Volume 10, Number 3, Spring 2004
This issue is also available in PDF format
In This Issue:
- Making the Most of Your Third-Year Medicine Clerkship
- Focus on Internal Medicine Careers
- Articles from Annals of Internal Medicine: Medicine and the Media
- Military Medicine: Show Me the Money
Making the Most of Your Third-Year Medicine Clerkship
.You've made it through the basic sciences, and it's time to start seeing patients and learning on the wards. While all inpatient internal medicine clerkships will be organized somewhat differently, and all teams run somewhat differently, they generally have the same components. What follows is meant as a guide that encompasses many aspects of inpatient internal medicine clerkships that are relatively common between various institutions. This article is designed to help you know what to expect when starting your clerkship and how to be successful during your clerkship.
The Players
There are several people with whom you will have close interaction during your medical rotation. Your team will consist of at least a resident, an intern (first-year resident), and yourself. There may also be other students on your team, either a fellow third-year student, or a fourth-year student completing a sub-internship. The resident is in charge of the team and bears the responsibility for supervising the other members, directing the overall goals of treatment, and ensuring that patients are properly cared for. The resident often has the time and knowledge to teach the more junior members of the team. This teaching may take a didactic form in addition to informal teaching on rounds. The intern bears the brunt of the responsibility for the implementation of patient care. The intern is the first team member to be called if any of the team's patients have an immediate need. The intern's time is therefore very limited, and you will likely find they have less time for teaching and discussion.
There are several other individuals with whom you will also have interaction. The attending physician supervises the residents, and has the principal roles of teacher for the entire team and care manager for the patient. Nurses, by the nature of their job, have much more contact with patients than you do, and can be great sources of information on any events concerning the patient, as well as where you can find supplies on the ward. Unit secretaries are great at locating everyone and everything on the ward, whether you are looking for patients, nurses, supplies, or charts. Ancillary providers such as social workers, physical therapists, and nutritionists add valuable areas of expertise to round out the care team.
The Day
A typical day on a medicine clerkship begins with pre-rounding. Pre-rounding entails going to see your patients before discussing them with the team. Pertinent information to ensure you collect during pre-rounds is how the patient did overnight, how the patient is currently doing, a focused physical exam, reviewing any new chart notes, looking up any new laboratory results, and beginning to formulate the plan for the day. Depending on your residents, you may also be expected to prepare a brief progress note during this time. Pre-rounding can be quite daunting at first and forces you to set your alarm for hours you never knew existed, but with some practice your pre-rounding can become quite efficient.
Work rounds with your team will begin at a specified time every morning. Here, all of the team's patients will be reviewed and discussed with the resident, intern, and students. Events will be reviewed, and the day's plan will be determined. These rounds are typically brief, with the students and interns presenting each patient in a quick, 1-2 minute summary highlighting any changes or new information.
Next is attending rounds, where final decisions about patient care are made. More time is available generally for teaching and discussion during attending rounds. The team's patients are presented to the attending physician, and this can take place at the bedside or in a conference room. The presentation is usually more lengthy and formal than during work rounds. For these rounds it is important to be the expert on what has been happening with your patient. This is also the time when you are most likely to be "pimped," so some knowledge about your patient's disease process can be quite useful.
Call day can take different forms. At many hospitals, this is the day your team admits a number of patients to their service who will be followed throughout their hospital course. Because of the additional duties in completing full histories and physicals for admissions, these days can (and will!) go well into the evening. Teams working in hospitals that use this system will typically take call every fourth day.
At other hospitals, call may take the form of staying late with the night house staff, who cover the patients in the hospital, typically responding to pages regarding acute changes in a patient's condition or nursing concerns that require immediate attention.
Grading and Evaluations
Clerkship grades are typically determined primarily on subjective evaluations from the attendings and residents with whom you work. The residents will have the clearest picture of you, since they will have had contact with you in multiple facets, including presentations, your chart notes, interactions with patients, ability to work within and for the team, as well as your interactions with other staff members. Attendings' contact with you will often be limited to your presentations and chart notes, so to excel in the clerkship, it is important to do extremely well in these areas.
A lesser part of the grade is from a written exam, typically the medicine shelf exam, supplied by the National Board of Medical Examiners (NBME). Questions here cover a wide range of material with a focus on diagnosis and what one would do next (what laboratory tests to order, what treatments to initiate, etc.). Given the wide encompassing nature of the medicine shelf, it is a difficult exam to study for, and most students find it most helpful to read about each of their patients' diseases rather than study review books for the test. If you are so compelled, there are several review books available in many different formats, depending on your studying preferences.
How to Be Successful
Now that you know what to expect, how can you be successful on your medicine rotation? Like any rotation, the first key is enthusiasm. It is part of the job of residents and attendings to teach you. Being enthusiastic lets them know that you want to learn and will encourage them to dispense clinical pearls.
Be the expert on your patient. This does not mean that you know every in and out of the patient's disease process, but rather that you know everything about your patient. Know lab test results, what lab tests are pending, radiology results, what any consultants' recommendations are, try to identify any potential barriers to discharge, and ensure that social work and physical therapy is taking place if applicable.
Be nice to the nurses. Simply by the nature of their jobs, the nurses have the most contact with the patients of any care providers. They can be quite helpful in identifying events that occurred overnight and let you know any nursing questions or concerns about the care of the patient. They will also be able to help you find things on the floor.
Make your intern's life easier. Interns are often overloaded with writing orders, filling out paper work, and other similar tasks denoted as "scut work." Helping the intern with these tasks is a good way to ensure that you are being a valuable team member, and also will give the intern more free time to teach you.
Good luck with your clerkship!
Ryan Brecker
Council of Student Members Representative, North Atlantic Region
University of Rochester School of Medicine, 2005
Focus on Internal Medicine Careers
.View from the Sidelines: Interview with a National Football League Team Physician
As the Southwestern Region Representative to the Council of Student Members and a fourth-year medical student at Louisiana State University in New Orleans (LSUNO), Nita Kohli has had the opportunity to work closely with the National Football League's (NFL) New Orleans Saints team internist, Dr. John Amoss, on both general medicine wards and clinics.
Dr. Amoss, a hospitalist, completed medical school and residency at LSUNO, and then gained experience working in various emergency rooms around the city for 3 years. He then became a full-time faculty member at LSUNO and is currently the Director of the Hospitalist Program at the Medical Center of Louisiana-New Orleans, as well as the Acting Section Head of Comprehensive Medicine at LSUNO. He has been a Saints team physician for four seasons.
IMpact: How did you get involved in this? How does one go about becoming a doctor for a professional team?
Dr. Amoss: I don't think you can make it a goal to become a physician for a professional team. I just happened to be in the right place at the right time. My predecessor of 30 years thought it was time for an administrative change and was looking for a young person; he talked to me about it and I agreed to do it. If you want to get involved in sports teams, I would recommend starting at the high school and college levels.
IMpact: What do you do?
Dr. Amoss: Well, I treat the players who are generally healthy people, and I also take care of the coaches and their families, as well as players' spouses, if they ask me to. I've seen things ranging from hypertension and asthma, to concussions, methicillin-resistant staphylococcus aureus (MRSA), testicular torsion, Wolff-Parkinson-White and atrial fibrillation, and eye injuries (which, of course, get seen by the ophthalmologist).
IMpact: How much of your time does all this take?
Dr. Amoss: Travel takes up the most time. If it's a home game, then we have to be there 2 hours pre- and post- game. If it's an away game, then we usually leave around 1 p.m. Saturday and get back anywhere from 7 p.m. Sunday to 5 a.m. Monday, depending on where we're flying back from. There are ten away games, and traveling can be hard on my family, as well as on me, since I still have to come back Monday morning, see patients, and be on call.
IMpact: What's the most interesting diagnosis you've seen?
Dr. Amoss: Wolff-Parkinson-White, which was picked up on a routine physical. The standard of care is to have an electrophysiology study. It took 3 or 4 weeks to convince the player to get it checked out, and he had been symptomatic for 2 weeks. He ended up going into atrial fibrillation and had to be cardioverted in the emergency room.
IMpact: Most exciting or scary moment on the team?
Dr. Amoss: Most scary . . . the owner of the team asked me to be his doctor, and he told me he was having chest pains. Well, it turned out he was having unstable angina and he had coronary artery disease, so he had to undergo surgery. We knew that if there were complications, the team might have to be sold to someone else, someone who might not be from New Orleans, and we could possibly lose the New Orleans Saints. That's a big deal because the team means a lot to the people of New Orleans and the rest of Louisiana. However, the owner ended up doing well and pulling through.
IMpact: Do you feel pressured at times to let people play when they shouldn't? How does sitting out of a game affect a player?
Dr. Amoss: Yes, there is pressure to let people play, and there's a constant battle between the patient's interests and the team's interests. You have to balance the safety issues and you must always put the patient first. However, it's not like treating a patient with a regular job. This is true from the standpoint of both the orthopedist and the internist. Most times, players want to go back into the game. Other times, they may think, "Well, I don't have to work so hard this week."
IMpact: Are you certified in sports medicine?
Dr. Amoss: No, and I don't pretend to be. I don't do any orthopedics, so if there's an ortho problem, it goes to an orthopedist.
IMpact: Is the internal medicine or the family medicine route to sports medicine better?
Dr. Amoss: It depends on what you want to do. Family medicine allows you to learn some ortho, where, as an internist, I don't do any ortho.
IMpact: What do you like best or least about working with professional athletes?
Dr. Amoss: There is pressure to do things and treat certain things. For instance, if a player has an upper respiratory infection and we tell them no antibiotics, then they look at you funny.
IMpact: Where do you sit during the game?
Dr. Amoss: On the sidelines.
IMpact: What other physicians do you work with on the team?
Dr. Amoss: For home games, there are two orthopedists, a dentist, an ophthalmologist, and an internist (myself) on the sidelines. For away games, there are two orthopedists and myself.
IMpact: Is there an organization for sports team physicians?
Dr. Amoss: Yes, there is an NFL Physicians Society, which meets once a year to discuss any problems or issues. For example, MRSA infections have been a big problem this year, ranging anywhere from small boils to full-blown cellulitis.
IMpact: Are there any liability issues?
Dr. Amoss: Yes, for away games, you are going out of the state where you are licensed to practice medicine. Also, the insurance policies in Louisiana are capped, and in some other states, there is no cap. The amount of potential lawsuits can be enormous.
IMpact: What are the fringe benefits?
Dr. Amoss (smiling): Besides getting to go to the games, I can get an autographed football for my son. And, it's also a bit of an ego boost to be the doctor for a big team.
Articles from Annals of Internal Medicine: Medicine and the Media
.When you enter medical practice, be prepared to answer questions from patients who have heard about recent medical research in reports by the lay press. Below is a recent article from Annals, as summarized by the Editors of Annals, and a summary of the same article from a New York Times article. In addition, below is a recent study in the Annals that quantifies the impact of the press on patient behavior. Was the press helpful in these two examples? In the editorial below from Annals, Schwartz and Woloshin note that both authors and the press have been parties to misinformation. The excerpts from the editorial provide common sense guidelines for you and your patients when reading medical news in the media.
Medical Student Members can get full access to Annals Online by registering.
Graded Activity for Low Back Pain in Occupational Health Care: A Randomized, Controlled Trial
J. Bart Staal, PT, PhD et al. Ann Intern Med 2004;140:77-84 Jan 20
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Summary written by the Editors of Annals:
Context: Low back pain causes frequent disability and lost productive time.
Contribution: This randomized trial compared a behavioral-oriented graded activity program with usual care in 134 Dutch airline company workers who had missed work because of persistent low back pain. Graded activity consisted of biweekly 1-hour exercise sessions with physiotherapists who emphasized operant-conditioning principles. Over 6 months of follow-up, participants in the graded activity program missed 58 days of work, while participants receiving usual care missed 87 days.
Implications: A behavioral-oriented graded activity program returned participants with low back pain to work more often than did usual care.
Summary by the New York Times:
The New York Times covered this study in an article titled "Performance: Back Pain Takes a Vacation," on January 20th in their "Vital Signs" column. The Times noted the methodology used, "they enlisted 134 KLM airline employees who had missed work because of lower back pain. They were assigned to receive advice on ergonomics and injury prevention or to the activity program," and concluded "On average, workers in the standard care group missed 87 days of work in the 6 months that followed enrollment in the study. Workers in the activity group missed an average of 58 days, even though they reported only slightly lower pain levels and slightly higher functional abilities."
Changes in the Use of Postmenopausal Hormone Therapy after the Publication of Clinical Trial Results Jennifer S. Haas, MD, MSPH et al. Ann Intern Med 2004;140:184-8. 3 February 2004
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Summary written by the Editors of Annals:
Context: Since 1998, 2 large trials have drastically changed the evidence for the preventive health benefits of postmenopausal hormone replacement therapy. However, changes in practice often lag behind changes in evidence.
Contribution: Among mammography recipients in San Francisco, California, the use of hormone replacement therapy decreased 1% per quarter after publication of the Heart and Estrogen/progestin Replacement Study and 18% per quarter after publication of results from the Women's Health Initiative (WHI). Reduction in use was unrelated to a woman's age, hysterectomy status, or race or ethnicity.
Implications: The WHI resulted in more dramatic changes in practice than are often associated with changes in evidence. The vigorous media coverage of the WHI may have contributed to rapid changes in practice.
The Media Matter: A Call for Straightforward Medical Reporting
Lisa M. Schwartz, MD, MS and Steven Woloshin, MD, MS. Ann Intern Med 2004;140:226-8. Feb 3
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Believe nothing that you see in the newspapers...if you see anything in them that you know is true, begin to doubt it at once.
—Sir William Osler (1)
While many physicians may share Osler's sentiments about the sometimes sloppy and sensationalized press coverage of health care, doctors and researchers have real reasons to help journalists do their job well. The public pays attention to health in the media—over half of U.S. adults report that they follow health news closely; only community events and crime get more attention (2). Thus, the press is well positioned to educate the public about health and health risks and about what medicine can (and cannot) do. In short, the press could be a positive influence on the nation's thinking about health.
This issue contains an impressive example of the power of the press to educate the public. Haas and colleagues (3) report on the decline in hormone replacement therapy (HRT) use following the release of the main findings of the Women's Health Initiative (WHI) (4), a randomized trial that examined the efficacy of HRT in the primary prevention of heart disease. The WHI received enormous media coverage—more than 400 newspaper stories and 2500 television—radio stories appeared in the month after release of the findings. Haas and coworkers studied women in a San Francisco mammography registry and found that the proportion of women receiving HRT decreased by about one third (from 40% to 28%) during that period. Recently, investigators from New Zealand reported similar findings: Use of HRT in that country initially decreased by about half among women who had been using it before release of the WHI results (5). Although some women and their physicians may have responded directly to the WHI results, we think the rapid decline in HRT use points to the influence of the media: It is hard to imagine another mechanism that would explain how the message got out so quickly.
This study is not the first to show that the media affect health care utilization, clinical practice, and even researchers. A recent Cochrane review identified 5 studies that evaluated health care utilization before and after media coverage of specific events (6). Each found changes in utilization: Favorable publicity was associated with higher use; unfavorable publicity was associated with lower use. The Cochrane review concluded that media reports played an important role in influencing the public's use of health care interventions. A recent study of physician practice described an association between mass-media coverage of the so-called "flesh-eating bacteria" and testing for group A streptococcal disease in a pediatric emergency department after a cluster of invasive streptococcal cases in Kansas City (7). The investigators found a clear and substantial increase in such testing following the peak in media attention (testing rate increased from 55 to 103 per 1000 visits) despite no increase in the number of children presenting with symptoms that might warrant such testing. Another study examined the role of the media in the dissemination of research (8). The authors showed that New England Journal of Medicine (NEJM) articles were more likely to be cited in the medical literature if they had been covered in The New York Times. To evaluate whether coverage in the Times was simply a marker of the most important articles, the investigators also studied a 3-month period during which there was a strike at the paper, but the editors continued to prepare an "edition of record" that was not distributed. The authors found no difference in subsequent citations for the NEJM articles the Times planned to cover (but did not because of the strike) and subsequent citations for all other articles in the same issues of NEJM. This finding suggests that media coverage—distinct from the scientific importance of the work-plays an important role in transmitting knowledge to the scientific community.
Of course, the more the media matter, the more we need to be concerned about whether they are doing a good job. Medical journalists have a very difficult role: They translate complex messages under deadline into news that people can understand. Not surprisingly, the quality of media reports varies greatly. Recently, a number of studies criticized press coverage for exaggerating the benefits and minimizing the harms; of medications (9, 10); hyping a variety of health risks (11); and overemphasizing preliminary work (for example, scientific meeting reports), some of which never get published in the medical literature (12). Fortunately, many leaders in the journalism community are working hard to improve the state of medical reporting. These efforts include workshops for journalists held by the Association of Health Care Journalists, the National Institutes of Health (Medicine in the Media), and the Knight Foundation (medical evidence "boot camp"); educational materials for reporters (for example, tip sheets [13]); and planned changes in curriculum, like those at the Columbia School of Journalism, to promote better critical thinking about medical research.
Further, we believe that the quality of medical reporting would improve substantially if journalists adhered to the following basic principles:
In general, don't report preliminary findings. It is tempting to report the latest findings, but what is new may turn out to be wrong. This caveat applies especially to phase I trials, animal studies, and reports based on intermediate end points (for example, for a laboratory finding such as cholesterol level) in contrast to a clinical outcome (for example, coronary artery disease mortality). "Work in progress" presented at scientific meetings is especially vulnerable to mischaracterization: Promising reports often fail to pan out, and methods, results, and interpretations change over time. When the press reports preliminary findings, they should highlight the cautions listed here. Researchers should do the same when being interviewed by the press.
Communicate the absolute magnitude of differences. Most clinical research reports come down to comparisons between groups. The simplest way to represent such results is by providing absolute event rates for the various exposure groups. Reporting relative risk reductions without clearly specifying event rates is a bad practice because it leads readers to overestimate the magnitude of findings (14). For example, consider one drug that lowers disease risk from 20% to 10% and another drug that lowers it from 0.000002% to 0.000001%. Both yield a "50% relative risk reduction," yet the 2 drugs differ dramatically in clinical importance. Similarly, the presentation of benefits and harms should give equal prominence to both by using the same format (that is, absolute event rates for both benefits and harms).
Include caveats. All studies have limitations. The press should state major limitations and important caveats (such as limited generalizability of findings). Reporters should highlight potential conflicts of interest by noting the study's funding sources and, where relevant, financial conflicts of interests of any commentators. Researchers should help the press report these facts accurately.
Finally, the medical community should take more responsibility to help make straightforward medical reporting a reality. Scientific meetings are an obvious place to start. Researchers, their academic institutions and funding agencies, and the organizers of scientific meetings could stop courting press coverage of preliminary work. "Press releases" are a second obvious target. The goal of the press release should be to communicate the content of the science, not to generate the largest amount of press coverage. This principle applies not only to university and scientific meeting press releases but also to medical journal press releases. Medical journal press releases often express study findings in formats that exaggerate the perceived importance of findings (for example, relative risk without a base rate) or fail to note study limitations or potential conflicts of interest (15). Better press releases could help journalists get stories right.
Too often, medical researchers and the media focus more on getting attention for their message than on getting their message right. Straightforward medical reporting might garner less attention, but it would serve the public better.
Military Medicine: Show Me the Money
.The military pay structure for medical offers can be confusing, even to those with prior military service. For medical students on military scholarships with no prior experience, figuring out what your future salary will be can seem almost hopeless. Keeping that in mind, I spent some time in the trenches to sort through it all. I checked, rechecked, cross-checked, and am pretty sure I even cross-matched this information in my endeavor to get it right. I hope you find it useful.
The basic military pay scale is based upon time in grade, or the number of years spent in a particular rank. All military physicians are commissioned officers in the Medical Corps, and, if entering the service directly from medical school, will enter as a 0-3 on the pay scale. This determines the physician's Base Pay. As of January 2004, a physician entering the military directly from medical school with no prior military experience would earn a monthly Base Pay of $3,018.90. In addition, this officer would receive a Basic Allowance for Housing (BAH) of $689.40 (without dependents) or $818.10 (with dependents) and a Basic Allowance for Subsistence of $175.23 each month. Those in high-cost areas receive an adjusted BAH to compensate for the increased cost of housing. For example, I will be completing my residency in the San Diego area, and will receive a BAH of $1,988.00 per month (versus $818.10).
In addition to the above, military medical officers receive a number of additional pay bonuses. Board-certified medical officers are eligible for Board Certification Pay, which ranges from $200 to $500 per month. They also receive Variable Special Pay, which ranges from $100 per month for interns to $1,000 per month for those with 6-8 years of service. Furthermore, they are eligible for Medical Additional Special Pay once they complete residency, which is currently a yearly lump sum of $15,000.
Once physicians "pay back" their service obligation, they are eligible for further bonuses as well. Multi-year Special Pay requires a 2-4 year service commitment, and was $14,000 in 2003. There are also Incentive Special Pay annual contracts available to some subspecialists who have completed their initial payback period. Lastly, a Critical Skills Retention Bonus has been offered in the past to certain specialties. In 2002 this was a lump sum payment of $30,000 for a one-year service obligation.
So, in putting all of this together, a Board-certified internist right out of residency with no prior service can expect to earn about $110,000 per year. But wait! Don't order that Ginsu set yet, because it gets better! In addition to their salary, Active Duty service members are also entitled to receive other benefits, which include full medical coverage for the service member and his or her family, full dental coverage, life insurance, discount shopping at military facilities, and 30 days paid annual leave. And don't forget that fantastic benefit for military physicians: malpractice insurance is paid entirely by the U.S. Government!
Steven Bernick, Military Liaison, Council of Student Members
Uniformed Services University of the Health Sciences, 2004
E-Mail: s4sbernick@usuhs.mil
MKSAP Question 1
.A 59-year-old woman is seen for her annual examination. She has no signs or symptoms of illness. Her medical and family history are negative. She has two children. Her last menstrual period was 3 years ago. She has occasional hot flashes and vaginal dryness.
On physical examination, there is a round, firm, nontender, and mobile mass approximately 1 cm in diameter in the upper outer quadrant of the patient's left breast. A mammogram is negative, and a subsequent ultrasound identifies no cysts.
Which of the following is the best approach to the management of this patient?
(A) Reexamine the breast during a different part of the menstrual cycle.
(B) Needle aspiration of the mass
(C) Reassurance and yearly examinations and mammograms
(D) Mammogram in 3 months
(E) Biopsy of the mass
MKSAP Question 2
.A 46-year-old man with a history of cirrhosis is evaluated because of increasing abdominal girth, swelling of his ankles, and a 30-lb weight gain. Physical examination demonstrates moderate ascites, muscle wasting, cutaneous stigmata of advanced liver disease, and no sign of hepatic encephalopathy. Laboratory studies reveal the following: albumin, 3.0 g/dL; aspartate aminotransferase (AST), 66 U/dL; alanine aminotransferase (ALT), 78 U/dL; total bilirubin, 1.4 mg/dL; international normalized ratio (INR), 1.2; sodium, 132 meq/L; potassium, 3.8 meq/L; serum creatinine, 0.9 mg/dL; and UNa, 15 meq/d. Ascitic fluid findings on paracentesis include a leukocyte count of 270/µL (60% polymorphonuclear leukocytes) and an albumin level of 1.3 g/dL.
In addition to a salt-restricted diet, which of the following initial measures is most appropriate to manage this patient's ascites?
(A) Dietary protein and fluid restriction
(B) Serial large-volume paracentesis
(C) A loop diuretic
(D) Spironolactone and a loop diuretic
MKSAP Question 3
.A 67-year-old man is evaluated because of bright red blood in his stool 2 weeks ago, which seemed to resolve spontaneously. Rectal examination reveals increased sphincter tone, a small fissure, and a normal prostate gland. Stool is brown and negative for occult blood.
Which of the following is the most appropriate next step in managing this patient?
(A) No further investigation
(B) Three tests of stool for occult blood
(C) Colonoscopy
(D) Barium enema
(E) CT scan of the abdomen
MKSAP Question 4
.A 48-year-old woman (gravida 3, para 3) is evaluated because of right upper quadrant pain. She has had three discrete episodes of moderate to severe right upper quadrant pain that radiates to the right scapula and lasts 4 to 5 hours. The last of these episodes occurred 72 hours ago. These attacks occur 30 minutes to 90 minutes after eating and are associated with nausea, but not vomiting. Her medical history is otherwise unremarkable. Physical examination reveals moderate obesity, and abdominal examination is normal. She takes no medications.
Which of the following is the best test to confirm the diagnosis?
(A) CT scan of abdomen
(B) Ultrasonography
(C) Hepatoiminodiacetic acid (HIDA) scan
(D) Oral cholecystography
(E) Upper endoscopy
MKSAP Question 5
.An 80-year-old man who had a hemicolectomy for colon cancer is evaluated because of a 4-month history of diarrhea, anorexia, and fatigue. He had a remote history of alcoholism.
On physical examination, he is cachectic and mildly confused. His pulse rate is 70/min, and blood pressure is 140/85 mm Hg. His tongue is smooth. The abdomen is soft; there are no palpable masses or hepatosplenomegaly. A stool specimen is negative for occult blood. Neurologic examination shows loss of position sense in the feet. He has a wide-based gait. The Romberg test is positive. His hemoglobin is 9.4 g/dL, reticulocyte count is 2.5%, mean corpuscular volume is 125 fL, and serum lactate dehydrogenase is 400 U/L.
Which of the following is the most likely cause for his symptoms?
(A) Alcoholic cerebellar degeneration
(B) Vitamin B12 deficiency
(C) Brain metastases
(D) Folate deficiency
(E) Liver metastases
Answer - Question 1
.Answer: E
Educational Objective: Evaluate and manage a discrete breast lump.
This patient illustrates the need for aggressive evaluation of her discrete, solid breast mass. Any middle-aged woman with a discrete breast mass should be referred to a surgeon for biopsy regardless of the presence of benign characteristics on physical examination or a negative mammogram. The risk of malignancy increases with age, leading to the axiom that any discrete mass detected on physical breast examination in a woman aged 50 years or older should be considered to be malignant until proven otherwise. Although certain characteristics are associated with benign lesions (for example, masses that are round, mobile, and soft), a review of malignant masses found a significant portion to be regular (41%) and mobile (61%). Therefore, clinical characteristics cannot be relied upon to predict the pathologic nature of a discrete mass. If this were a younger woman with multiple, round, tender lumps or if cysts were identified on ultrasound, a return in 6 weeks for examination during a different part of the menstrual cycle or an attempt at aspiration would be appropriate. However, there is no evidence to support the presence of a cyst. Although a "negative triad" - benign characteristics on physical examination, negative cytology on fine-needle aspiration, and a negative mammogram - has been suggested as an adequate evaluation, studies have reported false-negative rates as high as 16% in the presence of a malignant mass. Risk factors for breast cancer are helpful in predicting the likelihood of a mass's being malignant, but 75% of women with newly diagnosed breast cancer have no identifiable risk factors. Mammograms are the most sensitive method for detecting breast cancer, but large trials have reported that 3% to 45% of breast cancers are detected by palpation in women with negative mammograms.
References
1. Baines CJ, Miller AB, Bassett AA. Physical examination. Its role as a single screening modality in the Canadian National Breast Screening Study. Cancer. 1989;63:1816-22.
2. Venet L, Strax P, Venet W, Shapiro S. Adequacies and inadequacies of breast examinations by physicians in mass screening. Cancer. 1971;28:1546-51.
3. Yelland A, Graham MD, Trott PA, Ford HT, Coombes RC, Gazet JC, et al. Diagnosing breast carcinoma in young women. BMJ. 1991;302:618-20.
4. Barton MB, Harris R, Fletcher SW. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA. 1999;282:1270-80.
Answer - Question 2
.Answer: D
Educational Objective: Manage a patient presenting with new-onset ascites.
This patient has new-onset ascites due to portal hypertension. Diuretic therapy and dietary salt restriction should be instituted to prevent recurrence of ascites. In a minority of patients with mild fluid retention, dietary salt restriction alone is sufficient to mobilize ascites, but most patients require the addition of diuretic therapy. The traditional stepwise approach to diuretic treatment is initiation of an aldosterone antagonist, such as spironolactone, in increasing doses to a maximal dose (400 mg/day) as necessary, followed by addition of escalating doses of a loop diuretic in patients in whom the preceding treatment is unsuccessful. However, this stepwise approach often takes a long time, and many experts begin treatment with a combination of an aldosterone antagonist and a loop diuretic. In the setting of fluid retention due to cirrhosis, institution of therapy with a loop diuretic alone (Option C) is typically less effective than a potassium-sparing agent, is often complicated by hypokalemia, and should be avoided. Diet therapy is the cornerstone of ascites treatment: sodium restriction at the level of approximately 2 g/day is adequate without compromising the palatability of the diet too much. However, protein intake should not be restricted in patients with advanced liver disease, particularly in the setting of muscle wasting, unless problematic hepatic encephalopathy persists despite treatment with lactulose and/or antibiotics. Dietary free water restriction is indicated only in patients with hyponatremia (<130 meq/L). Initial, large-volume paracentesis is appropriate in patients who present with symptomatic, tense ascites that can often be successfully managed subsequently with dietary and diuretic therapy. Repeat, serial, large-volume paracentesis is reserved for the small number of patients with recurrent ascites that is refractory to medical management.
References
1. Runyon BA. Care of patients with ascites. N Engl J Med. 1994;330:337-42
Answer - Question 3
.Answer: C
Educational Objective: Follow-up rectal bleeding in an older patient.
Age and first-time bleeding are risk factors for significant colonic disease associated with episodes of bright red blood in the stool. This patient who has a visible rectal fissure should still undergo colonoscopy based on the history of a first-time bleed 2 weeks before the visit. Barium enema with flexible sigmoidoscopy would be an acceptable alternative, but barium enema alone would not adequately assess the rectosigmoid. Stool occult blood tests are not sufficient evaluation in a patient with a history of a recent bleed. A CT scan of the abdomen is also not sufficient for further evaluation of this patient.
References
1. Helfand M, Marton KI, Zimmer-Gembeck MJ, Sox HC Jr. History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up. JAMA. 1997;277:44-8.
Answer - Question 4
Answer: B
Educational Objective: Order the appropriate test in a patient with suspected symptomatic gallstones.
This patient has symptoms that are characteristic of biliary pain, including right upper quadrant pain radiating to the scapula after eating. The best diagnostic test in this situation is ultrasonography, which has an accuracy of approximately 90% for cholelithiasis and is widely available, noninvasive, and relatively inexpensive. Computed tomography is less sensitive than ultrasonography in detecting cholelithiasis and is also more expensive and less readily available. Hepatoiminodiacetic acid (HIDA) scans are used to detect cystic duct obstruction and are not useful for detecting stones within the gallbladder itself. Oral cholecystography is not sufficiently accurate to use as a diagnostic test in this situation. Endoscopy is not useful for the diagnosis of biliary disease.
References
1. Kalloo AN, Kantsevoy SV. Gallstones and biliary disease. Prim Care. 2001;28:591-606.
Answer - Question 5
.Answer: B
Educational Objective: Recognize the presentation of pernicious anemia in an elderly patient.
The patient most likely has vitamin B12 deficiency, based on the degree of macrocytosis and neurologic findings. An elevated serum lactate dehydrogenase level, due to intramarrow cell death from ineffective erythropoiesis, is consistent with this diagnosis.
Severe macrocytosis (mean corpuscular volume > 120 fL) is often associated with vitamin B12 deficiency or folate deficiency (megaloblastic anemia), usually seen in conjunction with "oval" macrocytes. The presence of frequent hypersegmented neutrophils (< 5 segments) is strongly suggestive of vitamin B12 or folate deficiency.
Bone marrow morphology in patients with vitamin B12 or folate deficiency is referred to as "megaloblastic" and is characterized by the presence of large cells with immature nuclear chromatin but maturing erythrocyte cytoplasm (nuclear-cytoplasmic dissociation). Anemia accompanies this process; hence the term "ineffective erythropoiesis." The intramarrow death of megaloblastic cells causes the serum lactate dehydrogenase level to rise. If a patient has a low serum vitamin B12 or folate level, a bone marrow examination is probably unnecessary. However, the physician should determine the cause of the deficiency. If a patient has a normal serum vitamin B12 or folate level, a bone marrow examination is frequently helpful to exclude myelodysplastic syndromes or other infiltrative marrow disorders.
Folate deficiency can induce megaloblastosis within weeks to months, whereas vitamin B12 deficiency requires years to cause megaloblastosis since stores of vitamin B12 persist for years in the liver and other tissues. In patients with vitamin B12 or folate deficiency, parenteral or oral repletion of vitamin B12 or folate reverses some morphologic abnormalities within hours. Serum folate levels fluctuate quickly with changes in dietary consumption. Low erythrocyte folate levels often reflect prior nutritional depletion. In patients who are hospitalized and are begun on regular diets, the erythrocyte folate test may provide a better assessment of tissue folate levels than determination of the serum folate level. The erythrocyte folate test often requires a special laboratory, and results often are not quickly available.
In patients with megaloblastic anemias, erythrocyte production is diminished and a "corrected" reticulocyte count is inappropriately low for the degree of anemia. This patient had a corrected reticulocyte count of 1% (inappropriately low for a hemoglobin level of 9.4 g/dL).
In addition to changes in the blood, the epithelial cells in patients with megaloblastic anemias may become atrophic and cause a smooth tongue and cheilosis. Posterior column dysfunction, particularly in patients with vitamin B12 deficiency, may lead to changes in vibratory or position sense, causing ataxia. Signs of dementia may appear. However, neurologic dysfunction is very uncommon in adults with folate deficiency.
Alcoholic cerebellar degeneration results in ataxia but not position loss. Although liver metastases are possible in a patient with a history of colon cancer, their presence would not account for the neurological findings in this patient. Brain metastases would most likely produce focal neurological findings and also would not account for the blood findings.
References
1. Toh BH, van Driel IR, Gleeson PA. Pernicious anemia. N Engl J Med. 1997;337:1441-8. PMID: 9358143
2. Carmel R. Cobalamin, the stomach, and aging. Am J Clin Nutr. 1997;66:750-9. PMID: 9322548
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