August 2007 E-Newsletter

Win a 128 MB Flash Drive from ACP! IMpact Contest Question for August

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If you are among the first 30 respondents to answer the following question correctly you will receive a 128 MB flash drive from ACP. E-mail your answer to ImpactContest@acponline.org. The correct answer to August’s contest question will be included in the September issue of IMpact. You must be an ACP Medical Student Member to be eligible to win. Contest winners are not eligible to win again for 4 months.

A 22-year-old man with sickle cell disease has four to six painful crises per year that require parenteral hydration and narcotics. Two weeks ago the patient developed an acute chest syndrome characterized by fever, dyspnea, and the radiographic appearance of pulmonary infiltrates. The patient's condition rapidly responded to aggressive exchange transfusions and empiric broad-spectrum antibiotics; he has been asymptomatic for 1 week.

Laboratory Studies:
Hemoglobin 10.4 g/dL
Hematocrit 32%
Leukocyte count 12,000/μL
Platelet count 277,000/μL

Hemoglobin electrophoresis shows the following results.

Laboratory Studies:
Hemoglobin A (α2β2) 62% (normal > 97.5%)
Hemoglobin A2(α2δ2) 2% (normal < 2.5%)
Hemoglobin F (α2γ2) 1% (normal 0%)
Hemoglobin S (α2βS2) 35% (normal 0%)

What is the best next step in this patient's management?

( A ) Long-term transfusion therapy
( B ) Hydroxyurea therapy
( C ) Consultation for therapeutic gene therapy
( D ) Consultation for therapeutic bone marrow transplantation
( E ) Long-term oxygen therapy

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Answer for July Contest Question

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Click here to see July's question.

Answer to July Contest Question: (B) Colonoscopy

Colorectal cancer is of greatest concern in this postmenopausal black woman who has symptomatic iron deficiency anemia. Black race and iron deficiency anemia in a postmenopausal woman are both risks for colorectal cancer. Colonoscopy is the most appropriate test because it has the best diagnostic accuracy and allows for biopsy or removal of any lesions. A negative fecal occult blood test in a patient with iron deficiency anemia does not rule out the need for colonoscopy.

Upper endoscopy should be reserved for patients with upper gastrointestinal tract symptoms or negative findings on colonoscopy. Barium enema examination is less accurate than colonoscopy and cannot be used for therapy. However, it may be considered for the rare patient in whom colonoscopy is unsuccessful or who cannot tolerate the procedure. Flexible sigmoidoscopy is inappropriate because it does not evaluate the proximal colon. In addition, if a distal lesion is detected, colonoscopy would still be required to look for synchronous neoplasms. CT is not a sensitive test for detecting an early neoplasm or a mucosal process such as an arteriovenous malformation.

References
Pignone M, Rich M, Teutsch SM, Berg AO, Lohr KN. Screening for colorectal cancer in adults at average risk: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:132-41. Summary for patients in: Ann Intern Med. 2002;137:I38.
Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J, et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003;124:544-60.

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Medical Student Perspectives: Five Easy Steps to Writing a Personal Statement or Autobiographical Sketch

Writing a personal statement for residency applications has been an angst-ridden task for medical students everywhere for decades. To ease the anxiety, I recommend taking the following “baby steps” toward the final product.

Step 1. Motivate yourself to begin the process of writing by thinking about how good it will feel to be done. Think about how relieved you were after taking shelf exams during the first year. Then, think about how relieved you were after taking USMLE Step 1 after second year. Now, think about the moment that your head hit the pillow on all of the post-call days during third year when you knew that sleep was just a moment away. Those are great feelings, and you can experience similar feelings of relief and accomplishment once you have finished your personal statement.

Step 2. Begin brainstorming. Which specialty were you interested in when you first arrived at medical school? Which specialty are you interested in now? If they are different, what have you experienced that has molded your interests? If your interests have remained the same, what originally drew you to that specialty and what reinforced your desire to remain dedicated to that specialty? What are the strengths that others compliment you on most? You may mention strengths in your personal life if they are relevant to your career choice, but most important are those strengths which pertain to your professional life. You may want to request copies of your clerkship grading narratives from your registrar. Although these may be quoted in your Dean’s letter, they may serve as reminders of strengths that you have forgotten. Additionally, by reviewing these narratives, you may find there is a strength that you possess that is not emphasized in your Dean’s letter.

Step 3. Prioritize the goals of your personal statement. After reviewing your CV, transcript and narratives, letters of recommendation, and performing Step 2 above, decide what should be addressed in your personal statement.

Step 4. Begin writing the first draft. Remember, this statement is your chance to tell your story. What personal journey landed you on the doorstep of (fill in the blank) as a specialty? How did you make this choice? What is it about you, not already found elsewhere in your application, that makes you great for that particular specialty? Where did you find that your strengths were most useful? If there have been any circumstances that have caused an extension of traditional curriculum, be sure to address them and include how these circumstances eventually benefited you and/or your education.

Step 5. Proofread and revise. Make sure that you have given your brain a rest from working on your statement in-between drafts; this will prevent you from glazing over errors. Do not overload the reader with details, as your personal statement should be a brief introduction to who you are and why you would be excellent as a doctor in that specialty. Craft your statement so that it is easy and interesting to read. It should be a true story about yourself and the journey that led you to apply to a specific residency. Be sure to read your statement aloud to others to ensure that it flows well and makes sense to the audience. A large part of being a physician is the ability to communicate well so be sure that this statement demonstrates your ability.

There are online services to assist in preparing a personal statement; however, there are free services through your school, trusted advisors, peers, mentors and friends. Best of luck!

Anna Makela
Council of Student Members, Military Representative
Uniformed Services University of the Health Sciences, 2008
E-mail: s8makela@usuhs.mil

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My Kind of Medicine: Real Lives of Practicing Internists: Cristin Mount, MD

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In the Army, they have a saying: “Be all that you can be.” As a captain in the United States Armed Forces, Dr. Cristin Mount uses this statement to hold herself to a personal standard. The statement leaves room for error, but none for carelessness or disregard. As is true for all physicians, many of Dr. Mount’s patient cases have produced successful results, while others have not; it is a part of being a doctor. But while the end result may vary, a physician’s purpose never does.

Dr. Cristin Mount with her husband, Dr. George Mount, in Kauai, Hawaii

Dr. Cristin Mount with her husband, Dr. George Mount, in Kauai, Hawaii.


It was this purpose that guided Dr. Mount one evening during her resident ICU rotation, as she sat by the bedside of a patient through the night. The patient was suffering from septic shock and a severe case of pneumonia. Dr. Mount and her colleagues did everything by the book, but nothing seemed to turn the patient’s condition around. By the morning, the patient passed away. “She was the sickest person I have ever seen,” recalls the 30-year-old from Silver Spring, Maryland. “We did all the right things, but in the end the pneumonia was too overwhelming. It was a humbling moment for me because I realized that there will be times when even if I do my best, it might not be enough.” It was a hard lesson to swallow but she never lost sight of her job.

Early Leanings

As a young girl, Dr. Mount loved to listen to her father talk about his job. He was a doctor, an obstetrician. The more she watched her father, the more interest she developed in becoming a doctor. “I always knew what I wanted,” she says, “and for me, there was nothing else. I decided I would go into family medicine. I tend to be a stubborn person, so once I decided on family medicine, I was determined.” With soldier-like exactness, she set out after her goal, all the way through college, medical school, and finally residency. But then something happened she had not counted on: she fell in love with internal medicine. It was not an epiphany and it did not happen overnight. In fact, she was not really aware of it until a fellow student pointed it out. “We were making rounds on our ICU rotation and he asked me why I was taking notes,” she recalls, “and I told him, ‘because the ones here aren’t detailed enough!’ He said, ‘You can’t go into family medicine—you have the mind of an internist.’” Because she was stubborn, the comment bothered her for a while since she had already made up her mind. But finally, she gave in to her gut feeling. “Deep down I knew he was right, so I changed my fourth-year student rotation around and that was it.”

A few years later, Dr. Mount is once again on a mission. This time it is studying for an ICU fellowship in a two-year program offered by the Army. Once finished, she plans to split her time between working in the ICU, teaching, and working in the general wards. Working in the ICU, she says, exposes her to the best of the best. “I get to work with some of the best staff in the hospital and interact a lot with my surgical colleagues,” she explains. “I’ve always been drawn to the ICU because it has the sickest of the sick and so it’s a challenge. As an internist, I’m expected to know a lot—I like that. And working at a teaching institution, I really have to think on my feet and be able to apply knowledge in rapid fire succession, so to speak.”

The Kinship

Because Dr. Mount’s father was also a military physician, she grew up in and around the Army healthcare system. She thinks highly of it. “It’s a robust system; it works well,” she says, adding further that as the Iraq War churns out patients with new types of war injuries, the brunt falls on the military medical system. “Soldiers come back here with mind-boggling injuries,” she explains. “Most are blast injuries, and many times you’ll have to treat multiple injuries in the same person. The Army has improved the body armor since Vietnam, so we do a great job protecting the head and chest. Now they are all extremity injuries, and we’ve had to develop a multi-disciplinary approach because they are multi-trauma injuries—stuff you don’t normally see in the civilian world.”

Although she has been on active duty for eight years, Dr. Mount has not been deployed to a war zone; her status as a student, resident, and now as a fellow, precludes her from eligibility. The Army does this to minimize the disruption of training, which, in Dr. Mount’s case, you find yourself somewhat relieved to hear. She is cheerful, open, and easy going; her voice is sweet and full of happiness. She epitomizes “the girl next door.” But in reality these qualities make her congruous with the culture, because as those in uniform know, the military is more community than machine.

“When I was in my residency at the Madigan Army Medical Center Program in Tacoma, Washington, I ran into a doctor whom my dad had trained, who knew me when I was a little girl,” she says. “It’s a small world and you really get to know people.” At the Walter Reed Army Medical Center in Washington, D.C., she treats more of her extended family—every generation of it, from World War II veterans to soldiers returning from Iraq. She finds joy in all of it. “It is extremely rewarding to work here,” she says. “The veterans have done some amazing things and I love talking to them and treating them. Treating the soldiers coming back from Iraq can sometimes be hard to handle because they are so young, but it is extremely rewarding to take care of these men and women. My father told me to always do the best I could do, and so that is what I strive for.”

Broad Shoulders

At age 30 with just over one year of experience as a practicing physician, Dr. Mount is in the toddler years of her professional life. She is a bit of a “newbie”—she has not yet had the big peaks and valleys that pepper one’s career. She says the most rewarding experience for her so far in her career has been simply the opportunity to practice medicine in the military medical system. It is an honest and sincere statement that shows her devotion to the system and the institution she works for, but it also reveals her relative inexperience. She has not suffered a big hit either—the closest was during her residency when she cared for the patient with pneumonia—which while significant, was something she technically was not directly responsibly for. But what is telling about the episode is the way she handled it. By staying at the patient’s bedside through the entire night, she claimed responsibility. She saw it through to the end, because in her mind, she was ultimately responsible for the patient. Some might call that “touching” or “dedicated.” In the military, they call it doing your job. And so while Dr. Mount might still be a little green, when those peaks and valleys do come, she will be ready for them.

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Internal Medicine Interest Group of the Month: Harvard Medical School

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Finding a Mentor
Whether you are looking for a mentor to serve as the faculty advisor for your internal medicine interest group (IMIG), or for a personal mentor to advise you about your research, or someone to shadow in the clinic, there are certain questions to keep in mind to make the process rewarding and meaningful: How do I find the right mentor? When should I go about finding a mentor? How many mentors should I have? The following suggestions will guide you as you ask these questions and make these decisions.

Do Your Homework
Before approaching a professor or clinician to serve as your mentor, make sure you read up on what this person does and what his or her interests are. Many students make the mistake of seeking out a mentor based upon seniority or title, but some of the most enthusiastic mentors can be junior faculty or new clinicians eager to interact with and teach students. It is more important to find a mentor whose research or public health interests match yours, rather than seeking out a mentor based upon his or her rank or prestige. In addition to scouring academic Web sites for biographical information, consider approaching advisors or other faculty members and inquiring whether they know of anyone who matches your interests. It may also be important to ask other professors and clinicians whether the mentor you have identified might be a good fit; faculty often have a strong sense as to who is eager to take on students or who may be too busy to assume a mentorship role.

Approach Your Mentor Early in the Year
Even though the beginning of the year can be a stressful, hectic time, reach out and connect to your mentor! Postponing the process until late in the fall will be difficult for you both; as the academic year progresses more and more responsibilities accumulate, making it difficult for you and your mentor to meet. A short meeting the week school begins can be a great launching point. Your mentor can be a source of support as you continue through the year, and it is nice to have someone with whom you can discuss your course work and stresses over the course of the year.

Consider the Type of Person You Approach
If you are looking for a clinician to shadow, the type of person you choose could really make or break your experience. I have several classmates who had been paired with young clinicians, and had been initially wary about the youthfulness of their mentors. However, these classmates have ultimately grown to love the experience of being mentored by a younger clinician. Finding someone who may be only a few years senior to you in training can be a terrific way to answer the important questions you have been wondering about: How can I balance work and family? Can I define my hours? How can I pay off my student loans? As much as younger clinicians might help you think about the transition from student to clinician, older mentors can be a reservoir of wisdom and inspiration. One of my friends draws great motivation from shadowing a 78-year-old nephrologist who, as my friend puts it, “knows absolutely everything.” From anatomy of the neck to the physiology of nerves, this clinician scholar inspires students with his depth of knowledge and his ability to use that knowledge to help his patients. When choosing a mentor, think about what types of questions you have and what interests you, and move forward from there.

Consider Connecting to a Variety of Mentors
One of the biggest mistakes a medical student can make is to only have one mentor. Once you find a good mentor with whom who have a strong working relationship, take the time to get to know at least one other mentor. This can seem challenging, especially when schedules become hectic, but it is important to have several mentors from whom you can seek advice and get an opinion. Approach a variety of potential mentors with diverse backgrounds and experiences so that when you have a challenging question (such as, “What should I do with the rest of my life?”), you hear lots of perspectives and can make the most informed decision.

Look for Diversity in Practice Style and Setting
Community-based clinics look a lot different than academic practices, which look a lot different than private practices. Think about expanding your horizons and getting a perspective on life in a community-based practice or in an underserved setting by finding a mentor who works in such a practice. One of the complaints I hear most often from fourth-year students is the lack of exposure they have had to practice styles outside of academia. Consider shadowing a few individuals in diverse practices, and if a particular practice environment seems interesting, then work on finding a mentor in that setting.

Define a Role for Your Mentor Early On
When your mentor is also your research advisor, it is important to frequently check in with him or her, even between projects. If you learn of other clinical or public health interests your mentor has, inquire as to whether you can help. If this person is more of an academic advisor, check in with this person periodically, and consider meeting with him or her every three to six months. You do not need to formally call your mentor your “mentor” but you can and should be clear about the fact that you want to get his or her feedback often. It can be difficult to find reasons to meet with your mentor to check in, so be up front that you want to frequently meet with him or her and receive feedback so that you have established a clear purpose for your visits.

Ultimately, finding a good mentor can be challenging and can take a while, but having a strong relationship with a supportive mentor can bring tremendous rewards. Do not get discouraged—it can take a few tries for you and your mentor to click—but, hopefully, you will emerge from the process energized and renewed!

Maya Babu
Council of Student Members Representative, New England Region
Harvard Medical School, 2010
E-mail: mbabu@hms.harvard.edu

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Winning Abstracts from the 2007 Medical Student Abstract Competition: Curing Diabetes and Solving the Stem Cell Dilemma: In Vitro Differentiation of Mouse Amniotic Fluid Cells into Pancreatic Islet-like Cells

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Author:
James Knutson, Wake Forest University Bowman Gray School of Medicine, 2008

Introduction:
Blindness, end-stage renal disease, amputation, and cardiovascular disease are just a few of the well-documented effects of diabetes, a disease that affects about 20 million Americans. Embryonic stem cells may hold a cure, but research is limited by ethical concerns. A line of amniotic fluid cells expressing the stem cell marker CD117 might be a pluripotent alternative to embryonic stem cells.

Using stem cell differentiation protocols and pancreatic embryology, we hypothesize that amniotic fluid cells can differentiate into pancreatic islet-like cells. We also hypothesize that these cells can restore glycemic control in a diabetic mouse model.

Methods:
Mouse amniotic fluid cells expressing CD117 were isolated and transduced with pdx-1, an important gene in pancreatic islet cell development. Western blot and RT-PCR of Pax6 (a gene controlled by PDX-1) were performed to examine PDX-1 protein expression and functionality. Control cells were cultured in Chang media; differentiated cells received serum-free culture media with basic fibroblast growth factor (bFGF). Cell morphology and insulin/glucagon production were examined. Finally, an in vivo study was performed by injecting diabetic mice with pdx-1-transduced cells and measuring blood glucose levels.

Results:
Western blot demonstrated expression of PDX-1, and RT-PCR of Pax6 showed an increase in Pax6 levels.

Control cells showed no changes in morphology and did not stain for insulin or glucagon. Differentiated cell morphology resembled pancreatic islet cells; differentiated cell aggregates stained centrally for insulin and peripherally for glucagon.

Diabetic mice receiving pdx-1-transfected cells exhibited glycemic control similar to non-diabetic mice, while diabetic mice receiving non-transduced cells lacked glycemic control.

Conclusion:
Amniotic fluid cell differentiation into pancreatic islet-like cells was demonstrated genetically, morphologically, and functionally. In vivo studies with these cells demonstrated correction of diabetes in mice. These results suggest a possible cure for diabetes and support the possibility of using amniotic fluid cells as an embryonic stem cell alternative.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Rheumatology

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The Discipline

From the Greek word rheuma, "that which flows as a river or stream." In ancient medical writings, "rheuma" was used to describe any thin discharge from a body surface or orifice. This term was eventually applied to an infection of the joints, presumably because an effusion of the joint space marks the various forms of arthritis.

Rheumatology deals with the prevention, diagnosis, and management of crystalline diseases, systemic rheumatic diseases, spondyloarthropathies, vasculitis, inflammatory muscle disease, osteoporosis, osteoarthritis, recreational sports injury, soft-tissue diseases and trauma. The goal of the rheumatologist is the early diagnosis and treatment of these conditions to prevent disability and death.

Procedures

Important procedural skills include diagnostic and therapeutic joint aspiration, and joint and soft tissue injection of corticosteroids. Rheumatologists are expert in the interpretation of joint fluid analysis, including crystal identification, and the interpretation of serology associated with rheumatological disorders.

Training

Rheumatology fellowship training requires two years of accredited training beyond general internal medicine residency. Of the two years, a minimum of 12 months must include clinical training in the diagnosis and management of a broad spectrum of medical diseases. Dual certification in Rheumatology and Allergy and Immunology requires a minimum of three years of training which must include (a) at least 12 months full-time clinical rheumatology, (b) weekly attendance for 18 consecutive months in a rheumatology ambulatory care program which must include continuity of patient care, and (c) at least 18 months of full-time allergy and immunology.

Certification

The American Board of Internal Medicine offers certification in Rheumatology. Dual certification in Rheumatology and Allergy and Immunology requires completion of the entire three-year program.

Training Positions

As of August 2005, there were 108 ACGME-accredited training programs in Rheumatology. 61% of the trainees were female, and 62% were US medical graduates.

Practice

Approximately 65% of the graduates enter clinical practice in Rheumatology in the United States, and 26% enter academic medicine.

Major Professional Societies

American College of Rheumatology
1800 Century Place, Suite 250
Atlanta GA 30345
(404) 633-3777

American College of Allergy, Asthma, & Immunology
85 West Algonquin Road, Suite 550
Arlington Heights IL 60005

Major Publications

Arthritis and Rheumatism
Arthritis Care and Research
Annals of Allergy, Asthma & Immunology
Journal of Allergy and Clinical Immunology
Clinical and Vaccine Immunology
Clinical Immunology

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Advocacy Briefs: Enroll in ACP’s Key Contact Program

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ACP’s continued success on Capitol Hill greatly depends on year-round grassroots efforts from the College’s nearly 4,500 Key Contacts. Key Contacts communicate with their local members of Congress on issues of importance to internists and their patients and report the results back to ACP. To enroll as a Key Contact, ACP members are not required to have existing relationships with members of Congress. ACP provides members with the tools necessary to develop and maintain these relationships. The program is open to all membership categories. Enroll now in the Key Contact Program.

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Did You Know You Can Attend ACP Chapter Scientific Meetings Free of Charge?

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ACP Medical Student Members can attend their local ACP chapter scientific meeting with no fee. Many chapters hold events especially for medical students at their annual scientific meetings. To find out when your chapter is holding its scientific meeting, visit your ACP Chapter Web site.

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MKSAP for Students 3 Question 1

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A 54-year-old man is discharged from the hospital 3 days after undergoing stenting of the left anterior descending coronary artery for acute coronary syndrome. He is asymptomatic, and left ventricular function, blood pressure, and plasma glucose level are normal. The serum cholesterol level was high on admission. Telemetry showed frequent premature ventricular contractions, with occasional couplets. At discharge, the patient was prescribed clopidogrel, 75 mg/d; aspirin, 325 mg/d; metoprolol, 50 mg twice a day; and simvastatin, 20 mg/d.

Addition of which of the following medications would likely prevent future cardiac events?

( A ) Angiotensin-converting enzyme inhibitor
( B ) Class Ia antiarrhythmic agent
( C ) Folic acid
( D ) Long-acting nitrates
( E ) Vitamin E

MKSAP for Students 3 Question 2

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A 70-year-old man with type 2 diabetes mellitus, hypertension, and hypercholesterolemia is evaluated in the emergency department because of acute pulmonary edema and chest pressure. Blood pressure is 180/100 mm Hg. The electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy with strain. An echocardiogram shows a moderately reduced ejection fraction and mild mitral regurgitation. Myocardial infarction is excluded by serial electrocardiograms and measurement of cardiac enzyme levels. His pulmonary edema responds rapidly to intravenous administration of diuretics and nitroglycerin.

During the hospital stay, which of the following diagnostic tests should be performed?

( A ) Coronary angiography
( B ) 24-Hour Holter monitoring
( C ) Exercise electrocardiographic stress test
( D ) Measurement of the B-type natriuretic peptide level
( E ) Right ventricular endomyocardial biopsy

MKSAP for Students 3 Answer 1

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Answer: A

Educational Objective: Understand appropriate secondary prevention for patients who have coronary artery disease.

In randomized clinical trials, the angiotensin-converting enzyme inhibitor ramipril reduced the incidence of cardiac events in patients with coronary artery disease. The mechanism of this effect is unclear and seems unrelated to either left ventricular function or blood pressure control.

Folic acid therapy reduces high serum homocysteine levels, which are correlated with outcomes in patients who have coronary artery disease. Small trials have shown a reduction in the incidence of clinically apparent restenosis after stenting, but no reduction in the incidence of myocardial infarction or death. Several well-done clinical trials have shown no benefit of high-dose vitamin E. Although nitrates are sometimes given after angioplasty to prevent coronary vasospasm, with the advent of stents, this use has declined and there is no evidence that it has any long-term prophylactic value. Although frequent premature ventricular contractions are cause for concern in an asymptomatic patient who has normal left ventricular function, studies show an increase in the mortality rate as a result of the proarrhythmia effects of type Ia agents.

References
Dagenais GR, Yusuf S, Bourassa MG, Yi Q, Bosch J, Lonn EM, et al. Effects of ramipril on coronary events in high-risk persons: results of the Heart Outcomes Prevention Evaluation Study. Circulation. 2001;104:522-6.
Schnyder G, Roffi M, Flammer Y, Pin R, Hess OM. Effect of homocysteine-lowering therapy with folic acid, vitamin B(12), and vitamin B(6) on clinical outcome after percutaneous coronary intervention: the Swiss Heart study: a randomized controlled trial. JAMA. 2002;288:973-9.

MKSAP for Students 3 Answer 2

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Answer: A

Educational Objective: Understand the appropriate diagnostic tests in patients who have pulmonary edema as a result of systolic left ventricular dysfunction.

Identifying the cause of heart failure is critical because some disorders can be reversed or treated easily. An important example is heart failure caused by coronary artery disease. This condition can be treated with percutaneous or surgical revascularization. Although this patient did not have an obvious myocardial infarction, he had flash pulmonary edema with chest pressure, which is often a manifestation of severe left ventricular ischemia. A patient who has diabetes may not have typical angina. Although this patient had no previous diagnosis of coronary artery disease, this problem is common. In contrast, diseases that are diagnosed by endomyocardial biopsy are not common, and an endomyocardial biopsy is not indicted. Routine ambulatory Holter monitoring is not recommended because it most likely will not identify the cause of the patient's left ventricular dysfunction. Even if rhythm disturbances are identified on ambulatory monitoring, treatment should be directed toward improving left ventricular dysfunction. Measurement of the natriuretic peptide level may be helpful when dyspnea is not clearly due to congestive heart failure, but in this patient, there was clear evidence of heart failure. Because of his preexisting electrocardiographic abnormalities, the results of exercise electrocardiography will likely be abnormal, but the findings will be nonspecific and difficult to interpret.

References
Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldmanmd AM, Francis GS, et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): Developed in Collaboration With the International Society for Heart and Lung Transplantation; Endorsed by the Heart Failure Society of America. Circulation. 2001;104:2996-3007.

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Internal Medicine Residency Program Fast Facts

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Program Name: Carolinas Medical Center Program
Location: Charlotte, North Carolina
Hospital Type: Community-based Hospital
Program Size: 16 First Year Positions, 36 Positions Total
First Year Salary: $44,000
Web Site Address: http://www.carolinashealthcare.org/education/meded/internal/

Program Name: University of Minnesota Program
Location: Minneapolis, Minnesota
Hospital Type: University-based Hospital
Program Size: 27 First Year Positions, 81 Positions Total
First Year Salary: $43,000
Web Site Address: http://www.medres.umn.edu/

Program Name: University of Washington Program
Location: Seattle, Washington
Hospital Type: University-based Hospital
Program Size: 74 First Year Positions, 174 Positions Total
First Year Salary: $42,000
Web Site Address: http://depts.washington.edu/medweb/education/residency/index.html

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Student Members Receive a 30% Discount When Ordering MKSAP for Students 3

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MKSAP for Students 3 includes over 400 patient-centered self-assessment questions and their answers in print and on CD-ROM. Designed for medical students participating in their clerkship rotation, the questions help define and assess a student’s mastery of the core knowledge base requisite to internal medicine education in medical school. The questions reflect the daily management dilemmas faced by internal medicine physicians and when coupled with the answer critiques, provide a focused, concise review of important content.

New in MKSAP for Students 3:

  • All new questions and critiques
  • More topics and chapters
  • 12 electrocardiogram questions
  • 24 color figure dermatology questions

List Price: $44.50; Student Member Price: $30.00

To order MKSAP for Students 3 please visit here.

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Join Now: Sign-up today and begin enjoying the benefits of ACP Medical Student Membership.

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