Discover your future in Internal Medicine

The General Internist Career Path

Internal Medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.

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The Subspecialist Career Path

Subspecialists in internal medicine have chosen to receive additional, more in-depth training and board certification in the diagnosis and management of diseases of a specific type or diseases affecting a single organ system.

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The Hospitalist Career Path

Hospitalists are providers who dedicate most of their career to the care of hospitalized patients. They focus on clinical management, with an added eye to quality, safety, and utilization.

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My Kind of Medicine:
Real Stories of ACP Internists

Susan L. Turney, MD, MS, FACMPE, FACP

Dr. Susan L. Turney

CEO, Marshfield Clinic Health System

Farzanna S. Haffizulla, MD, FACP

Dr. Farzanna S. Haffizulla

Internist in Private Practice

Saad Z. Usmani

Dr. Saad Z. Usmani

Director of Clinical Research

Joshua M. Liao, MD

Dr. Joshua M. Liao

Internal Medicine Resident

Dr. Valerie J. Lang

Dr. Valerie J. Lang

Associate Professor of Medicine

Dr. David Fleming

Dr. David Fleming

ACP President with Dr. Robert Centor, ACP Chair, Board of Regents

Dr. Kent J. DeZee

Dr. Kent DeZee

Program Director, General Medicine Fellowship

Dr. Erik Wallace

Dr. Erik Wallace

Associate Dean

Dr. Suchitra Behl

Dr. Suchitra Behl

Consultant for FORTIS C-DOC

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MKSAP 5 - Question of the Week

A 28-year-old woman is evaluated following the diagnosis of HIV infection discovered during a routine screening examination.

On examination, the patient appears well. Temperature is 37.1C (98.8F), blood pressure is 105/70 mm Hg; pulse rate is 88/min, and respiration rate is 10/min. The remainder of her examination is normal.

Her CD4 cell count is 77/μL and her HIV-1 RNA level is 200,000/mL. Her toxoplasma antibody is positive, and her tuberculin skin test is negative. All of her immunizations are up to date.

The patient agrees to begin antiretroviral drug therapy.

This patient should receive trimethoprim-sulfamethoxazole. Several drugs have been shown to provide effective prophylaxis against opportunistic infections in patients with HIV infection and to prolong life in some patients. The CD4 cell count is an indicator of immune competence. Recommendations regarding when to initiate prophylaxis are based on CD4 cell count levels. The threshold for Pneumocystis and toxoplasmosis prophylaxis is 200/μL and 100/μL, respectively. The patient's CD4 cell count is 77/μL, and she should receive prophylaxis for Pneumocystis and for toxoplasmosis if her antibody titer is positive (demonstrating previous infection but not immunity). Trimethoprim-sulfamethoxazole is the first-line agent for both.

Azithromycin is used for prophylaxis against Mycobacterium avium complex in patients with a CD4 cell count less than 50/μL. This patient's CD4 cell count is not at this threshold and, therefore, prophylactic azithromycin therapy is not recommended. Fluconazole is not recommended for the primary prophylaxis of Candida infections despite its effectiveness in this role. The potential for drug resistance, numerous potential drug-drug interactions, the ease and effectiveness of treating infection when it does occur, and lack of survival benefit argue against prophylactic use. Isoniazid would be indicated if the patient were found to have a positive tuberculin skin test greater than 5 mm and a negative chest x-ray excluding active tuberculosis. There is no reason to provide prophylactic isoniazid therapy for patients who have not been exposed to Mycobacterium tuberculosis. Although valganciclovir is effective in preventing cytomegalovirus (CMV), infection, decisions regarding prophylaxis are complex. Valganciclovir is expensive, a theoretical concern about the development of drug resistance exists, it is toxic to the bone marrow, and treatment of early infection is very effective. Finally, no proven survival benefit is associated with CMV prophylaxis.

Key Point

  • In patients with HIV infection, prophylactic therapy for Pneumocystis, toxoplasmosis, and Mycobacterium avium complex are determined by the CD4 cell count.
Q. Which of the following treatments is also indicated at this time?
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