Internal Medicine Board Review Topic: JNC8

Perhaps no topic is as difficult to categorize into the appropriate section of the ABIM Board, NBME Shelf, or USMLE Step exams as is hypertension.

Is elevated blood pressure a topic for General Internal Medicine (we see it more than any other speciality)? Cardiology (where the patients with difficult-to-control hypertension go)? Or is it related to Nephrology (where most of the anti-hypertensive medications act)? Fortunately, agreeing on the perfect location in the syllabus is not for you to worry about. Nor do you need a deep understanding of each previous iteration of the somewhat fickle hypertension guidelines. When it comes to hypertension for the sake of the boards and the wards, all you need to do is master the latest recommendations regarding blood pressure management.

In December 2013, the 8th edition of the Joint National Committee (JNC 8) hypertension guidelines released after multiple delays, leading some critics to dub it “JNC Late.”

Despite their tardiness, the JNC 8 guidelines serve as the gold standard for determining the goal systolic and diastolic blood pressure levels in our patients, taking into account age and comorbid conditions.

• Patients age 60 years or older who do not have diabetes or chronic kidney disease (CKD) should be targeted to have a goal blood pressure of less than 150mmHg systolic and less than 90mmHg diastolic.
• Patients age 18 to 59 years have a goal of less than 140mmHg systolic and less than 90mmHg diastolic.
• Patients of any age with diabetes or CKD also have a goal of less than 140mmHg systolic and less than 90mmHg diastolic.

 One of the best changes of the JNC8 over JNC7 for board exam purposes is the simplification of the goal diastolic blood pressure. All patients, based on age or the presence of diabetes/CKD are managed to a goal of less than 90mmHg.

Much of the focus of the JNC 8 is on the target blood pressure readings. However, it also provides recommendations to promote the safer use of specific anti-hypertensive agents. Preferred medications to be used as first-, second-, and third-line agents include the following four drugs:

• Angiotensin converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARBs)
• Calcium channel blockers (CCBs)
• Thiazide diuretics

With the exception of concurrent ACE inhibitors and ARBs, other combinations of the 4 agents can be administered to titrate to goal blood pressure. Note that missing from the above list are beta blockers, which are no longer considered top candidate medications for hypertensive patients in the absence of comorbidities (patients with prior myocardial infarction or congestive heart failure). 

ACE inhibitors or ARBs are an essential part of hypertensive management in patients up to age 75 with CKD, regardless of ethnic background. Meanwhile, in patients greater than age 75 with CKD there isn’t evidence supporting renin-angiotensin system inhibitor treatment. While ACE inhibitors or ARBs can be used, CCBs and thiazide diuretics are also an option.

Lastly, the ethnicity also plays a role in determining the preferred anti-hypertensive agent. When initiating blood pressure lowering medication in patients of African descent, ACE inhibitors should be avoided in favor of CCBs or thiazides.

One of our Twitter followers asked when the December 2012 guidelines would appear on board exams, partly given their controversy.

Despite an outreach attempt to the folks at ABIM, the response I got was a generic “…We advise test takers to answer all questions according to their current understanding of clinical principles and practice. If ABIM determines that any question has been compromised by new information, that question will not be counted in your overall examination score. This information appears in the instructions at the start of every ABIM examination…”

My recommendation is that given the adoption of these guidelines by large medical organizations such as Kaiser Permanente, you should start to use the updates for both the boards and the wards. Drop a note below giving your take on the JNC 8 guidelines.

“Baby Blues”: What Every Internist Should Know About Postpartum Psychiatric Dx

The postpartum period can be a chaotic time for many women. Right after birth, women experience an abrupt decline in their estrogen and progesterone levels which are known to help regulate mood states. As a result, many new mothers are susceptible to drastic mood changes during this period. Their risk for postpartum psychiatric issues can dramatically increase when dealing with stressful life events, interpersonal problems, an infant with health issues, a prior history of depression, family history of depression, an unplanned pregnancy, and/or poor social support.

Between 50 to 85% of new mothers experience a common and transient state of mood symptoms called the postpartum blues. Women often report mild symptoms of tearfulness, anxiety, irritability, moods swings, and sleep disturbances that usually start 3 days after delivery and spontaneously resolve by the second week. Most women suffering from postpartum blues get better. Validation and reassurance that they’re doing a great job and assistance in childcare during this stressful period can be very helpful.

If postpartum blues symptoms worsen or persist for more than two weeks, your patient may be developing postpartum depression which affects 20% of new mothers. It looks very similar to clinical depression with a depressed mood most of the day, loss of interest in activities, fatigue, high anxiety, poor concentration, poor sleep, and feelings of worthlessness. Some women may express thoughts of death or suicide. They may obsess over the health and well being of their baby despite constant reassurance by others. It can be common to have unwanted, intrusive thoughts and images of harming their infant such as throwing the baby out the window or drowning them. Make sure to check the thyroid level as 10% of postpartum women can develop hypothyroidism (which can lead to depression).

Rarely, new mothers can experience postpartum psychosis which occurs in 1-2 women per 1000 births. It is very rare but considered a serious psychiatric emergency. Women with a history of bipolar disorder or previous history of postpartum psychosis are at a higher risk for this illness. Studies report a recurrence rate as high as 30-50% with each subsequent delivery. Psychotic symptoms often appear within 3 weeks postpartum. Symptoms include mood swings, confusion, agitation, bizarre behavior, paranoia, and poor sleep. Women can have delusional thoughts such as the belief that someone is trying to kill their baby or their breast milk is poisoning the baby and hallucinations such as hearing voices telling them to kill their baby. Postpartum psychosis is important to identify and treat immediately because it can lead to suicide or infanticide if left untreated.

Of note, the diagnoses described above were extrapolated from DSM-IV TR. With the new DSM-V edition, all mood and psychotic symptoms occurring during pregnancy or within the first 4 weeks following delivery are referred to as peripartum mood or psychotic episodes (unless the patient meets full criteria for another diagnosis, e.g. major depressive disorder).

Though it is common for postpartum women to develop depressive symptoms, many of these women are improperly diagnosed and/or treated. Some women convince themselves they are just “stressed” or that their symptoms are “normal for women with babies”. Other women feel guilty for having such negative emotions during a time that is meant to be joyful and therefore are ashamed to seek help. What these mothers don’t realize is that their own mental health can significantly impact their baby’s short- and long-term physical and emotional development. Depressed or psychotic mothers have difficulty bonding with their baby, are less responsive to their baby’s needs, and can be indifferent or upset towards their child.

Treatment usually starts with increasing the mother’s support system and education about depression and/or psychosis. Increasing help around the house and getting adequate sleep and rest can significantly reduce the risk for such symptoms. Psychotherapy can be helpful in different forms- couples therapy for those having martial conflicts, individual therapy to work on personal issues, and group therapy to learn from other mothers dealing with the same problems. If medications are needed, anti-depressants such as Sertraline, Bupropion, Fluoxetine and Velaaxine can be very effective at treating depression. If a patient is suffering from psychotic symptoms, anti-psychotic medications such as Risperidone, Olanzapine or Haloperidol may be used to treat delusions and hallucinations.

When medications are indicated, it is crucial to provide education about the potential risks of breastfeeding as many of these medications can pass into the breast milk. The relative risk for harm or toxicity is low but should still be discussed. Some women may choose to substitute with formula milk during their pharmacologic treatment. Women with postpartum symptoms should continue treatment between 6-12 months and then be reassessed by their psychiatrist to see if treatment is still indicated. If therapy and medications are ineffective or one’s symptoms are severe enough (acute suicidality or psychosis) requiring immediate results, ECT (electroconvulsive therapy) can be a safe and successful option.

It’s important for primary care providers to encourage and empower their new mothers to seek mental health services if there are any signs or risk for postpartum mood or psychotic symptoms. Stigma and poor insight can be major barriers to seeking treatment. But with the help of primary care providers who have established rapport with their patients, we can help bridge the gap between medical and psychiatric care.

Internal Medicine Board Review: Ring-Enhancing and Non-Enhancing Lesions

A favorite of the USMLE Steps, NBME Internal Medicine Shelf, and ABIM Internal Medicine Board Exams seems to be those ring-shaped lesions picked up on imaging studies. Often, the scenario is a ring lesion identified on a CT head scan in an immunocompromised patient (particularly one with HIV or AIDS). These can be challenging because the clinical vignette focuses on the description of the lesion without providing detailed serologies. So let’s use an efficient approach to identifying the most commonly encountered ring lesion etiologies on medical exams.

The first step is to determine whether the lesion presented on the CT scan is ring-enhancing or non-enhancing.

If it is a ring-enhancing lesion, the most commonly seen etiologies are

• Cerebral toxoplasmosis (50%)
• Primary central nervous system (CNS) lymphoma (30%)
• Less commonly, Bacterial or Fungal abscess (e.g. Cryptococcosis, Histoplasmosis, Aspergillosis, Tuberculosis and Trypanosomiasis)

Cerebral Toxoplasmosis is the most common cause of ring-enhancing cerebral lesions. Often, multiple lesions are seen, usually located in the basal ganglia. It is unlikely to be seen in a patient who is already receiving prophylactic trimethoprim-sulfamethoxazole (TMP-SMX). Patients with AIDS and CD4 count less than 100/microL are at increased risk. It’s very important to remember that Toxoplasmosis serologies are non-specific but patients with cerebral toxoplasmosis are seropositive for T. gondii IgG antibody.

Primary CNS Lymphoma is the second most common cause of a ring-enhancing cerebral lesion. Unlike cerebral toxoplasmosis, primary CNS lymphoma may be solitary. Thus, if a solitary lesion is detected, even if toxoplasma serology is positive, CNS lymphoma is the more likely diagnosis than toxoplasmosis. The location of CNS lymphoma is more commonly in the periventricular areas. Lesions greater than 4cm in diameter are more likely to be primary CNS lymphoma rather than cerebral toxoplasmosis. Epstein-Barr virus (EBV) DNA in the cerebrospinal fluid (CSF) is quite specific for primary CNS lymphoma.

And the ring non-enhancing lesions are typically due to…

Progressive Multifocal Leukoencephalopathy (PML), which is attributed to the JC virus. It presents with multiple demyelinating lesions. It predominantly affects the white cerebral matter, in particular the brainstem and the cerebellum. Other patients at risk of developing PML are those receiving natalizumab therapy for relapsing-remitting multiple sclerosis, efalizumab for psoriasis, and brentuximab for Hogkin’s lymphoma.

I hope you find this review helpful in rapidly identifying the cause of each brain-ring lesion you may encounter on the USMLE Steps, NBME Internal Medicine Shelf, and ABIM Internal Medicine Board Exams.

Internal Medicine Board Review: Ring-Enhancing and Non-Enhancing Lesions

A favorite of the USMLE Steps, NBME Internal Medicine Shelf, and ABIM Internal Medicine Board Exams seems to be those ring-shaped lesions picked up on imaging studies. Often, the scenario is a ring lesion identified on a CT head scan in an immunocompromised patient (particularly one with HIV or AIDS). These can be challenging because the clinical vignette focuses on the description of the lesion without providing detailed serologies. So let’s use an efficient approach to identifying the most commonly encountered ring lesion etiologies on medical exams.

The first step is to determine whether the lesion presented on the CT scan is ring-enhancing or non-enhancing.

If it is a ring-enhancing lesion, the most commonly seen etiologies are

• Cerebral toxoplasmosis (50%)
• Primary central nervous system (CNS) lymphoma (30%)
• Less commonly, Bacterial or Fungal abscess (e.g. Cryptococcosis, Histoplasmosis, Aspergillosis, Tuberculosis and Trypanosomiasis)

Cerebral Toxoplasmosis is the most common cause of ring-enhancing cerebral lesions. Often, multiple lesions are seen, usually located in the basal ganglia. It is unlikely to be seen in a patient who is already receiving prophylactic trimethoprim-sulfamethoxazole (TMP-SMX). Patients with AIDS and CD4 count less than 100/microL are at increased risk. It’s very important to remember that Toxoplasmosis serologies are non-specific but patients with cerebral toxoplasmosis are seropositive for T. gondii IgG antibody.

Primary CNS Lymphoma is the second most common cause of a ring-enhancing cerebral lesion. Unlike cerebral toxoplasmosis, primary CNS lymphoma may be solitary. Thus, if a solitary lesion is detected, even if toxoplasma serology is positive, CNS lymphoma is the more likely diagnosis than toxoplasmosis. The location of CNS lymphoma is more commonly in the periventricular areas. Lesions greater than 4cm in diameter are more likely to be primary CNS lymphoma rather than cerebral toxoplasmosis. Epstein-Barr virus (EBV) DNA in the cerebrospinal fluid (CSF) is quite specific for primary CNS lymphoma.

And the ring non-enhancing lesions are typically due to…

Progressive Multifocal Leukoencephalopathy (PML), which is attributed to the JC virus. It presents with multiple demyelinating lesions. It predominantly affects the white cerebral matter, in particular the brainstem and the cerebellum. Other patients at risk of developing PML are those receiving natalizumab therapy for relapsing-remitting multiple sclerosis, efalizumab for psoriasis, and brentuximab for Hogkin’s lymphoma.

I hope you find this review helpful in rapidly identifying the cause of each brain-ring lesion you may encounter on the USMLE Steps, NBME Internal Medicine Shelf, and ABIM Internal Medicine Board Exams.

Medical Mnemonics: Felty Syndrome Components

Medical Mnemonics: Felty Syndrome

Felty syndrome is a rare condition that involves rheumatoid arthritis, decreased white blood cell count, and a swollen spleen. It can develop into a serious and life-threatening infection.

Unfortunately, there is not much known about the condition. The underlying cause is unknown and treatment generally focuses on controlling the underlying RA.

Components of Felty Syndrome can be remembered by the mnemonic: SANTA

• S – Splenomegaly
• A – Anemia
• N – Neutropenia
• T – Thrombocytopenia
• A – Arthritis (Rheumatoid)

Check out the list of the previous Medical Mnemonics here.

Book Review: The John Hopkins Internal Medicine Board Review

The John Hopkins Internal Medicine Board Review

Publication Date: April 25, 2012

Editors: Bimal H. Ashar, Redonda G. Miller, Stephen D. Sisson

Overview:

The John Hopkins Internal Medicine Board Review, 4^th edition book, published by Elsevier, is a review guide for those preparing for the ABIM Internal Medicine Board Exam. The book contains over 600 pages and covers all the major aspects of the Internal Medicine Board Exam.

The book also contains a companion website for additional information.

Breakdown of Book (Chapters):

• Pre-Read: Maximizing Test Performance: Effective Study and Test-Taking Strategies (3 pages)
• Section I: Cardiology (64 pages)
• Section II: Infectious Disease (58 pages)
• Section III: Pulmonary and Critical Care Medicine (56 pages)
• Section IV: Gastroenterology (45 pages)
• Section V: Nephrology (33 pages)
• Section VI: Endocrinology (40 pages)
• Section VII: Rheumatology (33 pages)
• Section VIII: Hematology (38 pages)
• Section IX: Oncology (39 pages)
• Section X: Neurology (24 pages)
• Section XI: Selected Topics in General and Internal Medicine (106 pages)

Price:

• List price: $94.12
• Current Amazon price: $94.12
• eBook (Kindle): $56.97

Amazon average reviews (as of 12/16/2013): 4.2 out of 5

Amazon Best Sellers Rank (as of 12/16/2013): #59,506

Our opinion as a book for Internal Medicine Board Exam Review:

The Cleveland Clinic Intensive Review of Internal Medicine is a fantastic review book for those preparing for the Internal Medicine Boards. The book contains all the major categories you would expect to find on the ABIM Internal Medicine Board Exam. Each section is broken into chapters (75 in total) detailing many of the subcategories found in the ABIM Internal Medicine Exam Blueprint. The book, despite being over 600 pages, is easy to carry around and relatively light weight.

The use of tables and images, many in color, in this book is second-to-none! It’s an often overlooked factor but with the amount of information that needs to be digested for the ABIM exam, a user-friendly book can be an extremely valuable learning tool.

An additional item that we believe can be of value for a lot of people is the online access that is provided with the book. This allows users to search topics within the book and even practice questions online.

This is one of the best review books you can find for the internal medicine boards – a  concise, high-yield review of the topics important for the boards in a user-friendly book.

To see other internal medicine board review books, head over to the Knowmedge Internal Medicine Question Bank Blog.

Book Review: Mayo Clinic Internal Medicine Board Review

Mayo Clinic Internal Medicine Board Review

The Mayo Clinic Internal Medicine Board Review, 10^th edition book, published by Oxford University Press, was developed as a comprehensive review guide specifically for those preparing for the ABIM Internal Medicine Board Exam. Edited by Dr. Amit Ghosh, this approximately 800 page book is used by residents and internists, both as a reference tool and a book for internal medicine board review.

Publication Date: June 27, 2013

Editor: Robert Ficalora MD

Breakdown of Book (Chapters):

• ABIM Exam Overview (8 pages)
• Part I: Cardiology (121 pages)
• Part II: Gastroenterology and Hepatology (63 pages)
• Part III: Pulmonary Diseases (55 pages)
• Part IV: Infectious Disease (107 pages)
• Part V: Rheumatology (50 pages)
• Part VI: Endocrinology (61 pages)
• Part VII: Oncology (19 pages)
• Part VIII: Hematology (41 pages)
• Part IX: Nephrology (39 pages)
• Part X: Allergy (30 pages)
• Part XI: Psychiatry (10 pages)
• Part XII: Neurology (39 pages)
• Part XIII: Dermatology (20 pages)
• Part XIV: Cross-Content Areas (101 pages)

Price:

• List price: $99.99
• Current Amazon price: $89.37
• eBook: Book is currently not available in eBook format

Amazon average reviews (as of 12/16/2013): N/A

Amazon Best Sellers Rank (as of 12/16/2013): #70,188

Our opinion as a book for Internal Medicine Board Exam Review:

The Mayo Clinic Internal Medicine Board Review is a great resource for Medical Students, Residents, and Internists. The information is up-to-date and the editor has done a great job bringing all the pieces together. The book is well-written, thorough and comprehensive for board review. The authors have done an excellent job of ensuring the information is properly cited throughout the book. The use of images and tables in this book is also fantastic! The book is extremely high-yield and we could certainly see someone highlighting much of the book.

After complaints of the size of the previous edition book (~1,000 pages), this book has been redesigned, updated and condensed slightly 801 pages. The biggest reason for the reduction is size is that this book no longer contains questions & answers. The 168-page Mayo Clinic Board Review Questions and Answers book can be purchased separately (currently $40.22 on Amazon). The book is now much more user friendly than the previous version and the long chapters have been broken into smaller sections.

Unfortunately, there are some downsides – including the size and weight (almost 6 lbs!) of the book. While we like how the book is broken up into different sections, it can still be a significant struggle for someone who has difficulty reading a lot of text and retaining information. In addition, while the tables and images are great, they are largely in black and white. Use of vivid imagery would have helped the pictures be more memorable. We believe the book also would have been strengthened with strong summaries or key concept boxes throughout the book. At the end of some chapters is a brief summary, though this could have been expanded to every section. We would also add that there are certain sections of the book that simply don’t seem like they cover enough content (e.g., Oncology is only 20 pages while the ABIM exam blueprint indicates it is ~7% of the exam)

If you are a text reader and can get through this book – we applaud you! If you can retain the information – by all means, this is a wonderful book! However due to its size and small font, we would almost categorize this more as a reference book that can be bought early in residency or post residency as a reference resource. While not as comprehensive asHarrison’s Principles of Internal Medicine, this is still a significant amount of text to digest and effectively retain for the ABIM Internal Medicine Board Exam.

To see other internal medicine board review books, head over to the Knowmedge Internal Medicine Question Bank Blog.