The Brigham Intensive Review of Internal Medicine Question & Answer Companion

227 Pages·2018·8.814 MB·English

by  Ajay K. Singh, Joseph Loscalzo, Sarah Hammond

Any screen.
Any time.
Anywhere.
Activate the eBook version
of this title at no additional charge.
Expert Consult eBooks give you the power to browse and find content,
view enhanced images, share notes and highlights—both online and offline.
Unlock your eBook today.
Visit
1 expertconsult.inkling.com/redeem Scan this QR code to redeem your
eBook through your mobile device:
2 Scratch off your code
3 Type code into “Enter Code” box
4 Click “Redeem”
5 Log in or Sign up
6 Go to “My Library”
Place Peel Off
It’s that easy!
Sticker Here
For technical assistance:
email [email protected]
call 1-800-401-9962 (inside the US)
call [phone] (outside the US)
Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on
expertconsult.inkling.com. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book,
at expertconsult.inkling.com and may not be transferred to another party by resale, lending, or other means.
2015v1.0
Second Edition

The
Brigham
Intensive
Review
of
Internal
Medicine
QUESTION & ANSWER COMPANION
Ajay K. Singh,
MBBS, FRCP, MBA
Senior Associate Dean
Global and Continuing Education
Harvard Medical School
Physician, Renal Division
Brigham and Women’s Hospital
Boston, MA
Sarah P. Hammond,
MD
Assistant Professor of Medicine
Harvard Medical School
Division of Infectious Diseases
Department of Medicine
Brigham and Women’s Hospital
Boston, MA
Joseph Loscalzo,
MD, PhD
Hersey Professor of the Theory and Practice of Physic
Harvard Medical School
Chairman, Department of Medicine
Physician-in-Chief
Brigham and Women’s Hospital
Boston, MA
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
THE BRIGHAM INTENSIVE REVIEW OF INTERNAL MEDICINE
QUESTION & ANSWER COMPANION, SECOND EDITION ISBN: 978-0-323-48043-7
Copyright © 2019 by Elsevier, Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or me-
chanical, including photocopying, recording, or any information storage and retrieval system, without permis-
sion in writing from the publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
his book and the individual contributions contained in it are protected under copyright by the Publisher (other than
as may be noted herein).
Notices
Knowledge and best practice in this ield are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others, including parties for whom they have a profes-
sional responsibility.
With respect to any drug or pharmaceutical products identiied, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,
to verify the recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate
safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liabil-
ity for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise,
or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Previous edition copyrighted 2014 by Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Names: Singh, Ajay, 1960- editor. | Loscalzo, Joseph, editor.
Title: he Brigham intensive review of internal medicine question & answer
companion / [edited by] Ajay K. Singh, Joseph Loscalzo.
Description: Second edition. | Philadelphia, PA : Elsevier, [2019] | Includes
index.
Identiiers: LCCN 2017042502 | ISBN 9780323480437 (pbk. : alk. paper)
Subjects: | MESH: Internal Medicine--methods | Physical Examination--methods
| Problems and Exercises
Classiication: LCC RC46 | NLM WB 18.2 | DDC 616--dc23 LC record available at
https://lccn.loc.gov/2017042502
Executive Content Strategist: Kate Dimock
Senior Content Development Specialist: Joan Ryan
Publishing Services Manager: Catherine Jackson
Book Production Specialist: Kristine Feeherty
Design Direction: Patrick Ferguson
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contributors
Amy Bessnow, MD Ole-Petter R. Hamnvik, MB BCh BAO, MMSc
Instructor in Medicine Assistant Professor of Medicine
Harvard Medical School Harvard Medical School
Department of Medicine Division of Endocrinology, Diabetes, and Hypertension
Brigham and Women’s Hospital Department of Medicine
Dana-Farber Cancer Institute Brigham and Women’s Hospital
Boston, MA Boston, MA
Hematology and Oncology Endocrinology
Robert Burakof, MD, MPH Galen V. Henderson, MD
Vice Chair for Ambulatory Services Assistant Professor of Medicine
Department of Medicine Harvard Medical School
Weill Cornell Medical College Department of Neurology
New York, NY; Brigham and Women’s Hospital
Site Chief Boston, MA
Division of Gastroenterology and Endoscopy General Internal Medicine
New York–Presbyterian Lower Manhattan Hospital
New York, NY; Jennifer A. Johnson, MD
Visiting Scientist Assistant Professor of Medicine
Harvard Medical School Harvard Medical School
Boston, MA Division of Infectious Diseases
Gastroenterology Department of Medicine
Brigham and Women’s Hospital
Elizabeth Gay, MD Boston, MA
Member of the Faculty of Medicine Infectious Diseases
Harvard Medical School
Division of Pulmonary and Critical Care Medicine Ann S. LaCasce, MD
Department of Medicine Associate Professor of Medicine
Brigham and Women’s Hospital Harvard Medical School
Boston, MA Department of Medical Oncology
Pulmonary and Critical Care Medicine Dana-Farber Cancer Institute
Department of Medicine
Sarah P. Hammond, MD Brigham and Women’s Hospital
Assistant Professor of Medicine Boston, MA
Harvard Medical School Hematology and Oncology
Division of Infectious Diseases
Department of Medicine Ernest I. Mandel, MD
Brigham and Women’s Hospital Instructor in Medicine
Boston, MA Harvard Medical School
Infectious Diseases Division of Renal Medicine
General Internal Medicine Department of Medicine
Brigham and Women’s Hospital
Boston, MA
Nephrology and Hypertension
iii
iv Contributors
Muthoka L. Mutinga, MD Scott L. Schissel, MD
Assistant Professor of Medicine Instructor in Medicine
Harvard Medical School Harvard Medical School
Division of Gastroenterology, Hepatology, and Endoscopy Chief, Department of Medicine
Department of Medicine Brigham and Women’s Faulkner Hospital
Brigham and Women’s Hospital Division of Pulmonary and Critical Care Medicine
Boston, MA Brigham and Women’s Hospital
Gastroenterology Boston, MA
Pulmonary and Critical Care Medicine
Anju Nohria, MD, MSc
Assistant Professor of Medicine Lori Wiviott Tishler, MD
Harvard Medical School Assistant Professor of Medicine
Division of Cardiovascular Medicine Harvard Medical School
Department of Medicine Division of General Internal Medicine and Primary Care
Brigham and Women’s Hospital Department of Medicine
Boston, MA Brigham and Women’s Hospital
Cardiovascular Disease Boston, MA
General Internal Medicine
Molly Perencevich, MD
Instructor in Medicine Derrick J. Todd, MD, PhD
Harvard Medical School Instructor of Medicine
Division of Gastroenterology, Hepatology, and Endoscopy Harvard Medical School
Department of Medicine Division of Rheumatology, Immunology, and Allergy
Brigham and Women’s Hospital Department of Medicine
Boston, MA Brigham and Women’s Hospital
Gastroenterology Boston, MA
Rheumatology
Megan Prochaska, MD
Research Fellow in Medicine
Harvard Medical School
Department of Medicine
Brigham and Women’s Hospital
Boston, MA
Nephrology and Hypertension
Preface
Preparing for the American Board of Internal Medicine their eforts and commitment to this project. We asked
(ABIM) certifying or recertifying examination requires them to put themselves “in the head” of the ABIM to
knowledge and clinical experience that can be evaluated identify the topics that might be addressed in the board
by successfully answering questions in a test format. In examination. We believe this book will be a valuable
this Question and Answer book, our goal is to provide the study tool to gauge one’s knowledge in preparation for the
reader with 450 questions across 9 subspecialties in inter- examination.
nal medicine. hese questions test knowledge on topics rel- We wish to thank Stephanie Tran and Michelle Deraney
evant to the ABIM boards. As a companion to the Brigham for supporting us in the development of this book. Without
Intensive Review of Internal Medicine, now in its third edi- them this book would not have been possible. Our thanks
tion, this book is focused on how one applies knowledge to also go to our families who have supported all of our aca-
answer board questions successfully. he annotated answers demic activities, including this important project.
are detailed, and they review the steps in critical thinking
required to get to the correct answer. Ajay K. Singh, MBBS, FRCP, MBA
he authors who have contributed questions and anno- Joseph Loscalzo, MD, PhD
tated answers to this book are some of our most senior Sarah P. Hammond, MD
physicians in the department. We sincerely thank them for
v
Contents
1. Infectious Diseases, 1
Sarah P. Hammond and Jennifer A. Johnson
2. Hematology and Oncology, 28
Amy Bessnow and Ann S. LaCasce
3. Rheumatology, 49
Derrick J. Todd
4. Pulmonary and Critical Care Medicine, 78
Scott L. Schissel and Elizabeth Gay
5. Endocrinology, 104
Ole-Petter R. Hamnvik
6. Nephrology and Hypertension, 129
Megan Prochaska and Ernest I. Mandel
7. Gastroenterology, 145
Muthoka L. Mutinga, Molly Perencevich,
and Robert Burakof
8. Cardiovascular Disease, 165
Anju Nohria
9. General Internal Medicine, 191
Lori Wiviott Tishler, Sarah P. Hammond,
and Galen V. Henderson
Index, 212
vi
1
Infectious Diseases
SARAH P. HAMMOND AND JENNIFER A. JOHNSON
1. A 28-year-old woman who has lived her entire life in donor for polycystic kidney disease and has had no
Providence, Rhode Island, presents 3 days after return- episodes of rejection since. Her donor was cytomega-
ing from a 2-week trip to hailand complaining of lovirus (CMV) immunoglobulin G (IgG) negative,
fever to 102°F, muscle aches, and severe retroorbital and she was CMV IgG positive before transplant. Her
headache. She has no gastrointestinal symptoms. She chronic medications for transplant include tacrolimus,
traveled only to the towns of Bangkok, Chiang Mai, low-dose prednisone, and mycophenolate mofetil and
and Phuket. She attended a travel clinic before travel- have not changed in several years. She is a third-grade
ing and was told there was no malaria in these towns, teacher and has recently been taking care of the class
so she did not take prophylaxis. She denied contact pets, which include two goldish and a hamster. On
with bodies of fresh water. Examination is unremark- presentation she has a fever to 102.1°F and has difuse
able other than temperature of 101.8°F. Remarkable tenderness of the abdomen without rebound.
laboratory indings include a leukocyte count of 2200 he most likely cause of her present illness is:
cells/µL3, hematocrit of 37%, and platelets of 62,000 A. Salmonellosis
cells/µL3. Chemistries are normal. A peripheral blood B. Medication-induced diarrhea related to the cumu-
smear for parasites is sent and is negative. lative efects of mycophenolate
Which of the following is the most likely diagnosis C. Cytomegalovirus colitis
in this traveler? D. Norovirus gastroenteritis
A. Leptospirosis E. Irritable bowel syndrome
B. Malaria
C. Typhoid 4. A 24-year-old man with ulcerative colitis presents in
D. Hepatitis A January for a irst primary care clinic visit with you as
E. Dengue his new primary care physician. He was diagnosed with
ulcerative colitis involving the entire colon 10 months
2. A 55-year-old male smoker with severe chronic ago and initially was treated with corticosteroids and
obstructive pulmonary disease (COPD) is hospitalized mesalamine. In the last 3 months he has been doing
in the medical intensive care unit. He now requires well on mesalamine and azathioprine, which are his
intubation and mechanical ventilation for hypercarbic only medications. He works as a paralegal and hopes
respiratory failure after failing noninvasive ventilation. to attend law school in the next few years. He lives
To reduce this patient’s risk for developing ventila- with his girlfriend of 2 years with whom he is monoga-
tor-associated pneumonia, you recommend: mous. He uses condoms for birth control. He is feeling
A. Elevation of the head of the bed to 15 degrees to well today. Physical examination is unremarkable; he is
prevent aspiration afebrile and well appearing. You review his immuniza-
B. Suctioning of subglottic secretions tion history—he has not received any vaccines within
C. Twenty-four hours of prophylactic systemic anti- the past 6 years; his last vaccination was the conjugate
biotics, especially if the intubation was emergent meningococcal vaccine at age 18.
D. Daily changing of the ventilatory circuit In addition to vaccinating for inluenza and human
E. Nasotracheal intubation rather than orotracheal papillomavirus, he should also receive which of the
intubation following vaccines?
A. Tetanus, diphtheria (Td) vaccine
3. A 47-year-old woman with a history of renal transplan- B. Pneumococcal 13-valent conjugate (PCV13) vaccine
tation presents with 4 days of profuse nonbloody diar- C. Haemophilus inluenzae B vaccine
rhea, abdominal pain, and high fevers. She received her D. Pneumococcal 23-valent polysaccharide vaccine
kidney transplant 10 years ago from a living unrelated E. Meningococcus B vaccine
1
2 CHAPTER 1 Infectious Diseases
5. A 36-year-old man is found to have a positive tuber- hepatitis B DNA not detected, hepatitis C IgG nega-
culosis interferon gamma release assay result as part tive. She was treated with six cycles of rituximab,
of a workplace screening program. He is originally cyclophosphamide, doxorubicin, vincristine, and
from Bangladesh and was vaccinated with the bacil- prednisone (R-CHOP), which ended several weeks
lus calmette-Guérin (BCG) vaccine during childhood. ago and achieved complete remission based on posi-
He immigrated to the United States 6 months ago. He tron emission tomography (PET) CT imaging. Basic
reports feeling well. He has no fever, cough, or weight laboratory indings when she presents now are notable
loss. Physical examination is normal. for aspartate aminotransferase (AST) 527 U/L, alanine
he next best step in his management should be: aminotransferase (ALT) 495 U/L, total bilirubin 3.5
A. Sputum for smear microscopy and mycobacterial mg/dL, with a normal international normalized ratio
culture (INR). Her past history is notable for immigrating to
B. Initiation of isoniazid prophylaxis to prevent reac- the United States from rural Vietnam 2 years ago. She
tivation of latent tuberculosis infection had a PPD skin test at the time she immigrated and
C. Chest x-ray to assess for active pulmonary disease she was treated for latent tuberculosis with a 9-month
D. Perform a tuberculin skin test (puriied protein course of isoniazid that inished before the diagnosis of
derivative [PPD] test) to conirm the skin test lymphoma.
result A likely cause of her abnormal liver function tests
and malaise is:
6. A previously well 62-year-old man presents to the hos- A. Hepatitis C infection resulting from blood trans-
pital with increasing weakness in his lower extremities. fusion
Examination reveals decreased relexes symmetrically, B. Recurrence of her lymphoma
which progresses proximally over the course of several C. Acute hepatitis A infection
hours. He is diagnosed with Guillain–Barré syndrome D. Delayed isoniazid toxicity
and admitted to the intensive care unit for treatment. E. Reactivation of hepatitis B infection
On history, he reports several days of nausea, vomit-
ing, and diarrhea approximately 2 months prior. 9. A 34-year-old teacher presents to her primary care
he most likely infectious cause of his gastrointes- physician with 1 week of severe cough. Her symptoms
tinal illness was: began 2 weeks prior with a mild fever and rhinorrhea.
A. Campylobacter She has been experiencing posttussive emesis every
B. Giardia couple of hours. She takes levothyroxine for hypo-
C. Salmonella thyroidism but otherwise has no chronic illnesses.
D. Cryptosporidium Whooping cough is suspected, and a polymerase chain
E. Escherichia coli O157:H7 reaction (PCR) of a respiratory specimen is sent to test
for Bordetella pertussis.
7. A 24-year-old woman calls your oice complaining of he best management is:
burning with urination, and increased urinary urgency A. T reat with codeine-containing cough syrup for
and frequency. She reports no fever, nausea, vomiting, symptom control and wait for conirmation of B.
or lank pain. She has been in a monogamous rela- pertussis infection.
tionship for 3 years, and she had one prior episode of B. It is too late to treat for B. pertussis with antibiot-
cystitis, more than a year ago. ics; reassure her that the cough will improve in the
Which of the following agents is the best treatment next 2–4 weeks and administer the TDaP vaccine
for acute uncomplicated cystitis? now.
A. Cephalexin 500 mg twice daily for 7 days C. Start empiric azithromycin for a 5-day course.
B. Ciproloxacin 250 mg twice daily for 3 days D. Start empiric levoloxacin for a 7-day course.
C. Nitrofurantoin macrocrystals 100 mg twice daily E. It is too late to treat for B. pertussis with antibiot-
for 5 days ics; administer immunoglobulin to provide passive
D. Amoxicillin 500 mg three times daily for 7 days immunity.
8. A 65-year-old woman with recently diagnosed difuse 10. A 57-year-old man from lower Delaware presents to
large B-cell lymphoma presents with malaise, nausea, an urgent care center after being bitten by a tick. He
and mild jaundice. She was diagnosed with difuse reports that he spent many hours in his garden over the
large B-cell lymphoma after developing massive right weekend and was bitten by many insects. He returned
cervical lymphadenopathy and daily fevers 7 months to his work as an accountant after the weekend and
ago. She was profoundly anemic when she presented has been mostly spending time inside since then. his
and required a blood transfusion at that time. Pretreat- morning, a Tuesday, he noticed an engorged tick at
ment work up revealed the following: HIV antibody/ his waist line, which he removed. At the moment he
antigen negative, hepatitis A IgG positive, hepatitis B feels well other than worrying about getting sick from
surface antigen negative, hepatitis B core IgG positive, this tick. He has had no fevers, rashes, joint pains, or