2019 Kaplan USMLE Step 2 CK Internal Medicine Lecture Notes

The 4 malignancies for which regular screening is recommended are cancers of the colon, breast, cervix, and lung... A 50-year-old man gets his first screening for colon cancer viacolonos

MEDICINE

Lecture Notes

2019

USMLE® is a joint program of the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME), neither of which sponsors or endorses this product.

This publication is designed to provide accurate information in regard to the subject matter covered as of its publication date, with the understanding that knowledge and best practice constantly evolve The publisher

is not engaged in rendering medical, legal, accounting, or other professional service If medical or legal advice or other expert assistance is required, the services of a competent professional should be sought This publication is not intended for use in clinical practice or the delivery of medical care To the fullest extent of the law, neither the Publisher nor the Editors assume any liability for any injury and/or damage to persons

ISBN-13: 978-1-5062-3625-4

The editors would like to acknowledge

Manuel A Castro, MD, AAHIVS, Amirtharaj Dhanaraja, MD, Aditya Patel, MD, Irfan Sheikh, MD, and Frazier Stevenson, MD for their

Joseph J Lieber, MD

Director of Medicine Elmhurst Hospital Center

Associate Professor of Medicine Associate Program Director of Medicine for Elmhurst Site

PREVENTIVE MEDICINE

Describe appropriate screening methods as they apply to neoplasms of thecolon, breast, cervix, and lung

Describe epidemiological data related to incidence and prevention of commoninfectious disease, chronic illness, trauma, smoking, and travel risks

A 39-year-old woman comes to the clinic very concerned about her risk ofdeveloping cancer Her father was diagnosed with colon cancer at age 43,and her mother was diagnosed with breast cancer at age 52 She is sexuallyactive with multiple partners and has not seen a physician since a car

Finally, there may be a stigma associated with incorrectly labeling a patient as

“sick.”

For all diseases for which screening is recommended, effective intervention mustexist, and the course of events after a positive test result must be acceptable tothe patient Most important, the screening test must be valid, i.e., it must have

Several harmful effects may potentially result from screening tests

Any adverse outcome that occurs (large bowel perforation secondary to acolonoscopy) is iatrogenic

Screening may be expensive, unpleasant, and/or inconvenient

Screening may also lead to harmful treatment

The 4 malignancies for which regular screening is recommended are cancers of

the colon, breast, cervix, and lung.

In the patient with no significant family history of colon cancer, screening

should begin at age 50 The preferred screening modality for colon cancer iscolonoscopy every 10 years Other choices include annual fecal occult bloodtesting and sigmoidoscopy with barium enema every 5 years

In the patient with a single first-degree relative diagnosed with colorectal cancerbefore age 60 or multiple first-degree relatives with colon cancer at any age,colonoscopy should begin at age 40 or 10 years before the age at which the

youngest affected relative was diagnosed, whichever age occurs earlier In

these high-risk patients, colonoscopy should be repeated every 5 years The U.S.Preventive Services Task Force (USPSTF) does not recommend routine

screening in patients age >75

The tests used to screen for breast cancer are mammography and manual breastexam Mammography with or without clinical breast exam is recommendedevery 1–2 years from age 50–74 The American Cancer Society no longer

recommends monthly self breast examination alone as a screening tool Patientswith very strong family histories of breast cancer (defined as multiple first-degree relatives) should consider prophylactic tamoxifen, discussing risks andbenefits with a physician Tamoxifen prevents breast cancer in high-risk

individuals

Tamoxifen prevents cancer by 50% in those with >1 family member with breast cancer.

The screening test of choice for the early detection of cervical cancer is thePapanicolaou smear (the “Pap” test) In average risk women, Pap smear

screening should be started at age 21, regardless of onset of sexual activity It

should be performed every 3 years until age 65

Current recommendations for lung cancer screening are as follows:

year smoking history and currently smoke or have quit within past 15 yearsOnce a person has not smoked for 15 years or develops a health problemsubstantially limiting life expectancy or ability/willingness to have curativelung surgery, screening should be discontinued

Answer: C

Which of the following patients is undergoing an inappropriate method ofscreening as recommended by the USPSTF?

A 50-year-old man gets his first screening for colon cancer viacolonoscopy

)

A 50-year-old woman gets her first screening for breast cancer viamammography

)

A 17-year-old woman is screened for HPV via a Pap smear afterher first sexual encounter

)

dose CT

A 65-year-old man with a 30-pack-year smoking history gets a low-)

A 21-year-old woman with a high risk of developing breast cancer

is given tamoxifen

)

A 44-year-old executive comes to the clinic before traveling to Thailand forbusiness He has no significant past medical history and is here only

because his company will not let him travel until he is seen by a physician.The patient appears agitated and demands the physician’s recommendationimmediately

It is important to set up a pretravel counseling session 4–6 weeks before thepatient’s departure

Hepatitis A infection is travelers’ most common vaccine-preventable disease.

Hepatitis A infection is possible wherever fecal contamination of food or

drinking water may occur Infection rates are particularly high in nonindustrialcountries If a patient is leaving within 2 weeks of being seen, both the vaccineand immune serum globulin are recommended A booster shot given 6 monthsafter the initial vaccination confers immunity for approximately 10 years

All travelers to less-developed countries should get hep A vaccine

Hepatitis B vaccination is recommended for patients who work closely with

indigenous populations Additionally, patients who plan to engage in sexualintercourse with the local populace, to receive medical or dental care, or to

remain abroad for >6 months should be vaccinated

is an acceptable alternative to mefloquine, although photosensitivity can be

problematic For pregnant patients requiring chemoprophylaxis for malaria,chloroquine is the preferred regimen

preferred form for almost all subjects as it is well-tolerated and convenient (noneed for refrigeration) It is safe for HIV patients

Polio: Adults who are traveling to developing countries and have never received

a polio vaccine should receive 3 doses of the inactivated polio vaccine Patientswho have been previously immunized should receive a one-time booster Thelive attenuated polio vaccine is no longer recommended because of the risk ofvaccine-associated disease

Meningococcal vaccine is now routinely administered at age 11

To prevent traveler’s diarrhea, patients should be advised to avoid raw and

street vendor salads, unwashed fruit, and tap/ice water Patients who experiencemild loose stools without fever or blood can safely take loperamide Treatmentwith a fluoroquinolone or azithromycin is reserved for patients with moderate tosevere symptoms

A 52-year-old man comes to the clinic for a health maintenance evaluation.His recent colonoscopy showed no evidence of carcinoma Recent serumfasting glucose, serum cholesterol, and blood pressure are all within normallimits The patient has a history of smoking and continues to smoke 2 packsper day He was diagnosed with COPD 3 years ago

Patients must get Pneumovax, meningococcal, and Haemophilus vaccines 2 weeks before a

splenectomy.

Immunization is the best method available for preventing serious infectiousdisease Between 50,000–70,000 adults die every year from preventable

infectious disease (influenza, invasive pneumococcal disease, and hepatitis B).Surveys have shown that among patients who have an indication for any

Give the third dose 6–12 months later

Give a booster vaccination every 10 years for life; one of the boostersshould use Tdap instead of Td booster; if wound is dirty, revaccinate after 5years

Influenza vaccine is recommended annually for all adults regardless of age.Patients who have a history of cardiopulmonary disease, diabetes mellitus, orhemoglobinopathy, or are age 50+ residents of chronic care facilities will derivethe greatest benefit from an annual influenza vaccination Pregnant women whowill be in their second or third trimester during the influenza season should alsoreceive the vaccine

Pneumococcal vaccine is indicated for all adults age ≥65 Additionally, thefollowing individuals should receive the vaccine regardless of age:

Revaccination should be performed in healthy patients who received their initialvaccination age <65 and were age <60 at the time of primary vaccination

Patients with a high risk of fatal infection (CKD, asplenic patients,

immunocompromised patients) should be revaccinated 1x after 5 years No onegets >1 booster shot per lifetime

Those with history of sickle-cell disease or splenectomy

Those with history of cardiopulmonary disease, alcoholism, or cirrhosisAlaskan natives and certain Native American populations

Immunocompromised patients (patients with hematologic malignancies,chronic renal failure, or nephrotic syndrome; HIV-positive patients; or

patients receiving immunosuppressive medications)

The hepatitis A vaccine protects against the virus in >95% of cases There are 2types of vaccine, both of which stimulate active immunity against a future

infection

For the best protection, give the vaccine in 2 doses: initial dose and then a

booster 6-12 months later Protection against hepatitis A begins approximately2–4 weeks after the initial vaccination

In the United States, the vaccine is strongly recommended for all children age12–23 months in an attempt to eradicate the virus nationwide There are alsorecommendations that the following populations be vaccinated:

Hepatitis A is the most common vaccine-preventable virus acquired duringtravel, so people travelling to places where the virus is common (Indian

The varicella vaccine is a live attenuated vaccine recommended for use in alladults who lack a history of childhood infection with varicella virus Being a liveattenuated vaccine, varicella vaccine should not be given to

immunocompromised patients, HIV-positive patients when symptomatic or <200CD4 cells, or pregnant women

Patients age ≥60 are recommended to receive the varicella zoster (shingles)vaccine, which has been shown to reduce the risk of zoster and its associatedpain (post-herpetic neuralgia) It is indicated regardless of whether there is ahistory of shingles, as it is possible to have a second herpes zoster infection

usually given in childhood Healthy adults born after 1956 should receive 1 dose

of the vaccine Pregnant women and immunocompromised patients should not

be vaccinated HIV-positive patients who are asymptomatic may receive thevaccine

The meningococcal vaccine is recommended for everyone at age 11 visit It isalso recommended for young adults living in dormitories or barracks, peopleexposed to outbreaks, those with asplenia or terminal complement deficiencies,those who travel to endemic regions (traveling to Mecca), and those exposed to

Neisseria meningitidis.

VACCINE

The human papillomavirus (HPV) vaccine is recommended for women age 9-26,regardless of sexual activity The regimen is in 3 doses: 0, 2, and 6 months Itshould not be administered in pregnancy

The zoster vaccine is a live vaccine that has been shown to reduce the incidence

of shingles by 50% It has also been shown to reduce the number of cases ofpost-herpetic neuralgia, as well as the severity and duration of pain/discomfortassociated with shingles The vaccine is, basically, a larger-than-normal dose ofthe chicken pox vaccine, as both shingles and chickenpox are caused by thesame virus, varicella zoster (VZV)

The shingles vaccine (Zostavax), a live vaccine given as a single injection, isrecommended for adults age ≥60, whether they have already had shingles or not.Some people report a chickenpox-like rash after receiving it The vaccine shouldnot be given to the following individuals:

Those with a weakened immune system due to HIV/AIDS or another diseasethat affects the immune system

Those who are receiving immune system-suppressing drugs or treatments,such as steroids, adalimumab (Humira), infliximab (Remicade), etanercept(Enbrel), radiation or chemotherapy

Those who have neoplasia, which affects the bone marrow or lymphatic

system, such as leukemia or lymphoma

Answer: D

In which of the following patients will the vaccination have the greatestbenefit?

Routine hepatitis A vaccination in a 2-month-old infant)

Influenza vaccine in a 16-year-old asymptomatic high schoolstudent

)

VZV vaccination given to an AIDS patient with CD4 count 100)

Pneumococcal vaccination given to a 48-year-old male COPDpatient

)

HBV vaccination given to a heart failure patient)

A 25-year-old man comes to the clinic for evaluation of a stuffy nose andfever Over the course of the interview the patient states that he smokes 3packs of cigarettes per day and has been doing so for the last 7 years

Smoking is responsible for 1 in every 5 deaths in the United States Smokingcessation is the most preventable cause of disease Physicians can take the

patches

ARRANGE follow-up If the quit attempt was successful, then provide

positive reinforcement If it was not successful, then determine why the

patient smoked and elicit a recommitment to smoking cessation Most patientsrequire several attempts before being successful

Do not use varenicline in patients with a history of psychiatric disease.

Monotherapy treatment for smoking cessation includes nicotine replacementtherapy (transdermal nicotine patches, gum, lozenges, inhalers), bupropion, andvarenicline

Place a follow-up call 1–2 weeks after quit date The use of pharmacotherapydoubles the effect of any tobacco cessation intervention

Bupropion lowers the seizure threshold so do not use in cases of alcoholabuse

Varenicline causes an increased rate of suicidal thoughts, so first screen fordepression

All women age >65 should be given DEXA bone density scan Screening shouldbegin at age 60 if there is low body weight or increased risk of fractures A bonedensity test uses x-rays to measure how many grams of calcium and other boneminerals are packed into a segment of bone The bones that are tested are

typically the spine, hip and forearm Bone density test results are reported in 2numbers: T-score and Z-score

T-score >2.5 SD indicates the likelihood of osteoporosis and increased risk offracture

The diagnosis of osteoporosis by DEXA scan also means that treatment

should be initiated with bisphosphonates, oral daily calcium supplementation,and vitamin D

Z-score ≤-2 may suggest that something other than aging is causing abnormalbone loss (consider drugs causing osteoporosis such as corticosteroids)

The goal in this case is to identify the underlying problem