ｄｒａｍｒｏｏ＠ｙａｈｏｏ．ｃｏｍ Self-Assessment for Board Exam Review Mayo Clinic Images in Internal Medicine Front matter_FINAL.qxd 5/25/04 8:09 AM Page i dramroo@yahoo.com Front matter_FINAL.qxd 5/25/04 8:09 AM Page ii dramroo@yahoo.com Self-Assessment for Board Exam Review Mayo Clinic Images in Internal Medicine Editor Furman S. McDonald, MD Co-Editors Paul S. Mueller, MD Gautam Ramakrishna, MD MAYO CLINIC SCIENTIFIC PRESS CRC PRESS Front matter_FINAL.qxd 5/25/04 8:09 AM Page iii dramroo@yahoo.com ISBN-0-8493-3079-3 The triple-shield Mayo logo and the words MAYO and MAYO CLINIC are marks of Mayo Foundation for Medical Education and Research. ©2004 Mayo Foundation for Medical Education and Research. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without the prior written consent of the copyright holder, except for brief quotations embodied in critical articles and reviews. Inquiries should be addressed to Mayo Clinic, 200 First Street SW, Rochester, MN 55905. For order inquiries, contact CRC Press, 2000 NW Corporate Blvd., Boca Raton, FL 33431. www.crcpress.com Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication. This book should not be relied on apart from the advice of a qualified health care provider. The authors, editors, and publisher have exerted efforts to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care providers to ascertain the FDA status of each drug or device planned for use in their clinical practice. Front matter_FINAL.qxd 5/25/04 8:09 AM Page iv dramroo@yahoo.com v DEDICATED TO Four very special people: • Charles H. Rohren, MD—the best physical diagnostician I know. A great physician, teacher, mentor, and friend. You are the reason I am an internist today. I will always see you when I think of the physician I want to be. • Darryl S. Chutka, MD—a great physician and teacher. When you told me to “make the book as large as you like,” I don’t think you expected what would come of it. Without your support and allowance for creative freedom, this book would never have been written. • Henry J. Schultz, MD—the greatest single influence on my professional life. Program director, adviser, friend. I hope that this book will be useful to the residents you care so much about, of whom I know I am one. • Elizabeth S. McDonald, MD, PhD—my devoted wife. Thanks for putting up with me while I put so much time into this book. One very special program: Proceeds from the book will support the Mayo International Health Program, which defrays the cost of elective experiences for Mayo Clinic residents and fellows caring for underserved patients in international settings. Furman S. McDonald, MD Front matter_FINAL.qxd 5/25/04 8:09 AM Page v dramroo@yahoo.com Front matter_FINAL.qxd 5/25/04 8:09 AM Page vi dramroo@yahoo.com vii PREFACE Mayo Clinic Images in Internal Medicine: Self-Assessment for Board Exam Review was begun in 1998 as an adjunct to a presentation for the Mayo Internal Medicine Board Review Course. Images were presented in random order with brief case scenarios. The reader was encouraged to consider the cases before turning the page to read a few learning points about each image. That first book contained 38 cases and 57 images from 6 contributors. Year by year the work was expanded until now the current book has 173 cases with 287 images from 28 contributors. As with the first book, all images are from patients seen at Mayo Clinic, and the cases have been designed to illustrate important teaching points. American Board of Internal Medicine–type board review questions accompany the cases. The references from which the content for each case scenario was built are provided so the reader can obtain further information. Cases are presented in random order to be a more effective review tool that simulates examination (and clinical practice) condi- tions. However, with the increase in size, a detailed index was developed to allow the reader to find cases more efficiently. In addition, this edition introduces chain referencing, an innova- tive learning technique that allows the reader to move from case to case based on specialty designation. With access to the information in this book through random case review, the detailed reference index, and specialty chain referencing, Mayo Clinic Images in Internal Medicine: Self-Assessment for Board Exam Review is really three effective learning texts bound in one cover. It is hoped that Mayo Clinic Images in Internal Medicine: Self-Assessment for Board Exam Review will be an aid for prepa- ration for board examination certification or recertification and medical clerkship review and also a useful update for practicing clinicians. Furman S. McDonald, MD Editor Front matter_FINAL.qxd 5/25/04 8:09 AM Page vii dramroo@yahoo.com ACKNOWLEDGMENTS Many thanks are due to all who helped in the preparation of this book. There are many, and I will not try to name them all. This work was supported in part by the Clinical Educator and Educational Initiative Program, an integral grant program of Mayo Clinic. We are most appreciative of this support. viii Front matter_FINAL.qxd 5/25/04 8:09 AM Page viii dramroo@yahoo.com ix AUTHOR AFFILIATIONS Furman S. McDonald, MD Senior Associate Consultant, Division of General Internal Medicine–Hospital Medicine, Mayo Clinic Associate Program Director, Internal Medicine Residency, Mayo School of Graduate Medical Education, Mayo Clinic College of Medicine Assistant Professor of Medicine, Mayo Clinic College of Medicine Rochester, Minnesota Paul S. Mueller, MD Consultant, Division of General Internal Medicine, Mayo Clinic Assistant Professor of Medicine, Mayo Clinic College of Medicine Rochester, Minnesota Gautam Ramakrishna, MD Fellow in Cardiovascular Diseases, Mayo School of Graduate Medical Education, Mayo Clinic College of Medicine Assistant Professor of Medicine, Mayo Clinic College of Medicine Rochester, Minnesota Image Contributors Edith M. Andrist Marc H. Bivins, MD Emmanouil S. Brilakis, MD B. Ryan Brady, MD Darryl S. Chutka, MD Mark D. P. Davis, MD Laura A. Diamondopoulos, MD David Dingli, MD Jon O. Ebbert, MD Stephen C. Hammill, MD Melinda J. Johnson, MD Patrick S. Kamath, MD Thomas S. Lin, MD James S. Mathur, MD Elizabeth S. McDonald, MD, PhD Furman S. McDonald, MD David E. Midthun, MD Victor M. Montori, MD Carlos E. Morales, MD John (Jack) D. Myers, MD Roger L. Nelson, MD Julian J. Nicholas, MD Lynne E. Nowak, MD David M. Phelan, MD Jan Stepanek, MD Craig S. Stump, MD Wilber W. Su, MD Farhad Zangeneh, MD Front matter_FINAL.qxd 5/25/04 8:09 AM Page ix dramroo@yahoo.com [...]... cases in general clinical practice or on examinations Furthermore, learning styles differ The editors have endeavored to make Mayo Clinic Images in Internal Medicine: Self-Assessment for Board Exam Review useful for examination study, practice, and reference, realizing that users of the book may have different needs and different styles of learning With this understanding, we suggest the following ways... Habermann TM Mayo Clinic Internal Medicine Board Review 2004-2005 Philadelphia: Lippincott Williams & Wilkins; 2004:59, 180, 564-565, 755, 10001001 6 Next ID case, p 9 dramroo@yahoo.com Cases 1_10_FINAL.qxd 5/19/04 9:05 AM Page 7 Case 4 These are the hand and skin findings of a 26-year-old woman who complains of early satiety Her past medical history is notable for upper gastrointestinal bleeding and rectal... be referred for brain biopsy • On biopsy, immunoperoxidase stain shows cysts and tachyzoites of T gondii References Habermann TM Mayo Clinic Internal Medicine Board Review 2004-2005 Philadelphia: Lippincott Williams & Wilkins; 2004:485-486 Masur H Management of opportunistic infections associated with HIV infection In: Mandell GL, Bennett JE, Dolin R, eds Mandell, Douglas and Bennett’s Principles and... Angina Reference Habermann TM Mayo Clinic Internal Medicine Board Review 2004-2005 Philadelphia: Lippincott Williams & Wilkins; 2004:178, 365 8 Next cases: Genet p 29, Musc p 61 dramroo@yahoo.com Cases 1_10_FINAL.qxd 5/19/04 9:05 AM Page 9 Case 5 Clinical criteria for toxic shock syndrome include all of the following except: a b c d e Fever Positive blood cultures Hypotension Involvement of 3 or more organ... antibiotics and supportive care, the mortality rate for toxic shock syndrome has been estimated at 3% The use of corticosteroids (to lessen the overwhelming inflammatory response) and immunoglobulins remains controversial References Habermann TM Mayo Clinic Internal Medicine Board Review 2004-2005 Philadelphia: Lippincott Williams & Wilkins; 2004:601-602 Walker LE, Breiner MJ, Goodman CM Toxic shock syndrome... suggested for all patients with inflammatory myopathy • Patients with DM have an increased risk for cancer • DM is treated with immunosuppressive drugs Reference Habermann TM Mayo Clinic Internal Medicine Board Review 2004-2005 Philadelphia: Lippincott Williams & Wilkins; 2004:177, 789, 997-998 4 Next Rheum case, p 13 dramroo@yahoo.com Cases 1_10_FINAL.qxd 5/19/04 9:05 AM Page 5 Case 3 The lesions in this... the methemoglobin • N-Acetylcysteine is the antidote for acetaminophen overdose • Amyl nitrite is an antidote for cyanide overdose because nitrites precipitate the formation of methemoglobin, which is an alternative binder for cyanide Thus, it would be contraindicated in methemoglobinemia • Deferoxamine is the antidote for iron overdose • 4-Methylpyrazole is an alternative to ethanol for the treatment... transmitted diseases Med Clin North Am 1990;74:1543-1557 Habermann TM Mayo Clinic Internal Medicine Board Review 2004-2005 Philadelphia: Lippincott Williams & Wilkins; 2004:589-591 16 Next ID case, p 19 Cases 1_10_FINAL.qxd 5/19/04 9:05 AM Page 17 Case 9 A 54-year-old woman presents with nonreproducible upper back discomfort and dysphagia She has a history of coronary artery disease and abdominal aortic aneurysm... treatment of methanol toxicity References Habermann TM Mayo Clinic Internal Medicine Board Review 2002-2003 Philadelphia: Lippincott Williams & Wilkins; 2002:155, 160 Wright RO, Lewander WJ, Woolf AD Methemoglobinemia: etiology, pharmacology, and clinical management Ann Emerg Med 1999;34:646-656 20 Next cases: Hem p 21, ID p 23, Toxicol p 35 Cases 11_20_FINAL.qxd 5/19/04 9:36 AM Page 21 Case 11 A 57-year-old... diagnosis in up to 80% of patients Rectal biopsy confirms the diagnosis in up to 75% of patients • Congo red stain of histologic specimens may reveal a characteristic apple-green birefringence under crossed polarized light This remains the standard test for diagnosis References Gillmore JD, Hawkins PN Amyloidosis and the respiratory tract Thorax 1999;54:444-451 Habermann TM Mayo Clinic Internal Medicine Board . to make Mayo Clinic Images in Internal Medicine: Self-Assessment for Board Exam Review useful for examination study, practice, and reference, realizing that. Self-Assessment for Board Exam Review is really three effective learning texts bound in one cover. It is hoped that Mayo Clinic Images in Internal Medicine: Self-Assessment