December 2006 E-Newsletter

2007-2008 Council of Student Members (CSM) Call for Nominations

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For the 2007-2008 Council year, eight seats will be open on the CSM. These seats include:

Central Region (includes Illinois, Indiana, Iowa, Kentucky, and West Virginia)

Central Atlantic Region (includes Delaware, Maryland, New Jersey, Puerto Rico, Virginia, and District of Columbia)

Midwest Region (includes Arizona, Colorado, Kansas, Minnesota, Missouri, Nebraska, Nevada, North Dakota, South Dakota, Utah, and Wisconsin)

New England Region (includes Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont)

North Atlantic Region (includes New York)

North Central Region (includes Michigan, Ohio, and Pennsylvania)

Pacific Region (includes Alaska, California, Hawaii, Idaho, Montana, Oregon, Washington, and Wyoming)

Southeastern Region (includes Florida, Georgia, North Carolina, South Carolina, and Tennessee)

Nominations will be accepted from ACP Medical Student Members who are in their first, second, or third year of medical school. Candidates may be self-nominated. Council members serve one to three year terms, depending on where they are in their medical school careers.

Council members are required to attend three meetings each year and participate in several conference calls throughout the year. Council members also serve on various ACP committees which require additional travel. CSM representatives are reimbursed for their travel expenses for these meetings and other Council-related expenses.

Nominees must submit a statement of candidacy, a current curriculum vitae (CV), and one letter of recommendation. The statement of candidacy is a letter from the nominee indicating his or her interest in joining the Council. This statement should not exceed one typed page. To see a sample statement of candidacy, visit here.

The CSM encourages medical students to join the Council early in their medical school careers and realizes that it may be difficult for a first-year student to obtain a letter of recommendation from a medical school professor who knows them well. Therefore, the letter of recommendation may be written by a former college professor, by an advisor from a leadership position that was held prior to entering medical school, or by anyone else who knows the nominee in such a capacity.

The materials must be submitted to the CSM by January 15, 2007. Materials should be sent to:

Jim Small, Chair
ACP Council of Student Members
c/o Patty Moore, Medical Student Coordinator
190 N. Independence Mall West
Philadelphia, PA 19106-1572
Fax: (215) 351-2708
Phone: (800) 523-1546 ext. 2749
E-mail: pmoore@acponline.org

The elections will be held in February and candidates will be notified of the results by February 28, 2007. Each candidate will be reviewed with neutrality to gender, race, and ethnic background.

Please address any questions or concerns to Patty Moore at pmoore@acponline.org or at (800) 523-1546 ext. 2749.

Thank you for your interest in joining the Council of Student Members.

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Medical Student Perspectives: Overview of the Residency Application and Interview Process

How to Apply

  • Complete the Electronic Residency Application System (ERAS): You can begin filling out your ERAS paperwork on July 1 and submit your completed application by September 1. After submitting your application, you will receive e-mail invitations for interviews, which occur between late November and January. After interviewing, take time to rank your choices for a residency program. The magical match day will occur in March.

  • Apply Early: It is important to submit your application as soon as possible. Some programs have a rolling application process, meaning interviews could begin as early as November. Other programs offer all their interviews at one time so be certain to visit each program’s Web site for their interviewing schedule.

  • Write and Update Your Curriculum Vitae (CV): Continually updating your CV will help simplify the ERAS application process by allowing you to cut and paste from your CV directly into the application. Include any clubs or national committees that you are a member of as well as any papers you have had published. Many national organizations like the ACP hold meetings where they invite medical students to present their research. Participation in these meetings is also an important addition to your CV and ERAS application. If you do not currently have a CV, have no fear. Many Web sites are available to help you get started and most student affairs offices have sample CVs that you can examine.

  • Construct a Good Personal Statement: Your personal statement should explain why you chose your prospective field of medicine. It should not exceed 1½ pages, and it should not be a regurgitation of your CV or ERAS application. One suggestion is to include a brief explanation of challenges you faced while volunteering or working with various organizations and how you overcame these challenges. For more information on writing a personal statement, visit the September 2006 issue of IMpact.

  • Choose What Programs to Apply to: Know what you want and research each program. If you want to be a clinician, you should be looking at programs with particularly strong clinical teaching. If you are interested in research, you should focus on academic medical centers where research is emphasized. Visit the program’s Web site to learn more details about that program. Independently run Web sites like www.scutwork.com and www.studentdoctornetwork.com can also help you learn about a program, but should be used with caution. One unhappy resident may not accurately represent the entire program. If you are interested in pursuing a fellowship after residency, investigate what percentage of applicants get into fellowships from that program. Most residency programs in internal medicine publish their fellowship matches on their Web site.

  • Decide if You Want to do an Away Rotation: An away rotation is not required for an internal medicine residency program so you should carefully consider whether or not you choose to do one. If you decide to do an away rotation at the program of your choice, it allows the program to see your work ethic and put a face and personality to your application. Another benefit of doing an away rotation is that it gives you the opportunity to see what you like and dislike about the program. Things you should observe while on your away rotation include the interaction between residents and faculty, resident interaction outside work, and the amount of time set aside for learning in the day. Away rotations can be difficult if you do not have an outgoing personality, so before making your decision be confident that you can easily transition into new surroundings.

How to Have a Successful Interview

  • Dress in Appropriate Attire: Make sure you have an interview suit that is both comfortable and professional. Try on your suit before you begin interviews so you have plenty of time for any necessary alterations. It is important to look your best and make a good first impression. Appropriate attire is essential, you do not want anything to distract the interviewer from what you are saying.

  • Be Prompt: Show up early or at the very least on time. Arriving late could affect your chances of getting in the program.

  • Be Polite: Say please and thank you, hold the door for others, and wait for them to sit down before you. You are being interviewed and observed the entire day by residents, faculty and staff so be polite to everyone.

  • Do Your Research Beforehand: You do not want to ask questions that you should already know the answers to. For instance, if you are applying for an internal medicine/pediatrics combined residency, do not ask your interviewer about the difference between that and family medicine. These types of questions show poor preparation and research. Instead, have a few good questions prepared to ask the interviewer.

  • Have Confidence in Yourself: Be proud of your accomplishments and abilities.

  • Be Honest: Most interviewers have been interviewing students for a number of years and can see through falsehood.

  • Prepare for Open-ended Questions: You should be prepared to answer the following questions. Why do you want to be an internist? What do you like to do with your free time? What are your best qualities? What are your worst qualities? If you need some time to think, ask the interviewer for a minute or two.

  • Be Sensitive: Avoid being overly political or taking a radical stand on any hot-button issues. You do not know the personal views of your interviewer and you do not want to appear offensive.

  • Allow Yourself Some Time After Interviews: Do not schedule interviews on back-to-back days. They are more exhausting than you would think, so you should take at least one day off before the next one.

How to Follow-up After the Interview

  • Send Thank You Cards: Send cards to each person who interviewed you, including residents. Be sure to personalize each card.

  • Journal Your Thoughts: When you get home from the interview, immediately write down your thoughts and impressions of the program. Have a checklist of things you want in a program to help keep you focused.

  • Rank Potential Programs: Do not include any programs in your ranking that you would not want to attend. If you cannot see yourself at a program, eliminate it from your list. Rank your most desired program first, and see what happens.

Good Luck!

Tony Tarchichi
CSM Representative, Central Atlantic Region
UMDNJ, New Jersey Medical School, 2007
e-mail: tarchitr@umdnj.edu

My Kind of Medicine: Real Lives of Practicing Internists: Kimberly Bates, MD

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The year was 1988 and Kimberly Bates was a freshman at Bishop Hartley High School in Columbus, Ohio. It was Career Day at school, and while it may have passed without consequence for many of her classmates, for Kim it was a day that would define her life. One of the speakers that day was a pediatrician; a short and wiry man who spoke with an infectious passion and enthusiasm about his career. The more he spoke about being a physician, the more Kim wanted to be one. By the end of his presentation, Kim had made up her mind; she was going to be a doctor.

Dr. Kim Bates and her son Gregory


Fast forward fourteen years to the Intensive Care Unit of Christiana Hospital in Newark, Delaware, where a woman lay ill and unresponsive in her bed following a cardiac catherization. Dr. Bates, then a fourth year med-peds resident and her attending were uncertain how to proceed. The patient’s vital signs were stable and the imaging studies were normal, yet the patient was not recovering. It was clear something was very wrong.

The patient’s husband, visibly upset, questioned Dr. Bates: What was wrong? Couldn’t they turn it around? Was his wife going to die? She talked to him at length, trying to calm him down and asking him to trust her to keep working until she figured out what the problem was. Then she picked up the patient’s chart and set out to do what she had always done best; sit down and think it through. Solving complex problems had always been one of her greatest strengths and in that moment, she would need it more than ever.

Taking Charge

At five foot two, wearing lip gloss and a skirt, Dr. Bates is not your typical quarterback. This however is exactly the role she sees herself fulfilling as a physician. She likens the overall care coordination of a patient to a game plan. They both require making many decisions involving overlapping factors. “As an internist, you are the one who ties it all together,” she says. “There needs to be a quarterback for the team, and you are it. You have many different roles to play, but one thing you are always doing is making sure everything is in alignment.”

As was once written in a speech prepared for a former U.S. President, “leadership and learning are indispensable.” This is a notion Dr. Bates exercises in her own life, albeit sometimes without having chosen to do so. In her third year of residency, Dr. Bates was diagnosed with breast cancer. It was the time in her life she admits was the most challenging. She underwent surgery, chemotherapy and radiation—all while completing her residency. She struggles when asked to put into words what she learned through it all, but her answer reveals a true mark of leadership: the ability to face adversity head on without losing conviction or drive.

“It made me a better physician,” she explains. “Being the patient for once taught me the true meaning of empathy. It has changed the way I talk to patients. Now if I have to deliver bad news I do it much differently, because I realize how little of the information gets through after hearing the diagnosis for the first time.”

Now she uses her commitment to taking charge in her dual roles as an internist and as a pediatrician. Four days a week Dr. Bates practices internal medicine and pediatrics at a private medical practice and she spends two days a week working with internal medicine-pediatrics residents in the med-peds program at the Ohio State University/Columbus Children’s Hospital. She also works a half day each week in a family HIV clinic. She enjoys each job equally for different reasons. The intellectual stimulation and challenge of internal medicine enthrall her, while she relishes her work as a pediatrician because of the interaction she has with children. The latter gives her exposure to a brighter side of life, something she seems to value more than most her age. “Kids are funny. There is always humor in my day,” she says.

A Thirst for Knowledge

As early as high school, Dr. Bates discovered she thrived on learning. She developed a love for science and a fascination with the human body. She talks excitedly about the clinical years of medical school, when she would spend hours poring over a problem, or coming up with 50 different outcomes for a differential diagnosis. “It was so exciting to me, to do those things,” she says, “and it is what I miss about medical school, being able to take as long as you wanted to try and get to the bottom of a problem.”

Dr. Bates is certainly not an isolated academic type. She values an interactive environment for personal and professional growth. “Teaching is one of my favorite things and something I definitely see myself doing in five to ten years,” she says. “Working with and teaching residents and students keeps me sharp and focused because no one takes what you say for granted. You have to prove it every time.”

It is fitting that Dr. Bates is comfortable in the role of a teacher. The classroom, the teacher, and the student represent home base for her. This combination is a foundation to which she can always return for inspiration, answers, strength and stability.

The Softer Side of Science

Dr. Bates loves her dissertations and diagnoses, but she pursued internal medicine as much for her love of people as she did for her love of science. For every clinical decision she makes, there is a smile for a patient. For every bit of research she evaluates there is a conversation with a medical student or resident. “Ever since I was young I envisioned myself in a job where I had interaction with people,” she says. Everything about Dr. Bates seems to have a yin-and-yang quality to it. She is quite literally half scientist and half people person. Even as much as she loves her work, she says her favorite part of the day is returning home to see her four month old son Gregory and her husband Greg.

She is perceptive and instinctive. For example, she does not wear a doctor’s coat because she senses patients are more relaxed if she is dressed more or less similarly to them. “It’s especially true with pediatrics,” she says, “but also with adults. I get a lot more accomplished with adult patients if they feel as though they’re talking to a colleague or a friend.” It is this kind of intuition that makes the difference between a good doctor and a great doctor. People often refer to it as “bedside manner,” but with Dr. Bates it goes a bit deeper.

Years ago on that day in the intensive care unit as her patient clung to life, Dr. Bates put her analytical talents to use. After looking through the woman’s chart, she decided to order an arterial blood gas. When the test came back, it indicated a respiratory acidosis which had caused the woman’s decline. She and her attending immediately intubated the patient and corrected the condition, and by later that evening the patient was better and writing notes to her husband.

The scientist in Dr. Bates served her well that day, but so did the young girl in class, the quarterback, the compassionate woman, the cancer patient and the doctor. “I’ve learned many valuable things,” she says. “Put the patient first. Take time to sit down and think a problem through, no matter how urgent. And always, always trust your intuition.”

Internal Medicine Interest Group of the Month: Tufts University School of Medicine

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Over the past year-and-a-half, the Tufts University School of Medicine ACP-IMIG (Internal Medicine Interest Group) chapter has been in an exciting state of revival and growth. In the fall of 2005, then first-year medical students Brian Lee and Christopher Sales inherited the organization with little more than school funding and a club name; the chapter had been abandoned. There were no officers, no membership activities, and no faculty advisor associated with the IMIG. Membership numbers had dropped from an impressive 40% per class in 2002 to 8% in 2005. Internal medicine still led in the number of residency matches from Tufts in 2006, but the proportion had dropped to 22% of the graduating class.

Brian and Chris reasoned that the loss of student interest was in part due to a public image problem. Internal medicine was both misunderstood and poorly understood. Many students believed that the field of internal medicine was synonymous with the specialty of family medicine and/or exclusive to primary care. Few students knew of the diverse spectrum of subspecialties offered by internal medicine, and even those interested in fields such as cardiology and infectious disease were unaware that these subspecialties were branches of internal medicine. The gap between perception and reality needed to be addressed.

Talking to their peers also made it clear to Brian and Chris that students were just as interested in the intangibles of life as a practicing internist or subspecialist as they were about the respective clinical environments of these fields. Students wanted frank discussions about the pertinent questions never covered in class. For example, what are hours like during residency, and more important, what is life like as an attending? Why do physicians choose academic medicine over private practice? What is the pay like in both cases? What do primary care physicians and subspecialists love and hate about their respective medical practices? And how can teaching and research be incorporated into clinical practice?

Bearing in mind their peers’ concerns and the existing shortcomings of their IMIG, Brian and Chris devised a formula for sustained club interest and growth. Their strategic plan centered on building a core membership around talks that shed light on the diverse spectrum of clinical practices within internal medicine and addressed students’ questions about their future careers. With the help of a few dedicated students (Michael Silverman in particular) and a host of captivating speakers, Brian and Chris raised the public profile of the IMIG at Tufts and found themselves consistently filling their auditorium with first, second, and even third year medical students.

Last year’s focus was on addressing the public image problem of internal medicine. Activities included increasing interest in internal medicine and raising the profile of the IMIG on campus by scheduling subspecialty talks on infectious disease, interventional cardiology, and gastroenterology. The IMIG also cosponsored a residency panel and a talk given by Dr. Kassirer, former editor of the New England Journal of Medicine, on physician conflict of interest.

This year's continued efforts to raise awareness about internal medicine and the IMIG have doubled overall membership numbers and tripled the per class enrollment. The IMIG is now one of the largest student organizations on Tufts’ campus, and certainly among the most visible. Sessions have continued this year with subspecialty talks on cardiology and hematology/oncology. Speakers have highlighted key issues in the current medical zeitgeist, such as health care disparities. Other talks scheduled for the remainder of the year include critical care medicine, sports medicine, malpractice reform, and a residency panel. The IMIG has also started new activities to get students actively involved. Activities include a visit to a cardiac catheterization lab to participate in an interventional procedure demonstration for first and second year students and practicing clinical case presentations with the help of our faculty advisor and medicine clerkship director for third and fourth year students.

Brian and Chris, now joined by first-year co-chairs Craig Napolitano and Kinjalika Sathi, hope to continue the IMIG's growing momentum. Their mission will be to continue and build on the IMIG's activities, adding programs that will truly “add value” to IMIG membership. At the top of their new agenda are increasing and strengthening their partnership with the Department of Medicine at Tufts-New England Medical Center. A stronger bond with the Tufts-New England Medical Center will facilitate research collaboration between medical students and internal medicine faculty and also provide students with accessible mentoring opportunities. They also hope to open more opportunities for students interested in internal medicine to develop their clinical skills through adjunct tutorials given by Tufts faculty. Finally, Brian and Chris aim to introduce the Tufts IMIG onto the national scene by sending one of their talented members to Washington, DC in May 2007 to rub elbows with health care policy makers during ACP Leadership Day.

The Tufts IMIG has come a long way and indeed has a bright future. Its progress was due to funding and support from ACP and Tufts Student Council, as well as the guidance of Dr. Joseph Rencic and numerous guest speakers (particularly Dr. Jeffrey Kuvin), all of whom took time out of their schedules to support the IMIG's efforts. Most of all, the IMIG's success would not have been possible without the students at Tufts, whose exceptional professionalism and commitment to their careers have been the backbone of its growth.

Christopher Sales, M09
Brian Lee, M09
Craig Napolitano, M10
Kinjalika Sathi, M10
Co-Presidents Tufts ACP-IMIG
E-mail: christopher.sales@tufts.edu

Winning Abstracts from the 2006 National Medical Student Abstract Competition: Detection and Quantification of Cryptosporidium Parvum in HCT-8 Cells and Human Fecal Specimens using Real-time Polymerase Chain Reaction Assay

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Author: Jonathan B. Parr, University of Virginia School of Medicine, 2008

Introduction:
Cryptosporidium parvum is a significant cause of diarrheal illness worldwide, especially among children and immunocompromised patients. Currently used diagnostic techniques are time-consuming, require skilled technicians, and are not useful for quantification of oocysts in fecal and environmental samples.

Methods:
In this study, we examined the utility of a real-time polymerase chain reaction (PCR) assay for detecting and quantifying Cryptosporidium parvum oocysts in three distinct sets of samples: phosphate buffered saline (PBS), HCT-8 cells (human ileocecal carcinoma), and human fecal specimens. A reliable standard curve was generated using the PBS samples spiked with pure oocysts, and oocyst starting quantities were calculated for the infected HCT-8 cell and spiked fecal samples.

Results:
The average difference between known and calculated starting quantities was 1.4±0.3 logs oocysts/sample for the HCT-8 cells and 2.2±0.5 logs oocysts/sample for the spiked stool samples. Despite these losses, the assay detected oocysts in HCT-8 cells and fecal specimens infected/spiked with at least 3 logs oocysts/sample.

Conclusion:
Our results confirm that real-time PCR can be used to detect and quantify Cryptosporidium parvum oocysts in a variety of samples in the research laboratory and that it will likely prove to be a useful tool in the field.

Subspecialty Careers: Highlights about Careers in Internal Medicine: Geriatrics

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The Discipline

From the Greek word geron, "an old man," and iatreia, "the treatment of disease."

Geriatric medicine involves the recognition of differences in presentation of disease and the importance of maintaining functional independence in elderly patients. Geriatrics is a primary care discipline oriented toward preventive, routine, acute, and chronic medical care of elderly patients.

Procedures

Important procedural skills include cognitive assessment, functional assessment, gait assessment, home safety assessment, motor vehicle driving assessment, and needs assessment on hospital discharge, including rehabilitation. In addition, the geriatrician is expert in interpreting the following tests: urodynamic testing, cystometry, audiology, neuropsychiatric testing, videofluoroscopy for dysphagia, noninvasive tests of peripheral arteries, and biopsy of temporal artery.

Training

Geriatric fellowship training requires 12 months of accredited training beyond general internal medicine residency.

Certification

The American Board of Internal Medicine offers subspecialty certification in Geriatrics.

Training Positions

As of August 2005, there were 103 ACGME-accredited training programs with 301 active fellowship positions in Geriatrics. 56% of the trainees were female, and 37% were US medical graduates.

Practice

Approximately 50% of the graduates enter clinical practice in Geriatrics in the United States and 31% enter academic medicine.

Major Professional Societies

American Geriatrics Society
The Empire State Building
350 Fifth Avenue, Suite 801
New York, NY 10118
(212) 308-1414

The Gerontological Society of America
1030 15th Street, NW, Suite 250
Washington, DC 20005
(202) 842-1275

Major Publications

The Gerontologist
Journal of the American Geriatrics Society

Advocacy Briefs: Congressional Action Strengthens Future for Primary Care

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On December 9, Congress passed legislation that averted a 5 percent cut in the 2007 Medicare Physician Fee Schedule (SGR) and replaced it with a freeze. Because internists will gain an average of 5 percent in total Medicare payments thanks to the ACP-championed five-year review of the relative values for higher level office visits and other evaluation and management services, most ACP members will actually see a substantial gain in total Medicare payments, not a freeze.

The bill also included the ACP proposal for a medical home demonstration. The medical home pilot program would provide participating internists with a “care coordination fee” for managing the care of patients with multiple chronic conditions. The program would also provide the ability to share in savings from reductions in hospital admissions that may result from physician-directed care coordination. The adoption of the proposal is key to ACP's overall long-term strategy of overhauling Medicare payments to support primary and principal care.

None of this would have been possible without the grassroots support of ACP's Medical Student Members who contributed to over 12,000 e-mails and faxes expressing concern about the Medicare Physician Fee Schedule (SGR) sent to Congress via ACP's Legislative Action Center. For more information visit here.

Did You Know ACP Develops Policy and Advocates for a Better Practice Environment for its Members?

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ACP works directly with government entities and managed care organizations to influence their internal policies and procedures to ensure that the standards for professionalism and quality are upheld. ACP has been a leader in advocating for changes to improve the practice environment for its membership. For information about the current advocacy and policy development efforts of the College visit here.

MKSAP for Students 3 Question 1

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A 45-year-old man with alcoholic cirrhosis is evaluated because of hematemesis due to esophageal varices. He received eight units of uncrossmatched group O packed cells over 3 hours, but his blood pressure remained unstable and his bleeding continues.

When he was first evaluated in the emergency department, his prothrombin time and partial thromboplastin time were 34 seconds and 57 seconds, respectively. The blood bank never received a specimen for type and screen prior to releasing the group O blood, and no pretransfusion blood is available for testing.

What is the most appropriate transfusion product to treat this patient's bleeding?

( A ) Group O whole blood
( B ) Group AB whole blood
( C ) Group O fresh frozen plasma
( D ) Group AB fresh frozen plasma
( E ) N/A

MKSAP for Students 3 Question 2

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A 19-year-old man with epilepsy previously well controlled with phenytoin therapy is brought to hospital by emergency medical personnel because of a generalized seizure. The patient had stopped taking phenytoin about 3 weeks earlier. A second seizure occurred shortly after arrival at the emergency department and was successfully treated with lorazepam.

On examination, he is confused but his physical examination is otherwise normal.

Laboratory Studies:
Serum sodium: 140 meq/L
Serum potassium: 4.0 meq/L
Serum chloride: 104 meq/L
Serum bicarbonate: 10 meq/L
Serum creatine kinase: 45 U/L
Arterial blood gases: pH, 7.05; Pco2, 38 mm Hg

For the acid-base disorder, which of the following is the most appropriate course of action?

( A ) Acetazolamide
( B ) Intravenous bicarbonate
( C ) Mechanical ventilation
( D ) 0.45% normal saline
( E ) Observe

MKSAP Answer 1

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Answer: D

Educational Objective: Recall the principles of ABO compatibility.

This patient's liver disease makes it very likely that his ability to synthesize clotting factor is decreased; therefore, replacement therapy is warranted. Even if clotting factor levels were adequate for hemostasis before transfusion, the levels would have been diluted through replacement of his blood volume with packed red blood cells. The best choice for clotting factor replacement in this circumstance is group AB fresh frozen plasma.

ABO hemagglutinins arise naturally and are therfore expected to be present in plasma. In an emergency, when a patient's ABO type is unknown, group O packed cells have neither A nor B antigens and can be used since they are the “universal donor” and are compatible with all patients' plasma. Individuals who are group AB have both A and B antigens on their red cells, and so are incapable of making naturally occurring anti-A or anti-B. Just as group O is the universal donor for red cells, group AB is the universal donor for plasma. Whole blood is a poor choice to treat coagulopathies because it loses labile factors during storage.

References

Rapaport SI. Coagulation problems in liver disease. Blood Coagul Fibrinolysis. 2000;11 Suppl 1:S69-74.

MKSAP Answer 2

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Answer: E

Educational Objective: Recognize mixed acidosis after a seizure and understand the differential diagnosis and appropriate treatment.

The patient has an anion gap metabolic acidosis with concurrent respiratory acidosis. Lactic acidosis associated with the seizure is the most likely explanation for the metabolic acidosis. Since this state quickly reverses with cessation of the seizure, observation alone is warranted.

Metabolic acidosis is indicated by the low serum bicarbonate level and pH less than 7.4. The expected Pco2 in metabolic acidosis with a serum bicarbonate level of 10 meq/L is 23±2 mm Hg; thus, the measured Pco2 of 38 mm Hg indicates concurrent respiratory acidosis. The calculated anion gap is 26, and the ratio of change in the anion gap (14) to the change in serum bicarbonate level (14) is 1, suggesting no concurrent non-anion-gap metabolic acidosis or metabolic alkalosis.

Mechanical ventilation to correct the concurrent respiratory acidosis is not needed if the patient is awake and breathing normally. Acetazolamide may cause a proximal renal tubular acidosis with bicarbonate wasting and thus worsen the acidosis. Intravenous fluids are not contraindicated, but neither are they are necessary to correct the acid-base disturbance. Although the patient has an arterial blood pH less than 7.2, the transient nature of the acidosis along with the ability to regenerate bicarbonate from lactate makes bicarbonate therapy unnecessary.

References

Adrogue HJ, Madias NE. Management of life-threatening acid-base disorders. First of two parts. N Engl J Med. 1998;338:26-34.

Internal Medicine Residency Program Fast Facts

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Program Name: Winthrop University Medical Center
Location: Mineola, New York
Hospital Type: University Affiliated Hospital
Program Size: 37 First Year Positions, 81 Positions Total
First Year Salary: $43,000
Web Site Address: http://www.winthrop.org

Program Name: Carolinas Medical Center
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

Program Name: Cleveland Clinic Foundation Program
Location: Cleveland, Ohio
Hospital Type: University Affiliated Hospital
Program Size: 40 First Year Positions, 120 Positions Total
First Year Salary: $41,000
Web Site Address: www.clevelandclinic.org/im/res

Program Name: Providence Portland Medical Center
Location: Portland, Oregon
Hospital Type: University Affiliated Community Hospital
Program Size: 12 First Year Positions, 30 Positions Total
First Year Salary: $42,000
Web Site Address: http://www.providence.org/oregon/medical_education/
Providence_Portland/default.htm

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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