USMLE STEP 2 CK Lecture Notes 2018

STEP 2 CK

USMLE
UP-TO-DATE

Updated annually by Kaplans all-star faculty

Lecture Notes 2018

INTEGRATED
Packed with bridges between specialties and basic science

TRUSTED
Used by thousands of students each year to ace the exam
Internal Medicine
Tell us what you think!

Internal Medicine
Visit kaptest.com/booksfeedback and let us know about your book experience.

ISBN: 978-1-5062-2818-1

kaplanmedical.com
9 781506 228181

USMLE is a joint program of the Federation of State Medical Boards (FSMB) and the
National Board of Medical Examiners (NBME), neither of which sponsors or endorses this product.

978-1-5062-2818-1_USMLE_Step2_CK_Internal_Course_CVR.indd 1 6/22/17 9:58 AM

 STEP 2 CK

USMLE

Lecture Notes 2018

Internal Medicine

USMLE S2 Internal Medicine.indb 1 6/13/17 10:00 PM

 USMLE is a joint program of the Federation of State Medical Boards (FSMB) and the National
Board of Medical Examiners (NBME), neither of which sponsors or endorses this product.

This publication is designed to provide accurate information in regard to the subject matter covered
as of its publication date, with the understanding that knowledge and best practice constantly evolve.
The publisher is not engaged in rendering medical, legal, accounting, or other professional service.
If medical or legal advice or other expert assistance is required, the services of a competent profes-
sional should be sought. This publication is not intended for use in clinical practice or the delivery
of medical care. To the fullest extent of the law, neither the Publisher nor the Editors assume any
liability for any injury and/or damage to persons or property arising out of or related to any use of
the material contained in this book.

2017 by Kaplan, Inc.

Published by Kaplan Medical, a division of Kaplan, Inc.

750 Third Avenue
New York, NY 10017

All rights reserved. The text of this publication, or any part thereof, may not be reproduced in any
manner whatsoever without written permission from the publisher.

10 9 8 7 6 5 4 3 2 1

Course ISBN: 978-1-5062-2818-1

Retail Kit ISBN: 978-1-5062-2080-2

This item comes as a set and should not be broken out and sold separately.

Kaplan Publishing print books are available at special quantity discounts to use for sales promotions,
employee premiums, or educational purposes. For more information or to purchase books, please
call the Simon & Schuster special sales department at 866-506-1949.

USMLE S2 Internal Medicine.indb 2 6/13/17 10:00 PM

 Editors
Joseph J. Lieber, MD
Associate Director of Medicine
Elmhurst Hospital Center

Associate Professor of Medicine

Associate Program Director in Medicine for Elmhurst Site
Icahn School of Medicine at Mt. Sinai
New York, NY

Frank P. Noto, MD
Assistant Professor of Internal Medicine
Site Director, Internal Medicine Clerkship and Sub-Internship
Icahn School of Medicine at Mt. Sinai
New York, NY

Hospitalist
Elmhurst Hospital Center
New York, NY

The editors would like to acknowledge

Manuel A. Castro, MD, AAHIVS, Amirtharaj Dhanaraja, MD, and Aditya Patel, MD,
and Irfan Sheikh, MD for their contributions.

USMLE S2 Internal Medicine.indb 3 6/13/17 10:00 PM

http://ebooksmedicine.net/usmle

We want to hear what you think. What do you like or not like about the Notes?
Please email us at medfeedback@kaplan.com.

USMLE S2 Internal Medicine.indb 4 6/13/17 10:00 PM

 Table of Contents
Chapter Title 00
Chapter 1: Preventive Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 2: Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 3: Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Chapter 4: Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Chapter 5: Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Chapter 6: Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Chapter 7: Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Chapter 8: Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Chapter 9: Pulmonology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321

Chapter 10: Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361

Chapter 11: Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405

Chapter 12: Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433

Chapter 13: Radiology/Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455

Chapter 14: Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473

Additional resources available at

www.kaptest.com/usmlebookresources

USMLE S2 Internal Medicine.indb 5 6/13/17 10:00 PM

USMLE S2 Internal Medicine.indb 6 6/13/17 10:00 PM
 Preventive
Chapter
Medicine
Title #
1
Learning Objectives
Describe appropriate screening methods as they apply to neoplasms of the colon,
breast, cervix, and lung

Describe epidemiological data related to incidence and prevention of common

infectious disease, chronic illness, trauma, smoking, and travel risks

CANCER SCREENING
A 39-year-old woman comes to the clinic very concerned about her risk of developing
cancer. Her father was diagnosed with colon cancer at age 43, and her mother was
diagnosed with breast cancer at age 52. She is sexually active with multiple partners
and has not seen a physician since a car accident 15 years ago. She denies any
symptoms at this time, and her physical examination is normal. She asks what is
recommended for a woman her age.

Screening tests are done on seemingly healthy people to identify those at increased risk of dis-
ease. Even if a diagnostic test is available, however, that does not necessarily mean it should be
used to screen for a particular disease.
Several harmful effects may potentially result from screening tests.
Any adverse outcome that occurs (large bowel perforation secondary to a colonoscopy) is
iatrogenic.
Screening may be expensive, unpleasant, and/or inconvenient.
Screening may also lead to harmful treatment.

Finally, there may be a stigma associated with incorrectly labeling a patient as sick.

For all diseases for which screening is recommended, effective intervention must exist, and the
course of events after a positive test result must be acceptable to the patient. Most important, the
screening test must be valid, i.e., it must have been shown in trials to decrease overall mortality in
the screened population. For a screening test to be recommended for regular use, it has to be
extensively studied to ensure that all of the requirements are met.

http://ebooksmedicine.net/usmle 1

USMLE S2 Internal Medicine.indb 1 6/13/17 10:00 PM

http://ebooksmedicine.net/usmle
EBOOKSMEDICINE.NET
USMLE Step 2
Note
Tamoxifen prevents cancer by
50% in those with >1 family
member with breast cancer.
Note
Prostate Screening
USPSTF concludes that the
current evidence is insufficient
to assess the balance of
benefits/risks of prostate
cancer screening in men age
<75. It recommends against
screening in men age >75.
For USMLE, do not screen for
prostate cancer.
2 http://ebooksmedicine.net/usmle
USMLE S2 Internal Medicine.indb 2
l Internal Medicine
The 4 malignancies for which regular screening is recommended are cancers of the colon,
breast, cervix, and lung.
Colon Cancer
In the patient with no significant family history of colon cancer, screening should begin at age
50. The preferred screening modality for colon cancer is colonoscopy every 10 years. Other
choices include annual fecal occult blood testing and sigmoidoscopy with barium enema every
5 years.
In the patient with a single first-degree relative diagnosed with colorectal cancer before age 60
or multiple first-degree relatives with colon cancer at any age, colonoscopy should begin at age
40 or 10 years before the age at which the youngest affected relative was diagnosed, whichever
age occurs earlier. In these high-risk patients, colonoscopy should be repeated every 5 years.
The U.S. Preventive Services Task Force (USPSTF) does not recommend routine screening in
patients age >75.
Breast Cancer
The tests used to screen for breast cancer are mammography and manual breast exam.
Mammography with or without clinical breast exam is recommended every 12 years from age
5074. The American Cancer Society no longer recommends monthly self-breast examination
alone as a screening tool. Patients with very strong family histories of breast cancer (defined as
multiple first-degree relatives) should consider prophylactic tamoxifen, discussing risks and
benefits with a physician. Tamoxifen prevents breast cancer in high-risk individuals.
Cervical Cancer
The screening test of choice for the early detection of cervical cancer is the Papanicolaou smear
(the Pap test). In average risk women, Pap smear screening should be started at age 21,
regardless of onset of sexual activity. It should be performed every 3 years until age 65.
As an alternative, women age 3065 who wish to lengthen the screening interval to every
5years can do co-testing with Pap and HPV testing. In higher risk women, e.g., HIV, more
frequent screening or screening after age 65 may be required.
Lung Cancer
Current recommendations for lung cancer screening are as follows:
Annual screening with low-dose CT in adults age 5580 who have a 30-pack-year
smoking history and currently smoke or have quit within past 15 years
Once a person has not smoked for 15 years or develops a health problem substantially
limiting life expectancy or ability/willingness to have curative lung surgery, screening
should be discontinued
6/13/17 10:00 PM
http://ebooksmedicine.net/usmle
EBOOKSMEDICINE.NET

Chapter 1 Preventive Medicine

Clinical Recall

Which of the following patients is undergoing an inappropriate method of

screening as recommended by the USPSTF?

A. A 50-year-old man gets his first screening for colon cancer via
colonoscopy
B. A 50-year-old woman gets her first screening for breast cancer via
mammography
C. A 17-year-old woman is screened for HPV via a Pap smear after her
first sexual encounter
D. A 65-year-old man with a 30-pack-year smoking history gets a low-
dose CT
E. A 21-year-old woman with a high risk of developing breast cancer is
given tamoxifen

Answer: C

TRAVEL MEDICINE
A 44-year-old executive comes to the clinic before traveling to Thailand for
business. He has no significant past medical history and is here only because his
company will not let him travel until he is seen by a physician. The patient
appears agitated and demands the physicians recommendation immediately.

It is important to set up a pretravel counseling session 46 weeks before the patients departure.

Hepatitis A infection is travelers most common vaccine-preventable disease. Hepatitis

Ainfection is possible wherever fecal contamination of food or drinking water may occur.
Infection rates are particularly high in nonindustrial countries. If a patient is leaving within 2
weeks of being seen, both the vaccine and immune serum globulin are recommended.
Abooster shot given 6 months after the initial vaccination confers immunity for approximately
10 years.

All travelers to less-developed countries should get hep A vaccine.

Hepatitis B vaccination is recommended for patients who work closely with indigenous popula-
tions. Additionally, patients who plan to engage in sexual intercourse with the local populace, to
receive medical or dental care, or to remain abroad for >6 months should be vaccinated.

Malaria: Mefloquine is the agent of choice for malaria prophylaxis. It is given once per week; it
may cause adverse neuropsychiatric effects such as hallucinations, depression, s uicidal
ideations, and unusual behavior. Doxycycline is an acceptable alternative to mefloquine,
although photosensitivity can be problematic. For pregnant patients requiring chemoprophy-
laxis for malaria, chloroquine is the preferred regimen.

http://ebooksmedicine.net/usmle 3

USMLE S2 Internal Medicine.indb 3 6/13/17 10:00 PM