthma patients with this reaction

to aspirin fit the profile Many nonsteroidal anti-inflammatory

drugs can trigger the reaction; the likelihood correlates with a drug’spotency for inhibiting cyclooxygenase enzyme Structural aspects

of the drug seem unrelated to its tendency to provoke the reaction.Only nonacetylated salicylates such as choline salicylate (a weakcyclooxygenase inhibitor) seem not to provoke the reaction.Leukotriene-modifying drugs may be particularly helpful in aspirin-sensitive asthma

• Aspirin and other nonsteroidal anti-inflammatory drugs can causeacute, severe asthma

• Asthma, nasal polyposis, and aspirin sensitivity form the “aspirinallergy triad.”

• Leukotriene modifiers may be helpful in aspirin-sensitive asthma.Traditionally, asthma patients have been warned not to take anti-histamines because the anticholinergic activity of some antihista-mines was thought to cause drying of lower respiratory tract secretions,further worsening the asthma However, antihistamines do notworsen asthma, and, in fact, some studies have shown a beneficialeffect Thus, occasionally an antihistamine is specifically prescribedfor asthma because it may have some beneficial effect on asthmaticinflammation

• Antihistamines are not contraindicated in asthma

Cigarette Smoking and Asthma

A combination of asthma and cigarette smoking leads to acceleratedchronic obstructive pulmonary disease Because of accelerated decline

in irreversible obstruction, all asthma patients who smoke should

be told to stop smoking

Environmental tobacco smoke is an important asthma trigger

In particular, children with asthma who are exposed to mental smoke have more respiratory infections and asthma attacks

environ-Medical History

A medical history for asthma includes careful inquiry about symptoms,provoking factors, alleviating factors, and severity Patients withmarked respiratory allergy have symptoms when exposed to aero-allergens and often have seasonal variation of symptoms If allergy skintest results are negative, one can be reasonably certain that the patientdoes not have allergic asthma

• In allergic asthma, symptoms either are sporadic and consistentlyrelated to exposure or are seasonal

Respiratory infections (particularly viral), cold dry air, exercise, andrespiratory irritants can trigger allergic and nonallergic asthma

• Patients with allergic asthma are likely to respond to many immunologic triggers

non-• Cold dry air and exercise can trigger asthma

Assessment of Severity

Asthma is mild intermittent if 1) the symptoms are intermittent (≤2

times weekly), 2) continuous treatment is not needed, and 3) the

Table 2-3 Industrial Agents That Can Cause Asthma

Canine or feline saliva

Horse dander (racing workers)

Rodent urine (laboratory animal workers)

flow-volume curve during formal pulmonary function testing is

nor-mal between episodes of symptoms Even for patients who meet

these criteria, inflammation (albeit patchy) is present in the airways

and corticosteroid inhaled on a regular basis diminishes bronchial

hyperresponsiveness

• Corticosteroid inhaled regularly diminishes bronchial

hyper-responsiveness

Asthma is mild persistent or moderate when 1) the symptoms occur

with some regularity (>2 times weekly) or daily, 2) there is some

noc-turnal occurrence of symptoms, or 3) asthma exacerbations are

trou-blesome For many of these patients, the flow-volume curve is rarely

normal and complete pulmonary function testing may show evidence

of hyperinflation, as indicated by increased residual volume or an

increase above expected levels for the diffusing capacity of the lung

for carbon dioxide Patients with mild, moderate, or severe

persis-tent asthma should receive treatment daily with anti-inflammatory

medications, usually inhaled corticosteroids

Asthma is severe when symptoms are present almost

continu-ously and the usual medications must be given in doses at the upper

end of the dose range to control the disease Most patients with

severe asthma require either large doses of inhaled corticosteroid or

oral prednisone daily for adequate control Most of them have been

hospitalized more than once for asthma The severity of asthma can

change over time, and 1 of the first signs that asthma is not well

controlled is the emergence of nocturnal symptoms

• Nocturnal symptoms suggest that asthma is worsening

Methacholine Bronchial Challenge

If a patient has a history suggestive of episodic asthma but has normal

results on pulmonary function tests on the day of the examination,

the patient is a reasonable candidate for a methacholine bronchial

challenge The methacholine bronchial challenge is also useful in

evaluating patients for cough in whom baseline pulmonary function

appears normal Positive results indicate that bronchial

hyperre-sponsiveness is present (Table 2-4) Some consider isocapneic

hyper-ventilation with subfreezing dry air (by either exercising or breathing

a carbon dioxide–air mixture) or exercise testing as alternatives to a

methacholine challenge

Do not perform a methacholine challenge in patients who have

severe airway obstruction or a clear diagnosis of asthma Usually, a

20% decrease in forced expiratory volume in 1 second (FEV1) is

considered a positive result

• Patients with suspected asthma and normal results on pulmonary

function tests are candidates for methacholine testing

Differential Diagnosis

The differential diagnosis of wheezing is given in Table 2-5

Medications for Asthma

Medications for asthma are listed in Table 2-6 They can be divided

into bronchodilator compounds and anti-inflammatory compounds

Bronchodilator Compounds

Currently, the only anticholinergic drug available in the United Statesfor treating asthma is ipratropium bromide, although it is approvedonly for treating chronic obstructive pulmonary disease Severalshort-acting β-adrenergic compounds are available, but albuterol,levalbuterol, and pirbuterol are probably prescribed most Moreside effects occur when these medications are given orally ratherthan by inhalation Nebulized β-agonists are rarely used long-term

in adult asthma, although they may be lifesaving in acute attacks.For home use, the metered-dose inhaler or dry powdered inhalation

is the preferred delivery system Salmeterol and formoterol are 2long-acting inhaled β-agonists Both should be used in combinationwith inhaled corticosteroids Theophylline is effective for asthma, but

it has a narrow therapeutic index, and interactions with other drugs(cimetidine, erythromycin, and quinolone antibiotics) can increasethe serum level of theophylline

• Theophylline has a narrow therapeutic index

• β-Agonists are best delivered by the inhaler route

Chapter 2 Allergy 15

Table 2-4 Medical Conditions Associated With Positive Findings

on Methacholine Challenge

Current asthmaPast history of asthmaChronic obstructive pulmonary diseaseSmoking

Recent respiratory infectionChronic cough

Allergic rhinitis

Table 2-5 Differential Diagnosis of Wheezing

Pulmonary embolismCardiac failureForeign bodyCentral airway tumorsAspiration

Carcinoid syndromeChondromalacia/polychondritisLöffler syndrome

BronchiectasisTropical eosinophiliaHyperventilation syndromeLaryngeal edema

Vascular ring affecting tracheaFactitious (including psychophysiologic vocal cord adduction)

α1-Antiprotease deficiencyImmotile cilia syndromeBronchopulmonary dysplasiaBronchiolitis (including bronchiolitis obliterans), croupCystic fibrosis