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November 2010

Medical Student Perspectives: Is the Physical Exam Dying?

The future of the physical exam has come into question again in both the scientific journals and the popular press. For the last decade or longer, the debate has raged over the value of the annual physical exam. A study by the Agency for Healthcare Research and Quality (AHRQ)1, which began in 1989 and was published in 2006, is commonly cited by opponents of the annual physical.


My Kind of Medicine: Real Lives of Practicing Internists: Nirav Shah, MD

When it comes to New York City, there are two kinds of people-those who can live there and those who cannot. To be a true New Yorker, you have to thrive on the hustle and bustle, the never-ending cycle of action. There is never a dull day in NYC, and the people who make it their home would not have it any other way. That is how Dr. Nirav Shah feels about being a New Yorker. It is also how he feels about being an internist.

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Feature: Finding the Right Mentor for You

Once that you are medical school graduates all you have to remember to say is, "I do not know how to do this! Please help me." Finding the right mentor can really help you along in your journey as a young physician.


Internal Medicine Interest Group of the Month: Meharry Medical College

Since being first featured as the Internal Medicine Interest Group of the Month in the September 2008 issue of IMpact, the Thomas-Hardy Internal Medicine Society (THIMS) of Meharry Medical College's School of Medicine has continued to maintain an abounding presence on the Meharry campus and in the surrounding community of Nashville, Tennessee.


Winning Abstracts from the 2010 Medical Student Abstract Competition: The Sound Of Bleeding

Heyde's syndrome was first reported in 1958 as a correlation between aortic stenosis and gastrointestinal (GI) bleeding. Recently, it has been associated with the triad of aortic stenosis, gastrointestinal angiodysplasia, and acquired von Willebrand syndrome. Several case studies and small series have appeared in the literature, yet, 50 years later, there are no clinical guidelines for evaluation of anemia or GI bleeding in patients with aortic stenosis.


Subspecialty Careers: Highlights about Careers in Internal Medicine: Hematology

The discipline of hematology relates to the care of patients with disorders of the blood, bone marrow, and lymphatic systems, including the anemias, hematological malignancies and other clonal processes, and congenital and acquired disorders of hemostasis, coagulation, and thrombosis.


Did You Know: ACP's Council of Student Members is looking for new representatives?

If you are active in your local chapter, get involved nationally by running for a seat on the ACP Council of Student Members (CSM). The CSM is responsible for planning programs for the annual meeting for medical students and providing a student perspective on current issues impacting the field of internal medicine.



MKSAP for Students 4 Question 1

A 27-year-old woman with a 2-year history of systemic lupus erythematosus is evaluated in the office for new-onset fatigue and shortness of breath of 10 days' duration. Her medications are hydroxychloroquine and ibuprofen. The medical history is otherwise noncontributory.

On physical examination, the heart rate is 109/min, respiration rate is 14/min, and blood pressure is 130/80 mm Hg. Other than pale conjunctivae and pallor, the physical examination is normal.

Laboratory studies indicate a hemoglobin of 5.2 g/dL, compared with a normal value 3 months ago, and an absolute reticulocyte count of 300,000/µL (normal, 25,000 -75,000/µL). The peripheral blood smear shows polychromatic red blood cells and microspherocytes.

Which of the following is the most appropriate initial treatment for this patient?
A. Corticosteroid therapy
B. Erythropoietin
C. Oral ferrous sulfate
D. Plasmapheresis



MKSAP for Students 4 Question 2

A 50-year-old woman is hospitalized for lower-extremity edema and accelerated hypertension. She has a 3-year history of diet-controlled type 2 diabetes mellitus and hypertension treated with enalapril.

On physical examination, she is afebrile, heart rate is 60/min, respiration rate is 25/min, and blood pressure is 198/106 mm Hg. There is no jugular venous distention. Cardiopulmonary examination is normal. There is pitting edema in the bilateral lower extremities.

Laboratory Studies

Blood urea nitrogen 21 mg/dL
Creatinine 1.7 mg/dL
Albumin 3.2 g/dL
Urinalysis pH 5.0, specific gravity 1.015, 1+ blood, 4+ protein
Urine protein/creatinine ratio 3.5 mg/mg

Figure 9

A photomicrograph of the urine sediment is shown. Renal ultrasonography reveals small bilateral 1-cm simple cysts, normal-sized kidneys, and no hydronephrosis.

Which of the following is the most likely diagnosis?
A. Acute glomerulonephritis
B. Acute interstitial nephritis
C. Acute tubular necrosis
D. Prerenal azotemia


Advocacy Update: American College of Physicians Response to the Institute of Medicine's Report, The Future of Nursing: Leading Change, Advancing Health

The Institute of Medicine (IOM) recently released a study, The Future of Nursing: Leading Change, Advancing Health.1 The report calls for new and expanded roles for nurses in a redesigned health care system. It recommends improving education for all nurses and allowing nurses to practice to the full extent of their license and ability. It advocates overhauling state scope of practice acts and suggests that advanced practice registered nurses (APRNs) -- certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, and certified nurse practitioners - should be allowed to practice independently.



Ask the Program Director

IMpact is developing a new feature that will focus on providing medical students practical advice to help them navigate the process of obtaining a residency position in internal medicine. Issues to be covered include CV development, writing a personal statement, the Match process, residency program interviews, and more. At this time, we are collecting questions and issues that medical students would like addressed by program directors, program coordinators, clerkship directors and chief residents. We will then recruit volunteers to answer those questions in a series of monthly columns that will be included in upcoming newsletter editions.

In the Clinic: Hepatitis C

Chronic hepatitis C virus (HCV) infection is the most common bloodborne infection in the United States, with an estimated overall prevalence of 3.2 million persons (1.3%) and prevalence peaks between age 40 to 49 years (1). The worldwide prevalence of HCV infection is even higher at 2.0%, corresponding to 140 million persons (2).

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In the Clinic is a monthly feature in Annals of Internal Medicine that focuses on practical management of patients with common clinical conditions. It offers evidence-based answers to frequently asked questions about screening, prevention, diagnosis, therapy, and patient education and provides physicians with tools to improve the quality of care. Many internal medicine clerkship directors recommend this series of articles for students on the internal medicine ambulatory rotation.

Internist Articles

Grassroots initiative helps promote primary care
Grassroots efforts at Harvard Medical School helped lead to the launch of a new center for primary care education, research and delivery.

Marijuana requests: Relief or 'permission'?
Fourteen states have legalized medical marijuana. Internists who have issued the controversial authorizations describe how they sort out legitimate uses from trivial requests.

Lipid Management: Know the patient to achieve statin benefits
That statins work is without question. And with costs falling due to many drugs in the class going generic, physicians are now refining when to prescribe the ubiquitous drug class based on the degree of risk.

Physician Profile: Bringing health to low-income patients in the clinic and media
Erin N. Marcus, FACP, authors a practical health column directed to readers who don't have enough financial resources or access to care.

Test Yourself: From the MKSAP case studies
A 44-year-old man is evaluated for a 2-year history of joint pain in the wrists, hands, knees, ankles, and feet. He also has a 12-year-history of plaque psoriasis. There are large erythematous plaques with an overlying silvery scale on the elbows, knees, sacrum, and scalp...

Hopitalist Articles

Cover story: Top Docs
Meet our 2010 Top Hospitalists.

Your Practice: Agreeing on an ending
Hospitalists struggle with end-of-life-care disputes.

Is it peripheral neuropathy?
Learn the right way to diagnose this painful condition.

Day of the undead: The zombie intern
I didn't think my fellow first-years were really worried about my consuming them, but you never know about the strange prejudices of the living.


MKSAP for Students 4 Answer 1

Answer A: Corticosteroid therapy

This patient has warm-antibody autoimmune hemolytic anemia (AIHA); the first step in treatment is corticosteroid therapy. Polychromasia in patients with AIHA usually results from reticulocytosis. Reticulocytes contain nucleic acids that stain blue. Warm-antibody AIHA occurs when IgG antibodies bind to red blood cell antigens (usually of the Rh-type) at body temperature. These cells are eventually cleared by splenic macrophages. Spherocytes are detected in patients with warm-antibody AIHA because of membrane removal by macrophages in the spleen. Although warm-antibody AIHA is initially treated with corticosteroid therapy, intravenous immune globulin and splenectomy are also treatment options. However, intravenous immune globulin has not been shown to be as effective as corticosteroid therapy in these patients.

Red blood cells are microcytic in patients with iron deficiency, and reticulocytosis is decreased in the absence of iron. Therefore, iron and erythropoietin are not useful in the treatment of this patient. Plasmapheresis is used in the treatment of thrombotic thrombocytopenic purpura, which is a microangiopathic hemolytic anemia characterized by the presence of schistocytes.

1. Gehrs BC, Friedberg RC. Autoimmune hemolytic anemia. Am J Hematol. 2002;69:258-71. [PMID: 11921020] [PubMed].


MKSAP for Students 4 Answer 2

Answer A: Acute glomerulonephritis

This patient has acute glomerulonephritis characterized by hypertension, edema, and findings of proteinuria and glomerular hematuria and erythrocyte casts on microscopic examination of a urine sample. Serologic studies to assess the underlying cause of glomerular disease, such as assays for antineutrophil cytoplasmic antibodies in patients with small-vessel vasculitis, antinuclear antibodies in patients with lupus nephritis, and hepatitis C antibodies in those with cryoglobulinemia, may help to narrow the differential diagnosis. However, these studies should not preclude a renal biopsy to determine the diagnosis, indicate the cause, predict the natural history and prognosis of the injury, and, most importantly, direct treatment.

The absence of leukocytes and leukocyte casts in the urine excludes the diagnosis of acute interstitial nephritis. Prerenal azotemia is unlikely in the absence of any evidence for volume depletion, heart failure, or cirrhosis. Acute tubular necrosis is unlikely in the absence of any predisposing event such as a new medication, hypotension, or sepsis. Furthermore, the urinalysis in patients with acute tubular necrosis is either bland early in the course or associated with muddy brown casts.

1. Chadban SJ, Atkins RC. Glomerulonephritis. Lancet. 2005;365:1797-806. [PMID: 15910953] [PubMed].