MKSAP5.pdf

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MKSAP®_{FO R STUDENTS 5 (2011)} Front Matte r

Title Page

MKSAP® for Stude nts 5

Medical Knowledge Self-Assessment Program De ve lope d by

American College of Physicians Clerkship Directors in Internal Medicine C opyright Page

Editorial Production: Helen Kitzmiller Design: Michael E. Ripca

Com position: ACP Graphic Services

Copyright © 2011 by the American College of Physicians. All rights reserved. T his publication is protected by copyright. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic or mechanical, including photocopy, without the express consent of the American College of Physicians.

Printed in the United States of America by Sheridan Books

Im portant copyright inform ation from the Am erican College of Physicians:

Unauthorized reproduction of the publication is unlawful. T he American College of Physicians prohibits reproduction of this publication in its entirety in any form either for individual use or for distribution.

T he American College of Physicians will consider granting an individual permission to reproduce only limited portions of this publication for his or her own exclusive use. Send requests in writing to MKSAP®_{for Students 5, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106-1572.}

American College of Physicians 190 N. Independence Mall West Philadelphia, PA 19106-1572 215-351-2600

ISBN-13: 978-1-934465-54-7 ISBN-10: 1-934465-54-2 Acknowle dgme nts

MKSAP for Stude nts 5 Editorial Board

Eyad Al-Hihi, MD, MBA, FAC P Associate Professor of Medicine

Chief, Division of General Internal & Hospital Medicine Director, Internal Medicine Ambulatory Clerkship University of Missouri-Kansas City School of Medicine Medical Director, Medicine Clinics, T ruman Med Center Kansas City, Missouri

Ire ne Ale xandraki, MD, MPH, FAC P Assistant Professor, Department of Medicine Medicine Clerkship Director

University of Florida College of Medicine Jacksonville, Florida

Mark Alle e , MD, FAC P

Associate Professor, Department of Medicine Medicine Clerkship Director

University of Oklahoma School of Medicine Oklahoma City, Oklahoma

Saad Alvi, MD, FAC P

Assistant Professor of Clinical Medicine M3 Clerkship Director

University of Illinois College of Medicine at Peoria (UICOMP)

Peoria, Illinois

Alpe sh Amin, MD, MBA, FAC P Professor of Medicine

Medicine Clerkship Director University of California, Irvine Orange, California

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Lisa M. Ante s, MD Associate Professor

Department of Internal Medicine/Division of Nephrology Inpatient Internal Medicine Clerkship Co-Director Carver College of Medicine/University of Iowa Hospitals and Clinics

Iowa City, Iowa Joe l Appe l, DO

Director Ambulatory and Student Programs Wayne State University School of Medicine Chief Hematology/Oncology

Sinai-Grace Hospital Detroit Medical Center Detroit, Michigan

Jonathan S. Appe lbaum, MD, FAC P Associate Professor, Clinical Sciences Director, Internal Medicine Education Florida State University College of Medicine T allahassee, Florida

Scott Arnold, MD, FAC P

University of Alabama School of Medicine T uscaloosa Campus

T uscaloosa, Alabama Emily C hism Barke r, MD Assistant Professor of Medicine

Senior Associate Program Director for Internal Medicine University of T exas Houston Medical School

Houston, T exas

Je nnife r Bie rman, MD, FAC P Primary Care Clerkship Director

Northwestern University Feinberg School of Medicine Chicago, Illinois

Susan C rouch Bre we r, MD, FAC P Assistant Dean for Clinical Education Associate Chair for Student Programs College of Medicine

University of T ennessee Health Science Center Memphis, T ennessee

C ynthia A. Burns, MD, FAC P Assistant Professor

Internal Medicine Clerkship Director Department of Internal Medicine Section on Endocrinology & Metabolism Wake Forest University School of Medicine Winston-Salem, North Carolina

Maria L. C annaroz z i, MD, FAC P, FAAP

Associate Professor of Internal Medicine & Pediatrics Clerkship Director, Internal/Family Medicine University of Central Florida College of Medicine Orlando, Florida

Dane lle C aye a, MD, MS Assistant Professor of Medicine Medicine Clerkship Director

Johns Hopkins University School of Medicine Baltimore, Maryland

J. C harle s, MD, FAC P, FHM Assistant Professor of Medicine Division Education Coordinator Mayo Clinic Hospital

Phoenix, Arizona Brian J. C oste llo, DO

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Co-Clerkship Director Ambulatory Medicine Lehigh Valley Health Network

Allentown, Pennsylvania C amilla C urre n, MD

Assistant Clinical Professor of Internal Medicine Ohio State University Medical Center

Clinical Assistant Professor of Pediatrics Nationwide Childrens Hospital

Assistant Clerkship Director, Ambulatory Medicine Ohio State University College of Medicine Columbus, Ohio

Thomas M. De Fe r, MD, FAC P Clerkship Director

Division of Medical Education Department of Internal Medicine

Washington University School of Medicine St. Louis, Missouri

Ste phanie A. De tte rline , MD, FAC P Associate Program Director, Internal Medicine Union Memorial Hospital

Medicine Clerkship Site Director

University of Maryland School of Medicine Baltimore, Maryland

Gurpre e t Dhaliwal, MD

Site Director, Internal Medicine Clerkships San Francisco VA Medical Center Associate Professor of Clinical Medicine University of California San Francisco San Francisco, California

Gre tche n Die me r, MD, FAC P Assistant Professor of Medicine

Director of Undergraduate Medical Education Clerkship Director Internal Medicine Assistant Program Director Internal Medicine T homas Jefferson University

Philadelphia, Pennsylvania Anne Eacke r, MD, FAC P

Associate Professor, Department of Medicine Medical Director, General Internal Medicine Center University of Washington

Seattle, Washington Mark J Fagan, MD, FAC P Clerkship Director

Department of Medicine

Alpert Medical School of Brown University Providence, Rhode Island

Pame la J. Fall, MD, FAC P, FASH Professor of Medicine

Section of Nephrology, Hypertension and T ransplantation Clerkship Director, Internal Medicine

Medical College of Georgia Augusta, Georgia

L. C hristine Faulk, MD Medicine Clerkship Co-Director

University of Kansas School of Medicine-Wichita Wichita, Kansas

Sara B. Faz io, MD, FAC P

Associate Professor, Harvard Medical School Director, Core I Medicine Clerkship Division of General Internal Medicine Beth Israel Deaconess Medical Center Boston, Massachusetts

J. Michae l Finle y, DO , FAC P, FAC O I Associate Professor of Medicine

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Chief, Division of Rheumatology

Associate Dean for Graduate Medical Education Western University College of Osteopathic Medicine Pomona, California

Jose Franco, MD, AGAF

Professor of Medicine and Pediatrics Director of Hepatology

Medicine Clerkship Director Medical College of Wisconsin Milwaukee, Wisconsin Erica Frie dman, MD, FAC P Associate Dean

Associate Professor of Medicine and Medical Education Mount Sinai School of Medicine

New York, New York Pe te r Gliatto, MD, FAC P

Assistant Professor of Medicine and Medical Education Co-Director, Medicine-Geriatrics Clerkship

Director, Medicine Subinternship Mount Sinai School of Medicine New York, New York

Susan A. Glod, MD

Assistant Professor of Medicine

Associate Clerkship Director, Internal Medicine Penn State College of Medicine

Hershey, Pennsylvania Gabrie lle R. Goldbe rg, MD Education Director

T he Hertzberg Palliative Care Institute Assistant Professor

Department of Geriatrics and Palliative Medicine Department of Medicine

Mount Sinai School of Medicine New York, New York

Eric Gore n, MD

Medicine Sub-Internship Course Co-Director Assistant Professor of Clinical Medicine University of Pennsylvania School of Medicine Philadelphia, Pennsylvania

C yril M. Grum, MD, FAC P Professor and Senior Associate Chair for Undergraduate Medical Education Department of Internal Medicine Internal Medicine Clerkship Director University of Michigan

Ann Arbor, Michigan

He athe r Harre ll, MD, FAC P

Director of Fourth Year Programs University of Florida College of Medicine Gainesville, Florida

Dan A. He nry, MD, FAC P Professor of Medicine Director of Clinical Education Medicine Clerkship Director

University of Connecticut School of Medicine Farmington, Connecticut

Susan Thompson Hingle , MD, FAC P Associate Professor of Medicine Internal Medicine Clerkship Director

Internal Medicine Residency Associate Program Director Southern Illinois University School of Medicine Springfield, Illinois

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W illiam Howe ll, MBC hB Clinical Instructor of Medicine Medicine Clerkship Co-Director University of Utah School of Medicine Salt Lake City, Utah

Eric Hsie h, MD

Director, Internal Medicine Clerkship

Senior Associate Director, Internal Medicine Residency Department of Medicine

Keck School of Medicine University of Southern California Los Angeles, California

Hugh F. Huiz e nga, MD, MPH Assistant Professor of Medicine Clerkship Director-Inpatient Medicine Dartmouth Medical School

Hanover, New Hampshire T.J. Hundle y, MD, FAC P

Director, Internal Medicine Clerkship Assistant Professor of Medicine Department of Internal Medicine

University of South Alabama College of Medicine Mobile, Alabama

Nadia J. Ismail, MD, MPH, Me d, FAC P Director, Internal Medicine Core Clerkship Assistant Professor of Medicine

Baylor College of Medicine Houston, T exas

Harish Iye r, MD, MRC P (UK) Chief Medical Resident

Department of Medicine Albert Einstein Medical Center Philadelphia, Pennsylvania Robe rt Jablonove r, MD

Assistant Professor in Internal Medicine Clerkship Director in Internal Medicine

George Washington University School of Medicine Washington, District of Columbia

Jane t A. Joke la, MD, MPH, FAC P Associate Professor of Clinical Medicine Department of Medicine

University of Illinois at Urbana-Champaign Urbana, Illinois

Jason Kahn, MD, FAC P

Internal Medicine Clerkship Site Director St. Joseph Mercy Hospital

Ann Arbor, Michigan

C hristophe r A. Klipste in, MD Associate Professor of Medicine Director, Internal Medicine Clerkship

University of North Carolina School of Medicine Chapel Hill, North Carolina

Mary Ann Kuz ma, MD, FAC P Associate Professor of Medicine Medicine Clerkship Director

Drexel University College of Medicine Philadelphia, Pennsylvania

Rosa Le e , MD

Medicine Clerkship Site Leader, Montefiore Medical Center

Assistant Professor, Department of Medicine Albert Einstein College of Medicine Bronx, New York

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Be th W . Liston, MD, PhD, FAC P

Assistant Professor of Clinical Medicine/Pediatrics Sub-internship Clerkship Director

T he Ohio State University College of Medicine Columbus, Ohio

Mai A Mahmoud, MBBS, FAC P Assistant Professor of Medicine Medicine Clerkship Co-Director Weill Cornell Medical College in Qatar Doha, Qatar

Lianne Marks, MD, PhD, FAC P Division Director, Internal Medicine Scott & White Healthcare

Assistant Professor and Internal Medicine Clerkship Director for 3rd Year Medical Students T exas A&M College of Medicine

Round Rock, T exas Ke vin M. McKown, MD

Associate Professor and Head, Division of Rheumatology Co-Director M3 and M4 Student Programs

Department of Medicine University of Wisconsin

School of Medicine & Public Health Madison, Wisconsin

Laura Me inke , MD

Assistant Professor of Medicine Medicine Clerkship Director

Section of Pulmonary & Critical Care Medicine University of Arizona College of Medicine T ucson, Arizona

Jame s L. Me ise l, MD, FAC P

Clerkship Director/Evans Student Educator Assistant Professor of Medicine

Boston University School of Medicine Boston, Massachusetts

C had S. Mille r, MD, FAC P Internal Medicine Clerkship Director Associate Program Director, Residency T ulane University Health Sciences Center New Orleans, Louisiana

Nina Mingioni, MD FAC P

Associate Program Director, Internal Medicine Clerkship Site Director, Internal Medicine Albert Einstein Medical Center

Philadelphia, Pennsylvania Alita Mishra, MD, FAC P

Clerkship Director, Department of Medicine Hospitalist, Inova Fairfax Hospital

Clinical Assistant Professor of Medicine

Virginia Commonwealth University School of Medicine Inova Campus

Falls Church, Virginia

Archana Mishra, MD, MS, FAC P, FC C P Associate Professor of Medicine

Associate Clerkship Director

SUNY Buffalo School of Medicine and Biomedical Sciences Buffalo, New York

Lynda Misra, DO , FAC P, MA Ed

Director of Students - William Beaumont Hospital Medicine Clerkship Director

Oakland University William Beaumont School of Medicine Royal Oak, Michigan

Ne ha Mittal, MD Assistant Professor

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Year 4 Clerkship Director Department of Internal Medicine

T exas T ech University Health Science Center Lubbock, T exas

Justin B. Moore , MD Division Chief, Endocrinology

Assistant Professor, Department of Medicine Medicine Clerkship Co-Director

Mark T. Mune kata, MD, MPH, FAC P Associate Clinical Professor of Medicine

Co-Director, Ambulatory Internal Medicine Clerkship David Geffen School of Medicine at UCLA

Medical Director, Utilization Management Director, Urgent Care Clinic

Harbor-UCLA Medical Center T orrance, California Marty Muntz , MD

Assistant Professor of Medicine Division of General Internal Medicine Ambulatory Medicine Clerkship Director Medicine Subinternship Director Medical College of Wisconsin Milwaukee, Wisconsin David G. Naylor, MD Assistant Clerkship Director University of Kansas Medical Center Kansas City, Kansas

Ade soji E. O de rinde , MD, MSC R, FAC P Associate Program Director

Associate Director Student Education Department of Medicine

Morehouse School of Medicine Atlanta, Georgia

Thomas D. Painte r MD

Inpatient Internal Medicine Clerkship Director University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

C arlos Palacio, MD, MPH, FAC P

Associate Professor of Medicine, Department of Medicine Clerkship Director

University of Florida College of Medicine-Jacksonville Jacksonville, Florida

Robe rt I. Pargame nt, MD, FAC P Internal Medicine Clerkship Director York Hospital

York, Pennsylvania Alisa Pe e t, MD

Assistant Professor of Medicine Medicine Clerkship Director

T emple University School of Medicine Philadelphia, Pennsylvania

Roshini C . Pinto-Powe ll, MD Associate Professor of Medicine Dartmouth Medical School Lebanon, New Hampshire Suma Pokala, MD, FAC P

Associate Professor, Department of Medicine T exas A&M Health Sciences Center Central T exas Veterans Health Care System T emple, T exas

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Professor of Medicine Clerkship Director

Department of Internal Medicine UT Southwestern Medical Center Dallas, T exas

Te mple A. Ratcliffe , MD Assistant Professor of Medicine Assistant Clerkship Director F. Edward Hebert School of Medicine

Uniformed Services University of the Health Sciences Bethesda, Maryland

Emran Rouf, MD, FAC P

Assistant Professor, Department of Medicine Scott & White Healthcare

T exas A & M Health Science Center College of Medicine T emple, T exas

Gary M. Rull, MD, FAC P

Associate Professor of Clinical Internal Medicine Doctoring Director

Department of Internal Medicine

Southern Illinois University School of Medicine Springfield, Illinois

Jame s L. Se bastian, MD, FAC P Professor of Medicine

Division of General Internal Medicine Medical College of Wisconsin Milwaukee, Wisconsin Thomas K. Schulz , MD Associate Program Director, Internal Medicine Residency Program Associate Professor

Monica Ann Shaw, MD, FAC P Associate Professor of Medicine

Chief, Division of General Internal Medicine Director, Internal Medicine Clerkships University of Louisville School of Medicine Louisville, Kentucky

Le igh H. Simmons, MD Assistant in Medicine

Associate Medicine Clerkship Director Massachusetts General Hospital Harvard Medical School Boston, Massachusetts

Harold M. Sz e rlip, MD, FAC P, FC C P, FASN Professor and Vice-Chair, Department of Medicine Chief, Medical Service, UPH Hospital

University of Arizona College of Medicine T ucson, Arizona

He athe r Tarantino, MD Assistant Professor Medicine Clerkship Director

West Virginia University School of Medicine Charleston Division

Charleston, West Virginia

Robe rt L. Trowbridge , MD, FAC P Assistant Professor of Medicine T ufts University School of Medicine Director of Undergraduate Medical Education Department of Medicine

Maine Medical Center Portland, Maine John Varras, MD

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Associate Professor Interim Chair Clerkship Director

Department of Internal Medicine University of Nevada School of Medicine Las Vegas, Nevada

T. Robe rt Vu, MD, FAC P

Associate Professor of Clinical Medicine Director, Internal Medicine Clerkship Indiana University School of Medicine Indianapolis, Indiana

Jose ph T. W ayne , MD, MPH, FAC P Internal Medicine Clerkship Director Department of Internal Medicine Albany Medical College

Albany, New York Barry J. W u, MD, FAC P

Associate Program Director of Internal Medicine Hospital of Saint Raphael

Clinical Professor of Medicine Yale University School of Medicine New Haven, Connecticut

Pare kha Ye dla, MBBS, FAC P

Assistant Professor, Department of Medicine Medicine Clerkship Director

University of Alabama, Huntsville Campus Huntsville, Alabama

MKSAP for Stude nts 5 C ontributors

Arlina Ahluwalia, MD, FAC P Associate Professor of Medicine

Medicine Clerkship Site Director, Palo Alto VAHCS Stanford University School of Medicine

Palo Alto, California

Erik K. Ale xande r, MD, FAC P Director, Medical Student Education Brigham & Women's Hospital Associate Professor of Medicine Harvard Medical School Boston, Massachusetts

Ire ne Ale xandraki, MD, MPH, FAC P Assistant Professor, Department of Medicine Medicine Clerkship Director

University of Florida College of Medicine Jacksonville, Florida

Mark Alle e , MD, FAC P Associate Professor of Medicine Clerkship Director

Department of Internal Medicine

University of Oklahoma College of Medicine Oklahoma City, Oklahoma

Alpe sh Amin, MD, MBA, FAC P Professor of Medicine

Medicine Clerkship Director University of California, Irvine Orange, California

Joe l Appe l, DO

Director, Ambulatory and Subinternship Programs Wayne State University School of Medicine Detroit, Michigan

Jonathan S. Appe lbaum, MD, FAC P

Associate Professor, Clinical Sciences Department Director, Internal Medicine Education

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T allahassee, Florida

MJ Barchman, MD, FAC P, FASN Professor of Medicine

Internal Medicine Clerkship Director Section of Nephrology and Hypertension

Brody School of Medicine at East Carolina University Greenville, North Carolina

Gonz alo Be arman, MD, MPH Associate Professor of Medicine Associate Hospital Epidemiologist Medicine Clerkship Director Virginia Commonwealth University Richmond, Virginia

Se th Mark Be rne y, MD, FAC P Professor of Medicine

Chief, Section of Rheumatology

Director, Center of Excellence for Arthritis and Rheumatology

Louisiana State University Health Sciences Center School of Medicine in Shreveport

Shreveport, Louisiana

Je nnife r Bie rman, MD, FAC P Primary Care Clerkship Director

Northwestern University Feinberg School of Medicine Chicago, Illinois

C ynthia A. Burns, MD, FAC P Assistant Professor

Internal Medicine Clerkship Director Department of Internal Medicine Section on Endocrinology & Metabolism Wake Forest University School of Medicine Winston Salem, North Carolina

Dane lle C aye a, MD, MS Assistant Professor of Medicine Medicine Clerkship Director

Johns Hopkins University School of Medicine Baltimore, Maryland

J. C harle s MD, FAC P, FHM Assistant Professor of Medicine Division Education Coordinator Mayo Clinic Hospital

Phoenix, Arizona Amanda C oope r, MD Assistant Professor of Medicine University of Pittsburgh Medical Center University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Mark D. C orrie re , MD, FAC P

Associate Clerkship Director, Department of Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland

Gre tche n Die me r, MD, FAC P Assistant Professor of Internal Medicine Clerkship Director Internal Medicine Director of Undergraduate Medical Education Associate Program Director Internal Medicine T homas Jefferson University

Philadelphia, Pennsylvania Re e d E. Dre ws, MD, FAC P Associate Professor Harvard Medical School

Program Director, Hematology-Oncology Fellowship Beth Israel Deaconess Medical Center

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D. Michae l Elnicki, MD, FAC P

Professor and Chief, Section of General Internal Medicine, UPMC Shadyside

Ambulatory Clerkship Director University of Pittsburgh Pittsburgh, Pennsylvania Mark J. Fagan, MD, FAC P Clerkship Director

Department of Medicine

Alpert Medical School of Brown University Providence, Rhode Island

Sara B. Faz io, MD, FAC P

Associate Professor, Harvard Medical School Director, Core I Medicine Clerkship Division of General Internal Medicine Beth Israel Deaconess Medical Center Boston, Massachusetts

J. Michae l Finle y, DO , FAC P, FAC O I Associate Professor of Medicine Chief, Division of Rheumatology

Associate Dean for Graduate Medical Education Western University College of Osteopathic Medicine Pomona, California

Jane P. Gagliardi, MD, MHS

Assistant Professor of Psychiatry & Behavioral Sciences Assistant Professor of Medicine

Director of UME, Department of Medicine Medicine Clerkship and Subinternship Director Duke University School of Medicine

Durham, North Carolina Pe te r Gliatto, MD, FAC P

Associate Dean for Undergraduate Medical Education and Student Affairs

Mount Sinai School of Medicine New York, New York

Eric H. Gre e n MD, MSc, FAC P Clinical Associate Professor of Medicine Drexel University College of Medicine Associate Program Director

Mercy Catholic Medical Center Darby, Pennsylvania

He athe r Harre ll, MD, FAC P

Director of Fourth Year Programs University of Florida College of Medicine Gainesville, Florida

W arre n He rshman, MD, MPH Director of Student Education Boston University School of Medicine Department of Medicine

Boston, Massachusetts

Susan Thompson Hingle , MD, FAC P Associate Professor of Medicine Internal Medicine Clerkship Director

Internal Medicine Residency Associate Program Director Southern Illinois University School of Medicine Springfield, Illinois

Bryan Ho, MD

Assistant Professor, Department of Neurology Neurology Clerkship Director

T ufts University School of Medicine Boston, Massachusetts

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Mark D. Holde n, MD, FAC P Vice-Chair for Undergraduate Education Department of Internal Medicine University of T exas Medical Branch Galveston, T exas

Je ffre y Guy House , DO , FAC P Assistant Professor of Medicine

Program Director Internal Medicine Residency

University of Florida Health Science Center-Jacksonville Jacksonville, Florida

Eric Hsie h, MD

Director, Internal Medicine Clerkship

Senior Associate Director, Internal Medicine Residency Department of Medicine

Keck School of Medicine University of Southern California Los Angeles, California

Robe rt Jablonove r, MD

Assistant Professor in Internal Medicine Clerkship Director in Internal Medicine

George Washington University School of Medicine Washington, District of Columbia

Saba Khan, MD

Fellow, Section of Rheumatology

Shreveport, Louisiana Sarang Kim, MD, FAC P Assistant Professor of Medicine Division of General Internal Medicine

University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School

New Brunswick, New Jersey Vale rie J. Lang, MD, FAC P Director, Inpatient Medicine Clerkship

University of Rochester School of Medicine & Dentistry Hospital Medicine Division

Rochester, New York Rosa Le e , MD

Clinical Assistant Professor, Department of Medicine Albert Einstein College of Medicine

Site Leader, Medicine Clerkship Montefiore Medical Center Bronx, New York Bruce Le ff, MD, FAC P Professor of Medicine

Co-Director, Basic Medicine Clerkship Johns Hopkins University School of Medicine Baltimore, Maryland

Kyle L. Lokitz , MD

Fellow, Section of Rheumatology

Shreveport, Louisiana Fre d A. Lope z , MD, FAC P Richard Vial Professor and Vice Chair Department of Medicine

Louisiana State University Health Sciences Center New Orleans, Louisiana

Ke vin M. McKown, MD, FAC P

Associate Professor and Head, Division of Rheumatology Co-Director M3 and M4 Student Programs

Department of Medicine University of Wisconsin

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School of Medicine & Public Health Madison, Wisconsin

C had S. Mille r, MD, FAC P Director, Student Programs

Associate Program Director, Residency Department of Internal Medicine T ulane University Health Sciences Center New Orleans, Louisiana

Kathe rine Nicke rson, MD Professor of Clinical Medicine Vice Chair, Department of Medicine Clerkship Director, Internal Medicine College of Physicians & Surgeons Columbia University

New York, New York L. Jame s Nixon, MD

Vice Chair for Education, Department of Medicine Medicine Clerkship Director

University of Minnesota Medical School Minneapolis, Minnesota

Isaac O . O pole , MD, PhD, FAC P Assistant Dean for Student Affairs Internal Medicine Clerkship Director Kansas University Medical Center Kansas City, Kansas

C arlos Palacio, MD, MPH, FAC P

Associate Professor of Medicine, Department of Medicine Clerkship Director

University of Florida College of Medicine-Jacksonville Jacksonville, Florida

Suma Pokala, MD, FAC P

Associate Professor, Department of Medicine T exas A&M Health Sciences Center Central T exas Veterans Health Care System T emple, T exas

Nora L. Porte r, MD, MPH, FAC P Co-director, Internal Medicine Clerkship Saint Louis University School of Medicine St. Louis, Missouri

Shalini Re ddy, MD Associate Dean

Student Programs and Professional Development T he University of Chicago Pritzker School of Medicine Chicago, Illinois

Klara J. Rose nquist, MD Clinical/Research Fellow

Division of Endocrinology, Diabetes and Hypertension Brigham & Women's Hospital

Harvard Medical School Boston, Massachusetts

Kathle e n F. Ryan, MD, FAC P Associate Professor of Medicine Department of Medicine

Drexel University College of Medicine Philadelphia, Pennsylvania

Mysti D. W . Schott, MD, FAC P Associate Professor of Medicine

Course Director, Advanced Clinical Evaluation Skills Department of Medicine, Division of General Medicine & Office of Educational Programs

University of T exas Health Science Center San Antonio San Antonio, T exas

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Ambulatory Medicine Clerkship Director University of North Carolina School of Medicine Chapel Hill, North Carolina

Monica Ann Shaw, MD, FAC P Associate Professor and Chief

Division of General Internal Medicine, Palliative Medicine and Medical Education

Medicine Clerkship Director University of Louisville Louisville, Kentucky Patricia Short, MD, FAC P Assistant Professor of Medicine Associate Clerkship Director

Uniformed Services University of the Health Sciences Madigan Army Medical Center

T acoma, Washington Kare n Sz aute r, MD, FAC P Professor

Department of Internal Medicine and Office of Educational Development

Co-Director, Internal Medicine Clerkship University of T exas Medical Branch Galveston, T exas

Harold M. Sz e rlip, MD, FAC P, FC C P, FASN Professor and Vice-Chair, Department of Medicine Chief, Medical Service, UPH Hospital

University of Arizona College of Medicine T ucson, Arizona

Gary Tabas, MD, FAC P Associate Professor of Medicine

University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Dario M. Torre , MD, MPH, PhD, FAC P Associate Professor of Medicine

Associate Program Director Internal Medicine University of Pittsburgh-Shadyside

University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

John Varras, MD Associate Professor Interim Chair Clerkship Director

Department of Internal Medicine University of Nevada School of Medicine Las Vegas, Nevada

H. Douglas W alde n, MD, MPH, FAC P Professor of Medicine

Co-Director, Internal Medicine Clerkship Saint Louis University School of Medicine St. Louis, Missouri

John A. W alke r, MD, FAC P Professor and Vice-Chair for Education Department of Medicine

Medicine Clerkship Director

University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School

New Brunswick, New Jersey

Jose ph T. W ayne , MD, MPH, FAC P Internal Medicine Clerkship Director Department of Internal Medicine Albany Medical College

Albany, New York

John Jason W hite , MD, FASN Associate Professor of Medicine

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Section of Nephrology, Hypertension & T ransplantation Georgia Health Sciences University

Augusta, Georgia

T he American College of Physicians gratefully acknowledges the contributions to MKSAP for Students 5 of Scott Hurd (production systems), Lisa Rockey (editorial production support), Rosemarie Houton (editorial production support) and the Self-Assessment editorial staff. T he College also wishes to acknowledge that many other persons, too numerous to mention, have contributed to the production of this product. Without their dedicated efforts, the publication would not have been possible. Fore word

Dear Student:

As the national organization for internal medicine specialists and subspecialists, the American College of Physicians is committed to providing the highest quality educational materials and resources throughout the continuum of training and practice in internal medicine. Early in that continuum are the clinical clerkships in internal medicine for students during their third and fourth years of medical school. Recognizing the critical importance of these clerkships for all students - whether or not they plan to enter the specialty of internal medicine - the College has been collaborating with the Clerkship Directors in Internal Medicine to develop and produce two publications specifically targeted to medical students on their internal medicine clerkships.

T his publication, MKSAP for Students, now in its 5th_{edition, employs an interactive, case-based model of topic-based questions (with accompanying answers and critiques) to} teach students about the major clinical problems in internal medicine. T he companion publication, Internal Medicine Essentials for Medical Students, nicely complements MKSAP for Students, providing a concise text that can be read from cover to cover during an internal medicine clerkship. Both MKSAP for Students and Internal Medicine Essentials are modeled after the much larger Medical Knowledge Self-Assessm ent Program (MKSAP), which has served for the past 43 years (and through 15 editions) as the gold standard for residents preparing for the certifying examination in internal medicine and for practicing physicians who wish to refresh, update, and assess their knowledge. Internal medicine is an exciting and intellectually stimulating specialty. We hope that MKSAP for Students will reinforce that feeling for you, enriching your clinical

experiences and serving as a useful companion as you learn the fundamental concepts of the specialty and apply them in clinical settings. Remember, the knowledge we gain is not just abstract learning - it provides the foundation for the care of our patients, who deserve only the best!

Best of luck to you in your studies and in your future career. Ste ve n E. W e inbe rge r, MD, FAC P

Executive Vice President and Chief Operating Officer American College of Physicians

Pre face

Welcome to the newest edition of MKSAP for Students. T he fifth edition of this popular series contains over 450 comple te ly ne w multiple-choice questions, updated references, more color photographs and ECG tracings than ever before. MKSAP for Students is intended primarily for third-year students participating in their required internal medicine clerkship. Other audiences include fourth-year students on an advanced medicine clerkship; second-year students involved in problem-based learning; and physician assistant students.

MKSAP for Students 5 is supported by its companion textbook, Internal Medicine Essentials for Students. Authors who contributed to the Essentials textbook also wrote questions for MKSAP for Students. Additional questions were written by internal medicine clerkship directors. Like Essentials, MKSAP for Students 5 is organized into 11 chapters that correspond to the traditional subspecialty disciplines of internal medicine and general internal medicine. T he editors and authors have made every effort to ensure that all questions in MKSAP for Students are associated with relevant content in the textbook that can directly answer the question. T his allows a one-to-one correspondence between the textbook and the self-assessment questions.

As in previous issues, the questions are formatted as clinical vignettes that resemble the types of questions you will encounter at the end of the clerkship subject examination and the internal medicine component of the USMLE licensing examination. Each question has a detailed answer critique that identifies the correct answer and explains why that answer is correct and the other options are incorrect, an educational objective, and a short bibliography. Succinct "Key Points" summarize the important "take-home messages" for each question. We anticipate that reviewing the "Key Points" will be an efficient way to prepare for upcoming examinations. We recommend that students read the clinical vignette, select an answer, and then read the associated answer critique. Each question has been specifically reviewed by at least three clerkship directors to ensure that it meets the learning needs of students participating in the medicine clerkship.

New to this edition is a categorization scheme for the self-assessment questions. All questions are categorized as either Advanced (A) or Basic (B) by the MKSAP for Students Editorial Board, which consists entirely of clerkship directors. Advanced questions are difficult and assess knowledge expected of an honors-level student or beginning first-year internal medicine resident. Basic questions assess knowledge expected of all third-first-year students completing the basic internal medicine clerkship. It is our expectation that clerkship students will be able to answer most of the Basic questions and approximately half of the Advanced questions. We hope that this new system will provide students with a better measure of their knowledge acquisition.

T he fifth edition of MKSAP for Students would have been impossible without the valuable and entirely voluntary contributions of many people, some of whom are named in the Acknowledgments section. Others, not specifically named, were representatives of a wide spectrum of constituencies and organizations, such as the Clerkship Directors in Internal Medicine and various committees within the American College of Physicians, including the Education and Publication Committee and the Council of Student Members.

As in the past, we hope to receive more excellent feedback from students to improve future editions. T hank you for making MKSAP for Students such a success! Patrick C. Alguire, MD, FACP

Editor-in-Chief

Senior Vice President for Medical Education Am erican College of Physicians

Note : T he drug dosage schedules contained in this publication are, we believe, accurate and in accordance with current standards. However, please ensure that the recommended dosages concur with information provided in the product information material, especially for new, infrequently used, or highly toxic drugs.

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C onte nts

Acknowle dgme nts…iii Fore word…xi

Pre face…xiii

Cardiovascular Medicine Questions…1

Cardiovascular Medicine Answers and Critiques…17 Endocrinology and Metabolism Questions…39

Endocrinology and Metabolism Answers and Critiques…46 Gastroenterology and Hepatology Questions…61

Gastroenterology and Hepatology Answers and Critiques…73 General Internal Medicine Questions…91

General Internal Medicine Answers and Critiques…107 Hematology Questions…139

Hematology Answers and Critiques…147 Infectious Disease Medicine Questions…161

Infectious Disease Medicine Answers and Critiques…172 Nephrology Questions…193

Nephrology Answers and Critiques…201 Neurology Questions…215

Neurology Answers and Critiques…222 Oncology Questions…235

Oncology Answers and Critiques…241 Pulmonary Medicine Questions…253

Pulmonary Medicine Answers and Critiques…262 Rheumatology Questions…279

Rheumatology Answers and Critiques…288 Normal Laboratory Value s…305 C olor Plate s

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Se ction 1. C ardiovascular Me dicine

Q ue stions

Ite m 1 [Basic]

A 66-year-old man is evaluated in the emergency department for left-sided chest pain that began at rest, lasted for 15 minutes, and has since resolved. A similar episode occurred at rest yesterday. Pertinent medical history includes hypertension and type 2 diabetes mellitus. Current medications are amlodipine, glyburide, and aspirin. On physical examination, blood pressure is 125/65 mm Hg, heart rate is 70/min, and respiratory rate is 12/min. Estimated central venous pressure is 6 cm H₂O, carotid upstroke is normal, there are no cardiac murmurs, and the lung fields are clear.

Laboratory findings include an elevated serum troponin I level. Electrocardiogram is shown. Chest radiograph is normal.

W hich of the following is the most like ly diagnosis?

(A) Chronic stable angina

(B) Non-ST -elevation myocardial infarction (C) ST -elevation myocardial infarction (D) Unstable angina

Ite m 2 [Basic]

A 63-year-old woman is admitted to the hospital with pleuritic chest pain, diaphoresis, and dyspnea of 1 hour's duration. T he pain is not affected by food, antacids, or exertion. It may be worse when supine and with deep breathing. She has a 10-year history of hypertension and hyperlipidemia. Her medications are chlorthalidone and lovastatin.

On physical examination, temperature is 37.8°C (100.0°F), blood pressure is 145/90 mm Hg (both arms), heart rate is 108/min, and respiration rate is 22/min. Cardiovascular examination reveals a regular rhythm and a biphasic, scratchy sound best heard at the lower left sternal border. No murmur, S3, or S4 is heard. T he lungs are clear to

auscultation. T he jugular venous pressure is normal and no peripheral edema is noted.

T he electrocardiogram shows sinus tachycardia with diffuse ST elevation. T roponin level and chest radiograph findings are normal. W hich of the following is the most like ly diagnosis?

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(B) Acute pericarditis (C) Aortic dissection (D) Pulmonary embolism Ite m 3 [Basic]

A 78-year-old man is evaluated in the emergency department for new-onset chest pain. He describes a crushing pain that is located in the left substernal area and has been present for 10 hours. He has had no prior episodes of chest pain. His medical history is notable for hypertension and hyperlipidemia. Current medications are aspirin, hydrochlorothiazide, and atorvastatin.

On physical examination, blood pressure is 100/70 mm Hg in both arms, pulse is 100/min, and respiration rate is 16/min. T here is no jugular venous distention and no cardiac murmurs or rubs. T he lungs are clear.

Laboratory results are notable for elevated levels of serum creatine kinase and troponin I. T he initial electrocardiogram is shown. Chest radiograph is normal.

W hich of the following is the be st manage me nt for this patie nt?

(A) Chest CT with contrast (B) Echocardiogram

(C) Percutaneous coronary intervention (D) T hrombolytic therapy

Ite m 4 [Basic]

A 50-year-old man is evaluated for a 2-hour episode of epigastric discomfort and dyspnea during exercise that is relieved by rest. He is now pain free. T he patient states a similar episode occurred on three previous occasions, but he did not seek medical advice. He has been using antacids for the past 6 weeks with partial relief. He reports no fever, chills, nausea, vomiting, diaphoresis, or postprandial abdominal pain. He has a 15-year history of hypertension and hyperlipidemia; his only medication is chlorthalidone.

On physical examination, he is afebrile, blood pressure is 150/85 mm Hg, pulse rate is 88/min, and respiration rate is 14/min. BMI is 28. Estimated central venous pressure is normal. Cardiac examination reveals a regular rhythm. T he S2 is normal, and an S4 is heard at the apex; no murmurs or other extracardiac sounds are heard. T he lungs are clear to auscultation. T he abdomen is not tender to palpation.

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(A) Acute pericarditis (B) Aortic dissection (C) Ischemic heart disease (D) Peptic ulcer disease Ite m 5 [Advanced]

A 52-year-old woman is evaluated in the emergency department for ongoing substernal chest pressure associated with nausea, diaphoresis, and lightheadedness. Her symptoms began 3 hours ago. She has hypertension and hypercholesterolemia. Her medications are hydrochlorothiazide, pravastatin, and aspirin.

On physical examination, her blood pressure is 84/62 mm Hg, pulse is 68/min, and respiration rate is 20/min. Cardiac auscultation reveals distant heart sounds with an S₄. T he lungs are clear bilaterally; estimated central venous pressure is elevated at 11 cm H₂O.

Electrocardiogram with right-sided precordial leads is shown. (Leads V₁ through V₆ are recorded from the right side of the chest.)

W hich of the following should be give n ne xt in the tre atme nt of this patie nt?

(A) Dobutamine intravenously (B) Metoprolol intravenously (C) Nitroglycerin sublingually (D) 0.9% saline intravenous bolus Ite m 6 [Basic]

A 58-year-old woman is evaluated in the emergency department for substernal chest pain of 18 hours' duration. She describes the pain as a tightening that is not associated with eating or exertion and that radiates to the neck. T he pain is not accompanied by dyspnea, nausea, or diaphoresis and is not associated with exertion. She also reports symptoms of occasional heartburn and acid regurgitation. She had a similar episode of substernal chest pain 1 month ago, and an exercise stress test that achieved 90% her predicted maximal heart rate showed no ischemia. T he patient's medical history is otherwise unremarkable.

On physical examination, temperature is 37.2°C (99.0°F), blood pressure is 130/74 mm Hg, pulse rate is 88/min, and respiration rate is 16/min; BMI is 32. T he cardiopulmonary examination is normal. Electrocardiography shows nonspecific ST -segment and T -wave abnormalities, which are unchanged from several previous examinations.

W hich of the following is the most appropriate manage me nt for this patie nt?

(20)

(B) Coronary angiography (C) Esophagogastroduodenoscopy (D) Oral proton pump inhibitor therapy (E) Repeat exercise stress test

Ite m 7 [Advanced]

A 22-year-old man is evaluated during the month of June in the emergency department for intermittent palpitations and dizziness for the past week. He has not experienced chest pain, dyspnea, or orthopnea. He has no prior medical history and is healthy and active. He reports being ill 6 to 8 weeks ago with fever, fatigue, myalgia, and a gradually expanding, flat, erythematous rash on his abdomen measuring a minimum of 5 cm at widest point. He works as a forester in Massachusetts and has not traveled out of the area recently.

On physical examination, his temperature is normal, blood pressure is 120/70 mm Hg, and pulse is 45/min. T here are cannon waves in the jugular pulsation. T here is no rash, and results of cardiac and pulmonary auscultation are normal.

T he electrocardiogram is shown.

(A) First-degree atrioventricular block (B) Mobitz type I atrioventricular block (C) Mobitz type II atrioventricular block (D) T hird-degree atrioventricular heart block Ite m 8 [Basic]

A 46-year-old man is evaluated for an 8-year history of episodic chest pain associated with dyspnea, tachycardia, diaphoresis, and dizziness that occurs several times each week. T he symptoms develop suddenly, are often so severe that he feels that he is going to die, and improve significantly within 20 to 30 minutes. T he patient does not know what precipitates these episodes or whether anything makes the symptoms better or worse.

Previous medical evaluations have been unremarkable. Studies have included electrocardiographic exercise stress testing, 24-hour electrocardiographic monitoring, echocardiography, cardiac catheterization, and upper endoscopy. T he patient takes no medications. Findings on physical examination are unremarkable. Medical records reveal that during these episodes, hypertension or tachycardia have never been documented.

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(A) Acute coronary syndrome (B) Panic disorder

(C) Pheochromocytoma (D) Pneumothorax (E) Pulmonary embolism Ite m 9 [Basic]

A 65-year-old woman is hospitalized for chest pain secondary to an acute coronary syndrome. Her immediate treatment consists of metoprolol, heparin, nitroglycerin, and aspirin, which results in immediate relief of her chest discomfort. A rhythm strip is shown.

W hich of the following is the most like ly e le ctrocardiographic diagnosis?

(A) First-degree atrioventricular block

(B) Mobitz type I second-degree atrioventricular block (C) Mobitz type II second-degree atrioventricular block (D) T hird-degree atrioventricular block (complete heart block) Ite m 10 [Advanced]

A 65-year-old man is evaluated during a routine follow-up examination for coronary artery disease. He was diagnosed with a myocardial infarction 5 years ago, and was started on aspirin, metoprolol, atorvastatin, lisinopril, and sublingual nitroglycerin. He was asymptomatic until 3 months ago, when he noted exertional angina after walking two blocks. He now uses sublingual nitroglycerin on a daily basis. He has not had any episodes of pain at rest or prolonged chest pain that were not relieved by sublingual nitroglycerin.

On physical examination, blood pressure is 146/94 mm Hg and heart rate is 87/min. Carotid upstrokes are normal with no bruits. Cardiac examination is normal. T he lungs are clear.

His electrocardiogram is unchanged since the last visit, with no evidence of acute changes.

In addition to adding a long-acting nitrate , which of the following is the most appropriate manage me nt for this patie nt?

(A) Add ranolazine (B) Coronary angiography (C) Exercise treadmill stress testing (D) Increase metoprolol

A 48-year-old woman is evaluated in the emergency department 3 hours after the sudden onset of central anterior chest pain and dyspnea. T here is constant chest pressure, tightness, and dyspnea. She is not on any medications.

On physical examination, the patient is afebrile. Blood pressure is 144/76 mm Hg bilaterally, pulse is 118/min, and respiration rate is 18/min. Estimated central venous pressure is 15 cm H₂O. T here are no murmurs, rubs, or gallops on cardiac auscultation. Her lungs are clear. T here is mild pedal and lower leg edema that is more pronounced on the right side.

T he electrocardiogram shows ST -segment depression in the lateral leads. T he chest radiograph is normal. Handheld echocardiography shows a small, hyperdynamic left ventricle with normal regional wall motion.

W hich of the following te sts should be pe rforme d ne xt?

(A) CT pulmonary angiography (B) Coronary angiography (C) Radionuclide perfusion imaging (D) T ransesophageal echocardiography Ite m 12 [Basic]

A 68-year-old woman is evaluated for chest pain of 3 months' duration. She describes the pain as a left-sided burning that occurs both at rest and when she exercises. It lasts for about 10 minutes, and is relieved by eating and by rest. She has hypertension, for which she takes hydrochlorothiazide. She has asthma, for which she takes inhaled corticosteroids and inhaled albuterol as needed. If she pretreats herself with the inhaled bronchodilator, she can walk long distances at a brisk pace without dyspnea. She continues to smoke cigarettes and has smoked 1 pack per day for 40 years.

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results of an electrocardiogram are normal.

W hich of the following is the most appropriate diagnostic te st for this patie nt?

(A) Adenosine nuclear perfusion stress test (B) Coronary angiography

(C) Dobutamine stress echocardiography (D) Exercise stress test

Ite m 13 [Basic]

A 54-year-old man is evaluated for 2 days of fatigue and dyspnea on exertion. He denies chest pain and lightheadedness. He has no other medical problems, and his only medication is aspirin.

On physical examination, his blood pressure is 123/65 mm Hg and his pulse is 100/min. Cardiac examination reveals a normal S₁ and S₂ and no murmurs or gallops. Lungs are clear to auscultation.

T he electrocardiogram is shown.

(A) Atrial fibrillation (B) Atrial flutter

(C) Sinoatrial node dysfunction (D) Ventricular tachycardia Ite m 14 [Basic]

A 75-year-old man with chronic stable angina is evaluated during a routine appointment. He had a myocardial infarction 5 years ago treated medically and has had no complications. He only gets chest pain with significant exertion, typically occurring less than once a week. T he pain is relieved by one sublingual nitroglycerin tablet or resting. He reports no shortness of breath or edema. Medications are lisinopril, carvedilol, simvastatin, aspirin, and nitroglycerin, as needed.

On examination, temperature is 37.0°C (98.6°F), blood pressure is 118/70 mm Hg, pulse rate is 60/min, and respiration rate is 14/min. BMI is 22. Cardiovascular examination reveals normal heart sounds without murmurs, gallops, or rubs. Lungs are clear to auscultation. T he remainder of the examination is normal.

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T riglycerides 100 mg/dL (1.1 mmol/L) HDL cholesterol 44 mg/dL (1.1 mmol/L) LDL cholesterol 76 mg/dL (2.0 mmol/L)

W hich of the following is the be st manage me nt for this patie nt?

(A) Add clopidogrel (B) Add ranolazine (C) Coronary angiography (D) No changes

A 43-year-old man is evaluated in the emergency department for dyspnea. He has no prior personal or family history of cardiovascular disease, diabetes mellitus, or hypertension. On physical examination, the lungs are clear. Cardiovascular examination is unremarkable with the exception of a rapid heart rate.

T he chest radiograph is normal. T he electrocardiogram is shown.

(A) Atrial fibrillation (B) Atrial flutter (C) Sinus tachycardia (D) Ventricular tachycardia Ite m 16 [Basic]

A 48-year-old man is evaluated after a coworker had a myocardial infarction; he is worried about having a heart attack. He reports no episodes of chest pain or shortness of breath. He jogs on a treadmill 30 minutes a day four times a week. He does not smoke. He has hypertension for which he takes hydrochlorothiazide. Family history is negative for coronary artery disease.

On physical examination his vital signs are normal. T he cardiopulmonary examination is normal, as is the remainder of the physical examination.

T he most recent lipid panel shows: total cholesterol 208 mg/dL (5.4 mmol/L), HDL cholesterol 70 mg/dL (1.8 mmol/L), and LDL cholesterol 114 mg/dL (3.0 mmol/L). T he patient's Framingham Risk Score for a major cardiac event is calculated as 4% over the next 10 years.

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(A) Coronary angiography (B) Coronary calcium scoring (C) CT angiography (D) Exercise stress test (E) No additional testing Ite m 17 [Advanced]

A 26-year-old nurse is evaluated in the emergency department after an episode of syncope. While working in the intensive care unit, she developed tachycardia and then lost consciousness. She has had brief episodes of rapid palpitations in the past but no prior syncope.

Physical examination is unremarkable and the patient is in sinus rhythm. T he chest radiograph is unremarkable. T he electrocardiogram is shown.

(A) Accelerated idioventricular tachycardia (B) Atrial flutter

(C) Atrioventricular reentrant tachycardia (D) Multifocal atrial tachycardia

A 62-year-old man with coronary artery disease is evaluated for angina. He was diagnosed with coronary artery disease 4 years ago. Medical therapy was started with aspirin, metoprolol, isosorbide mononitrate, pravastatin, and sublingual nitroglycerin. He was asymptomatic until 8 months ago, when he noted exertional angina; his dosages of metoprolol and isosorbide mononitrate were increased and long-acting diltiazem was added, resulting in control of his symptoms. Over the past 2 months, however, he has had gradually increasing symptoms, and currently he requires daily nitroglycerin for angina relief during exercise. He has not had any episodes of angina at rest.

On physical examination, blood pressure is 100/60 mm Hg and heart rate is 48/min. Carotid upstroke is normal with no bruits. Cardiac examination reveals no murmurs, and the lungs are clear.

An electrocardiogram shows no acute ischemic changes.

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(A) Coronary angiography (B) Exercise treadmill stress testing (C) Increase metoprolol

(D) Intravenous heparin and nitroglycerin Ite m 19 [Basic]

A 62-year old man with a history of a myocardial infarction 1 year ago is evaluated in the emergency department for sudden episodes of dyspnea and weakness. He is diaphoretic, cool, clammy, and pale; cannon waves are noted in the jugular pulsations. An electrocardiogram taken at the beginning of a typical episode is shown.

(A) Atrial fibrillation with left bundle branch block

(B) Atrial fibrillation with preexcitation (Wolf-Parkinson-White syndrome) (C) Supraventricular tachycardia with right bundle branch block

(D) Ventricular tachycardia Ite m 20 [Basic]

A 54-year-old woman is evaluated in the emergency department for jaw and shoulder pain that has occurred intermittently for the past week. T he symptoms occur with activity and are relieved by rest. Medical and family history is unremarkable. She is not taking any medications.

Physical examination shows a blood pressure of 150/68 mm Hg and a pulse of 90/min. T here is no jugular venous distention and carotid upstrokes are normal. T here are no cardiac murmurs and the lung fields are clear. Extremities show no edema and peripheral pulses are normal bilaterally. T he troponin I level is elevated.

Electrocardiogram shows 1.0-mm ST -segment depression in leads V1 through V4 with T -wave inversions.

T he patient is given aspirin, intravenous nitroglycerin, low-molecular-weight heparin, clopidogrel, and atorvastatin. W hich of the following is the most appropriate additional imme diate tre atme nt for this patie nt?

(A) Intra-aortic balloon pump (B) Metoprolol

(C) Verapamil (D) Warfarin

(26)

A 72-year-old man is evaluated in the emergency department for dyspnea. One week ago, an episode of severe chest pain and dyspnea awoke him from sleep. Over the next several days his dyspnea stabilized. On the morning of admission, the patient noted a sudden increase in dyspnea. His medical history is significant for hypertension and hyperlipidemia. He has no history of heart murmur. He currently takes simvastatin, aspirin, and lisinopril.

On physical examination, the patient is sitting up with labored breathing. Blood pressure is 86/52 mm Hg, pulse is regular at 110/min, and respiration rate is 24/min. Oxygen saturation is 92% on 6 L of oxygen. Jugular veins are distended to the angle of the jaw while sitting upright. Cardiac examination reveals a grade 3/6 holosystolic murmur at the cardiac apex radiating toward the left axilla. Bibasilar crackles are present.

An electrocardiogram is shown. A chest radiograph shows pulmonary vascular congestion.

(A) Acute mitral regurgitation (B) Left ventricular aneurysm (C) Pulmonary embolism (D) Ventricular free wall rupture Ite m 22 [Advanced]

A 62-year-old woman is brought to the emergency department for chest pain that has been present for 5 hours. Medical history is notable for type 2 diabetes mellitus, hyperlipidemia, and hypertension. Medications are glyburide, lisinopril, atorvastatin, and aspirin.

On physical examination, blood pressure is 160/80 mm Hg, pulse rate is 88/min, and respiration rate is 16/min. Cardiac examination shows no murmurs, extra sounds, or rubs. T he lungs are clear. Neurologic examination is normal.

T he electrocardiogram shows 2-mm ST -segment elevation in leads II, III, and aVF.

A coronary catheterization laboratory is not available, and the nearest hospital with percutaneous intervention capability is 3 hours away. W hich of the following is the be st manage me nt option for this patie nt?

(A) Aggressive medical therapy without reperfusion attempt (B) Immediate thrombolytic therapy

(C) T ransfer for coronary artery bypass graft surgery (D) T ransfer for percutaneous coronary intervention

(27)

A 65-year-old man is evaluated before beginning an exercise program. He is asymptomatic and his only medical problem is chronic hypertension that is well controlled on hydrochlorothiazide. He takes no other medications.

On physical examination, blood pressure is 138/76 mm Hg, and pulse is 80/min and regular. Physical examination is normal, except for a soft S₁. His electrocardiogram is shown.

W hich of the following be st de scribe s the e le ctrocardiographic findings?

(A) First-degree atrioventricular block (B) Second-degree atrioventricular block

(C) T hird-degree (complete) atrioventricular block

(D) Ventricular preexcitation (Wolff-Parkinson-White) syndrome Ite m 24 [Advanced]

A 56-year-old man is evaluated in the emergency department for chest discomfort that began 3 hours ago. He describes the pain, which is well localized to the left chest, as pressure. He denies prior episodes. Medical history is notable for type 2 diabetes mellitus and hyperlipidemia. Medications are aspirin, metformin, and atorvastatin. On physical examination, he is diaphoretic. Blood pressure is 95/60 mm Hg and heart rate is 110/min. T here is jugular venous distention, with an estimated central venous pressure of 14 cm H₂O. An S₃ is heard on cardiac auscultation, but no murmurs are present. T he lung fields are clear and there is no peripheral edema.

T he electrocardiogram shows sinus tachycardia, 2-mm ST -segment elevation in leads II, III, and aVF, and 0.5-mm ST -segment elevation in lead V₁. T he chest radiograph is normal.

W hich of the following is the most like ly cause of hypote nsion in this patie nt?

(A) Increased vagal tone (B) Pericardial tamponade (C) Right ventricular infarction (D) Ventricular septal defect Ite m 25 [Basic]

An 85-year-old woman is admitted to the coronary care unit following successful thrombolytic therapy for an acute anteroseptal ST -elevation myocardial infarction. Blood pressure is 120/70 mm Hg and heart rate is 90/min. T here is no jugular venous distention and no cardiac murmurs. T he lung fields are clear. Medications started in the hospital are aspirin, low-molecular-weight heparin, intravenous nitroglycerin, and metoprolol.

On hospital day 3, the patient experiences acute onset of respiratory distress and her systolic blood pressure falls to 80 mm Hg. Her oxygen saturation remains at 80% despite the administration of 100% oxygen by face mask. On physical examination, blood pressure is 96/40 mm Hg, pulse rate is 100/min, and respiration rate is 28/min. Findings include jugular venous distention, crackles throughout both lung fields, and a grade 4/6 systolic murmur associated with a thrill.

(A) Aortic dissection (B) Pericardial tamponade (C) Pulmonary embolism (D) Ventricular septal defect Ite m 26 [Advanced]

A 77-year-old woman is admitted to the hospital for intermittent dizziness over the past few days. She has hypertension, hyperlipidemia, and paroxysmal atrial fibrillation with a history of rapid ventricular response. Medications are metoprolol, hydrochlorothiazide, pravastatin, lisinopril, aspirin, and warfarin.

On physical examination, blood pressure is 137/88 mm Hg and pulse is 52/min. Estimated central venous pressure is 7 cm H2O. Cardiac auscultation reveals bradycardia with regular S1 and S2, as well as an S4. T he lungs are clear to auscultation.

On telemetry, she has sinus bradycardia with rates between 40/min and 50/min, with two symptomatic sinus pauses of 3 to 5 seconds each. W hich of the following is the most like ly diagnosis?

(28)

(A) Mobitz I atrioventricular block (B) Mobitz II atrioventricular block (C) T hird-degree atrioventricular block (D) Sinoatrial node dysfunction Ite m 27 [Advanced]

A 70-year-old man is evaluated in the emergency department for bradycardia that was detected in the nursing home and is found to have second-degree atrioventricular block. T he patient has Alzheimer dementia. His medications are donepezil (dosage recently increased); memantine (recently started); vitamin E; and trazodone for agitation. W hich of the patie nt's me dications is like ly to e xplain the bradycardia?

(A) Donepezil (B) Memantine (C) T razodone (D) Vitamin E Ite m 28 [Basic]

A 67-year-old man is brought to the emergency department after he lost consciousness. His wife reports he had been experiencing palpitations and lightheadedness earlier in the day. He has hypertension, dyslipidemia, and chronic obstructive pulmonary disease. His medications are lisinopril, hydrochlorothiazide, pravastatin, and a fluticasone-salmeterol inhaler.

On physical examination, the patient is awake but confused and in respiratory distress. He is afebrile, blood pressure is 80/45 mm Hg, pulse rate is 167/min, and respiration rate is 24/min and labored. Oxygen saturation is 86% on ambient air. T he cardiac rhythm is irregular, and bibasilar crackles are present on pulmonary examination. An electrocardiogram shows atrial fibrillation.

W hich of the following is the most appropriate imme diate manage me nt for this patie nt?

(A) Bedside echocardiography (B) CT pulmonary angiography (C) Coronary angiography (D) Electrical cardioversion Ite m 29 [Basic]

A 62-year-old-woman is evaluated for a 6-month history of difficulty falling asleep and an unexplained 4.5-kg (10 lb) weight loss. She is active and rides her bicycle 5 miles a day. She does not drink alcohol, smoke cigarettes, or use recreational drugs. She has no other medical problems and takes no medications.

On physical examination, she is afebrile, blood pressure is 125/75 mm Hg, pulse rate is 108/min, and respiration rate is 14/min. On cardiac examination, a regular rhythm without murmurs or extra cardiac sounds is heard. T he remainder of the physical examination is normal.

A metabolic profile and complete blood count are normal. An electrocardiogram shows only sinus tachycardia.

W hich of the following is the most appropriate manage me nt for this patie nt?

(A) Administer adenosine intravenously

(B) Measure serum thyroid-stimulating hormone level (T SH) (C) Obtain an exercise stress test

(D) Radiofrequency ablation of the sinoatrial node Ite m 30 [Advanced]

A 79-year-old man is evaluated in the emergency department for a 1-week history of dyspnea and weakness. He has had several such episodes over the past 5 years but has never sought medical attention. He reports that 1 year ago, he had a 10-minute episode of left arm weakness that resolved spontaneously. He was never evaluated for this problem. He has hypertension treated with lisinopril and hydrochlorothiazide.

On physical examination, blood pressure is 135/80 mm Hg and heart rate is 143/min. Other than a rapid heart rate, the cardiopulmonary examination is normal, as is the remainder of the physical examination.

Electrocardiogram shows atrial fibrillation with a rapid ventricular rate without evidence of ischemic changes. Cardiac enzyme values are normal. Following the administration of metoprolol, he converts to sinus rhythm, with a heart rate of 74/min.

W hich of the following is the most appropriate long-te rm tre atme nt for this patie nt?

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(B) Low-molecular-weight heparin followed by warfarin (C) Metoprolol

(D) Metoprolol and warfarin Ite m 31 [Basic]

A 28-year-old man is evaluated for a pre-employment physical examination and electrocardiogram before entering the police academy. He has no medical problems, describes no worrisome symptoms, and does not take any medications. He does not smoke cigarettes, has one alcoholic drink or less each week, and rarely consumes caffeine. He runs 4 miles a day 3 days a week and bikes 25 to 50 miles on the weekends. His parents are both alive and in good health as are his two older brothers.

On physical examination, vital signs are normal. T he cardiopulmonary examination is normal as is the remainder of the examination. T he resting 12-lead electrocardiogram shows 3 unifocal premature ventricular contractions.

W hich of the following is the be st manage me nt plan for this patie nt?

(A) Begin amiodarone (B) Begin metoprolol (C) Exercise stress test

(D) No further investigation or therapy

(E) Order 24-hour ambulatory electrocardiography Ite m 32 [Advanced]

A 55-year-old man is evaluated for fatigue, dyspnea with modest exertion, occasional lightheadedness, and palpitations. He has a history of ischemic cardiomyopathy following a large anterolateral myocardial infarction 6 weeks ago. He does not have chest pain, and a postdischarge adenosine stress test with nuclear imaging demonstrated no inducible ischemia. His medications are lisinopril, carvedilol, furosemide, spironolactone, digoxin, and aspirin.

On physical examination, he is afebrile, blood pressure is 130/83 mm Hg, pulse rate is 50/min, and respiration rate is 12/min. He has no jugular venous distension. S₁ and S₂ are soft, and S₃ and S₄ are present. A grade 2/6 holosystolic murmur at the cardiac apex is present. T he lungs are clear. No peripheral edema is noted.

An electrocardiogram shows an episode of nonsustained ventricular tachycardia. Echocardiography shows diminished anterior wall motion with an ejection fraction of 25%. W hich of the following is the most appropriate tre atme nt for this patie nt?

(A) Amiodarone (B) Flecainide (C) Procainamide

(D) Implantable cardioverter-defibrillator (ICD) Ite m 33 [Advanced]

A 67-year-old man presented to the emergency department 2 days ago with an acute ST -elevation myocardial infarction. During the initial evaluation, he became

unresponsive due to ventricular fibrillation. He was successfully resuscitated and taken to the cardiac catheterization lab, where a 100% occlusion of his proximal left anterior descending artery was stented. His postinfarction course was notable for mild heart failure, which has now resolved. He is now stable on aspirin, metoprolol, atorvastatin, clopidogrel, and lisinopril.

On physical examination, blood pressure is 115/72 mm Hg, pulse is 65/min, and respiration rate is 12/min. T here is no jugular venous distention, crackles, murmur, or S₃. T he electrocardiogram shows ST -segment changes consistent with a resolving anterior myocardial infarction but is otherwise unremarkable. T ransthoracic echocardiogram reveals mild hypokinesis of the anterior wall and a left ventricular ejection fraction of 42%.

W hich of the following is the be st manage me nt option at this time ?

(A) Add amiodarone

(B) Continue medical management

(C) Implantable cardioverter-defibrillator placement (D) Pacemaker placement

An 18-year-old woman is evaluated for recurrent syncope. She has experienced four syncopal episodes in her lifetime, all of which occurred during activity. Episodes have no prodrome, and she has had no dizziness. She is healthy and active, without cardiopulmonary complaints, and takes no medications. Her maternal cousin drowned at age 10 years, and her mother has been evaluated for recurrent episodes of loss of consciousness.

On physical examination, blood pressure is 112/65 mm Hg, and pulse is 67/min and regular. T he cardiopulmonary and general physical examinations are normal. An echocardiogram examination is normal. An electrocardiogram is ordered.

W hich of the following e le ctrocardiographic findings is most like ly to provide a diagnosis?