May 2007 E-Newsletter

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

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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 May’s contest question will be included in the June 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 67-year-old obese (body mass index, 34) white man has had type 2 diabetes mellitus for the past 8 years. The disease was originally diagnosed on the basis of a routine fasting plasma glucose level of 156 mg/dL and responded well to initiation of a nutrition and exercise plan. The hemoglobin A1c value decreased from 8.8% at diagnosis to 6.9% after 6 months of nutrition therapy and a 5.5-kg (12-lb) weight loss. After 2 years, the hemoglobin A1c increased to 8.1%; therapy with glyburide, titrated up to 10 mg/d, was started. The hemoglobin A1c value then decreased 6.6% and remained less than 7% until 1 year ago. At that time, the patient noted a 7 kg (15-lb) weight gain and some symptoms of distal paresthesias. The hemoglobin A1c had increased to 7.7%. The patient is counseled to intensify diet and exercise to lose 7 kg (15 lb).

What is the most appropriate additional intervention at this time?

( A ) Add repaglinide therapy before breakfast and dinner
( B ) Increase the glyburide dosage to 10 mg twice daily
( C ) Discontinue glyburide therapy and begin metformin therapy
( D ) Add metformin therapy to the current glyburide regimen
( E ) Switch from glyburide therapy to glipizide therapy

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Answer for April Contest Question

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Click here to see April’s question.

Answer to April Contest Question: D

Although most patients with generalized pruritus have xerosis, this patient did not improve with empiric therapy and scabies is unlikely without a characteristic rash. A minority of patients with generalized pruritus have an underlying disorder, which is more likely in this patient with no skin lesions other than excoriations. Laboratory testing for hematologic causes, renal failure, cholestasis, endocrine disorders, and chronic infection is indicated.

Skin biopsy of an excoriation is unlikely to provide useful information. Treatment with topical corticosteroids without a working diagnosis is not appropriate. Symptomatic treatment with hydroxyzine hydrochloride may help but does not identify the cause. Although referral to a dermatologist would be helpful, the patient should first be evaluated for systemic causes of the pruritus.

References

Etter L, Myers SA. Pruritus in systemic disease: mechanisms and management. Dermatol Clin. 2002;20:459-72, vi-vii. PMID: 12170879 [PubMed]

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Medical Student Perspectives: Cultural Differences and Considerations When Working with Hispanic Patients

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The American College of Physicians has been an early proponent of the need for cultural competency, as reflected by its 2003 position paper, “Race and Ethnic Disparities in Health Care.” The Hispanic population is the fastest growing racial group in the U.S., with a projected 25% of the U.S. population being Hispanic by 2050, according to the U.S. Census Bureau’s 2000 report. This brief introduction is intended to be a framework for awareness of concepts and preferences of Hispanic patients. It bears saying that in any culture, while one size does not fit all, awareness of cultural norms is the starting point for a respectful and effective relationship.

The Language Barrier

Working with an interpreter for a non-English speaker: If translators are provided by your hospital or clinic, be sure to use their services. Their training is focused on medical Spanish and they also understand the legal framework of the situation. If a professional translator is not available, then you must fall back on a family member of the patient, if one is available. If you must use a family member as translator, you should be aware that a family member of any cultural background has limited knowledge of medical terminology and a tendency to “soften” questions or statements that he or she perceives as having potentially negative consequences. There may also be issues that the patient does not want the family member to know, so the patient may not be totally forthright in answering sensitive questions.

Working without an interpreter: If no family member is available, then your Spanish from that spring break in Cozumel back during your undergrad years will come in very handy. Have a pocket reference close by; several good ones are available, but make sure that the focus of your reference book is on medical Spanish. The best references come with pre-written dialogues that can walk you through an interview. Try to conduct an imaginary interview or two as a decision aid for choosing the right reference book.

Introducing yourself: Set the stage with a formal and polite introduction. State your name and role, then ask the patient what he or she prefers to be called. Make sure that the patient understands the flow of a visit, especially in a teaching hospital, where more than one person will be coming to talk to the patient.

Taking a history: While you are taking the patient’s history, be sure to keep in mind there is a high possibility that the patient is using botanical or herbal remedies. You should also be aware of the regional names for common ailments and symptoms.

Botanical Remedies

A recent study published in the February 2006 issue of Texas Medicine found that 79% of the patients surveyed were taking an herbal remedy at the time of their visit, and a similar study found that educational background, citizenship, and work status were poor predictors of the use of botanicals. Following is a list of five of the most common herbal medicines used by Hispanics, including their potential interactions and side effects.

Manzanilla means chamomile. Chamomile is used as a tea for its sedative effects, or topically as an antiseptic, including vaginally for candidiasis. The most common side effects are allergic reactions and uterine contractions.

Aloe Vera is used topically as anesthetic or internally as a laxative due to its mildly irritant effect. Aloe Vera increases the hypoglycemic effects of antidiabetic drugs and hypokalemic effects of diuretic drugs.

Barbas de Elote means corn silk. Corn silk is ingested as a tea for urinary tract irritation; often causes inflammation of the urinary tract.

Eucaliptus Alcanfor means eucalyptus and camphor. This combination is commonly brewed as a tea or used as a liniment, similar to Vick’s Vapo Rub, for stimulating mucus clearance and circulation. Eucalyptus and camphor can be toxic if ingested in large doses, but it is commonly reported that children are given ointments such as Vick’s Vapo Rub orally for colds and fever. Eucalyptus interferes with P450 metabolism and is neurotoxic.

Common Latin Symptoms

The following are different or unusual names given to symptoms. Some are related to cultural beliefs and others are merely names that do not commonly appear in dictionaries or other resources. These terms are not diagnostic, or specific to any one cause, but rather commonly understood terms for a symptom or a suite of symptoms.

Ronchas or Comezones are boils or sites of skin irritation that have an element of itching or inflammation.

Mal de Ojo means the “Evil Eye,” an unexplained catch-all for illnesses in children. The belief that a curse can be placed on someone or transmitted by looking at the person is especially prevalent in immigrants from Haiti and the Dominican Republic.

Bilis literally means “bile.” This term can stand for either anger or acid reflux, or especially the two in conjunction. This stems from the old belief that the four humors control temperament.

Empacho means “impaction,” gastrointestinal discomfort characterized by distension and discomfort. This is frequently attributed to eating too much at one sitting or eating new foods.

Catarro is a broad term for sore throat. You must ask for a clear characterization of symptoms in order to determine what the patient means when using this term.

Gripa or Gripe is a broad term for flu-like symptoms.

Making Medical Decisions

Always ask patients who they would like to help them make any medical decisions. Often, contrary to our training, the family likes to be informed of bad news before the patient, and the best way to deal with this is to ask the patient if you can share information with the family first. Do not plant the idea of “bad news” specifically in the patient’s mind, but obtain permission for the family to be informed first while the family is present to witness the patient’s wishes. Commonly, the father is the head of the home, and family members defer to his judgment. If this is the case and the patient has agreed, include the father in decision-making and discussions at the earliest phase possible. Recognize the father’s role as the head of the household by greeting him formally and shaking his hand firmly at the beginning of each visit.

Cultural Competency

Only recently have we as physicians started to realize the importance of cultural competency in medicine. In order to ensure the quality of care and gain patient trust and compliance, we must be culturally competent. In their 1983 article in the Western Journal of Medicine, Berlin and Fowlkes suggest using the LEARN acronym to foster the ongoing improvement of cultural competency.

Listen with sympathy and understanding to the patient's perception of the problem.
Explain your perceptions of the problem and your strategy for treatment.
Acknowledge and discuss the differences and similarities between these perceptions.
Recommend treatment while remembering the patient's cultural parameters.
Negotiate agreement. It is important to understand the patient's explanatory model so that medical treatment fits in his or her cultural framework.

Patrick Nichols
Council of Student Members Representative, Southwestern Region
Texas College of Osteopathic Medicine, 2009
E-mail: pnichols@hsc.unt.edu

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My Kind of Medicine: Real Lives of Practicing Internists: Charles Hamori, MD

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Dr. Charles Hamori has attended live performances of Beethoven’s 9th Symphony at least four times that he can recall, the most recent of which was at the Copley Symphony Hall in San Diego, California. Since the age of 15 it has been his favorite piece of music; he never tires of it. He describes Beethoven’s 9th Symphony as an interesting combination of romantic passion and youthful idealism and says every time he listens to it he is struck by its complex composition. In his eyes, these are the aspects that make it beautiful.

Dr. Charles Hamori at Giant’s Causeway in Northern Ireland

Dr. Charles Hamori at Giant’s Causeway in Northern Ireland.


The 41-year old internist from La Mesa, California, recognizes a similar structure in internal medicine, which he often refers to as a mixture of art and science. In part, the idea took root in the tutelage he received from an attending internist who taught him in his third year of medical school at the University of California in San Diego, where he also completed residency. “I loved his approach.” Dr. Hamori says. “He had an old school way of practicing medicine that I liked. He would say, ‘OK, let’s go down to the lab now,’ and we would go down there and sit and look through the microscope, just trying to figure something out. I think of him as an early adopter of evidence-based medicine.” Dr. Hamori also admired his mentor for his active involvement in AIDS research. “It was the early nineties, which was the height of the AIDS epidemic. I really admired his compassion. I thought it was wonderful.”

It is not uncommon for medical students to make decisions about which path of medicine to follow based on their experience with a teacher or mentor. Dr. Hamori’s experience with his own teacher left such an impression on him that not only did he decide to pursue internal medicine, he also chose to become a teacher and mentor. Dr. Hamori became an assistant clinical professor of medicine in the same program that he previously graduated from. He says the experience has given him some of his proudest accomplishments. One particular case he recalls is providing guidance to a student, which began during the student’s freshman year in college. “I invited him to come to my office and follow me while I worked,” he explains, “and he continued coming to my office all the way through college and all the way through medical school. Today he is an internist. For me, that is a great success story.”

While his enjoyment of giving to others is obvious, Dr. Hamori is also able to recognize when something holds value for him. For example, he teaches as much for himself as he does for his students. “Teaching keeps me fresh,” he says. “When you work with students you really have to be on your game because they’ll challenge you. They’ll ask me ‘why are you doing that?’ and then they’ll go ask someone else on the faculty and compare the answers! But I like that because it is true to the art of medicine—there are different ways to approach it.”

Proud to Be an Internist

Dr. Hamori has a joke he likes to tell his patients from time to time. When faced with the unspoken question ‘are you sure?’ he says the only way he could be more sure of a diagnosis would be to perform an autopsy. He says he gets laughs, but admits to using discretion when deciding with whom it is appropriate to use the joke. Joking aside, making the right diagnosis is something he takes very seriously. “Knowledge is difficult,” he says. “No matter how many times I have correctly diagnosed something, I will always get the book out and try to figure out whether or not I’ve missed anything. Making a differential diagnosis is a hard thing to do, and I’m proud of my identity as an internist because we are specially trained to do it.”

A close call with a patient several years ago reminded Dr. Hamori of just how much weight the right or wrong diagnosis can make. A young man had come into the hospital in San Diego where Dr. Hamori was working. The man’s symptoms were so grave that the doctors thought he might not survive. The patient had an overwhelming systemic immune reaction that was attributed to fulminant Coccidioidomycosis—a combination of pneumonia, liver abnormalities, kidney failure, embolic strokes, and gangrene in the fingers caused by a small arterial emboli. At least, that’s what they thought it was. “In the San Diego region, Cocci is endemic, and it is known to cause the conditions suffered by this patient,” he says. “Since the patient was in a line of work in which he was regularly exposed to soil, his ethnicity was right, and he even had a serologic test that was IgM positive, I thought we had a match.” But after ten days of treatment, the young man’s condition had not improved. “We couldn’t figure it out, we didn’t know what we were overlooking,” he recalls. “After reevaluating, we finally figured out that he was suffering from hypereosinophilic syndrome, which can be devastating. The man suffered a degree of disability from it, but we did save his life. It was an example of how you can’t rule out anything. Everything about his case was pointing us toward that first diagnosis. You always have to go back and consider what you might be overlooking.”

The Finer Things in Life

Currently, Dr. Hamori works in the Kaiser Permanente Preventive Medicine Clinic in San Diego, where he is very happy. “It is professionally very rewarding where I am now. We perform as many preventive services as we can,” he says, “and I feel fortunate to be a part of that because not many hospitals have clinics that do what we do.” His next move will be to a primary care office, a change he says he is able to make because he is an internist. “There are so many different things you can do, you don’t have to be pigeonholed,” he says. “You can reinvent yourself throughout your career.”

Career satisfaction is not the only thing Dr. Hamori appreciates about his job. “One of the big reasons why I chose the group I’m with now is because it’s predictable and steady,” he explains, “which means I can set my schedule to spend time with my wife and two daughters—helping with homework, playing or just spending valuable time with them. Every week we have a night I call Daddy-Daughter Night.”

If you talk to enough internists eventually you start to notice a pattern. Most or all are affable, they derive pleasure from interaction, and while they each have their own style and qualities that make them unique, one thing they all seem to share is an aptitude for people. It was this aptitude that Dr. Hamori drew on one day, as he honored a “do not resuscitate” order for an elderly patient. The patient had suffered a stroke followed by complications which would not allow him to breathe without the help of a ventilator. The patient made it clear to Dr. Hamori that he wanted to be taken off the ventilator and be taken home. Against the wishes of the hospital staff, Dr. Hamori followed through with the patient’s wishes and took him off the ventilator. He then rode with the patient in the ambulance to his home, where his family waited for him. After the family got the man settled in his favorite easy chair, Dr. Hamori removed the endotracheal tube. “He was so thrilled to be able to talk with his family and friends,” recalls Dr. Hamori. “It was bittersweet of course, but they laughed and joked and had a great time. They poured him a scotch and water and he even had a few token sips!” Gradually, the patient grew tired and drifted off to sleep, but before he did he thanked Dr. Hamori for respecting his wishes. “I have never forgotten that,” he says. The man passed away about 45 minutes later; his favorite Frank Sinatra album played in the background.

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Internal Medicine Interest Group of the Month: Mercer University

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The Internal Medicine Interest Group (IMIG) at Mercer University School of Medicine has gained in popularity over the past few years. The level of interest has risen due to the wide variety of speakers and their ability to tap into the relevant questions of the first and second year students. To allow for maximum attendance we provide lunch to an average of 50 students during each meeting, but it is not just the food that students are interested in.

At Mercer University School of Medicine the first two years consist of a problem-based learning curriculum organized by a systems approach. As such, the first phase of the second year is cardiology, the second phase is pulmonology, the third is gastroenterology, and so on. This structure provides a unique opportunity to tailor the speakers we invite to each meeting to the system we are studying. For example, as we buried our heads in the subject matter of the heart, most of the students were anxious to hear more about the clinical side of life as a cardiologist. These meetings provide refreshing answers to the inquisitive minds of the doctor-wannabes. Hearing physicians describe their family lives, what a day at the office is like, and even why they chose their career paths allows students to dream of better days as a “real” doctor. The fact that several of our speakers have graduated from our school and still have smiles on their faces gives us hope that our dreams just may one day come true.

Our most recent speaker was Steven Presley, MD, FACP, a residency program director from Baptist Hospital in Birmingham, Alabama. He provided us with guidance in choosing our career paths as well as the opportunity to ask questions about what we should do to boost our CVs. Because of the informal nature of the meeting, Dr. Presley was able to give us personal and practical advice. He also provided a window for us to see what residency is like and what kind of programs we will be able to choose from. He answered questions on subjects ranging from choosing the right residency program to his vision of the future of medicine.

Several members and officers of our club recently attended the Georgia Chapter ACP Scientific Meeting in Savannah, Georgia. Five of us gave presentations on our recent research projects. This provided us with an opportunity to receive some constructive criticism on our work. A few of the students who attended the Georgia Chapter Meeting are currently preparing to present the same research at a professional conference for tissue engineering and development in Snowbird, Utah.

A continuing issue from year to year is the drop in participation once the students reach the hospital in their third and fourth years of medical school. In an effort to bridge the gap between the upper- and lower-classmen, we decided to celebrate with the fourth year students by having a dinner party for those who matched in an internal medicine residency program. This will provide an excellent atmosphere to ask the recently matched students for advice on how to study and approach the last few years of medical school. This will also serve as a time to congratulate these students for making it through medical school and into residency!

Shaefer Spires
Mercer University School of Medicine, 2009
E-mail: spires_ss@med.mercer.edu

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Winning Abstracts from the 2007 Medical Student Abstract Competition: Distribution of Total Body Water in Acutely Ill Elderly Patients

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Author:
Nitin K. Gupta, Vanderbilt University School of Medicine, 2007

Introduction:
Multifrequency Bioelectrical Impedance Analysis (MBIA) is used in clinical settings to estimate body composition and interstitial and extracellular water compartments. The objective of this study is to validate MBIA as a clinically useful tool for the measurement of total body weight (TBW) and lean body mass in critically ill patients. In healthy individuals, changes in body weight can estimate changes in TBW. In critically ill patients, however, TBW does not reliably reflect fat free mass due to intracellular disturbances caused by protein malnutrition, changes in total body water and in the ratio of intracellular and extracellular water (ECW) due to injury and inflammation. These values are of clinical significance because in acutely ill patients, the amount of lean muscle mass is often overestimated by anthropometric equations when compared to actual values measured by the segmental compartments of TBW or intracellular water (ICW). Therefore, an undetected decrease or increase in ICW could cause errors in estimation of drug doses calculated based on body mass. Additionally, measurement of ECW is of considerable clinical importance since excessive fluid retention in the extracellular space is known to cause increased morbidity in critically ill patients. Currently, the only approved method for determining TBW in this patient population is via isotope dilutions, which are impractical tools for use at bedside due time limitations and cost. This study attempts to validate MBIA as a clinically useful tool in measuring TBW and ECW in critically ill patients by correlating results obtained using MBIA to reference measurements for TBW using deuterium dilution and ECW using sodium bromide.

Methods:
TBW and ECW will be measured utilizing a multifrequency bioimpedance SEAC SFB3 analyzer. Thirteen critically ill patients were enrolled in the pilot study. Testing was conducted at bedside, in the morning, and at least two hours after the last meal. Body height and weight were recorded from the patients’ charts. Following MBIA, research participants will receive isotope dilutions to measure TBW and ECW.

Results:
When comparing TBW and ECW measurements obtained using MBIA and calculated using anthropometric equations, we found a significant difference in amount of TBW between these two methods (p=0.01). When using MBIA and isotope dilutions, however, there was no significant difference in ECW between these two methods (p>0.05). Anthropometric methods resulted in overestimation of TBW and ICW (p=0.001).

Conclusion:
We found MBIA easy to administer at bedside and well tolerated by the patients. Preliminary data on ten acutely ill elderly subjects suggests that MBIA may reliably estimate TBW and that anthropometric methods are not a reliable tool to determine TBW and ICW in acutely ill patients.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Nephrology

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The Discipline

The word nephrology comes from the word nephros, the Greek word for kidney. Nephrology involves the diagnosis and management of diseases of the kidneys, the contiguous collecting system, and the associated vasculature.

The commonly encountered conditions in nephrology include disorders of fluid, electrolyte, and acid-base balance. Other problems include disorders involving the glomerulus, asymptomatic urine abnormalities, tubulointerstitial disorders, renal vascular diseases, renal failure, nephrolithiasis, tubular defects, and infections and neoplasms of the kidney, collecting system, and bladder. The nephrologist must understand how systemic diseases affect the kidneys, and recognize the potential toxicities of various therapeutic and diagnostic agents.

Procedures

Important procedural skills for the nephrologist include peritoneal dialysis, percutaneous kidney biopsy, and temporary placement of vascular access for hemodialysis. In addition, the nephrologist is expert at interpreting 24-hour urine excretion of minerals and electrolytes, serological tests for evaluating glomerulopathies, acid-base studies, and studies of sodium and water balance.

Training

Nephrology fellowship training requires two years of accredited training beyond general internal medicine residency. Of the two years, a minimum of 12 months must include clinical training in the diagnosis and management of a broad spectrum of renal diseases.

Certification

The American Board of Internal Medicine (http://www.abim.org/) offers certification in nephrology.

Training Positions

As of August 2005, there were 135 ACGME-accredited training programs with 822 active positions in nephrology. 295 of the trainees were female and 54% were US medical graduates.

Practice

Approximately 61% of the graduates enter clinical practice in nephrology in the United States and 29% enter academic medicine.

Major Professional Societies

American Society of Nephrology
1725 I Street, NW, Suite 510
Washington, DC 20006
(202) 659-0599

National Kidney Foundation
30 East 33rd Street, 8th Floor
New York, NY 10016
800-622-9010

Major Publications

American Journal of Kidney Disease
Journal of the American Society of Nephrology
Kidney International
Renal Failure

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Advocacy Briefs: ACP Endorses Medical Education Affordability Act

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On March 28, 2007, ACP endorsed the "Medical Education Affordability Act" (S.1066). The bill, introduced by Senator Christopher Dodd (Democrat–Connecticut) on March 29 and co-sponsored by Senators John Kerry (Democrat–Massachusetts), Richard Durbin (Democrat–Illinois), and Russ Feingold (Democrat–Wisconsin), would allow physicians to defer repayment of their student loans while they complete their medical training. Currently, the Economic Hardship Deferment allows physicians that meet specific debt-to-income ratios to defer repayment of federal educational loans for up to three years. S.1066 would extend this deferment to include the length of "post graduate medical or dental internship, residency, or fellowship programs." This letter can be found online.

House Passes Student Loan Oversight Bill

On May 9, 2007, the U.S. House of Delegates overwhelmingly passed (414-3) the "Student Loan Sunshine Act" (H.R.890) to establish conflict of interest requirements for lenders and institutions of higher education. Among other provisions, the Sunshine Act would:

  • Require institutions to develop and administer a code of conduct for their financial aid offices;
  • Require institutions to disclose all relationships with lenders;
  • Ban all gifts, opportunity pools, and revenue-sharing between lenders and institutions;
  • Prohibit financial aid administrators' participation on lender advisory boards (other college officials may participate without compensation or reimbursement of expenses);
  • Require "preferred lender lists" to include at least 3 unaffiliated lenders and the process that was used to develop the list; and
  • Prohibit staffing of campus financial aid offices by lenders or their employees, excluding services provided in exit interviews for borrowers.

Senate Health, Education, Labor, and Pensions Chair Edward Kennedy (Democrat–Massachusetts) introduced his version of the "Student Loan Sunshine Act" (S. 486) on February 1, 2007. Senator Kennedy plans to address this issue as part of the broader Higher Education Act reauthorization.

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Did You Know You Have Access to the Physicians’ Information and Education Resource (PIERŪ)?

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PIER is ACP’s electronic, web-based decision-support tool designed for rapid point of care delivery of up-to-date, evidence-based guidance. PIER offers more than 400 modules focusing on the diagnosis and treatment of diseases, as well as an extensive drug database and valuable patient information. ACP Medical Student Members have free online access to PIER after they register online.

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MKSAP for Students 3 Question 1

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A 72-year-old woman is evaluated because of morning headaches and swelling in the lower extremities that worsens as the day progresses. She is able to sleep supine, using one pillow at night, and notices shortness of breath when walking distances greater than 20 feet.

On physical examination, significant findings include diminished breath sounds; distant heart sounds, with a pulmonic valve component equal in intensity to the aortic valve component; and paradoxical splitting of the S2. Laboratory findings include a Pao2of 59 mm Hg, Paco2of 44 mm Hg, and pH of 7.41. An electrocardiogram shows right ventricular hypertrophy with cor pulmonale and right axis deviation.

Which of the following is the most important indication for long-term supplemental oxygen for this patient?

( A ) Cor pulmonale and a Pao2 between 55 and 60 mm Hg
( B ) Dyspnea
( C ) Morning headaches
( D ) Pao2 less than or equal to 65 mm Hg

MKSAP for Students 3 Question 2

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A 48-year-old man is evaluated because of a 7-year history of persistent hypertension despite treatment. His blood pressure readings are approximately 160/95 mm Hg despite following a low-sodium diet and taking atenolol, 100 mg/d; lisinopril, 40 mg/d; and hydrochlorothiazide, 25 mg/d. He is fatigued after a day at work, and he usually naps when he gets home, eats dinner, and then goes to bed. He falls asleep quickly and sleeps soundly all night. His wife reports that he snores loudly.

On physical examination, his body mass index is 30, pulse rate is 56/min and regular, and blood pressure is 154/96 mm Hg. The posterior oropharynx is crowded from a large tongue and long soft palate. His neck is obese, measuring 17 inches in circumference, without bruits or jugular venous distention. The remainder of the examination is unremarkable. His electrolytes, renal function, and urinalysis are normal; a 24-hour urine sample is normal for metanephrines, catecholamines, and vanillylmandelic acid.

Which of the following would be the best next step in the evaluation of this patient?

( A ) Measurement of blood lead level
( B ) Measurement of plasma metanephrines
( C ) Overnight dexamethasone suppression test
( D ) Polysomnography
( E ) Renal artery duplex ultrasonography

MKSAP Answer 1

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Answer: A

Educational Objective: Recognize the clinical indications for the use of long-term supplemental oxygen.

The Nocturnal Oxygen Therapy Trial and Long-Term Oxygen Therapy studies demonstrated improved outcomes in patients who received oxygen when they met certain criteria. In patients with a Pao2 between 55 and 60 mm Hg, oxygen is beneficial if there is evidence of cor pulmonale. The evidence of cor pulmonale in this case is a loud P2, paradoxical splitting of the S2, and electrocardiographic changes. Oxygen can also be prescribed in patients with angina and during exercise to keep the oxygen saturation greater than 88%. In the absence of cor pulmonale, oxygen is prescribed when the Pao2 is 55 mm Hg or less. In the absence of hypoxemia or cor pulmonale, supplemental oxygen is not indicated for the relief of dyspnea; these patients should be referred to a pulmonary rehabilitation program. In patients with chronic obstructive pulmonary disease, morning headaches are often a sign of nocturnal carbon dioxide retention, and supplemental oxygen therapy is unlikely to improve this symptom.

References

Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93:391-8. PMID: 6776858

MKSAP Answer 2

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Answer: D

Educational Objective: Recognize obstructive sleep apnea as a cause of difficult-to-treat hypertension.

This patient's history of snoring and daytime sleepiness, in conjunction with his crowded oropharynx and large neck, suggests that he may have obstructive sleep apnea. In large epidemiologic studies, this disorder has been clearly associated with hypertension, independent of obesity, and with a dose-dependent relationship between the severity of sleep-disordered breathing and the likelihood of hypertension. The Wisconsin Sleep Cohort Study found a higher rate of hypertension developing in normotensive persons who had sleep-disordered breathing than in those without it, independent of weight. Sleep studies in patients with difficult-to-treat hypertension who were evaluated in a specialty clinic found previously undiagnosed obstructive sleep apnea in 83% (96% in men, 65% in women). Although treatment of obstructive sleep apnea with nocturnal continuous positive airway pressure (CPAP) does not reduce blood pressure significantly in established hypertension, CPAP can reduce daytime sleepiness and improve the quality of life.

The other causes of secondary hypertension listed are less supported by the findings in this case. Although normal results on one round of urinary catecholamine testing do not rule out pheochromocytoma, the clinical absence of paroxysmal tachycardia, diaphoresis, tremor, and anxiety make this an unlikely diagnosis. The absence of physical findings of hypercortisolism (moon facies, buffalo hump, and purple abdominal striae) and normal plasma glucose tests make Cushing's syndrome unlikely. Normal renal function, absence of a renal artery bruit, and limited benefit from an angiotensin-converting enzyme inhibitor are all evidence that there is no significant renal artery stenosis. Chronic lead intoxication causes hypertension in the setting of chronic renal insufficiency, which is not present in this case.

References

Logan AG, Perlikowski SM, Mente A, Tisler A, Tkacova R, Niroumand M, et al. High prevalence of unrecognized sleep apnoea in drug-resistant hypertension. J Hypertens. 2001;19:2271-7. PMID: 11725173
Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med. 2000;342:1378-84. PMID: 10805822
Finn L, Young T, Palta M, Fryback DG. Sleep-disordered breathing and self-reported general health status in the Wisconsin Sleep Cohort Study. Sleep. 1998;21:701-6. PMID: 11286346

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Internal Medicine Residency Program Fast Facts

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Program Name: Greenville Hospital System
Location: Greenville, South Carolina
Hospital Type: University Affiliated Community Hospital
Program Size: 14 First Year Positions, 34 Positions Total
First Year Salary: $42,000
Web Site Address: http://www.ghs.org/

Program Name: Creighton University Program
Location: Omaha, Nebraska
Hospital Type: University Based Hospital
Program Size: 23 First Year Positions, 53 Positions Total
First Year Salary: $42,000
Web Site Address: http://medicine.creighton.edu/medschool/
medicine/index.html

Program Name: Oregon Health & Science University Program
Location: Portland, Oregon
Hospital Type: University Based Hospital
Program Size: 30 First Year Positions, 90 Positions Total
First Year Salary: $42,000
Web Site Address: http://www.ohsu.edu/medicine/residency

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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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