USMLEMD

State Medical Licensure Requirements and Statistics – 2014

dokidok — Sat, 15 Aug 2015 17:14:23 +0000

These are the State Medical Licensure Requirements and Statistics for 2014.

continuing-medical-education-licensure (1)

NEJM Knowledge+ Strategies for Working Through ABIM Board Questions

dokidok — Sat, 31 May 2014 13:28:50 +0000

The complex questions that appear on medical board exams pose challenges for every test taker, even those who are highly experienced. There are up to 70 questions in each 2-hour segment of an ABIM internal medicine exam, so you need to make the most of your time and knowledge. This post will help you sharpen your approach to do just that.

Most medical certification exams, and all ABIM exams, are made up of multiple-choice questions. The majority are case-based scenarios that require reasoning and decision making. Each question has three distinct parts:

The patient vignette or question scenario

The lead-in or the question itself

The answer options, which include one correct answer and several distractors

– See more at: http://knowledgeplus.nejm.org/

Low-Dose Estrogen and Venlafaxine Similarly Effective for Menopausal Symptoms

dokidok — Sat, 31 May 2014 13:26:29 +0000

Low-dose estradiol and venlafaxine are both effective treatments for vasomotor symptoms in menopausal women, a JAMA Internal Medicine study finds.

Some 340 peri- or postmenopausal women with bothersome vasomotor symptoms (hot flashes, night sweats) were randomized to receive low-dose estradiol (0.5 mg/day), low-dose venlafaxine (a serotonin-norepinephrine reuptake inhibitor; 75 mg/day), or placebo daily for 8 weeks.

Symptom frequency was reduced significantly more with estradiol (by 53%) and with venlafaxine (48%) than with placebo (29%). Both active treatments were well tolerated, although estradiol was more often associated with abnormal vaginal bleeding and venlafaxine with blood pressure increases.

The researchers note that “while the efficacy of low-dose estradiol may be slightly superior to that of venlafaxine, the difference is small and of uncertain clinical relevance.” They conclude: “Treatment decisions should weigh the risk profile of each agent for each individual woman, taking into account her risk factor status and personal preferences regarding treatment options.”

See more at: http://www.jwatch.org/fw108875/2014/05/27/low-dose-estrogen-and-venlafaxine-similarly-effective#sthash.6Pz6evr6.dpuf

Low-Dose Estrogen and Venlafaxine Similarly Effective for Menopausal Symptoms — Physician’s First Watch.

AFP Screening in Patients with Hepatitis C

dokidok — Thu, 24 Apr 2014 20:53:16 +0000

Positive predictive value for hepatocellular cancer was low; AFP screening is not recommended.

Recent guidelines recommend against serum α-fetoprotein (AFP) testing to screen for hepatocellular carcinoma (HCC) in patients with chronic hepatitis C (Hepatology 2011; 53:1020). Nevertheless, I still encounter cases in which clinicians have conducted AFP screening. In this study of 855 patients with histologically advanced chronic hepatitis C, researchers measured levels of AFP and two other biomarkers (AFP-L3 and des-γ-carboxy prothrombin [DCP]) every 3 months for 4 years. Patients also underwent yearly screening ultrasound imaging. HCC developed in 46 patients (5% of the cohort).

α-Fetoprotein Screening in Patients with Hepatitis C – NEJM Journal Watch.

Malingering vs Factitious Disorder

dokidok — Thu, 01 Aug 2013 19:59:28 +0000

Malingering → siMulation of Sx for secondary gain (Money, drugs, absents of work,”cold feet” = afraid to get Married). It’s not a disorder.

FAKtitious disorder → FAKing of Sx w/o secondary gain. These patients just want to be sick (they love the sick role and the attentions they got in a hospital). It’s a disorder, as the name shows.

#QOTD 3

dokidok — Tue, 16 Jul 2013 23:34:44 +0000

A 62-year-old woman is evaluated in the stroke unit for a 2-day history of difficulty speaking and right arm weakness. She has a history of hypertension and dyslipidemia and a 35-pack-year smoking history. Medications are lisinopril, atenolol, simvastatin, and aspirin.

On physical examination, blood pressure is 148/78 mm Hg, pulse rate is 84/min and regular, and respiration rate is 12/min. Other general medical examination findings are normal. Neurologic examination shows mild sensory aphasia and right arm drift.

An MRI of the brain shows an acute infarct in the left middle cerebral artery distribution that appears embolic. A magnetic resonance angiogram of the head and neck is normal. An electrocardiogram shows sinus rhythm and is normal. Telemetry performed over the next 3 days shows occasional premature ventricular complexes. A transesophageal echocardiogram shows no intracardiac thrombus, normal left atrial appendage velocities, and a patent foramen ovale with an atrial septal aneurysm. No evidence of deep venous thrombosis is found.

Which of the following is the most appropriate next step in management?

A Percutaneous patent foramen ovale closure

B Prolonged cardiac rhythm monitoring

C Surgical closure of the patent foramen ovale

D Warfarin

Educational Objective

Manage cryptogenic ischemic stroke.

This patient’s condition should be managed with prolonged cardiac rhythm monitoring. She has infarcts that appear embolic on an MRI and no evidence of proximal arterial disease. As such, her stroke is classified as a cryptogenic ischemic stroke. According to data from recent studies, up to 25% of patients with cryptogenic ischemic stroke have paroxysmal atrial fibrillation on prolonged cardiac monitoring. A diagnosis of atrial fibrillation would be the only reason for this patient to start warfarin for stroke prevention. The risk of recurrent stroke in patients with an otherwise isolated patent foramen ovale, with or without an atrial septal aneurysm, is low in most clinical trials.

Percutaneous or surgical closure of a patent foramen ovale has not been shown to reduce the risk of ischemic stroke in patients with an otherwise cryptogenic stroke. Patent foramen ovale, especially in combination with an atrial septal aneurysm, is associated with an increased risk of ischemic stroke in epidemiologic studies, but the optimal medical treatment remains unknown. Preliminary results from the CLOSURE I trial showed no significant difference in the risk of stroke recurrence in patients with cryptogenic stroke randomized to either the percutaneous patent foramen ovale closure arm or the best medical treatment arm.

Warfarin is an inappropriate treatment for this patient at this time, pending results of cardiac rhythm monitoring. No clinical trials, including a substudy of the Warfarin-Aspirin Recurrent Stroke Study (WARSS), have shown the superiority of warfarin compared with aspirin in the prevention of recurrent cryptogenic stroke, even in the presence of a patent foramen ovale.

Bibliography

Tayal AH, Tian M, Kelly KM, et al. Atrial fibrillation detected by mobile cardiac outpatient telemetry in cryptogenic TIA or stroke. Neurology. 2008;71(21):1696-1701. PMID: 18815386

QOTD #2

dokidok — Sat, 13 Jul 2013 21:08:44 +0000

An 82-year-old man is evaluated for recurrent obscure gastrointestinal bleeding. He has experienced four episodes of melena in the past 6 months. Results of a colonoscopy and upper endoscopy 3 months ago were unremarkable. There is no family history of bleeding diathesis. His only medication is iron sulfate for anemia.

On physical examination, vital signs are normal. BMI is 32. There is no abdominal tenderness. Digital rectal examination is normal.

Laboratory studies reveal a hemoglobin level of 10.1 g/dL (101 g/L); platelet count, complete metabolic panel, and INR are normal.

Which of the following is the most appropriate diagnostic test to perform next?

A Intraoperative endoscopy

B Repeat upper endoscopy

C Single-balloon enteroscopy

D Wireless capsule endoscopy

ANSWER:

Answer & Critique(Correct Answer: B)

Key Point

Patients with suspected obscure gastrointestinal bleeding should undergo repeat colonoscopy and/or upper endoscopy (depending on the suspected site of bleeding), as approximately 30% to 50% of lesions can be detected using this approach.

Educational Objective

Evaluate obscure gastrointestinal bleeding.

The next diagnostic step is to repeat the upper endoscopy. The sources of gastrointestinal bleeding may not be readily identified at the time of the initial endoscopy for various reasons. Lesions may bleed intermittently. Volume contraction or a low hemoglobin concentration may alter the appearance of a bleeding source. In a patient with recurrent bleeding, endoscopy and/or colonoscopy should be repeated. Endoscopy also allows for treatment of the lesion if one is found. Approximately 30% to 50% of lesions can be detected on repeat endoscopy. If a repeat study is nondiagnostic, the next step depends upon the severity and suspected location of blood loss.

Wireless capsule endoscopy, single-balloon enteroscopy, and intraoperative endoscopy are reserved for patients in whom repeat endoscopy does not identify a diagnosis. Intraoperative endoscopy is not usually required for diagnosis because wireless capsule endoscopy and double-balloon enteroscopy have improved the ability to diagnose and treat small-bowel sources of bleeding. Nevertheless, intraoperative endoscopy may be required for ongoing life-threatening bleeding without an identified source. Push single-balloon enteroscopy consists of direct insertion of an endoscope longer than the standard upper endoscope. Push enteroscopy is most often performed for the evaluation of lesions detected on capsule endoscopy that are within the reach of the enteroscope. In wireless capsule endoscopy, a patient swallows a video capsule that passes through the stomach and into the small intestine. The video capsule transmits images to a recording device worn by the patient. The images are downloaded onto a computer where they can be reviewed. Capsule endoscopy has been shown to detect sources of bleeding in 50% to 75% of patients and is considered the test of choice to follow standard endoscopy in patients with obscure bleeding.

Question of the Day #1

dokidok — Wed, 10 Jul 2013 17:08:59 +0000

A 32-year-old man is evaluated for significant blood glucose elevations associated with exercise. The patient has a 22-year history of type 1 diabetes mellitus. He reports that after a recent 6 AM five-mile run, his blood glucose level was 386 mg/dL (21.4 mmol/L); the level was 297 mg/dL (16.5 mmol/L) just before the run and 215 mg/dL (11.9 mmol/L) at bedtime the night before. He took no insulin and ate no food in the morning before his run. During the run, he felt slow and fatigued but was significantly better after drinking water and giving himself insulin. The patient had one episode of diabetic ketoacidosis 15 years ago. Medications are insulin detemir, 16 units/d in the morning, and insulin lispro, 4 to 6 units before each meal, depending on his preprandial blood glucose level and expected carbohydrate intake. Physical examination findings, including vital signs, are normal.

Which of the following is the most likely cause of his postexercise hyperglycemia?

A Excess nocturnal carbohydrate intake

B Gastroparesis

C Inadequate insulin replacement

D Nocturnal hypoglycemia

Source: MKSAP 16

ANSWER

Key Point

Hypoinsulinemia causes increased hepatic glucose output and decreased peripheral glucose uptake, which results in a higher blood glucose level and, ultimately, a higher hemoglobin A_1c value; prolonged exercise, which further stimulates hepatic glucose release, exacerbates this condition.

Educational Objective

Diagnose postexercise hyperglycemia.

This patient’s significantly increased blood glucose level after running most likely results from baseline hypoinsulinemia exacerbated by the physiologic changes associated with prolonged exercise, such as stimulation of hepatic glucose release. A patient who has had type 1 diabetes mellitus for more than 20 years, including one episode of diabetic ketoacidosis, will be completely insulin deficient. Although long-acting, the treatment effect of insulin detemir does not always last a full 24 hours. The fact that his blood glucose level was 215 mg/dL (11.9 mmol/L) at bedtime the night before his run and was even higher the next morning before exercise suggests that he had low levels of insulin present in his system during the night and before starting his run. This hypoinsulinemia most likely triggered increased hepatic gluconeogenesis. In the absence of sufficient plasma insulin, the glucose could not be absorbed by the muscles and other tissues, and his blood glucose level continued to increase. Appropriate treatment is to adjust his insulin regimen to ensure adequate insulin replacement before running to minimize the expected physiologic changes associated with exercise.

Excess carbohydrate intake in the evening would likely contribute to his noted elevated bedtime and pre-exercise blood glucose levels but would not independently account for the significant rise in his blood glucose level after exercise.

Although this patient may have some degree of gastroparesis given the duration of his diabetes, this disorder is an unlikely explanation for an increased blood glucose level 12 hours or more since he last ate.

Early morning blood glucose elevations may occur in response to the nocturnal hypoglycemia associated with diabetes therapy. Although this patient had an elevated morning blood glucose level before running, his bedtime measurement also was elevated, and he took no additional insulin beyond his single dose of long-acting insulin the morning before. Therefore, nocturnal hypoglycemia is unlikely to be the cause of this patient’s exercise-associated hypoglycemia.

Bibliography

Temple MY, Bar-Or O, Riddell MC. The reliability and repeatability of the blood glucose response to prolonged exercise in adolescent boys with IDDM. Diabetes Care. 1995;18(3):326-332. PMID: 7555475

Tricky MKSAP quesiton

dokidok — Wed, 03 Jul 2013 22:08:13 +0000

A 72-year-old man is evaluated in the emergency department for a severe headache, nausea, vomiting, and change in consciousness of 1 hour’s duration that developed after he fell earlier today. He has atrial fibrillation for which he takes warfarin and metoprolol.

On physical examination, temperature is normal, blood pressure is 160/90 mm Hg, pulse rate is 50/min, and respiration rate is 26/min. The patient is obtunded but responds to verbal commands and is able to follow simple instructions and swallow. No focal neurologic findings are present.

The INR is 12.

A CT scan of the head shows a subdural hematoma with a mass effect.

Which of the following is the most appropriate treatment?

A Fresh frozen plasma

B Intravenous vitamin K

C Intravenous vitamin K and prothrombin complex concentrate

D Oral vitamin K

E No additional treatment

Please choose the answer and respond in the comments.

Powerpoint image bank – Servier

dokidok — Mon, 01 Jul 2013 21:04:09 +0000

Servier Medical Art provides you with thousands of professionally designed medical elements. These high-quality vector images are classified thematically into Powerpoint files, from which they can be copied individually and used in combination in order to make your own Powerpoint presentations.

Powerpoint image bank | Servier.