September 2009 E-Newsletter

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ACP's Council of Student Members Supports National Primary Care Week

National Primary Care Week (NPCW) is an annual event to highlight the importance of primary care and bring health care professionals together to discuss and learn about generalist and interdisciplinary health care, particularly its impact on and importance to underserved populations. NPCW aims to focus the attention of health professional students from all disciplines on the failure of the healthcare system to provide equal, high quality health care to all individuals, regardless of ethnicity, race and other factors, and to provide students with the tools to address these inequalities.

The American Medical Student Association (AMSA) and NPCW student leaders at schools from a variety of health disciplines will be working in conjunction with local Area Health Education Centers (AHECs), National Health Service Corps, NHSC Ambassadors, health organizations and professionals to observe National Primary Care Week. No two schools will participate in the same way. While this is a national initiative, each school is encouraged to tailor the week as much as possible to reflect local need and interest.

For more information, please visit: http://www.amsa.org/npcw/.

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Medical Student Perspectives: Health Care Reform: How Does This Affect Me?

I attend a daily Surgical Morning Report, during which the department discusses the patients on our service as well as cases of note. On one particular morning, however, our rousing discussion on small bowel obstruction was interrupted by unwelcome guests: the billing department. I watched each doctor’s eyes glaze over while we were lectured to about the virtues of billing code 5521 versus 5526 to maximize compensation to the hospital. Some of these physicians didn’t know how to work a Blackberry, let alone a complicated billing system for patients. After our guest speakers left, I heard grumblings of “I’m a physician, not a billing clerk!” and other variations on that theme. We all shuffled out of the room shaking our heads and went about the rest of our day.

That night, I had a sobering thought: maybe the health care crisis is our fault.

Why is it that physicians happily schedule one hour to discuss the plethora of possible causes for left lower quadrant pain but refuse to learn the billing system through which they get paid and ultimately generate resources for the hospital to provide life-saving health care? Why is it that most of my classmates can spit out the mnemonic for the 12 causes of pancreatitis but do not know the difference between Medicare and Medicaid? My colleagues tell me, “Because that’s just not important to my daily life.” Standard medical school curricula do not train us in health care policy, and as a result, we are lulled into thinking that medical knowledge alone will promote health care. The only way meaningful health care reform will be achieved in this country is if physicians become savvier with the way it already works in order to think of how to make it better in the future. The best way to do this is to become involved as a medical student.

The first thing we should do early on in our medical careers is to get involved with national organizations to become informed on the issues. It is hard to be a health care advocate if you aren’t aware of the issues for which you should be advocating. It’s also difficult to care about health care unless you find an issue that has personal meaning for you. For example, ACP has an annual Leadership Day on Capitol Hill during which physicians from all over the U.S. discuss relevant medical issues with law makers in Washington, D.C. Legislators know we are busy, but by spending one day discussing policy matters, physicians are allowed to help many more potential patients than the ones they physically see each day. It also shows politicians that we wish to be leaders in the national discussion on health care.

Taking an interest in preventive medicine is another way to learn more about how to be an informed health care advocate. No matter which area of medicine you enter, it is essential to know general recommendations for patients. Colon cancer screening recommendations are different for a 50 year old man versus an 80 year old man, for example. National recommendations change frequently, so it is important to critically analyze new research in order to give our patients the most effective care.

Health care reform is about much more than increasing physician salaries and lowering insurance premiums. We seldom realize, as students, how much power we already have to positively impact the system. Not enough attention is given to the issue of how much we as professionals are contributing to the overall cost of health care. For example, how many redundant lab tests and imaging studies are ordered in order to confirm a diagnosis which we can test clinically? How many times do we suggest experimental therapy to patients without considering its cost-to-benefit ratio? Patients buy into this ŕ la carte style of medicine as well, demanding MRI’s and EKG’s because they assume that a clinical workup is incomplete without a battery of expensive tests. Effective communication between specialists and primary care physicians can decrease repeat tests and over-prescribing of medication.

Managing our health care spending drives down cost, so it can be more affordable for more people. This doesn’t require legislation; rather, it requires careful study of patient management strategies and knowledge of the system early on as students. By doing what is clinically right instead of trying to work patients up as much as we can, we can build more credibility in the national forum as we suggest ways to be compensated for our skills as well as how reform can be passed to help more patients.

The most popular answer medical students give to the question, “why do you want to be a doctor?” is to “help people”. Health care policy is the framework within which we help our patients, and it deserves our attention as students. Like much of medicine, becoming a health care policy advocate is a self-motivated endeavor, and there are many more questions than answers. Instead of complaining that there is nothing we can do to change health care, we should become stewards of our profession and start by taking control of the things we can do. Perhaps the next time the billing department holds an informational session for us, we can offer suggestions for making the system more user-friendly rather than ignoring them and choosing to do nothing but complain. As one of my patients said to me the other day, “when we know better, we do better.” Sometimes, that’s all it takes.

Lavanya Viswanathan, MS, 2LT, USAF
Military Representative, ACP Council of Student Members
American Association of Medical Colleges Representative
Uniformed Services University of the Health Sciences, Class of 2011
E-mail: Lavanya.Viswanathan@usuhs.mil

Check out more volunteer opportunities.

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My Kind of Medicine: Real Lives of Practicing Internists: Major Travis Richardson, MD, FACP

Major Travis Richardson, MD, FACP

As a boy, during his family’s annual trip to South Carolina to visit extended family, Travis Richardson would make the three-mile walk to the corner store to buy milk and flour for his grandmother. She was a diabetic and a subsequent amputee, and seeing this made Travis yearn to ease her discomfort. He would also be troubled by the health problems of his other relatives. As a child, he didn’t fully understand the illnesses at the time, although he knew that there were problems with “sugar” and “blood pressure” and he understood that it caused a great deal of suffering and stress, particularly for his grandmother. At the time, his ability to help was limited. “I would think to myself, ‘what can I do to help?’” he says. But by the time he reached high school, he knew the answer to that question, and he’s been helping people ever since.

One for All, All for One

Dr. Richardson knew himself well at an early age, and sought out a path to fit his needs and ambitions. As an undergrad at Johns Hopkins University, he decided he would go into primary care, and later on at medical school at Howard University, he was sold on internal medicine after one rotation. “One of the great things about internal medicine is the variety and flexibility,” he says, “and I liked the fact that is focuses on adults. That’s what I wanted to do. It matched me perfectly.” He was also influenced by his program director, who he says has been instrumental in crafting him into the physician he is today. “No matter how stressful a situation was, he always had an even keel,” he remembers. “He made things that were difficult easy.”

It was an approach he would emulate and later come close to perfecting in his own career, although he accomplished it in his own, unique way with the second big chapter in his life—joining the Army. He entered after college prior to starting medical school. Because of his relative maturity compared to his peers, most of whom were younger, Dr. Richardson was promoted quickly and was the highest ranking person at his boot camp in Fort Benning, in Georgia. His superiors chose him to be platoon leader, a role that had its ups and downs. “Every time someone’s boots weren’t right, I had to do 100 push-ups!” he recalls. Thousands of push-ups later, Dr. Richardson was still thriving in the military; he had found a natural fit for what he craved both personally and professionally. While he needed structure and routine—“I like things to go a certain way,” he says—he also wanted meaningful relationships and interactions with others. “I’m outgoing. I like to talk to people and find out things about them.”

He completed his internship at Walter Reed Army Medical Center in Washington, D.C, where he felt an immediate camaraderie with the staff and patients. “It’s a military hospital so I relate to the people,” he says. “These are veterans and retirees so I feel a special connection to them.” He adds that the working environment itself is also a big plus, because of the fact that Walter Reed is a non-profit hospital. “We have the freedom to practice medicine without constrictions. We can focus on the patient in front of us.”

One of his first assignments was as an Assistant Chief of the Internal Medicine Clinic at Fort Benning. The role came with a lot of responsibility, as Dr. Richardson had to act in capacities normally handled by subspecialists in the private sector. “All of the Army hospitals are community hospitals, so there are not a lot of subspecialists. You’re it … you’re the cardiologist, the pulmonologist … that’s the great thing about it though, because with that kind of background, you see so much and your skills are fresh…you’re ready for anything. It really goes a long way to improve your confidence.”

The Human Connection

Dr. Richardson has been deployed twice, the first time to Kuwait in 2002, and the second to Iraq in 2008. He says deployment during a war is hardest on families, which he sees the effects of first-hand, often treating men from the front lines who have lost limbs and suffered traumatic head injuries. It’s the not knowing, he says, that gets to people, including his own family. “It’s the 800-pound gorilla in the room,” he says. For his most recent trip, he oversaw and treated patients in a detainee medical facility, which meant that he was treating the enemy. The job requires the utmost of professionalism, as there are times when the staff is aware of a specific incident or incidents that a patient might have been directly responsible for or involved in. The job calls for sensitivity and restraint, but the Army doesn’t make considerations in terms of hand-picking the staff, because as Dr. Richardson explains, they operate under the assumption that all soldiers maintain professional conduct at all times. “It is the true definition of the Hippocratic Oath,” he explains, “You remove yourself from who they are and you treat them. You have to treat them as if they were your own mother.”

It’s a lesson he teaches students as well. Today, working as the Assistant Chief of the Department of Medicine at Walter Reed, he enjoys watching the transformation from student to physician, and being a part of it. “ It’s kind of neat seeing a student come in, not even knowing how to listen to the heart, and years later seeing them teaching themselves.” He also gains pleasure from knowing his patients. “I love seeing my patients. There are some I’ve been treating for 10 years now. I’d say the biggest accomplishment in my career has been dealing one-on-one with each of my patients. Seeing the expressions on their faces and the look in their eyes … you can’t put a price on it.”

He talks of one patient who had come to him with bad pain throughout her entire body. The woman had been bounced back and forth between doctors, and she felt that none of them had really made a concerted effort to figure it out. For years, she couldn’t sleep properly and by the time she reached Dr. Richardson she broke down into tears during the first interview. Dr. Richardson spent a good deal of time with her, making sure he was thorough in his testing and interviewing. Finally, he came to the conclusion that the patient was likely suffering from fibromyalgia, and he began treating her for it. Several weeks later the patient returned. “She was laughing and smiling,” Dr. Richardson recalls, “the treatment worked. She was so happy and so grateful … she thought I was the best thing since sliced bread! That’s why I love my job. It’s the things like that that stick with me.”

The Promise Keeper

Now when Dr. Richardson visits South Carolina to see family, he no longer makes the long walk to the corner store, but the memory of his grandmother remains. He lives in suburban Maryland, outside of Washington, D.C., with his wife of 15 years and three daughters, the oldest of whom just went off for her first year at Howard University. In his free time, Dr. Richardson is very involved in his church, for which he participates in a men’s support group, something he also has done during deployment. The groups are a source of support for members, who learn to count on one another when times get tough. Dr. Richardson likens it to the promise keeper movement and believes the spiritual support has helped him be a better physician, soldier, father and husband. He is satisfied and fulfilled in his life and says that choosing the career path and making the choices he did made it happen. “For me, going into internal medicine and also the Army has suited my goals and personality like a glove. I have been able to apply the skills I learned in every one of my jobs. Everything has happened perfectly, I have no regrets.”

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: University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine (UMDNJ-SOM)

The University of Medicine and Dentistry of New Jersey (UMDNJ) is New Jersey’s university of the health sciences with eight schools located on five campuses throughout the state. It is the largest institution of its kind in the nation. UMDNJ-School of Osteopathic Medicine (UMDNJ-SOM) has the largest number of faculty, the largest GME program, and the largest network of clinical affiliates among US osteopathic medical schools. It is also a leader among them in diversity, and research and extramural funding. The Internal Medicine Interest Group (IMIG) at UMDNJ-SOM, known as the Student Osteopathic Internal Medicine Association, has begun the 2009-2010 academic year with great enthusiasm because, this year, our school has expanded its first year class size from 110 students to 135. With that expansion came additional enrollment in our club and a heightened interest in the field of internal medicine. We are one of the largest organizations on our campus, currently with 123 student members, and one of the most active.

Our mission is not only to address the interests of students wishing to enter the field of internal medicine but also to bolster support for the field throughout the medical student community. We offer our members many benefits through their involvement in both academic and community service programs. Our flagship program is the monthly “Day in the Life of” luncheon lecture series in which physicians in internal medicine and its subspecialties meet with us to give us a better idea about their field of practice. We ended last semester with a presentation from John Bulger, DO, FACOI, FACP, who shared his experiences as an internist and presented an interactive, case-based lecture on analyzing liver function tests. This semester, we are planning similar experiences with a nephrologist, a hospitalist, and a gastroenterologist. Our other primary academic resource is the weekly internal medicine and monthly geriatric grand rounds lecture series presented in collaboration with our principal teaching hospital, the Kennedy Health System.

New to the club’s offerings this year is an internal medicine review class for third year medical students. In this monthly class, our internal medicine residents will provide their mentorship to help students navigate through their internal medicine rotation and prepare for the second step of their boards. Our next goal is to establish a shadowing program for first and second year medical students interested in internal medicine or any of its subspecialties.

We are very active in the community as well. We will be hosting our annual blood drive in collaboration with the Red Cross, on September 11th on UMDNJ’s campus. It is open to the students, faculty and staff of the five professional schools on our UMDNJ campus as well as the Kennedy Health System and the public-at-large. This fall our members will also volunteer in the annual Stratford Fall Festival and the Gloucester County Women’s Health Summit, which have over 10,000 and 2,500 attendees, respectively. The group will provide blood pressure screenings in addition to information on basic preventive health practices.

The current Executive Board of our IMIG consists of: Louis Marquet (OMS-II), President; Farook Taha (OMS-II), Second Year VP; Bhavesh Patel (OMS-II), Treasurer; Alex Lelyanov (OMS-I), First Year VP; Mike Favara (OMS-I), Secretary; and Rami Selim (OMS-I), First Year Representative. We are extraordinarily lucky to have Joanne Kaiser-Smith, DO, FACOI, FACP, as our faculty advisor. Dr. Kaiser-Smith is extremely helpful in all of our activities and also instrumental in promoting the interests of our club on campus and in the hospital. We are also very excited about the addition of Daena Flaxman, MD, ACP Member, as our second Faculty Advisor, and David Somerman, DO, ACP Associate Member, and Joan Wiley, DO, ACP Associate Member, as our Internal Medicine Resident Liaisons.

Louis Marquet, OMS-II
President, Student Osteopathic Internal Medicine Association
Univ. of Medicine and Dentistry of New Jersey School of Osteopathic Medicine, Class of 2012
Email: marquelj@umdnj.edu

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Winning Abstracts from the 2009 Medical Student Abstract Competition: Is All Angina Really Chest Pain?

Authors: Shashank Shekhar Sinha; matched at the University of Pennsylvania’s Internal Medicine residency program, Nathan Sandbo, MD; Instructor of Medicine, Section of Pulmonary/Critical Care, Department of Medicine, Vineet Arora, MD, FACP; Assistant Professor of Medicine, Assistant Dean for Scholarship and Discovery, Pritzker School of Medicine; Associate Program Director, Internal Medicine Residency Program

Case Presentation
A 50-year-old woman with hypertension, tobacco abuse, and a family history of early coronary artery disease presented with 10110 substernal chest pain over one day, without dyspnea, nausea or vomiting. She was afebrile, tachycardic, and hypotensive, with mild tachypnea but normoxia. Her EKG showed sinus tachycardia and ST depression in the inferolateralleads, raising concern for myocardial ischemia.

Her physical exam was significant for tongue elevation and bilateral fullness of the submandibular space, without overlying erythema or crepitus. Cardiac and pulmonary exams were unremarkable. Laboratory studies showed a leukocytosis with bandemia and normal cardiac enzymes. Head and neck CT demonstrated extensive subcutaneous emphysema in the parapharyngeal spaces bilaterally, tracking posteriorly to the retropharyngeal space, and inferiorly into the superior mediastinum.

Notably, three days prior to presentation, the patient noticed right mandibular tooth pain without antecedent trauma or dental procedures, with subsequent progressive neck swelling, trismus, and dysphagia.

A diagnosis of Ludwig's angina was made and she was empirically started on broad-spectnnn antibiotics. Nasotracheal intubation was performed given the risk of airway compromise and she was taken to the operating room for incision and drainage of the deep neck abscess. Intraoperative findings included a periapical abscess adjacent to the right mandibular second molar, which was extracted.

Discussion
Not all angina refers to chest pain. Ludwig's angina is a rapidly progressive cellulitis of the submandibular and sublingual spaces. Its name derives from the etymological root of angina, Latin angere, "to strangle," referring to the choking sensation experienced by affected patients. The condition is odontogenic in 90% of cases, arising trom the second and third mandibular molar teeth in 75%-85%, of cases. The infection spreads via the fascial planes, first expanding the submandibular space, followed by the parapharyngeal space (via the buccopharyngeal gap) and subsequently the retropharyngeal space and superior mediastinum. Causative organisms represent typical oral flora: streptococci, staphylococci, and anaerobes. Predisposing factors include dental caries, recent dental treatment, and systemic immunocompromise. Exam findings include symmetric swelling, induration, and tenderness of the neck ("bull neck"), occasionally with palpable crepitus. The tongue can significantly enlarge, distending posteriorly into the hypopharynx, potentially leading to airway obstruction. Trismus, mouth pain, drooling and dysphagia may also be present. Management includes empiric beta-Iactam based antibiotics or c1indamycin in penicillin-allergic patients. Airway compromise is of paramount concern. Endotracheal tube placement with flexible fiberoptic visualization should be performed before the onset of stridor, cyanosis, and asphyxia (most common cause of death). Definitive treatment requires intraoperative surgical drainage of the abscess, along with extraction of any infected teeth. These management strategies have decreased the mortality rate from over 50 percent in the preantibiotic era to o to 4 percent currently.

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Subspecialty Careers: Highlights about Careers in Internal Medicine: Interventional Cardiology

The Discipline
From the Latin word intervenire, “to come between,” Interventional Cardiology is the branch of Cardiology responsible for catheter-based interventions in the management of ischemic heart disease, congenital heart disease, and acquired valvular disease.

Procedures
Important procedural skills include coronary artery catheterization, angioplasty, intra-coronary thombolysis, valvuloplasty, coronary artery stent placement, and intra-aortic balloon counterpulsation.

Training
Interventional Cardiology fellowship training requires 12 months of accredited training beyond three years of general cardiology training.

Certification
The American Board of Internal Medicine offers certification in Interventional Cardiology.

Major Professional Societies

  • The Society for Cardiovascular Angiography and Interventions
    2400 N. Street, NW
    Washington, DC 20037-1153
    1-800-992-7224
    http://www.scai.org

Major Publications

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Advocacy Brief: Secretary Sebelius Releases $33 Million in ARRA Funds to Train Health Professionals

On September 14 HHS Secretary Kathleen Sebelius announced awards totaling $33 million to expand the training of health care professionals. The funds are part of the $500 million allotted to HHS’ Health Resources and Services Administration (HRSA) to address workforce shortages under the American Recovery and Reinvestment Act (ARRA).

The grants are distributed through six HRSA programs:

• Scholarships for Disadvantaged Students, $19.3 million. This program funds health professions schools and training programs which, in turn, provide scholarships to full-time health professions students, with priority given to those with financial need.
• Centers of Excellence, $4.9 million. This program funds health professions schools to establish or expand programs for minority individuals. Funds may be used to improve student academic performance, recruit and retain minority faculty, and expand opportunities to train at off-campus, community-based health care sites.
• Public Health Traineeships, $3 million. This program funds schools of public health to support traineeships that pay tuition, fees, and stipends for students in biostatistics, epidemiology, environmental health, toxicology, nutrition, or maternal and child health.
• Nursing Workforce Diversity, $2.6 million. This program increases nursing education opportunities for individuals from disadvantaged backgrounds through student scholarships or stipends, pre-entry preparation, and retention activities.
• Health Careers Opportunities, $2.5 million. This program funds schools and health professions training sites to establish or expand programs that help individuals from disadvantaged backgrounds enter and graduate from a health professions program.
• Dental Public Health Residency Training, $810,925. This program funds residency programs in dental public health, including financial aid to residents.

To date, HHS has announced the availability of nearly $200 million in ARRA workforce funds, of a total $300 million, to expand HRSA’s National Health Service Corps. The funds will pay for student loan repayments for primary care medical dental and mental health clinicians who wish to practice, for a minimum of two years, in NHSC sites that treat underserved and uninsured people.

More information can be found here.

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Did You Know You Can Enter the ACP’s National Medical Student Abstract Competition?

The College sponsors local and national abstract competitions for medical students that offer monetary awards and the chance to win recognition. The winning entries in both the National Clinical Vignette and Research competitions are featured each year at the College's premier annual Internal Medicine meeting. National winners are awarded a monetary prize to offset the cost of attending the meeting, and finalists are invited to compete on-site in the poster competitions for monetary prizes.

ACP will be holding a National Abstracts Competition as part of the Internal Medicine 2010 Meeting. The meeting will take place April 22 - 24, 2010, in Toronto, Canada. Please note that due to the international location, passports will be required for all attendees. The deadline for the National Medical Students Abstract Competitions is December 4, 2009, 11:59 PM EST.

Abstracts are divided into four categories: Clinical Vignette, Basic Research, Clinical Research, Quality Improvement - Patient Safety.

To find out more about the competition and win a chance to present at Internal Medicine 2010 in Toronto, Canada, please check out www.acponline.org/abstracts. All of the details and instructions for submitting an abstract are located on this site.

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MKSAP for Students 4 Question 1

A 43-year-old woman is evaluated in the office for an annual clinical breast examination. A careful visual inspection of each breast is completed. She is then carefully draped and positioned on the table to flatten the breast tissue evenly over the chest wall and is examined using an overlapping vertical-strip search pattern to systematically palpate the breast tissue, for a total of 3 minutes of examination time per breast.

Which of the following single clinical breast examination components is most likely to increase the accuracy of this patient's examination?

A. Duration of the examination
B. Movement and location of the examining fingers
C. Positioning of the patient
D. Type of search pattern used
E. Visual inspection of the breasts

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MKSAP for Students 4 Question 2

A 34-year-old woman is evaluated in the office for a 1-day history of fever, chills, and cough. She has a past history of iron deficiency anemia attributed to menorrhagia for which she has been treated effectively with ferrous gluconate daily for 1 year.

On physical examination, temperature is 38.6 °C (101.5 °F). Crackles and egophony are heard in the right posterior chest.

Laboratory Studies:
Hemoglobin 11.3 g/dL
Mean corpuscular hemoglobin 27.6 pg
Mean corpuscular hemoglobin concentration 33.2 g/dL
Mean corpuscular volume 83 fL
Leukocyte count 11,000/µL (80% neutrophils, 7% band forms, 10% lymphocytes, 3% monocytes)
Platelet count 440,000/µL
Ferritin 126 ng/mL
Iron 25 µg/dL
Total iron-binding capacity 277 µg/dL

Which of the following is most likely causing this patient's anemia?

A. Anemia of inflammation (anemia of chronic disease)
B. Combined iron deficiency anemia and anemia of inflammation
C. Iron deficiency anemia
D. Sideroblastic anemia

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MKSAP for Students 4 Answer 1

Answer: A: Duration of the examination

A careful examination should take approximately 3 minutes per breast. The duration of the examination correlates significantly with lump detection and accuracy in experimental models, which also has shown that the sensitivity of the examination increases, as does the number of proper techniques used.

Evidence supporting the role of careful inspection in breast cancer detection is lacking. Many physical examination textbooks recommend inspecting the patient's breasts while she is in various sitting positions, including arms at the side, arms above the head, hands pressed against the hips, and leaning forward to allow the breasts to hang from the chest wall. These maneuvers are performed to emphasize skin dimpling that may be associated with an underlying neoplasm. In one series of patients with breast cancer, 96% of cancers were discovered by palpation, 1% by skin retraction or dimpling, and 3% by visible nipple abnormalities. The study did not indicate whether special patient positioning was performed to elicit these signs. Based on these results, and because positioning the patient in three or four different positions takes time and has a relatively low yield of inspection, one authority has suggested that practitioners should concentrate on breast palpation as the primary means of cancer detection. During palpation, the practitioner can inspect the breasts for dimpling and nipple abnormalities.

The first step in the breast examination is to properly position the patient to spread the breast tissue over the chest wall. To examine the right breast, the patient should be shifted onto her left hip but with her shoulders rotated back to a supine position. Placing the right hand on the forehead completes the maneuver to flatten the lateral aspect of the breast. After examining the lateral right breast, asking the patient to resume a completely supine position and to move her right elbow level with her shoulder can flatten the medial portion of the breast. This process can be repeated for the left breast.

The breast examination should extend to an area bounded by the clavicles (top), midsternum and midaxillary line (sides), and the inframammary fold or bra line (bottom). Palpation is best accomplished with the finger pads of the middle three fingers, using a small circular motion. At each spot, the examiner should palpate three times, using different pressures to detect potential lumps located at superficial, intermediate, and deep levels of breast tissue. The preferred search technique begins in the axilla and extends down the midaxillary line to the inframammary fold. Then, the examiner should palpate along a vertical line upward, just medially to the first downward search line, until the clavicle is reached. The up-and-down pattern is repeated with overlapping rows until the entire rectangular search area is palpated thoroughly. This technique has been found to result in a more thorough examination than a radial or circular search pattern. The supraclavicular and axillary regions are then palpated to detect lymphadenopathy. Isolated lymphadenopathy in association with a normal clinical breast examination is an unusual but important presentation of breast cancer.

Bibliography
1. Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA. 1999;282:1270-80. [PMID: 10517431] [PubMed]

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MKSAP for Students 4 Answer 2

Answer: A: Anemia of inflammation (anemia of chronic disease)

Anemia of inflammation is most likely causing this patient's anemia. The patient has signs and symptoms of pneumonia. During infection, iron levels decrease, reflecting sequestration of iron in body storage pools (due to increased levels of hepcidin) and binding of iron by bacterial lactoferrin (which bacteria use to support their growth). Inflammatory cytokine levels also increase during infection, which profoundly affects transferrin and ferritin expression and results in low total iron-binding capacity, low transferrin levels (200–360 mg/mL), and high ferritin levels. Therefore, expected laboratory study findings during periods of inflammation include low or low-normal iron levels and total iron-binding capacity and normal or high ferritin levels, which this patient has.

This patient's ratio of iron to total iron-binding capacity is 0.09, which suggests iron deficiency anemia. However, 20% of patients with anemia of inflammation have iron/total iron-binding capacity ratios less than 0.10. Therefore, this patient's low iron/total iron-binding capacity ratio does not necessarily support a diagnosis of iron deficiency anemia, which generally also is associated with high-normal to high transferrin levels and total iron-binding capacity. In iron deficiency anemia, decreased ferritin levels reflect reduced storage pools of iron; conversely, in anemia of inflammation, inflammatory cytokines may increase ferritin levels by as much as threefold. Therefore, combined iron deficiency anemia and anemia of inflammation often is associated with low-normal ferritin levels, whereas this patient has high-normal ferritin levels.

This patient has a low-normal mean corpuscular hemoglobin level, low-normal mean corpuscular volume, and mid-normal mean corpuscular hemoglobin concentration. Hypochromic and/or microcytic erythrocytes are present in both iron deficiency anemia and anemia of inflammation. Sideroblastic anemia may potentially cause hypochromic anemia but also is often associated with a high iron/total iron-binding capacity ratio and high or high-normal ferritin levels, which reflect the abnormal accumulation of iron in sideroblasts.

Bibliography
1. Weiss G, Goodnough LT. Anemia of chronic disease. N Engl J Med. 2005;352:1011-23. [PMID: 15758012] [PubMed]

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Articles for Medical Students from ACP Internist and ACP Hospitalist

ACP Internist (formerly ACP Observer)

Find all of our print and online content, including ACP InternistWeekly, our blog, polls, and surveys (including our cartoon caption contest). Go online for the following stories:

  • Guiding clinicians through GI diagnoses
    ACP Internist wraps up highlights of Digestive Disease Week, including dyspepsia, weight loss and incontinence, as well as the latest about the risks of proton-pump inhibitors and antithrombotics. Don’t miss conference coverage that also includes a list of point-of-care tools, common coding problems and more about diarrhea, plus the MKSAP quiz on epigastric pain and daily heartburn.
  • MS confounds, calls for better coordination
    Internists are closely involved in care for multiple sclerosis, from recognizing symptoms to preventing complications. As the first line of defense, primary care physicians can find reassurance in guidance from a recent consensus paper on differential diagnosis.
  • Unmasking the patient’s hidden agenda
    Something about a response of ‘so-so’ triggers Ian Gilson, FACP, to delve further into how a patient is feeling—and a potentially suicidal hidden agenda.

ACP Hospitalist

The relaunched ACP Hospitalist is the place to find all of our print and online content, including ACP HospitalistWeekly, our upcoming blog, polls, and surveys (including our cartoon caption contest). Go online for the following stories:

  • The most basic therapy: Food
    Nutrition support experts want you to think of food as a drug. Not in the negative sense of addiction, but positively as a therapy that’s critical to helping hospitalized patients get better.
  • Renal failure
    When should you seek a nephrology consultation in patients with renal failure?
  • Hooked on mnemonics
    Memory is elusive (and of course, it “lights the corners of my mind”—or at least Barbra Streisand’s mind). That’s why there are so many tricks to remembering things, like acronyms, acrostics, rhyming keys, the image-name technique and the keyword method.

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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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