January 2009 E-Newsletter

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Medical Student Perspectives: Breaking down the Boards

The United States Medical Licensing Examination (USMLE) is a set of three examinations medical students and residents must take and pass in order to obtain a license to practice medicine in the United States. “The Boards” are currently divided into three “Steps,” with the first two taken during medical school, and the third traditionally taken any time after one year of postgraduate training. Mention the boards to a first or second year medical student and the same feelings of uneasiness and trepidation precipitated by the MCAT begin to resurface. This article presents background information and study tips focused mainly on Steps 1 and 2, as these are the examinations taken during medical school.

A passing score is all that is required on the USMLE examinations for the purpose of licensure, but the Step exams are also numerically scored and at present the scores from Step 1 (and sometimes Step 2) are used by residency programs in part to determine whom to interview and ultimately offer positions for training. An excellent resource to demystify the competitiveness of different specialties, provided by the Association of American Medical Colleges, is called Careers in Medicine (CIM) and is available free online at www.aamc.org/cim. On the CIM site there is a PDF version of a yearly report, “Charting Outcomes in the Match,” which lists the average board score and score ranges for matched and unmatched applicants for different specialties.

For students who know what specialty they wish to pursue, having an idea of a score to aim for on Step 1 can be helpful when taking self-assessments prior to the real exam. Last year, the mean Step 1 score for students who successfully matched in internal medicine, for example, was 222, with 207 being the 25th percentile of a successfully matched applicant, and 237 being the 75th percentile marker for the same group. While students with scores both above 237 and below 207 matched in internal medicine, the Charting Outcomes data on the CIM web site can be a helpful guide for students. This report looks at characteristics of successful versus unsuccessful applicants ranging from research experiences, publications, and Ph.D. degrees and helps give students a good idea of what the “typical successful applicant” for any given specialty looks like on paper.

Preparing for Step 1
Relax. Your pre-clinical years of medical school are designed to help prepare you for the boards, so while you have been studying for in-house exams, without knowing it you have already begun to study for Step 1! Step 1 is usually taken by students at the break between their pre-clinical and clinical training, normally the summer after their second year of medical school. There is no one right way to prepare for Step 1, but making a plan and sticking to it is critical; do not change review texts and study plans halfway through your formal preparation for the exam. Many students find First Aid for the USMLE Step 1 to be a useful general review text. New editions of the book are released every year that incorporate feedback from students and correct any errors found in previous editions. The majority of students currently dedicate between four and eight weeks of time to prepare for Step 1.

Step 1 is a computerized test composed of seven one-hour blocks of 48 questions, with a 15-minute computer tutorial, and a total of 45 minutes for breaks/lunch. Altogether, the test is scheduled for eight hours. You may take breaks in between your 50-minute exam blocks, not to exceed the total break time allotted. Because this is a 336-question exam, building up your endurance is a key part of mastering Step 1. There are many online question banks (referred to as Q-Banks) that offer practice Step 1 questions with explanations, analysis, and feedback. Students who obtain very high scores on Step 1 often attribute their success to having completed a large number of practice questions in a simulated exam format so that on the test day they were not exhausted halfway through the real exam. A good tip is to talk to upper-level students at your school to see how they prepared. Does your school offer a review course or discounts on review books? It is worth talking with your curriculum or student affairs deans to know what resources your school has made available to you. Most important, make a study plan and try to stick to it. Consider preparing for the exam with 1-2 other classmates you enjoy studying with to help keep everyone on track. Over 93% of U.S. MD medical students pass Step 1 on their first attempt (76% for U.S. DO students and 71% for foreign medical students).

If a student does not pass the exam on his or her first attempt, the USMLE allows the student to take the exam a second time. Each medical school has a different policy regarding students who fail Step 1 initially, and it is important to be familiar with your school’s policy. Students who are unsuccessful in passing Step 1 on their first two attempts are allowed to take the exam a third and final time, but must pass on this attempt to remain in medical school. It is important for a student who has had difficulty with the exam to evaluate the reasons why and take additional time to prepare before taking the exam again. Meeting with your academic affairs dean to discuss a new study strategy and get connected with academic support resources available through your school can be helpful for struggling students.

Step 2
Step 2 is broken down into two separate parts, a Clinical Knowledge (CK) exam similar in format to Step 1, and a Clinical Skills (CS) exam where students actually interview and examine standardized patients. Step 2 CK and CS are usually taken by students after the completion of their third year core clerkships (Medicine, Surgery, Pediatrics, Psychiatry and Obstetrics/Gynecology). Just like Step 1, schools set different deadlines for when their students must have completed the Step 2 exam. The focus of the exam material on Step 2 is less on pure basic science and more on the practical application of medical science to clinical scenarios. There is a First Aid for the USMLE Step 2 text available along with Step 2 Q-banks. A passing score on Step 2 is all that is needed for licensure, but a high Step 2 CK score that comes back early enough in a student’s fourth year to be reported to residency programs can help an applicant be more competitive at high tier programs, especially if his or her Step 1 score was not extremely high. The Step 2 CS examination is only offered at specific sites around the country, currently Atlanta, Chicago, Houston, Los Angeles, and Philadelphia www.usmle.org/Examinations/step2/cs/CSECAddresses.html. Picking an exam date that allows you time for the necessary travel arrangements is critical to minimize stress and help you focus on doing well on the exam.

When preparing for the boards, keep in mind that it is impossible to use every review text and Q-Bank resource available. No matter how tempting, resist the urge to buy review books you know you will never have time to use, and familiarize yourself with your review materials as early as possible during your first two years of medical school so that you are not looking at them for the first time several weeks before the boards. Take a deep breath and know that with adequate preparation you can join the many thousands of medical students who have successfully passed their boards and moved on to be skilled and dedicated physicians.

For official information regarding the USMLE, visit the official website:http://www.usmle.org/.

Matthew Rudy
Council of Student Members Representative, Southeastern Region
Medical College of Georgia, Class of 2010
Email: mrudy@mcg.edu

Check out more volunteer opportunities.

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My Kind of Medicine: Real Lives of Practicing Internists: Doron Schneider, MD

Doron Schneider, MD

“I saw an opportunity and went for it,” says Doron Schneider, MD, about the start of his career at Abington Memorial Hospital, just 20 miles outside of Philadelphia, PA. As a young physician looking for the right opportunity, Dr. Schneider liked Abington from the start, and they liked him back. Now twelve years later, he has a diverse career that has included many titles: physician, safety and health care quality director, assistant professor, internal medicine program director, and health care reporter among them. Dr. Schneider has worked hard for all of it, with much drive and focus and a healthy dose of emotional depth.

The Different Shades of Joy
“Bedside care brings me a tremendous amount of emotional pleasure because I can really feel the core of humanism,” he says about his role as an internist. “In my job I’ve learned to help people through both their tragedies and their joys, and that’s what really keeps me going.” One such instance he says had happened just that day, with a patient who had been diagnosed with brain cancer. Since the man was still an in-patient at Abington, Dr. Schneider paid him a visit in room 231, during which he promised the patient that he would do everything he could, from helping him navigate the health care system to finding a specialist. “What I told him was, ‘We’re going to go through this together. I’m not going to know all the answers, but I will be with you the entire way—making sure you get the best care and see the best specialists. And after you see them, I will help you decipher that care.’”

The 40-year-old from Dresher, PA was born in Israel but grew up in northern New Jersey. After graduating from Emory University, he completed his internship and residency at the Beth Israel Deaconess Medical Center in Boston. At Abington, he is the deputy program director of the internal medicine residency program. He is also an assistant professor of medicine at Drexel University School of Medicine and the founder of Community 2000, a community outreach and educational program in Newark, N.J. sponsored by The Robert Wood Johnson Foundation. Like many physicians, even after all of the training and preparing, his truly meaningful experiences treating patients have been learned on the job.

As an example, he talks of another experience that affected him in unexpected ways—losing a 45-year-old patient to asthma. “I’ve never cried so hard for a patient,” he recalls. “It was rewarding to get into touch with my emotions.” Dr. Schneider advocated relentlessly for the patient, trying to use his knowledge of the health care system to get the patient the best care, even at one point steering him towards a different healthcare system to see a top specialist. Sadly, the patient eventually passed, but Dr. Schneider’s work did not end there. As he explains, an internist can play an important role at the end of someone’s life and beyond. “At that point you are really healing the family,” he says. “When I went to the funeral, the wife and family hugged me and told me how much they appreciated what I had done for him. They are patients of mine still. My involvement with this family is an example of how as an internist you can feel both the joy and the sadness.”

Eye on the Ball
In the recreational soccer league comprised of fellow Abington colleagues, Dr. Schneider plays either forward or center. He likes being part of a team, and says team-based care is the future of internal medicine. “The whole model is going to change I think,” he says. “We’re starting to see more of a team emphasis … I think the new wave of internists will be able to gain a new sense of satisfaction from being able to function in that role … to see that the whole show doesn’t depend on them.”

In addition to his clinical care, Dr. Schneider works as the director at the Center for Patient Safety and Healthcare Quality at Abington, founded two years ago. He says the role allows him to use innovation and creativity to problem solve. “There are a lot of problems in health care and you need creative solutions,” he says. “The safety and quality work is very satisfying because I get to use my out-of-the-box approach in a manner that’s very freeing.” He adds how the work entails working across departments and disciplines. “I love how you have to have relationships across the hospital—it’s a web of relationships which I think is at the core of internal medicine—whether you’re trying to heal a health care system or a patient.”

One area he enjoys especially is the internal medicine residency program. He says residents are always pushing him and his peers to the next level of performance. “They are always going to ask the hard questions,” he says. “Being able to share your knowledge and experience with students and residents and help them grow as future clinicians is really tremendous, because you can see the beauty of the profession and how you can make a difference.”

Going for It
In addition to his talent for kicking soccer balls and treating patients, Abington has found another skill of Dr. Schneider’s that they have put to use: public speaking. When the hospital coordinated a series of community lectures on health related issues, Dr. Schneider, naturally articulate and expressive, was a perfect fit. This led to another opportunity when some time later, ABC Philadelphia affiliate Channel 6 approached area hospitals in search of a health reporter. Abington recommended Dr. Schneider and he got the job. He participates when time allows. He cites it as an example of the many interesting choices open to internists. “They were interested in me because I’m an internist,” he says. “I like that I’ve chosen a different career path that’s allowed me to have different challenges every day. It’s extremely rewarding to get out of bed every morning and never know what you’re going to face.” All of his professional activities he says, no matter what the setting, hold the same purpose for him. “I’m able to say that I can impact care, whether I’m at the bedside delivering one-on-one care to a patient, or working across the system to put policies and procedures into place that look at care and improve it.”

He complements his career with much valued down time, which he spends with his wife and four children, and by staying busy with jogging, playing soccer, or playing the saxophone. While accomplished, he comes across as grounded and self-deprecating. When asked how his friends or family would describe him he replies, “I guess they would say I’m kind … and that I try to be funny. Sometimes I think I’m funnier than I am.” But while his sense of humor might be of some debate, it seems no one would dispute his sense of duty as an internist, most of all his patients, who likely take comfort in knowing that their doctor will stand by their side, even when he is no longer obligated to do so. In fact, it seems Dr. Schneider makes the most impact in these moments, like the afternoon he made the decision to turn into room 231, rather than continuing to walk down the hall.

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: Wayne State University School of Medicine

Wayne State

Wayne State University Internal Medicine Interest Group leadership. From L to R: Christopher Saddler, MS2; Stephanie Judd, MS4; Diane Levine, MD, FACP; Harpreet Wadhwa, MS2; David Zhen, MS2; and Jawad Khan, MS2.


The Wayne State University School of Medicine Internal Medicine Interest Group (IMIG), founded in 1981, is one of the most active specialty interest groups on campus with more than 250 student members. Since its beginning, the mission has been to provide student-centered mentorship and career development for students potentially interested in careers in internal medicine.

Our faculty advisor, Diane Levine, MD, FACP, has been instrumental in helping the IMIG student leadership achieve this mission. Serving as faculty advisor for the past seven years, she has been a role model and mentor, assisting the coordinators in developing innovative programs that expose students to the field of internal medicine. When asked about her role, she states, “I try to be a liaison between the Department of Medicine and medical students. I use my position to provide clinical, networking, and mentoring opportunities for students. Providing opportunities and connections to the department allows for the development of relationships between attending faculty and students. These relationships enrich the medical student experience and help students see what being an internist means and the gratification one realizes as an internist.”

In past years, Wayne State’s IMIG has sponsored a wide range of events including an introductory seminar to the field, a dinner with John Flack, MD, MPH, FACP, Chair of the Department of Internal Medicine, a seminar on health literacy and cultural competency, an asthma health screening fair, and our most popular event, a clinical skills night. Throughout the year, we have also offered ongoing opportunities to shadow physicians at the Detroit Medical Center hospitals and clinics. This opportunity, along with the clinical skills nights, has allowed students in their pre-clinical years to cross the chasm between the basic sciences and clinical practice and to gain a sense of what they are striving towards as student doctors and future physicians.

This year, our coordinators kicked off the year with IMIG’s traditional American College of Physicians (ACP) sponsored introductory seminar. Dr. Levine and the residents shared their experiences in the field and reasons for choosing internal medicine as a career. Our second event of the year, entitled “Pathway through Medical School,” was a seminar which focused on how to successfully navigate through both the pre-clinical and clinical years as well as how to find research, volunteer, and mentoring opportunities in internal medicine. Our third event took place in Dearborn, MI, at the ACP Michigan Chapter Annual Scientific Meeting. Each year the Michigan ACP Chapter offers student-focused sessions at their meeting. This year, with the support of Ruth Hoppe, MD, FACP, Governor of the Michigan ACP Chapter, a symposium was organized to provide an opportunity for students to present their research, patient care, and community service experiences. Miriam Levine, a second year medical student, presented her summer research that she conducted in Israel as well as her volunteer work through the Code Blue student organization. Ms. Levine said, “It was a wonderful opportunity to present my work and to also meet other students and learn about their research. To see the ACP interested in students attests to their commitment in helping us succeed, and the meeting served as a stepping stone for further opportunities during medical school.”

The most recent event that IMIG hosted was a clinical skills night, where small groups of students were taken by an attending physician to inpatient wards at Detroit Receiving and Harper University Hospitals to interview and examine patients. Harpreet Wadhwa, IMIG co-coordinator, helped organize this event and stated, “This was an opportunity for students to go to the bedside—where real medicine happens. They were able to learn various examination techniques and see patients with diseases that they were learning about in the classroom. We had over 60 students attend; it was a very positive experience.” Having received many accolades from students, the coordinators plan to host additional clinical skills nights in the future. Other events planned for the year include a seminar on organ donation, a residency panel hosted by fourth year students who have matched in internal medicine, and a state-wide ACP student-only meeting.

The 2008-2009 IMIG Coordinators are Harpreet Wadhwa, MS2; David Zhen, MS2; Christopher Saddler, MS2; and Jawad Khan, MS2. Traditionally, second-year students who have participated in the group during their first year of medical school have served as coordinators for IMIG. However, a new addition to our team this year is Stephanie Judd, MS4, a former IMIG co-coordinator who is serving as Senior Student Advisor. Together with our faculty advisor, our group strives to provide educational, research, and volunteer opportunities through IMIG and ACP, foster career development, and improve the care of the patients we serve. We look forward to continuing an already productive and exciting year and would appreciate your comments and suggestions for future events.

Stephanie Judd
Senior Student Advisor, Internal Medicine Interest Group
Wayne State University School of Medicine, Class of 2009
Email: sjudd@med.wayne.edu

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Winning Abstracts from the 2008 Medical Student Abstract Competition: Correlation Of The Asthma Control Test With Exhaled Nitric Oxide

Authors: Douglas L Nguyen, Dominique M. Brandt , Jessica Wentworth, Jonathan A.Bernstein

Introduction
Clinicians typically rely on patient symptoms, spirometry, and peak expiratory flow rates to assess patient with asthma. However, fractionated exhaled nitric oxide (FENO) is becoming increasingly recognized as an important clinical tool for diagnosing and assessing asthma because it correlates well with airway inflammation, is non-invasive, easy to perform and reproducible. Our objective is to determine the utility of using the Asthma Control Test (ACT) alone or in combination with FENO in order to further improve the clinician’s ability to measure asthma control.

Methods
This study enrolled 100 patients between the ages of 18-79 with a physician-diagnosis of asthma confirmed by a 12% improvement in FEV1 post-bronchodilators. Patients were excluded if they had a diagnosis of chronic obstructive pulmonary disease and/or were active smokers. Correlation coefficients were obtained using the Spearman rho for nonparametric data and multiple regression analysis was performed using ACT as the dependant variable while controlling for medication, asthma severity, age, gender, body mass index (BMI), FENO, FEV1, FVC, and PEFR.

Results
Population characteristics were as follows: 56% female, 45% male, 79% Caucasians, 20% African Americans and 1% Asian. The median age of the population was 50 (range 18-79 yrs) and the median FENO was 28 ppb (range 3.3-205 ppb). Seventeen patients were on oral corticosteroids (CS). The analyses were performed including and excluding the oral CS population. After excluding subjects on oral CS’s, the average FENO level correlated very well with the ACT for subjects between the ages 25 to 67 (rho= - 0.31 p=0.01) but not for subjects younger than 24 or older than 68. The ACT correlated with FEV1, FVC and PEFR regardless of age. Using a cut off of 20 ppb for average FENO and 19 for ACT, there was concordance between the FENO and ACT in 68% of subjects between the ages 25 to 67. Regression analysis of subjects in the 25-67 y/o age range revealed that the ACT results significantly interacted with FENO (p=0.07), FEV1 ( p=0.03), FVC (p=0.03), PEFR (p=0.0007) and a trend with gender (p=0.08), but not BMI , age, medications or asthma severity.

Conclusion
The ACT correlates well with average FENO and other lung function markers for asthma in subjects between the ages of 25 to 67 whereas poor correlation was seen in younger and older age groups. These findings suggest that optimal correlation between the average FENO levels, ACT, and lung function may be age dependent. These results also emphasize that FENO is a useful biomarker for identifying asymptomatic patients with poorly controlled asthma.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Infectious Disease

The Discipline
From the Latin word inficere, "to dye or stain" but also "to corrupt or spoil." The ancients conceived that disease could result from the entrance of invisible agents into the body, a sort of "tainting."

Infectious disease medicine requires an understanding of the microbiology, prevention, and management of disorders caused by viral, bacterial, fungal, and parasitic infections. This understanding includes the appropriate use of antimicrobial agents, vaccines, and other immunobiological agents. Important content includes the environmental, occupational, and host factors that predispose to infection, as well as the basic principles of epidemiology and transmission of infection.

Procedures
Important procedural skills include the proper collection of culture specimens, Gram and other staining techniques. The specialist in infectious disease is an expert in ordering and interpreting antibiotic sensitivity tests and serum levels, CD4 counts, ELISA, polymerase chain reaction, immunoblotting studies, and serology for infections.

Training
Infectious disease fellowship training requires two years of accredited training beyond general internal medicine residency. During the two years, a minimum of 12 months must include clinical training in the diagnosis and management of a broad spectrum of medical diseases.

Certification
The American Board of Internal Medicine offers certification in infectious disease.

Training Positions
As of August 2005, there were 141 ACGME-accredited training programs in infectious disease with 679 active training positions. 41% percent of the trainees were female, and 48% were US medical graduates.

Practice
Approximately 40% of the graduates in the United States enter clinical practice in infectious disease, and 43% enter academic medicine.

Major Professional Societies

  • Infectious Diseases Society of America

    • 66 Canal Center Plaza, Suite 600
    Alexandria, VA 22314
    (703) 299-0200

    http://www.idsociety.org

Major Publications

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Advocacy Brief: House Economic Stimulus Package Includes Provisions to Support Primary Care

The U.S. House of Representatives is considering an $825 billion economic stimulus package that contains $157 billion in health care related provisions. Several provisions support and strengthen the nation's primary care infrastructure, clearly showing that Congress and the incoming Obama administration view primary care as a critical health care component in the nation's overall economic recovery plan.

Specifically, the draft measure provides $600 million to train primary care health professionals, such as primary care physicians, dentists and nurses, while also helping medical students who agree to practice in underserved areas after graduation pay their medical school expenses through the National Health Service Corps.

Other Health Care Provisions

Other provisions in the economic stimulus package related to health care spending include:

  • $20 billion for health care information technology

  • $1.1 billion for comparative effectiveness research conducted by the Agency for Healthcare Research and Quality.

  • $550 million to modernize technology at Indian Health Service hospitals and health care facilities;

  • $3 billion to promote preventive care and wellness programs;

  • $1.5 billion for renovations and expansions of community health centers;

  • $900 million for research into an experimental pandemic flu vaccine and countermeasures for potential chemical and biological attacks.

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ACP’s Leadership Day and Key Contact Program Experience: Viral Patel

I Made an Impact on Capitol Hill by Participating in ACP’s Leadership Day and Key Contact Program

One hundred and thirty million people let their voices be heard during this past election. We all understood the importance of voting and how our futures will be shaped by this new administration. Along with the new administration, new members of Congress need to hear the voices of their constituents.

Every year, the American College of Physicians hosts a Leadership Day where internists, residents, and students congregate and visit their congressional representatives as a team. Both times I have attended Leadership Day, I learned so much about the deficits in our healthcare system and the improvements that need to be made. Not only did I feel like I was actively participating in reform movements but I also was able to see the outcomes of our work.

President Obama understands the challenges that so many Americans face. With the rising costs of healthcare and our healthcare insurance unable to meet these costs, primary care medicine and taking care of families is imperative.

Politicians do not see the lines of people waiting to see physicians. They do not get to see internists running around the clinic and spending ten minutes per patient just to pay the bills. This is why we, as healthcare providers, need to unify our voices to describe this plight and project this message to Capitol Hill and President Obama.

The question from medical students is why should we spend time talking to people about things over which we have no control and that will not affect us for another 5-6 years? At first, I felt like that. Then our ACP Kentucky Chapter Governor, Mary Duke, MD, FACP, spoke at our internal medicine interest group meeting and assured me that I could make a difference. The Kentucky Chapter was able to finance my trip, so off I went to Washington, DC.

My questions and anxiety did not end there. I still wondered why I was spending two days in Washington, DC, being part of a team to see our Kentucky representatives, when I could be studying for anatomy or rounding on patients.

The first time I went to Capitol Hill I realized how important Leadership Day was. I never thought that I, as a student, could make an impact on my elected officials, but they listened. Not only did they listen, they asked me questions about why I was thinking about not entering primary care and what concerns I had about the current state of healthcare. They know that students are future of healthcare and this is why we should take an active stand on healthcare reform.

There are times when I feel so overwhelmed with school and life that I cannot even fathom taking two or three days out to travel to Capitol Hill. ACP has come up with a perfect solution for members who want to take an active part, but do not necessarily have the time that needs to be dedicated to a full advocacy trip. The Key Contact Program is the perfect grassroots solution. It allows members to have their voices heard and gives them the tools necessary to develop and maintain relationships with their congressional representatives.

The Key Contact program informs members about important upcoming decisions being made on Capitol Hill and the stance that would best support primary care. Key Contacts are sent an e-mail template ready for one to review, edit and then easily push the send button. This message is sent right to the e-mail boxes of your senators, representative, and their staff members. It is the perfect solution to our busy lives and I encourage all of you to join. If urgent action is needed, we are asked to call our congressional representatives instead. We are given talking points that make calling very easy.

Remember, it is important to shape the future because we are the ones who will live in it. I hope to see some of you at Leadership Day this May and I hope you become a Key Contact today. If you have any questions about these programs, please feel free to contact the ACP Washington staff persons below, or e-mail me directly at viral.patel@uky.edu.

Leadership Day
Shuan Tomlinson
State Health Policy Coordinator
stomlinson@acponline.org

Key Contact Program
Jolynne Flores
Supervisor Grassroots Advocacy & PAC
jflores@acponline.org

Viral Patel
Council of Student Members Representative, Central Region
University of Kentucky College of Medicine, 2010
viral.patel@uky.edu

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Did You Know You Have Access to Annals of Internal Medicine Online?

The most widely cited medical specialty medical journal in the world, Annals of Internal Medicine delivers major review articles, incisive original research, topical clinical reviews, thought-provoking editorials, and a spirited exchange of medical opinion. To access your Annals Online subscription, register on the Annals web site at www.annals.org.

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MKSAP for Students 4 Question 1

A 68-year-old man is evaluated in the office for pain in his right great toe. Two days ago, he had coronary angiography from the right femoral artery that showed three widely patent bypass grafts and a total occlusion of the second diagonal artery. Percutaneous revascularization was attempted but was unsuccessful. The patient has a history of type 2 diabetes mellitus, hypertension, and exertional chest pain.

On examination, his toe is painful to touch but not warm (Figure 1). Laboratory studies show a normal hematocrit and leukocyte count; serum creatinine is 2.2 mg/dL (pre-procedure serum creatinine was 1.6 mg/dL). Urinalysis shows eosinophils. Electrocardiogram is unchanged from a previous tracing.

Which of the following is the most likely diagnosis?

A. Cholesterol emboli
B. Gout
C. Femoral artery dissection
D. Radiocontrast nephropathy

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MKSAP for Students 4 Question 2

A 73-year-old woman is evaluated in the office during a routine examination. She has no complaints and feels well. Her medications are levothyroxine for hypothyroidism and hydrochlorothiazide for hypertension. An electrocardiogram performed 2 years ago was normal.

On physical examination, heart rate is 42/min and regular. The remainder of the examination is normal. Her thyroid-stimulating hormone level is normal. An electrocardiogram obtained as part of the current evaluation is shown (Figure 2).

Which of the following diagnoses is confirmed by the electrocardiogram?

A. First-degree atrioventricular heart block
B. Mobitz type I second-degree atrioventricular block
C. Mobitz type II second-degree atrioventricular block
D. Third-degree atrioventricular block (complete heart block)

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MKSAP for Students 4 Answer 1

Answer: A: Cholesterol emboli

Any patient who develops a new peripheral ischemia after an invasive procedure involving arterial access should be suspected of having cholesterol emboli. In a prospective study of 1786 consecutive patients =40 years of age who underwent left-heart catheterization, cholesterol embolism syndrome was found in 25 patients (1.4%) including 12 (48%) with cutaneous signs and 16 (64%) with renal insufficiency. Eosinophil counts were significantly higher in patients with this syndrome. Urinary eosinophilia is also common. The in-hospital mortality rate was 16.0% (compared with 0.5% of unaffected patients). The incidence of cholesterol embolism syndrome increased in patients with atherosclerotic disease, hypertension, a history of smoking, and elevation of baseline C-reactive protein values. This patient's presentation is typical for cholesterol emboli likely related to catheter manipulation and dislodgement of an atherosclerotic plaque during cardiac catheterization. Treatment is supportive.

This patient has no history of gout; in addition, his extremity was not warm to touch, and there was evidence of ischemic necrosis of tissue. Femoral artery dissection would not be associated with renal dysfunction or urinary eosinophils. Radiocontrast nephropathy, common in elderly patients with diabetes mellitus, would not be associated with ischemic necrosis of the toe.

Bibliography
1. Fukumoto Y, Tsutsui H, Tsuchihashi M, Masumoto A, Takeshita A. The incidence and risk factors of cholesterol embolization syndrome, a complication of cardiac catheterization: a prospective study. J Am Coll Cardiol. 2003;42:211-6. [PMID: 12875753] [PubMed]

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MKSAP for Students 4 Answer 2

Answer: D: Third-degree atrioventricular block (complete heart block)

Third-degree atrioventricular block, or complete heart block, refers to a lack of atrioventricular conduction (characterized by lack of conduction of all atrial impulses to the ventricles), as seen in this patient's electrocardiogram. Many patients with complete heart block are symptomatic and are treated with a pacemaker. There is some evidence that pacemaker implantation may improve survival for patients with asymptomatic complete heart block; therefore, all patients with complete heart block should be treated with pacemaker implantation.

First-degree heart block is recognized electrocardiographically as a prolongation of the PR interval; all P waves are conducted and this condition requires no specific treatment. Second-degree heart block is characterized by intermittent nonconduction of P waves and subsequent “dropped” ventricular beats. Second-degree heart block is divided into types, Mobitz I and Mobitz II. Mobitz type I second-degree heart block is characterized by progressive prolongation of the PR interval until a dropped beat occurs. This type of heart block is characteristically transient and usually requires no specific treatment. Mobitz type II second-degree heart block is characterized by a regularly dropped beat (e.g., a nonconducted P wave every second or third beat) without progressive prolongation of the PR interval and is usually associated with evidence of additional disease in the conduction system, such as bundle branch block or bifascicular or trifascicular block. Mobitz type II heart block suddenly and unpredictably progresses to complete heart block and is usually treated with a pacemaker.

Bibliography
1. Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, et al. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation. 2002;106:2145-61. [PMID: 12379588] [PubMed]

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ACP’s Online, Mobile Game based on the Popular ACP Doctor's Dilemma™ Competition

Test your knowledge in a variety of disciplines with this new online game based on the popular ACP Doctor's Dilemma™ Competition from the ACP's annual Internal Medicine meetings. The game is simple to play and all you need is a web browser.

Because this product was designed using standards for mobile web content, all devices equipped with a Web browser are supported, including mobile smartphones and PDAs like Windows Mobile devices and Palm OS devices. An active Internet connection is required to play, but there is nothing to download or install. Learn more.

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Attend the Fifth Annual Internal Medicine Residency Fair

The Fifth Annual Internal Medicine Residency Fair will be held during ACP’s national scientific meeting, Internal Medicine 2009, on Saturday, April 25th. We have acquired a better location and time slot for the Residency Fair this year, which will be held from 11:30 a.m. to 1:30 p.m. in Exhibit Hall B of the Pennsylvania Convention Center, next to the Medical Student-Associate Poster Area and the action on the Exhibit Hall Floor.

At the Residency Fair, you will learn about internal medicine residency programs throughout the United States, while you gather essential information about the residency application process and the Match. You will also have the opportunity to practice your networking skills while introducing yourself to internal medicine residency program staff and meeting fellow medical students.

To register for Internal Medicine 2009 visit: www.acponline.org/meetings/internal_medicine/2009/attendees/. If you have questions about the Residency Fair please e-mail Membership Development at mbrdev@acponline.org.

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Articles for Medical Students from ACP Internist

ACP Internist (formerly ACP Observer)

  • Clinical Research
    When trials are cut short, who benefits?
    Does speeding a potentially effective drug to market benefit patients, or does it benefit drug companies? Experts offer tips on how to decide.
  • Perspectives
    Mindful Medicine: Perils of diagnosing the physician-patient
    A physician diagnoses himself, leaving a colleague to undo some of the mistaken thinking and come up with a simple diagnosis.

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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

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

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.

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