July 2007 E-Newsletter

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

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

A 58-year-old black woman is evaluated because of fatigue and increasing dyspnea on exertion. She began menopause approximately 6 years ago and is taking hormone replacement therapy for debilitating hot flashes. Medical history is otherwise noncontributory. She does not take any other medications, eats a well-balanced diet, and has not lost weight. Although she goes for yearly mammograms, she has put off being screened for colorectal cancer. There is no family history of colorectal cancer.

Significant findings on physical examination are conjunctival pallor and a faint systolic flow murmur.

Laboratory Studies
Hematocrit: 30%
Mean corpuscular volume: 72 fL
Serum ferritin: 2 ng/mL
Serum transferrin saturation: 10% (normal: 15% to 55%)
Serum electrolytes: Normal
Liver chemistry tests: Normal
Renal function tests: Normal
Urinalysis: Normal
Fecal occult blood test (six windows): Normal

Which of the following should be done next?

( A ) Upper endoscopy
( B ) Colonoscopy
( C ) Barium enema examination
( D ) Flexible sigmoidoscopy
( E ) CT of the abdomen and pelvis

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Answer for June Contest Question

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Click here to see June's question.

Answer to May Contest Question: D

Answer to June Contest Question: (E) Stop the alendronate

This patient has an alendronate-induced esophageal stricture. The mid-esophageal location of the stricture and the temporal association of starting alendronate shortly before symptoms developed are highly suggestive of this diagnosis.

Although a mid-esophageal stricture may also be due to Barrett’s epithelium, the biopsy specimens show only chronic inflammation. The most appropriate management after endoscopic dilation is to stop the causative agent. Surgical procedures or additional changes in the patient’s drug regimen are not needed.

References

Naylor G, Davies MH. Oesophageal stricture associated with alendronic acid. Lancet. 1996;348:1030-1. PMID: 8855876

Kikendall JW. Pill induced esophageal injury. In: Castell DO, Richter JE, eds. The Esophagus. 3rd Ed. Philadelphia: Lippincott Williams & Wilkins; 1999.

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Medical Student Perspectives: How to Be Successful in your Third-Year Clerkships

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The third year of medical school is arguably one of the most important years of your medical career. It is also one of the most challenging and rewarding years at the same time. You will be surrounded by unfamiliar faces and environments, and just when you start to get the hang of things, you will switch rotations and start all over again! Despite the unfamiliarity, the year is full of excitement, and looking back, seems way too short. Having just finished up my core rotations, I now look back and wonder where the time went. So how do you make the most of your third year clerkships and impress your residents and attendings? Following are some helpful hints.

Ask for Advice
Get information regarding the clerkship from students who have gone before you. They can give you advice on which rotations are the most rewarding, which are somewhat malignant, and most importantly, what to expect. When you start your clerkship, make sure you have a sit-down meeting with both your residents and attendings to go over their expectations of you for the month. Be sure to arrange a mid-month evaluation to track your progress and identify areas of improvement. This meeting is your responsibility to initiate, and be firm that you would like specific suggestions for improving.

Work as a Team
Teamwork is one of the most important components of the third year. Your primary responsibility is to learn, but there is also a lot of work that needs to be done to ensure good patient care. Though it may not be fun, try to take on any “scutwork” (i.e., fetching lab results, discharge summaries, making social-work related phone calls) with grace and show your team that you are willing to help in whatever way. The right attitude will go a long way, not only with ensuring that the team runs smoothly, but with your evaluations as well.

Get Ready to Round
Rounding can make up the majority of your day. Typically students “pre-round” first and see their assigned patients alone, then “work round” with their residents, and then have “attending rounds” where they see all the patients with the attending. If you are just starting out, leaving about half an hour per patient in the mornings should be more than enough time to get all your work done. One word of caution: if you know your team is admitting patients the night before, expect to go in a little earlier than normal because you may be expected to pick up and present a new patient that was admitted overnight. Although many attendings will not expect you to present a patient that you did not admit, it can vary, and is better to be safe than sorry.

Be Prepared to Present
When making presentations during rounds, be sure you ask your attending how much detail he or she would like during your presentation and then adjust accordingly. You should be prepared to give a whole history and physical on rounds for a new patient. Old patients can be presented in the SOAP note format. The most important parts of your presentation and notes are the physical exam and the assessment and plan. By leaving yourself enough time in the morning, you will be able to think about the patient’s presentation and come up with your own plan. No one expects you to get this part right, but they do want to see that you made an attempt to come up with a care plan for your patient. Be prepared to explain “why” for anything you say or write. You will be asked questions regarding pathophysiology and treatment during rounds. While presenting can sometimes be scary, some of my best learning experiences have occurred during the questioning period during rounds. If you are asked a question regarding the physical exam about something that you forgot to check do not lie! Courteously respond that you did not check that area. You will be doing yourself and your patient a huge disservice by lying and you will inevitably get burned even more for lying than for not checking a specific physical finding.

Stay Organized
Stay as organized as possible on the wards. There is a myriad of information that you will need to have readily available during rounds. One of the toughest parts of the rotation is staying organized. You will have to experiment and find your own system. Ideally, all of the patient’s information from his or her current hospital stay should be kept on one single sheet of paper. You can also carry around things like the patient’s echocardiography report if it is very detailed and likely that someone will want to see the original. It is important to keep the previous lab values readily available, since you will frequently be asked to compare the current values to the last values. Templates for organizing patient information can be found on the web. Make check boxes for all the tasks that need to be done after rounds and check them off as you complete them.

Keep Up on Your Studying
Days on the wards can be exhausting. Another challenge of third year is making effective use of your time. Speaking from experience, it is essential that you set aside at least one hour every day for studying. Once you get home and have had dinner, it is not uncommon to feel like it is time for bed! Make it a priority to study every night in your review books and also about your patients’ specific conditions. Your grade is determined by both your evaluations on the wards and by the test, so do not neglect one to do well on the other. Great study resources include ACP’s MKSAP for Students 3 and Internal Medicine Essentials for Clerkship Students. One of the common medicine textbooks, like Cecil’s, Harrison’s, or ACP Medicine, will be a great resource for reading up on your patients’ conditions.

Do Not Be a Gunner
Attendings know a gunner when they see one and they do not appreciate this personality style. Patients and work should be evenly divided among the medical students. If an attending asks a question that is clearly directed to someone else, and that person does not know the answer, do not shout out the right answer. Wait to be asked or for the question to be offered to the group. There is also such a thing as rounding etiquette. It is poor form to make anyone on your team look bad during rounds. You are a team and should work together to make everything run smoothly. You may experience several scenarios such as the following: you present an assessment and plan during work rounds with your resident, however your resident corrects you and offers an alternative plan. When you offer that new plan in attending rounds, your attending corrects you and offers your original plan as the right course of action. In such a case, do not expose your resident as the source of erroneous information—take the criticism maturely and move on. You can hope that next time your resident will be big enough to admit when he or she is wrong.

Make Time for Yourself
It is important to continue doing the things that you love to do. You may not be able to exercise as much as you used to, but certainly several times a week is a reasonable goal. Be sure to take time for yourself, even if it just means “vegging” for a little while. Identify someone in your class that you can talk to about any issues you have. If you find yourself struggling emotionally or physically during the year, do not wait to get help. There are many people who have a lot of experience helping medical students.

Keep a Positive Attitude
The most important advice I can provide is to have a good attitude. By being willing and eager to learn, you will make your superiors willing and eager to teach. Volunteer to help whenever you can, because you never know what you will learn in any given situation. The more you see, the more you will remember. It is much easier to retain information about a disease after you have seen it in a patient rather than read about it in a book. Most of all, have fun! Third year is exciting. It is also probably the only time you will get to see such a broad range of medicine, providing a variety that you will not be able to experience once you are in practice.

Jacquelyn Coloe
Vice Chair, Council of Student Members
The Ohio State University School of Medicine, 2009
E-mail: Jacquelyn.Coloe@osumc.edu

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My Kind of Medicine: Elizabeth Warner, M.D.

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Elizabeth Warner, M.D.When Dr. Ruth Hoppe talks about her patients, her eyes glow. This is the image Dr. Elizabeth Warner sees when she thinks of her most influential mentor. She also thinks about what a great communicator Ruth is and how she uses her talent for it to put people at ease. “She never opens her mouth without having the words well crafted and well thought out,” says Dr. Warner. “I thought how comforted I would be as a patient if my doctor talked to me that way.”

The Optimist

As an undergrad, Dr. Warner had an epiphany. While studying the brain in a psychology class for an international relations degree, it occurred to her that a career in medicine might be just what she wanted. Her inclination was further encouraged by a pathologist she met who had entered the field of medicine at the age of 30. Within a week she had a plan. “That was in October of 1991 and by January 2002, I was taking all of my premed courses. I never looked back.” By the time she was in medical school at Michigan State University, the influence of Dr. Hoppe, who currently serves as Governor for ACP’s Michigan chapter and her other mentors was all she needed to make up her mind. “My decision to go into internal medicine was in part driven by my own tendencies toward detail and comprehensive understanding and part by interacting with practicing physicians,” she says. “I saw how they dealt with patients—to me they were examples of excellent professionalism. I knew I wanted to be able to do the same thing. That’s how I knew I was a primary care gal.”

Dr. Warner works for Bronson Healthcare Group, an award-winning practice system serving southwest Michigan and northern Indiana. She shares a practice with three other partners in Kalamazoo, MI. It is a good fit for Dr. Warner, even though there are times when she has to give a little more than usual, such as a week in July when one partner had an emergency appendectomy and the two others were out on scheduled vacation. But weathering these temporary bumps is a small sacrifice for such a rewarding career, according to Dr. Warner. She is thrilled by the flexibility her career allows her and says it’s this flexibility that gives her the chance to spend time with her family and to pursue her many interests.

A conversation with Dr. Warner reveals an infectious enthusiasm and compassionate warmth. In the face of a disappointment, she is able to rebound and turn it around, as she did once in her first six months of practice after a humbling experience with a patient. The patient had a foot ulcer that Dr. Warner had missed in its early stages. The condition worsened and grew infected. After being successfully treated by a specialist, the patient returned to Dr. Warner, upset and wanting an explanation. “This was one of my more challenging moments—I apologized over and over— I just said ‘I messed up and I’m sorry,’” she says. “He’s still my patient today. I think he is because I was honest with him. I am grateful to be his internist. To be able to be involved in people’s lives is a reward I never take for granted.”

A Passion for Progress

The condition and challenges of the U.S. health care system are well known to many, and while anyone can say they “stand” for reform, few can say they do something to actively promote it. Dr. Warner is a full participant in life and channels her positive energy in many ways—as a mother of two boys, as a volunteer for the American Cancer Society, and now as a member of Physicians for a National Health Program, a national organization dedicated to the right to high quality health care for all. She is new to the organization, but no less informed about the issues, which she struggles with first hand every day. “Every hour of every day I dance with insurance companies—finding the medicine they like, the code for the test I think is medically necessary and that they think is justifiable for payment,” she says. “I love my job but this is the aspect which makes it the most difficult,” she admits.

Another topic she is passionate about is the obesity epidemic. “So much of the medical care I provide now relates to the treatment of obesity,” she says, “and I see how it affects the health of my patients. I would really like to write a book about it.” She plans on continuing her career as an internist. “This is a wonderful career. It gives me the luxury of balancing my professional life with my family life and it gives me that quality of patient interaction that I absolutely require.”

At the age of 38, Dr. Warner’s quest to be the skilled communicator like her mentor Dr. Hoppe hasn’t waned. She has made a misstep or two along the way, but she has also made triumphs as well. Not too long ago, a longtime patient of Dr. Warner’s was diagnosed with early prostate cancer. The wife of the patient, also a longtime patient of Dr. Warner’s, had just finished follow-up treatment for a surgical procedure. It was a difficult time for the couple, and Dr. Warner, who by then was not only the couple’s physician but also a trusted friend of sorts, felt she needed to give it her all. “I tried my best to do everything within my power to do everything I could for them, explaining everything and getting them the treatment and referrals they needed,” she explains. “And while I won’t ever have that drama of “curing” someone, that’s not really life. For me, the icing on the cake is doing what I can to maximize someone's health over the long term and forge a relationship with my patients in education, support and treatment strategies to help them find their healthy path." After things settled down after the rush of activity surrounding the man’s diagnosis and treatment, the wife contacted Dr. Warner. "Thank you for the referrals, thank you for listening, thank you for everything, thank you for being our doctor," she said.

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Internal Medicine Interest Group of the Month: Stanford University

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At the Stanford University School of Medicine, the Stanford Internal Medicine Interest Group (IMIG) is entering a new stage. Having restarted our group 18 months ago, we enjoy the enthusiastic support of faculty, staff, and residents who have shared their experiences about internal medicine with students exploring future careers. The ACP at both the regional and national levels has been important in helping us during this development. Our student membership and participation have increased within the past year with more room yet to grow.

The Stanford IMIG has its roots together with The Shenson Society, a school organization which honors the memory of two medical graduates from Stanford, Drs. Ben and A. Jess Shenson. The Shenson brothers between them practiced a combined total of over 100 years of medicine in San Francisco. In addition to their many accomplishments in their profession, the Shensons always placed a special emphasis on providing medical students with new opportunities for learning about internal medicine as a career. The Shenson family and their generosity continues to inspire us all to build even more elements into the medical education experience.

Our current group of student members has worked closely with a very active group of faculty mentors and advisors. Drs. Kelley Skeff, Ted Harris, Greg Engel, Rex Chiu, and others have helped us every step along our group’s growth process, and we are experiencing an increasing momentum due to a large group of energetic faculty excited about interacting with students. Our interest group has hosted evening dinner and discussion events, where students and faculty can exchange ideas and personal experiences about several topic areas. Topics have included the many career paths of internal medicine, the combination of research with clinical care, generalists and specialists, career balancing with family, and the lifelong knowledge sphere of teachers as learners and learners as teachers. Our medical students have also participated in other special events, such as opportunities to meet with Shenson Professors Dr. Fred Lopez and Dr. Michele Barry and opportunities to participate in a Science at Stanford lecture series featuring innovation and medicine.

On a regional level, our group is establishing connections with our wider community. With the help of our ACP Northern California Chapter Governor, Dr. Molly Cooke, we are building new networks and bringing together the members of the regional IMIGs of University of California, San Francisco and University of California, Davis, as well as reaching out to other schools and hospitals in the Northern California region who are serving diverse communities. Our participation at local chapter and national level ACP meeting events has provided valuable forums for us to interact with fellow students and colleagues.

It is an exciting time for medicine. We look forward to creating new and unique experiences in our medical education. By learning from each other and exchanging ideas among people at all career levels and training backgrounds, the Stanford IMIG enjoys the exploration of the field of internal medicine both from its traditions and its future.

Ryan K. Louie
Stanford Internal Medicine Interest Group
Stanford University School of Medicine, 2009
E-mail: rklouie@stanford.edu

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Winning Abstracts from the 2007 Medical Student Abstract Competition: Severe Carnitine Deficiency Leading to Hyperammonemic Encephalopathy

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Author:
Berkeley Limketkai, MD, University of Cincinnati College of Medicine, 2007

Introduction:
Carnitine deficiency is an uncommon finding in adults that can lead to hyperammonemia and encephalopathy. We present a case of hyperammonemia that did not respond to traditional therapy until deficient carnitine stores were repleted.

Case Presentation:
A 35 year-old woman, status-post Roux-en-Y gastric bypass for morbid obesity and status-post Puestow and Frey procedures for chronic pancreatitis, presented with altered mental status. The patient demonstrated fluctuating levels of consciousness, disorientation, and perseveration of speech. Other physical findings included hepatomegaly, generalized muscle weakness, ataxia, and asterixis.

Serum electrolytes and glucose levels were normal. She was severely malnourished with an albumin level of 1.6 g/dL and a prealbumin level of 8.2 mg/dL (normal 16-35). Liver enzymes and serum bilirubin levels were mildly elevated. Her ammonia level was 276 µg/dL (normal 40-80), suggesting an encephalopathy secondary to hyperammonemia. She received lactulose and hemodialysis, but ammonia levels continued to rise, peaking at 582 µg/dL.

Workup revealed normal serum levels of ornithine, citrulline, and arginine, which excluded a urea cycle defect. Blood and urine cultures failed to grow urea-splitting organisms. Markers for autoimmune and viral hepatitis were negative. Normal 24-hour urinary copper and serum ceruloplasmin levels ruled out Wilson’s disease. Due to her malnourished state, a diagnosis of carnitine deficiency was entertained. Her total carnitine was low at 22 mM (normal 33.8-77.5). After therapy with oral and intravenous carnitine was initiated, ammonia levels normalized and her mental status returned to baseline.

Discussion:
Initial management of hyperammonemia includes a workup for common precipitating causes and administration of ammonia-reducing therapies. Classic disorders that increase ammonia levels include hepatic dysfunction, urea cycle defects, renal failure, and infection with urea-splitting organisms (e.g., P. mirabilis). Iatrogenic etiologies include total parenteral nutrition, portosystemic shunts, and medications (e.g., valproic acid). There are rare reports, predominantly in the pediatrics literature, that describe systemic carnitine deficiency leading to hyperammonemia.

Carnitine is an essential cofactor for long-chain fatty acid metabolism. It promotes translocation of fatty acyl molecules into the mitochondrial matrix, where ß-oxidation occurs. In carnitine deficiency, accumulation of unoxidized long-chain acyl-CoA inhibits ureogenesis, thereby impairing an important mechanism of ammonia excretion. Moreover, the concomitant decrease of acyl-CoA in the mitochondria indirectly reduces the synthesis of N-acetylglucosamine, an allosteric activator in the urea cycle. Inherited defects in carnitine translocation may present similarly, but with elevated carnitine and acylcarnitine levels.

Normally, 75% of body carnitine stores are derived from dietary protein. However, in the absence of an exogenous source (e.g., strict vegetarians), over 90% of carnitine is synthesized by the liver from lysine and methionine. In our patient, methionine levels were extremely low (6 mM; normal 12-56); hence, hypocarnitinemia resulted from the combination of poor dietary intake and impaired biosynthesis. Carnitine supplementation repleted body stores, restored hepatic excretion of ammonia, and permitted a return to baseline mental status.

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Selected Career Paths: Highlights about Careers in Internal Medicine: Combined Internal Medicine and Pediatrics

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The Discipline

Combined Internal Medicine and Pediatrics (Med-Peds) is the dual training in and dual practice of Internal Medicine and Pediatrics. Physicians practicing Med-Peds see both adults and children in a wide variety of practice settings and practice styles. Practice settings range from outpatient primary care to inpatient hospitalist practice and practice styles range from urgent acute illness care to the longitudinal chronic illness care of patients with congenital heart disease.

Recognizing the need for physicians with in-depth skills in the provision of care to adults and children, the American Board of Internal Medicine and the American Board of Pediatrics approved combined training leading to dual board eligibility in 1967. Since then, combined internal medicine-pediatrics residency programs have flourished, especially since the mid-1980s. Med-Peds attracts bright, capable physicians desiring a challenging career path either in primary care or further subspecialty fellowship training.

With their in-depth knowledge of internal medicine and pediatrics, Med-Peds physicians can synthesize their clinical knowledge onto a life’s spectrum from birth until death. They encounter patients from all walks of life: well baby visits, high risk deliveries, newborn assessments, common childhood illnesses, adolescents, emergency room visits, basic gynecology care, inpatient adult and pediatric patients, outpatient adult and pediatric patients, adult and pediatric intensive care.

Procedures

Important procedural skills include those necessary for both an internist and a pediatrician. Med-Peds physicians report competence in the wide range of procedures commonly performed in outpatient and inpatient settings.

Training

Med-Peds trainees and physicians receive the same in-depth training as their categorical pediatric and internal medicine colleagues. Recognizing a shared knowledge base, a Med-Peds residency is streamlined into 4 years of residency training. Residents change between their internal medicine and pediatric rotations every 3-4 months, depending on the residency program. By the end of 4 years, residents will have completed core requirements for both categorical internal medicine and categorical pediatrics, including some elective time.

Certification

At the completion of residency training, Med-Peds graduates are board eligible for certification by the American Board of Pediatrics and by the American Board of Internal Medicine.

Fellowship

Med-Peds residents may choose to enter a subspecialty fellowship in either or both internal medicine and pediatrics. Having dual board eligibility may prove more competitive to fellowship directors. Many residents choose a fellowship where their expertise in both specialties will be beneficial. Med-Peds trained physicians have pursued nearly every type of fellowship training; cardiology, endocrinology, and infectious disease are among the most popular fellowships. Combined internal medicine and pediatrics subspecialty fellowships can be streamlined via special arrangements with the fellowship directors and the boards.

Practice

Med-Peds physicians practice in the wide variety of settings and styles available to internists and pediatricians. Primary care, inpatient care, subspecialty practice, and urgent care are among the most popular practice styles. Practice settings range from solo practice to large multi-specialty groups to academic medical centers. Some Med-Peds physicians pursue international health careers in the U.S. or other countries.

Professional Societies

American Academy of Pediatrics
American College of Physicians
Society of General Internal Medicine
Pediatric Academic Society

Official Resident Website

National Med-Peds Residents’ Association (NMPRA)

Student Involvement

If you are interested in writing for the quarterly student Med-Peds newsletter or if you have any questions, please contact either Gitanjali Srivastava, MD at gitanjali.srivastava@mssm.edu or David Kaelber, MD at david.kaelber@case.edu, who head the National Student/Resident/Young Physician Med-Peds Subcommittee. They are actively recruiting interested medical students.

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Advocacy Briefs: Enroll in ACP’s Key Contact Program

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

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

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The most widely cited medical specialty 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.

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MKSAP for Students 3 Question 1

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A 28-year-old woman is evaluated in February because of a 6-week history of severe cough. She describes coughing paroxysms, often followed by emesis. She has no postnasal drip. The cough began after a severe upper respiratory tract infection characterized by rhinorrhea, lacrimation, conjunctival injection, malaise, low-grade fever, and sneezing that lasted nearly 2 weeks.

On physical examination, the patient is afebrile. The chest is clear to auscultation, and the chest radiograph is normal. Laboratory studies show a leukocyte count of 12,000/µL, with 30% neutrophils, 65% lymphocytes, 2% monocytes, and 3% eosinophils.

Which of the following is the most likely diagnosis?

( A ) Bordetella pertussis
( B ) Cough-variant asthma
( C ) Gastroesophageal reflux disease
( D ) Sarcoidosis
( E ) Sinusitis

MKSAP for Students 3 Question 2

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A 35-year-old man is evaluated because of difficulty hearing in his right ear since last night. He has no ear pain or drainage, cold symptoms, or vertigo, and he has not experienced any trauma. His history is unremarkable for hearing difficulties or ear surgery, but he has had allergic rhinitis.

On physical examination, he has rhinorrhea and nasal congestion, but appears otherwise healthy. His external canals and tympanic membranes are normal; his turbinates are swollen. A 512-Hz tuning fork is placed on his forehead, and he hears the tone more loudly in his left ear than in his right ear.

Which of the following diagnoses is most likely?

( A ) Left conduction defect
( B ) Right conduction defect
( C ) Left sensorineural defect
( D ) Right sensorineural defect

MKSAP for Students 3 Answer 1

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Answer: A

Educational Objective: Diagnose cough secondary to Bordetella pertussis infection.

The patient has Bordetella pertussis infection (whooping cough). Cough due to B. pertussis qualifies as a postinfectious cough; it usually lasts 4 to 6 weeks.

Whooping cough is increasing in prevalence in the adult and adolescent populations. Although adults may not display the characteristic inspiratory whoop at the end of a coughing paroxysm, they often vomit with coughing and usually have the typical initial catarrhal stage followed by paroxysmal and convalescent stages. Additional clues to the diagnosis include leukocytosis and lymphocytosis in an afebrile patient with a normal chest radiograph. A laboratory diagnosis may be made by detection of antibodies to pertussis toxin or by Bordetella polymerase chain reaction from nasopharyngeal swabs.

The three most common causes of chronic cough include postnasal drip syndrome, asthma, and gastroesophageal reflux; however, there is little supporting evidence for any of these diagnoses. Most patients with postnasal drip syndrome will have symptoms or evidence of one or more of the following: postnasal drainage, throat clearing, nasal discharge, cobblestone appearance of the oropharyngeal mucosa, or mucus in the oropharynx. While patients with asthma usually have paroxysmal attacks of wheezing, cough can be the sole manifestation in some cases. Similarly, while patients with gastroesophageal reflux usually have symptoms of acid reflux and sour taste, some may have cough as their predominant symptom. However, prolonged cough following a severe upper respiratory tract infection is more consistent with the patient's history than is either asthma or gastrointestinal reflux. Sarcoidosis is unlikely because the chest radiograph is normal.

References

Irwin RS, Madison JM. The persistently troublesome cough. Am J Respir Crit Care Med. 2002;165:1469-74. PMID: 12045118

MKSAP for Students 3 Answer 2

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Answer: D

Educational Objective: Properly interpret the Weber test.

Sudden hearing loss should prompt immediate evaluation. The Weber test with a 512-Hz tuning fork will lateralize to the affected side with conductive hearing loss and to the unaffected side with neurosensory hearing loss. This patient's examination strongly suggests right-sided sensorineural hearing loss. The cause of sudden sensorineural hearing loss is uncertain, but viral infections may be responsible. Urgent audiometry and further evaluation by an otolaryngologist are necessary to determine the cause and treatment.

References

Weber PC, Klein AJ. Hearing loss. Med Clin North Am. 1999;83:125-37, ix. PMID: 9927965

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Internal Medicine Residency Program Fast Facts

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Program Name: Brooklyn Hospital Center Program
Location: Brooklyn, New York
Hospital Type: University Affiliated Community Hospital
Program Size: 30 First Year Positions, 82 Positions Total
First Year Salary: $47,000
Web Site Address: http://tbh.org

Program Name: University of Oklahoma Health Sciences Center Program
Location: Oklahoma City, Oklahoma
Hospital Type: University-based Hospital
Program Size: 24 First Year Positions, 59 Positions Total
First Year Salary: $41,000
Web Site Address: http://w3.ouhsc.edu/imrp/

Program Name: University of Nevada School of Medicine Program
Location: Reno, Nevada
Hospital Type: University-based Hospital
Program Size: 16 First Year Positions, 36 Positions Total
First Year Salary: $40,000
Web Site Address: http://www.unr.edu/med/dept/imnorth/

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Announcing the New Internal Medicine Essentials for Clerkship Students 2007-2008 Textbook

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The new Internal Medicine Essentials for Clerkship Students 2007-2008 textbook is now available. Created by the American College of Physicians and the Clerkship Directors in Internal Medicine, Internal Medicine Essentials is written by 68 authors who direct internal medicine clerkships around the country, who help design the internal medicine curriculum, and who are actively involved in teaching students during their internal medicine clerkships. This invaluable guide demonstrates to students how to care for patients, prepare for clinical rounds, and study for the end of rotation examination. Internal Medicine Essentials covers the common problems and disorders a student is expected to understand and likely to encounter. The printed content is enhanced with clinical photographs, tables, screening tools, and other instruments on the Internet. This is a unique resource that provides medical students with the skills they need to enhance learning during the third-year internal medicine clerkship.

List Price: $49.95
ACP Student Member Price: $39.95
Product #: 330361030
ISBN: 1-930513-82-8

Order online.

You can also call ACP Customer Service to order at 800-523-1546, extension 2600 or 215-351-2600 (M-F, 9 a.m.-5 p.m. ET).

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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.