August 2009 E-Newsletter
- Medical Student Perspectives: Is There Such a Thing as Balance During Medical School?
- My Kind of Medicine: Real Lives of Practicing Internists: Sameer Badlani, MD
- Internal Medicine Interest Group of the Month: Louisiana State University, New Orleans
- Winning Abstracts from the 2009 Medical Student Abstract Competition: Unmasking Subclavian Steal Syndrome
- Subspecialty Careers: Highlights about Careers in Internal Medicine: Adolescent Medicine
- Advocacy Brief: Make Your Voice Heard on Capitol Hill
- Did You Know that there is little, to no cost for Medical Students to attend the majority of ACP Chapter Meetings?
- MKSAP for Students 4 Questions (1,2)
- MKSAP for Students 4 Answers (1,2)
- Articles for Medical Students from ACP Internist and ACP Hospitalist
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Medical Student Perspectives: Is There Such a Thing as Balance During Medical School?
When I started to write this column, I found myself wondering if I would be able to, because I was on a short deadline, had a long week of commutes to work, and was entering the final stages of training for a half-marathon. Is it impossible to balance? Was I trying to do too much? And if I was, what was going to give?
It is tempting to say that we should just write off having any sort of personal life or goals outside of medical school – after all, we are putting untold hours of effort and thousands of dollars towards a lifelong dream, so we might as well give it our all, right? It sounds reasonable, until you try to do it. Then, all too quickly, you end up a burned-out medical student who does not recognize that cadaver stories are really only amusing to other doctors-in-training.
It is possible to be an excellent medical student and still find time for your friends, family, and outside interests. It just requires the effort and the willpower to make it happen.
Goals
Sure, we all want to be great doctors who are adored by our patients and fellow physicians alike, but what else do you want from your life, now and in the future? Other than “done with residency,” where do you see yourself in 10 years? What should you be doing now to get there?
Priorities
What will you go insane without? If you need to exercise regularly to feel like a human being, then make sure it happens. Buy wrist reflectors so you can run at dusk after you have left the library, if need be. On the flip side, which of your activities are not helping you reach your goal? Personally, I probably do not need a detailed knowledge of the NCIS storylines to care for my patients or stay close to my family, so when push comes to shove, I have to say goodbye USA Network mini-marathons.
Capitalize
Not all rotations are created equal. Some will push you to the 80-hour limit and then ask you to do reading and shelf-prep at home. Others will have you wondering if you are crazy and wishing you were working more, because you feel so lame just hanging out. When you find yourself with free time, be sure to take advantage of it.
Network
Spending time with your friends, both in medical school and not, and your family, is essential to keeping yourself balanced. It can help to be reminded that even though you have a biochemistry final on Friday, your mom’s new dog just learned to “stay” on command. And while it can be tempting to think that no one can possibly understand what you are going through, your family and friends want to help. If you cannot get away to see them, remember that they are only a phone call away, even if you have to call them during their dinner so you can get to bed early enough to make it to the hospital by 4:30 a.m.
Just Ask – Attendings are People, Too
Now this is one to be used sparingly, but if an important event is coming up and you are scheduled to work, do not be afraid to ask if you can rearrange things. Most attendings I have encountered are surprisingly flexible when it comes to “Big Life Events,” as long as you do not suggest that you think rearranging the schedule or making up the time is something to be taken lightly. I have found that an offer to make up the clinical hours on my own free time, or to trade shifts with other students, is usually acceptable.
Doctor, Heal Thyself
If you ever doubt whether calling a friend to catch up is the best use of your time, remember that staying involved in things outside of medical school will only make you a better doctor. Not only will you be better able to focus on your studies once you know your friend’s outlook on your football team’s upcoming season, but you will be better able to relate to your patients if you resemble a human being and not a textbook.
Long story short: remember that being a medical student does not have to equal being miserable or one-dimensional. With a little effort, you can have it all, just not all the time. There will be times during medical school when you cannot go home, or to a friend’s party, or even for a run, and those times will be hard. But by making sure that you make the most of the time you have, and spending that time wisely, you will be able to fit in most of what you want to do. See? I even finished this column. Good luck!
Dana Mueller
Council of Student Members Representative, Central Atlantic Region
University of Virginia School of Medicine, 2011
E-mail: dcm4z@virginia.edu
Check out more volunteer opportunities.
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My Kind of Medicine: Real Lives of Practicing Internists: Sameer Badlani, MD
On study nights in the Badlani house in Delhi, India, the TV sat silent—a strict rule enforced by Mrs. & Mr. Badlani while sons Sameer and younger brother Puneet studied for their college entrance exams. Sameer studied for it in the mornings as well, beginning at 5 AM, when Mr. Badlani dropped him off early at school. Equivalent to the MCAT in the U.S., the medical school entrance exam is fiercely competitive, with an acceptance rate of around 2%. And the pressure comes on early in the Indian school system, where students can begin preparing for the exam immediately following completion of higher secondary school, at age 15-16. Compared to the average teenage high school existence, it may have been a bit intense, but Dr. Badlani has built a life and a career from it that he cherishes today.
The Chief
Salt Lake City, Utah is as different from Delhi, India as you can get, but it’s exactly the kind of place Dr. Badlani had in mind for completing a fellowship in bio-medical informatics. “I chose the University of Utah because I felt it was time for me to expand my horizons,” he says. He soon found several things that would take getting used to in the U.S. Coming from a city of 15 million he felt odd in the sprawling state, and even basic things such as eating dinner at 9 PM had to change. And then of course, there was the weather. He jokes about going with fellow out-of-towners in search of coats when the first snowfall hit. “We went out and bought the biggest, thickest down coats you’ve ever seen,” he says, “and then we never wore them again!”
His quick acclimation was a sign of things to come. Today, the personable and funny 35-year-old is fully entrenched in the medical community in Chicago, working as a hospitalist, an assistant professor at the University of Chicago, and clinical informaticist. He finds satisfaction in each for different reasons. His work as a hospitalist stimulates him. “I enjoy the intensity of the job,” he says, “I like making immediate decisions that impact patients’ lives. It’s what I do well.” The high acuity of the inpatient service is what Dr. Badlani finds challenging and keeps him interested.
Another stimulating career role is his work as a Computerized Physician Order Entry Champion at the University of Chicago. “It is exciting work,” he says. “Analyzing drug alerts, determining whether or not useful clinical information is getting utilized at point of care, reducing health care costs… I really enjoy the workflow analysis process. Redesigning, increasing efficiency—it is an intellectual play time.”
His work as Assistant Professor at the Pritzker School of Medicine is probably his favorite. He calls the job “a lot of fun” and says he takes comfort in the fact that he will always be doing what he loves. The joy he discovered in teaching came as a surprise. “I discovered when I was a chief resident at the University of Oklahoma that I really liked teaching, which I didn’t know about myself,” he explains. “I never grew up wanting to be a teacher, teaching found me.” He was even more surprised when his students at the University of Oklahoma, Tulsa awarded him the Crimson Apple Award for Best Teaching Resident. Being a chief resident was a responsibility he took seriously. He always has and continues to hold his mentors close-at-hand for guidance, advice, or even the occasional ego check. “Mentorship doesn’t stop with training,” he says. “No matter what stage of your career you’re in, you need that input from someone you respect, and you have to be willing to accept what they tell you, even if it’s hard to take.”
In high school, that person was his biology teacher, Mrs. Geeta Saini, who grounded him at a time when he admits he was cocky. “I was going around advertising how I was going to become a doctor,” Dr. Badlani recalls. “My teacher took me aside and said ‘If you really want to become a doctor, you have to actually study. Really, really hard.’” Another was his program director at the University of Oklahoma, Dr. Michael Weisz, where Dr. Badlani was having growing pains in his role as chief resident. The program director sat him down and gave him some very sobering feedback—that there were things he could be doing better. Dr Badlani was disappointed but not discouraged. “He gave me difficult and negative feedback that was hard to swallow, but I took what he said seriously and tried to change it over the next year or so,” he says. “And what he said meant a lot because if you don’t have people like that, you’re not going to make it. If you only have people around you who tell you how good you are all the time, you’re going to fall down hard.”
The mentor who made the biggest impression was his ex-boss at the University of Chicago, Dr. Chad Whelan, who gave him encouragement through one of the best compliments he’d ever received. “He told me I had tremendous potential and ability, and I knew he wasn’t just being nice,” says Dr. Badlani. “To have someone you respect enormously put that kind of faith in my future meant the world to me. Chad is the kind of person who doesn’t demand respect, but naturally gets it. My colleagues and I used to joke that we were going to create a web site called WhatWouldChadDo.com , since we were always turning to him for advice.’”
Just the Beginning
Dr. Badlani regards his career with palpable optimism. “I’ve been in the U.S. for ten years now and as an academic hospitalist, I truly feel like I’m at the beginning of a satisfying career,” he says. Recently while preparing for a lecture for medical students on how to not let debt affect career choices, he came across a study that he found to be indicative of his own feelings. “The study said that in most professional careers like law and medicine there is high likelihood of having a midlife dissatisfaction with your career and the best way to minimize this risk is to make a career choice based on interest and not money as the sole decision maker. It’s easy to follow temptation, but you have to choose what makes you happy. It’s important to not dread the Mondays in your life. Going into internal medicine allowed me to mold my career in ways that I could not have imagined.”
He believes that primary care is a field poised for growth. “I think all primary care physicians and internists will be in high demand because there are so few of us currently,” he says, “and even if you don’t want to be a general internist, with internal medicine you can transform into 10 different careers if you want to.”
Dr. Badlani credits his success in large part to his family and his wife, Kamlika. He says his wife keeps him happy and focused in his career. “She also helps me not to take myself so seriously,” he jokes. Their families knew each other in India, and while Dr. Badlani had always liked her for many reasons, he really took the fall when the two reunited two years ago in Chicago. “She’s always been beautiful of course, but her intelligence, passion for her work, and success just really impress me. I’ve found someone who understands me and what I do.”
When Dr. Badlani moved to Chicago about three years ago, he was busy and did not venture out much. He is finally exploring the windy city with his wife and enjoying the cosmopolitan experience Chicago has to offer. He says it’s important to take advantage of those times when they come. “Students should not work so hard that they forget about living life,” he says. “Stop thinking ‘Oh I don’t have a life now, but I’ll have it later when I am finished with training’ because that time will never come, the time is now.”
Check out previous articles as physicians share what motivated them to become physicians as well as why they chose their particular type of practice.
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Internal Medicine Interest Group of the Month: Louisiana State University, New Orleans
The Internal Medicine Interest Group at LSU School of Medicine in New Orleans was founded in 1999. The group was named the Edgar Hull Society in 2000 to honor the late Dr. Edgar Hull, past chairman of LSU’s Department of Medicine and renowned physician, professor of medicine, and cardiologist.
The mission of the Edgar Hull Society is to provide medical students with information about internal medicine and its subspecialties, to expose students to physicians in the field of internal medicine, and to provide an opportunity for students to learn, network, and relax together.
Under the guidance of Fred Lopez, MD, FACP and Charles Sanders, MD, MACP, the Edgar Hull Society has grown tremendously in recent years and now occupies a place among the largest campus organizations. Meetings are held monthly featuring speakers who discuss their experiences in the field of internal medicine. Past meetings have covered topics from general internal medicine, cardiology, hospitalist medicine, gastroenterology, student research opportunities, and case presentations that bring the Morning Report experience to first and second year students. These meetings give students opportunities to meet local physicians and ask candid questions about their training and careers. Students have also been invited to observe procedures in both cardiology and gastroenterology. In addition, Dr. Sanders and his wife host an annual party, "A Taste of New Orleans," for senior medical students who intend to pursue internal medicine residencies.
The Edgar Hull Society has actively participated in organized internal medicine on a national level by promoting membership in the American College of Physicians. In January 2009, 60% of LSU New Orleans’ student body was registered as Medical Student Members of ACP. This past year, Edgar Hull members were invited to participate in the Louisiana – Mississippi ACP regional meeting held in New Orleans, a meeting which attracted more than 150 ACP Fellows, Members, and Associates.
During the 2008-2009 school year, members of Edgar Hull elected two seniors as co-presidents: me and Nathan Ranney. Nathan and I took turns planning meetings and organizing events. We wanted to get students interested in internal medicine as early as first year and organized meetings around the first and second year test schedules. Having two seniors serve as co-presidents worked very well and this concept has continued with the election of Ana Paunovic and Matt Finn as the 2009-2010 co-presidents.
As the Edgar Hull society continues to grow, we hope to attract many more students to a career in internal medicine and its subspecialties.
Elizabeth Bollinger, MD
PGY-1, Louisiana State University Health Sciences Center
Past Co-president, Edgar Hull Society
Louisiana State University School of Medicine
Email: ebolli@lsuhsc.edu
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Winning Abstracts from the 2009 Medical Student Abstract Competition: Unmasking Subclavian Steal Syndrome
Authors: First Author: Roy Lin, Ross University School of Medicine 2010, Second Author: Rakesh Gupta, MD, FACP, Interventional Cardiologist at North Shore LIJ, New York Hospital Queens and Saint Vincent Catholic Medical Center
Introduction
Subclavian steal syndrome describes a condition where retrograde vertebral artery flow results in cerebral ischemia that is associated with transient neurological symptoms. Retrograde vertebral flow is a result of the lower pressure in the distal subclavian artery receiving flow from the contralateral vertebral artery via the basilar artery.
Case Presentation
A 66-year-old man presented to the emergency room with a syncopal episode. The patient described non-radiating chest pain that was 8/10 in intensity, which prompted self-administration of sublingual nitroglycerin. Subsequently, the patient began to feel light-headed and passed out. On admission, the patient’s blood pressure was 104/62 mmHg. He was afebrile with normal oxygen saturation and heart rate. ECG monitoring showed normal sinus rhythm of 71 beats per minute with no ST changes. There was no elevation of troponin or CK-MB on serial testing. Head CT was normal. Echocardiogram showed normal LV function with no vegetation or mass. When a more detailed physical examination was performed, the patient was noted to have unequal upper extremity blood pressures with 123/77 on the right arm and 101/72 on the left arm Additional history revealed complaints of left arm pain when lifting heavy objects. Carotid doppler was later performed indicating left subclavian stenosis. Suspicion of subclavian steal syndrome was confirmed via MRI. Left heart catheterization and aortogram with left subclavian angiogram were performed. A stent was placed in the left subclavian artery at the bifurcation of the vertebral artery. Following the procedure the patient remained symptom-free and denied any pain in the left arm when lifting. Blood pressures were equal in both arms. He was discharged on nitroglycerin as needed.
Discussion
This case describes the importance of pertinent history-taking and a thorough physical examination when patients present with syncope of unknown etiology. As illustrated in this case, the patient’s syncopal episode may have easily been attributed to the use of self- administered nitroglycerin. With the findings of his history of arm pain and of unequal upper extremity blood pressures, subclavian steal syndrome was suspected and correctly diagnosed. Recognition of this syndrome allowed for proper intervention, leading to stent placement and, hopefully, the prevention of future syncopal episodes.
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Subspecialty Careers: Highlights about Careers in Internal Medicine: Adolescent Medicine
The Discipline
Adolescent medicine focuses on the physical, psychological, social, and sexual development of adolescents and young adults. Multidisciplinary and comprehensive in approach, this specialty encompasses the full spectrum of acute, chronic, and preventive health care. Adolescent medicine evaluates medical and behavioral problems within the context of puberty and tailors management to the individual's developmental needs. Problems typically encountered include abnormalities in growth and development, vision and hearing disorders, learning disabilities, musculoskeletal problems (often sports related), allergies, acne, eating disorders, substance abuse, psychosocial adjustment problems, sexually transmitted diseases, contraception and pregnancy, and sexual identity concerns. In addition, adolescent medicine emphasizes the management of chronic diseases that begin in childhood and continue into adulthood, such as diabetes, asthma, cystic fibrosis, congenital heart disease, and inflammatory bowel diseases.
Opportunities for physicians to practice exclusively in this discipline are relatively few but growing in the private sector and are generally found within academic medical centers or in the public health sector. Adolescent medicine is an important part of general internal medicine, pediatrics, and family medicine.
Training
While most fellowship programs in adolescent medicine are clinically oriented, most fellowships do provide significant background in research, prevention, and education. Adolescent Medicine fellowships vary from one to three years in length. Candidates for fellowship programs must have completed an approved residency in internal medicine, pediatrics, family practice, or combined medicine-pediatrics.
Certification
The American Board of Internal Medicine ABIM and the American Board of Pediatrics have agreed to award certification in adolescent medicine on the basis of performance on an examination developed jointly by both Boards. The admission requirements are similar and the standard for certification by the two Boards is identical. The examination is offered in the fall of odd numbered years.
Training Positions
As of 2007, there were 26 training programs in Adolescent Medicine. Sixty-six percent of the trainees were female and 77% were US medical graduates. The Society of Adolescent Medicine annually publishes a list of available fellowships in the Journal of Adolescent Health.
Practice
The practice and procedures performed in this specialty are very similar to those of a general internist; however, additional gynecological procedures such as colposcopy and IUD implantation may be performed.
Major Professional Societies
The Society for Adolescent Medicine
1916 NW Copper Oaks Circle
Blue Springs, MO 64015
Phone: (816) 224-8010
www.adolescenthealth.org/
Major Publications
Source: This information came from the American College of Physicians’ Subspecialty Brochure.
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Advocacy Brief: Make Your Voice Heard on Capitol Hill
Key Contacts are asked to communicate with their members of Congress regarding issues of importance to internists and their patients and report the results back to ACP. As key issues approach the decision-making stage on Capitol Hill, the College e-mails or faxes legislative alerts to Key Contacts. Legislative alerts include all of the necessary information (including sample messages that can be easily personalized) to send informative communications to members of Congress.
ACP members are not required to have existing relationships with their members of Congress before becoming a Key Contact. Please help ACP with its efforts on Capitol Hill and encourage your fellow classmates to enroll today.
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Did You Know that there is little, to no cost for Medical Students to attend the majority of ACP Chapter Meetings?
Last year almost 1,000 Medical Students took advantage of this opportunity and enjoyed the full benefits of networking with leaders in the Internal Medicine community while learning about different hot topics in the medical field. Several chapters offer sessions at their meeting specifically for medical students. To view a list of upcoming meetings in your area, please see our Chapter/Regional Meeting Calendar or check your local Chapter’s Website for more information.
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MKSAP for Students 4 Question 1
A 42-year-old woman has a 2-week history of jaundice, low-grade fever, and fatigue. Medical history is noncontributory. The patient lives in Honduras but was born in the United States and returned to this country when she became ill. She has consumed at least one bottle of rum daily for 15 years and has taken acetaminophen, 1 g daily, for the past 3 days. She has no history of injection drug use, blood transfusions, or known exposure to anyone with hepatitis.
On physical examination, temperature is 37.9 °C (100.2 °F), heart rate is 100/min, and blood pressure is 110/70 mm Hg. Jaundice, spider angiomata, and mild muscle wasting are noted. Abdominal examination shows mild splenomegaly, mild hepatomegaly with tenderness, and no ascites.
Laboratory Studies:
Hemoglobin 12.8 g/dL
Leukocyte count 3400/µL
Platelet count 99,000/µL
Aspartate aminotransferase 124 U/L
Alanine aminotransferase 57 U/L
Total bilirubin 6.2 mg/dL
Direct bilirubin 3.8 mg/dL
Albumin 3.4 g/dL
INR 1.2
IgG antibodies to hepatitis A virus (anti-HAV IgG) Positive
Which of the following is the most likely diagnosis?
A. Acetaminophen hepatotoxicity
B. Alcoholic hepatitis
C. Autoimmune hepatitis
D. Hepatitis A
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MKSAP for Students 4 Question 2
A 67-year-old asymptomatic man is evaluated in the office during a routine physical examination. He quit smoking 3 years ago, watches his diet, and exercises 60 minutes every day. He wears his seatbelt while driving and consumes fewer than four alcoholic drinks per week. He takes no medications other than an occasional ibuprofen for muscle-related symptoms.
At age 63 years, he had a negative colonoscopy, a booster tetanus and diphtheria vaccination, and pneumococcal vaccination. This fall, he received herpes zoster and influenza vaccinations. He had a normal fasting lipid panel and blood glucose level 6 months ago.
On physical examination, blood pressure is 130/78 mm Hg, pulse rate is 60/min, and BMI is 24. General examination is normal.
Which of the following screening or preventive measures is recommended for this patient at this time?
A. Abdominal ultrasonography
B. Colonoscopy
C. Electrocardiography
D. Pneumococcal vaccine
E. Tetanus and diphtheria vaccine
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MKSAP for Students 4 Answer 1
Answer: B: Alcoholic hepatitis
Fatigue, a history of excessive alcohol consumption, low-grade fever, jaundice, tender hepatomegaly, examination findings consistent with chronic liver disease, and an aspartate aminotransferase to alanine aminotransferase ratio (AST:ALT) >2 are most consistent with alcoholic hepatitis.
Hepatitis A is associated with both AST and ALT values >500 U/L, often >1000 U/L, with the ALT greater than the AST. In addition, positive IgG antibodies to hepatitis A virus (anti-HAV IgG) are consistent with a remote prior infection with current immunity and not with acute hepatitis A. Patients who consume excess alcohol are at greater risk for developing acetaminophen hepatotoxicity than those who drink alcohol moderately or not at all. However, acetaminophen doses of >3 g/d are probably needed to cause hepatotoxicity, even for patients with alcoholism. In addition, acetaminophen toxicity typically results in AST and ALT values >5000 U/L. A patient with autoimmune hepatitis would generally have AST and ALT values similar to those of a patient with acute viral hepatitis and the AST:ALT ratio would be < 2.
Bibliography
1. Green RM, Flamm S. AGA technical review on the evaluation of liver chemistry tests. Gastroenterology. 2002;123:1367-84. [PMID: 12360498] [PubMed]
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MKSAP for Students 4 Answer 2
Answer: A: Abdominal ultrasonography
The most appropriate screening or preventive measure for this patient is abdominal ultrasonography. One-time screening for abdominal aortic aneurysm with ultrasonography is recommended for men ages 65 to 79 years who are, or have ever been, smokers. Data from randomized clinical trials indicate that ultrasound screening reduces abdominal aortic aneurysm–related mortality in older men with a smoking history. The U.S. Preventive Services Task Force makes no recommendation regarding screening for men who have never smoked because of insufficient evidence and recommends against screening for women because the harms outweigh the benefits.
All adults older than 50 years should be screened for adenomatous colon polyps, and removal of detected polyps significantly decreases the incidence of colorectal cancer. Colonoscopy every 10 years is a recommended screening technique. Some studies have found that colonoscopy is the most effective screening tool. Other recommended screening methods include annual fecal occult blood testing, flexible sigmoidoscopy every 5 years, annual fecal occult blood testing with flexible sigmoidoscopy every 5 years, and double-contrast barium enema examination every 5 to 10 years. This patient's most recent colonoscopy was 4 years ago, and therefore repeat screening is not indicated.
Routine screening for coronary artery disease in asymptomatic persons without cardiovascular risk factors is not recommended. Screening electrocardiograms are not recommended because abnormalities of the resting electrocardiogram are rare, not specific for coronary artery disease, and do not predict subsequent mortality from coronary disease. Because this patient has no cardiovascular risk factors other than his age, an electrocardiogram is not indicated.
The pneumococcal vaccine is associated with substantial reductions in morbidity and mortality among the elderly and high-risk adults and is therefore recommended for all adults age 65 years or older or with other risk factors (for example, asplenia). Patients who receive their initial vaccine at younger than 65 years should receive a second dose after 5 years. Because this patient was vaccinated at age 63 years, a second vaccination is not indicated at this time.
Booster tetanus and diphtheria vaccinations are recommended every 10 years; because this patient's vaccination is up to date, a repeat booster is not necessary at this time. If he were in the 19- to 64-year-old age range, the new tetanus, diphtheria, and acellular pertussis vaccine would be appropriate. A single dose of the new vaccine can replace a single dose of tetanus and diphtheria vaccine for active booster vaccination against tetanus, diphtheria, and pertussis.
Bibliography
1. U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med. 2005;142:198-202. [PMID: 15684208] [PubMed]
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Articles for Medical Students from ACP Internist and ACP Hospitalist
ACP Internist (formerly ACP Observer)
Find all of our print and online content, including ACP InternistWeekly, our blog, polls, and surveys (including our cartoon caption contest). Go online for the following stories:
- Cardiac care critical for diabetic patients
Even the experts feel like they’re missing potential cardiological complications in diabetic patients. They consider how to screen this population effectively for the 3% who experience cardiac-related deaths. - Urgent update on acute diarrhea
While most episodes of diarrhea are brief, and most people don’t seek medical attention for them, some do end up becoming more severe and requiring medical care. As such, internists need to know how to recognize the subtle differences in presentation. - From the MKSAP Case Studies
A 50-year-old woman is evaluated for a rash on the back of her elbows and knees. A similar rash has occurred in the past, with her first episode as a young adult. She has used over-the-counter hydrocortisone cream without relief. She does not smoke or drink and is otherwise healthy. What is the most appropriate next step in the management of this patient?
ACP Hospitalist
The relaunched ACP Hospitalist is the place to find all of our print and online content, including ACP HospitalistWeekly, our upcoming blog, polls, and surveys (including our cartoon caption contest). Go online for the following stories:
- Hospital medicine around the world
The field is catching on in several countries outside the U.S., Canada and Europe. Although the health care systems and situations may differ, supporters’ reasons for wanting hospital medicine to flourish there are often the same, and the barriers are often similar, as well. - On the front lines of aortic dissection
A leading cardiologist explains why hospitalists are key to improving long-term outcomes. - Caring for the pregnant patient
Every hospitalist is likely to encounter a pregnant patient during his or her career and needs to be versed in the diagnosis and treatment of hypertension, preeclampsia, asthma, venous thromboembolism and diabetes.
Students: Join ACP for Free
Benefits of Membership for Students: ACP's free Medical Student Membership includes benefits designed especially to meet students' needs.
Join Now: Sign-up today and begin enjoying the benefits of ACP Medical Student Membership.
MKSAP 15 Discount 10% Off
Get ready for the New Year with the newest edition of MKSAP. Enjoy a 10% discount off MKSAP 15 for a limited time. You must order by December 11, 2009 and use priority code E9048 to get the discount.
Holiday Gift offer - 10% off
A great gift for a colleague or yourself - Landmark Papers in Internal Medicine: The First 80 Years of Annals of Internal Medicine. Enjoy a 10% discount when you order by December 11, 2009 and use priority code E9049.