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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

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 33-year-old woman who has been trying to become pregnant for 8 years is evaluated after receiving positive pregnancy test results. Medical history is significant for three miscarriages occurring 6 years ago, 3 years ago, and 1 year ago, each of which occurred early in her pregnancy. She had an unprovoked venous thromboembolism 18 months ago. Her last menstrual period was approximately 5 weeks ago.

Results of physical examination, including vital signs and abdominal examination, are normal.

Results of laboratory studies show a prolonged activated partial thromboplastin time (aPTT). A mixing study does not correct the aPTT

The most appropriate next diagnostic step is testing for the lupus inhibitor and antiphospholipid antibody. The antiphospholipid antibody sometimes interferes with the coagulation cascade as measured by the activated partial thromboplastin time or prothrombin time and causes a prolongation that is not corrected with a corresponding mix that includes normal plasma. These antibodies, although they prolong in vitro coagulation tests, are associated with an increased risk of venous (approximately two thirds) and arterial thromboembolism. There also is a strong correlation between these antibodies and pregnancy loss, presumably due to placental insufficiency in affected patients secondary to thrombosis. The diagnosis of antiphospholipid antibody syndrome requires a history of a thrombotic event (including recurrent fetal loss) in association with a persistent lupus anticoagulant or persistently elevated levels of IgG anticardiolipin or β2-glycoprotein I antibodies. Lupus anticoagulants or elevated levels of antiphospholipid antibodies are frequently present in patients with systemic lupus erythematosus; they also occur in patients with cancer or infections (such as HIV) and in association with the use of certain drugs (for example, hydralazine, procainamide, or phenothiazines); the latter cases are often associated with IgM antibodies and do not result in a hypercoagulable state.

The factor V Leiden mutation results in resistance to activated protein C. In heterozygotes with the prothrombin G20210A mutation, prothrombin antigen and activity measurements are elevated by approximately 30% over those of normal persons. Among unselected white patients presenting with an initial symptomatic episode of deep venous thrombosis, 12% to 20% are heterozygous for the factor V Leiden mutation and 6% heterozygous for the prothrombin G20210A mutation, compared with 6% and 2%, respectively, in asymptomatic control populations. Neither the factor V Leiden mutation nor the prothrombin G20210A mutation is associated with increased fetal loss.

Hyperhomocysteinemia is associated with an increased risk of venous and arterial thrombosis. Plasma homocysteine levels are determined by genetic and environmental factors, the latter including primarily dietary intake of folic acid, vitamin B12, and vitamin B6. Administration of these B vitamins can lower plasma homocysteine levels, but this intervention has not yet been shown to reduce the risk of recurrent vascular events. Hyperhomocysteinemia is not associated with recurrent fetal loss.

Key Point

  • Antiphospholipid antibody syndrome consists of a history of a thrombotic event (including recurrent fetal loss) in association with a persistent lupus anticoagulant or persistently elevated levels of anticardiolipin or β2-glycoprotein I antibodies.
Q. Testing for which of the following is the most appropriate next step?
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