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Internal Medicine
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Internal Medicine
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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 (FSMB) and the
National Board of Medical Examiners (NBME), neither of which sponsors or endorses this product.
USMLE
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.
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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
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Please email us at medfeedback@kaplan.com.
Chapter 2: Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Chapter 3: Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Chapter 4: Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
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.
http://ebooksmedicine.net/usmle 1
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.
Tamoxifen prevents cancer by Mammography with or without clinical breast exam is recommended every 12 years from age
5074. 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 3065 who wish to lengthen the screening interval to every
current evidence is insufficient 5years 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
<75. It recommends against Lung Cancer
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 5580 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
2 http://ebooksmedicine.net/usmle
Clinical Recall
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 physicians recommendation immediately.
It is important to set up a pretravel counseling session 46 weeks before the patients departure.
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, s uicidal
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.
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