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ISBN: 978-1-5062-2818-1
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USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc.
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STEP 2 CK
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Lecture Notes
S
U Internal Medicine
USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc.
and the National Board of Medical Examiners.
USMLE S2 Internal Medicine.indb 1 6/13/17 10:00 PM
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
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the material contained in this book.
© 2017 by Kaplan, Inc.
Published by Kaplan Medical, a division of Kaplan, Inc.
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USMLE S2 Internal Medicine.indb 2 6/13/17 10:00 PM
Editors
Joseph J. Lieber, MD
Associate Director of Medicine
Elmhurst Hospital Center
Associate Professor of Medicine
Associate Program Director in Medicine for Elmhurst Site
Icahn School of Medicine at Mt. Sinai
New York, NY
Frank P. Noto, MD
Assistant Professor of Internal Medicine
Site Director, Internal Medicine Clerkship and Sub-Internship
Icahn School of Medicine at Mt. Sinai
New York, NY
Hospitalist
Elmhurst Hospital Center
New York, NY
The editors would like to acknowledge
Manuel A. Castro, MD, AAHIVS, Amirtharaj Dhanaraja, MD, and Aditya Patel, MD,
and Irfan Sheikh, MD for their contributions.
USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc.
and the National Board of Medical Examiners.
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We want to hear what you think. What do you like or not like about the Notes?
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00
Table of Contents
Chapter Title
Chapter 1: Preventive Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 2: Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Chapter 3: Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Chapter 4: Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
Chapter 5: Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Chapter 6: Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Chapter 7: Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Chapter 8: Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Chapter 9: Pulmonology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
Chapter 10: Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Chapter 11: Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Chapter 12: Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .433
Chapter 13: Radiology/Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Chapter 14: Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
Additional resources available at
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USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc.
and the National Board of Medical Examiners.
v
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USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc.
and the National Board of Medical Examiners.
USMLE S2 Internal Medicine.indb 6 6/13/17 10:00 PM
#1
PreventCivhea pMteedr iTciitnlee
Learning Objectives
❏ Describe appropriate screening methods as they apply to neoplasms of the colon,
breast, cervix, and lung
❏ Describe epidemiological data related to incidence and prevention of common
infectious disease, chronic illness, trauma, smoking, and travel risks
CANCER SCREENING
A 39-year-old woman comes to the clinic very concerned about her risk of developing
cancer. Her father was diagnosed with colon cancer at age 43, and her mother was
diagnosed with breast cancer at age 52. She is sexually active with multiple partners
and has not seen a physician since a car accident 15 years ago. She denies any
symptoms at this time, and her physical examination is normal. She asks what is
recommended for a woman her age.
Screening tests are done on seemingly healthy people to identify those at increased risk of dis-
ease. Even if a diagnostic test is available, however, that does not necessarily mean it should be
used to screen for a particular disease.
• Several harmful effects may potentially result from screening tests.
• Any adverse outcome that occurs (large bowel perforation secondary to a colonoscopy) is
iatrogenic.
• Screening may be expensive, unpleasant, and/or inconvenient.
• Screening may also lead to harmful treatment.
Finally, there may be a stigma associated with incorrectly labeling a patient as “sick.”
For all diseases for which screening is recommended, effective intervention must exist, and the
course of events after a positive test result must be acceptable to the patient. Most important, the
screening test must be valid, i.e., it must have been shown in trials to decrease overall mortality in
the screened population. For a screening test to be recommended for regular use, it has to be
extensively studied to ensure that all of the requirements are met.
USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc.
and the National Board of Medical Examiners.
1
USMLE S2 Internal Medicine.indb 1 6/13/17 10:00 PM
USMLE Step 2 l Internal Medicine
The 4 malignancies for which regular screening is recommended are cancers of the colon,
breast, cervix, and lung.
Colon Cancer
In the patient with no significant family history of colon cancer, screening should begin at age
50. The preferred screening modality for colon cancer is colonoscopy every 10 years. Other
choices include annual fecal occult blood testing and sigmoidoscopy with barium enema every
5 years.
In the patient with a single first-degree relative diagnosed with colorectal cancer before 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.
Breast Cancer
Note The tests used to screen for breast cancer are mammography and manual breast exam.
Mammography with or without clinical breast exam is recommended every 1–2 years from age
Tamoxifen prevents cancer by
50–74. The American Cancer Society no longer recommends monthly self-breast examination
50% in those with >1 family
alone as a screening tool. Patients with very strong family histories of breast cancer (defined as
member with breast cancer.
multiple first-degree relatives) should consider prophylactic tamoxifen, discussing risks and
benefits with a physician. Tamoxifen prevents breast cancer in high-risk individuals.
Cervical Cancer
The screening test of choice for the early detection of cervical cancer is the Papanicolaou smear
Note
(the “Pap” test). In average risk women, Pap smear screening should be started at age 21,
Prostate Screening
regardless of onset of sexual activity. It should be performed every 3 years until age 65.
USPSTF concludes that the
As an alternative, women age 30–65 who wish to lengthen the screening interval to every
current evidence is insufficient
5 years can do co-testing with Pap and HPV testing. In higher risk women, e.g., HIV, more
to assess the balance of
frequent screening or screening after age 65 may be required.
benefits/risks of prostate
cancer screening in men age
Lung Cancer
<75. It recommends against
screening in men age >75. Current recommendations for lung cancer screening are as follows:
For USMLE, do not screen for • Annual screening with low-dose CT in adults age 55–80 who have a 30-pack-year
prostate cancer. smoking history and currently smoke or have quit within past 15 years
• Once a person has not smoked for 15 years or develops a health problem substantially
limiting life expectancy or ability/willingness to have curative lung surgery, screening
should be discontinued
USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc.
and the National Board of Medical Examiners.
2
USMLE S2 Internal Medicine.indb 2 6/13/17 10:00 PM
Chapter 1 ● Preventive Medicine
Clinical Recall
Which of the following patients is undergoing an inappropriate method of
screening as recommended by the USPSTF?
A. A 50-year-old man gets his first screening for colon cancer via
colonoscopy
B. A 50-year-old woman gets her first screening for breast cancer via
mammography
C. A 17-year-old woman is screened for HPV via a Pap smear after her
first sexual encounter
D. A 65-year-old man with a 30-pack-year smoking history gets a low-
dose CT
E. A 21-year-old woman with a high risk of developing breast cancer is
given tamoxifen
Answer: C
TRAVEL MEDICINE
A 44-year-old executive comes to the clinic before traveling to Thailand for
business. 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 recommendation immediately.
It is important to set up a pretravel counseling session 4–6 weeks before the patient’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 nonindustrial countries. If a patient is leaving within 2
weeks of being seen, both the vaccine and immune serum globulin are recommended.
A booster shot given 6 months after 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 popula-
tions. Additionally, patients who plan to engage in sexual intercourse with the local populace, to
receive medical or dental care, or to remain abroad for >6 months should be vaccinated.
Malaria: Mefloquine is the agent of choice for malaria prophylaxis. It is given once per week; it
may cause adverse neuropsychiatric effects such as hallucinations, depression, suicidal
ideations, and unusual behavior. Doxycycline is an acceptable alternative to mefloquine,
although photosensitivity can be problematic. For pregnant patients requiring chemoprophy-
laxis for malaria, chloroquine is the preferred regimen.
USMLE® is a joint program of The Federation of State Medical Boards of the United States, Inc.
and the National Board of Medical Examiners.
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