USMLE Step 2 Audio Crash Course

USMLE II Complete Test Prep and Review for the United States Medical Licensure Examination Step 2 (USMLE II)

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Table of Contents Preface.......................................................................................................................................... 12 Chapter 1: Internal Medicine .................................................................................................... 15 Cardiovascular Disease ............................................................................................................. 15 Chronic Lung Disease ............................................................................................................... 16 Acute and Chronic Renal Failure.............................................................................................. 19 AKI or Acute Kidney Injury ..................................................................................................... 19 Chronic Renal Insufficiency ..................................................................................................... 20 Chronic Neurological Diseases ................................................................................................. 21 Dementia ................................................................................................................................... 21 Parkinson’s Disease .................................................................................................................. 23 Type 2 Diabetes ........................................................................................................................ 24 Chronic GI Diseases ................................................................................................................. 25 Gastroesophageal Reflux Disease or GERD............................................................................. 25 Inflammatory Bowel Diseases .................................................................................................. 27 Key Takeaways ......................................................................................................................... 28 Quiz ........................................................................................................................................... 28 Chapter 2: Preventive Medicine ................................................................................................ 35 Scope of Preventive Medicine .................................................................................................. 35 Childhood Preventive Care ....................................................................................................... 36 Adult Preventive Care ............................................................................................................... 38 Preventive Methods and Screening........................................................................................... 40 Key Takeaways ......................................................................................................................... 42 Quiz ........................................................................................................................................... 42 Chapter 3: Dermatology ............................................................................................................. 48 Benign Skin Lesions ................................................................................................................. 48 Skin Cancers ............................................................................................................................. 53 Bullous Diseases of the Skin..................................................................................................... 59 Acne and Rosacea ..................................................................................................................... 62 Papulosquamous Diseases ........................................................................................................ 64 Eczematous Diseases ................................................................................................................ 68 Granulomatous Diseases ........................................................................................................... 70 Key Takeaways ......................................................................................................................... 72 Quiz ........................................................................................................................................... 72

Chapter 4: Surgery ..................................................................................................................... 78 Orthopedic surgery.................................................................................................................... 78 Open Fracture Care ................................................................................................................... 78 Joint Replacement ..................................................................................................................... 80 Total Hip Replacement ............................................................................................................. 80 Total Knee Replacement ........................................................................................................... 82 Shoulder Joint Replacement ..................................................................................................... 83 Ligament Repair........................................................................................................................ 83 Neurosurgery............................................................................................................................. 84 Neurosurgical Emergency Surgery ........................................................................................... 84 Hydrocephalus Surgery............................................................................................................. 84 Epilepsy Surgery ....................................................................................................................... 84 Brain Tumor Surgery ................................................................................................................ 85 Aneurysms and AVM Repair.................................................................................................... 85 Abdominal surgery.................................................................................................................... 86 Appendectomy .......................................................................................................................... 86 Cholecystectomy ....................................................................................................................... 86 Bowel resection......................................................................................................................... 87 Laparoscopic Surgery ............................................................................................................... 88 Chest surgery ............................................................................................................................ 88 Lung Surgery ............................................................................................................................ 88 Coronary Artery Bypass Surgery .............................................................................................. 89 Valvular Heart Surgery ............................................................................................................. 89 Gynecological surgery .............................................................................................................. 90 Hysterectomy ............................................................................................................................ 90 Cesarean Section ....................................................................................................................... 91 Cosmetic surgery ...................................................................................................................... 92 Key Takeaways ......................................................................................................................... 92 Quiz ........................................................................................................................................... 93 Chapter 5: Sports Medicine ....................................................................................................... 98 Exercise Recommendations ...................................................................................................... 98 Osteoarthritis Exercises ............................................................................................................ 99 Exercises for Depression......................................................................................................... 100 Exercise for Peripheral Arterial Disease ................................................................................. 101

Exercise in Diabetes Mellitus ................................................................................................. 101 Common Sports Injuries ......................................................................................................... 101 Concussions ............................................................................................................................ 103 Anabolic Steroid Use .............................................................................................................. 105 Key Takeaways ....................................................................................................................... 105 Quiz ......................................................................................................................................... 106 Chapter 6: Ear, Nose, and Throat ........................................................................................... 112 Common Ear Problems ........................................................................................................... 112 Sinus Disorders ....................................................................................................................... 113 Nasal Disorders ....................................................................................................................... 116 Pharyngitis .............................................................................................................................. 118 Laryngitis ................................................................................................................................ 119 Head and Neck Cancers .......................................................................................................... 120 Key Takeaways ....................................................................................................................... 122 Quiz ......................................................................................................................................... 122 Chapter 7: Pediatrics ................................................................................................................ 128 The Acutely Ill Child .............................................................................................................. 128 Respiratory Disorders in Children .......................................................................................... 130 Gastrointestinal Diseases in Children ..................................................................................... 132 Congenital Heart Diseases ...................................................................................................... 134 Blood Diseases in Children..................................................................................................... 136 Children’s Cancers .................................................................................................................. 139 Neuromuscular Diseases in Children ...................................................................................... 141 Behavioral and Psychiatric Disorders in Children .................................................................. 144 Children and Depression ......................................................................................................... 144 ADHD in Childhood ............................................................................................................... 145 Anxiety in Childhood.............................................................................................................. 145 Autism ..................................................................................................................................... 146 Conduct Disorder .................................................................................................................... 146 Key Takeaways ....................................................................................................................... 147 Quiz ......................................................................................................................................... 147 Chapter 8: Obstetrics ............................................................................................................... 154 Pre-Pregnancy Care ................................................................................................................ 154 First Prenatal Visit .................................................................................................................. 155

Prenatal Care ........................................................................................................................... 156 Labor and Delivery ................................................................................................................. 158 Postpartum Care ...................................................................................................................... 161 Key Takeaways ....................................................................................................................... 162 Quiz ......................................................................................................................................... 162 Chapter 9: Gynecology ............................................................................................................. 169 Sexually Transmitted Infections ............................................................................................. 169 Abnormal Uterine Bleeding .................................................................................................... 172 Endometriosis ......................................................................................................................... 173 Polycystic Ovarian Syndrome................................................................................................. 174 Gynecological Oncology ........................................................................................................ 175 Menopause .............................................................................................................................. 177 Key Takeaways ....................................................................................................................... 178 Quiz ......................................................................................................................................... 178 Chapter 10: Radiology .............................................................................................................. 185 Plain Radiography................................................................................................................... 185 Fluoroscopy............................................................................................................................. 185 Ultrasonography...................................................................................................................... 186 MRI scan ................................................................................................................................. 190 PET Scan................................................................................................................................. 190 SPECT Scan ............................................................................................................................ 191 Interventional Radiology ........................................................................................................ 191 Radiation Therapy................................................................................................................... 192 Key Takeaways ....................................................................................................................... 193 Quiz ......................................................................................................................................... 193 Chapter 11: Ophthalmology .................................................................................................... 200 Cataracts ................................................................................................................................. 200 Retinal Disease........................................................................................................................ 202 Glaucoma ................................................................................................................................ 205 Uveitis ..................................................................................................................................... 213 Refractive Errors ..................................................................................................................... 214 Eye trauma .............................................................................................................................. 214 Key Takeaways ....................................................................................................................... 215 Chapter 12: Psychiatry ............................................................................................................. 222

Amnestic Disorders................................................................................................................. 222 Psychotic Disorders ................................................................................................................ 223 Mood Disorders ...................................................................................................................... 225 Anxiety Disorders ................................................................................................................... 226 Somatoform Disorders ............................................................................................................ 228 Dissociative Disorders ............................................................................................................ 229 Personality Disorders .............................................................................................................. 231 Substance Use Disorders......................................................................................................... 232 Key Takeaways ....................................................................................................................... 234 Quiz ......................................................................................................................................... 234 Chapter 13: Emergency Medicine ........................................................................................... 241 Fever and Sepsis ..................................................................................................................... 241 Cardiac Resuscitation.............................................................................................................. 243 Chest Pain ............................................................................................................................... 245 Acute Abdomen ...................................................................................................................... 247 Head Trauma........................................................................................................................... 248 Chest and Abdominal Trauma ................................................................................................ 251 Key Takeaways ....................................................................................................................... 253 Quiz ......................................................................................................................................... 253 Chapter 14: Ethics .................................................................................................................... 260 Doctor-Patient Relationship .................................................................................................... 260 Patient Confidentiality ............................................................................................................ 262 Conflict of Interest .................................................................................................................. 263 Reproductive Ethics ................................................................................................................ 265 Human Testing in Research .................................................................................................... 268 Euthanasia ............................................................................................................................... 269 Key Takeaways ....................................................................................................................... 270 Quiz ......................................................................................................................................... 271 Chapter 15: Biostatistics and Epidemiology........................................................................... 277 Epidemics and Pandemics....................................................................................................... 277 Types of Research Studies ...................................................................................................... 279 Sensitivity and Specificity ...................................................................................................... 281 Mean, Median, and Mode ....................................................................................................... 282 Prevalence and Incidence........................................................................................................ 283

Quiz ......................................................................................................................................... 284 Chapter 16: Cardiology ............................................................................................................ 290 Cardiac Assessment Tools ...................................................................................................... 290 Congestive Heart Failure ........................................................................................................ 291 Symptoms of CHF .................................................................................................................. 292 Acute Myocardial Infarction ................................................................................................... 293 Arrhythmia .............................................................................................................................. 297 Cardiomyopathy...................................................................................................................... 302 Key Takeaways ....................................................................................................................... 303 Quiz ......................................................................................................................................... 303 Chapter 17: Gastroenterology ................................................................................................. 310 Acute Abdominal Pain Evaluation.......................................................................................... 310 Constipation and Diarrhea ...................................................................................................... 311 Diarrhea................................................................................................................................... 312 Esophageal Disorders.............................................................................................................. 313 Gastric Disorders .................................................................................................................... 314 Peptic Ulcer............................................................................................................................. 314 Gallbladder Disease ................................................................................................................ 317 Inflammatory Bowel Disease.................................................................................................. 319 Irritable Bowel Syndrome ....................................................................................................... 319 Colon Disorders ...................................................................................................................... 320 Diverticular Disease ................................................................................................................ 320 Liver Disorders ....................................................................................................................... 321 Celiac Disease ......................................................................................................................... 322 Motility disorders of the Esophagus and Stomach ................................................................. 322 Key Takeaways ....................................................................................................................... 323 Quiz ......................................................................................................................................... 323 Chapter 18: Hematology .......................................................................................................... 330 Erythropoiesis and Red Blood Cells ....................................................................................... 330 Hemoglobin Structure and Function ....................................................................................... 331 Anemias .................................................................................................................................. 331 Polycythemia........................................................................................................................... 332 Leukocytes .............................................................................................................................. 333 Leukopenia.............................................................................................................................. 334

Leukocytosis ........................................................................................................................... 334 Platelets ................................................................................................................................... 335 Thrombocytosis....................................................................................................................... 336 Thrombophilia......................................................................................................................... 336 Coagulation Disorders ............................................................................................................ 337 Bone Marrow Failure .............................................................................................................. 337 Key Takeaways ....................................................................................................................... 339 Quiz ......................................................................................................................................... 339 Chapter 19: Oncology ............................................................................................................... 345 Cancer Etiologies .................................................................................................................... 345 Skin Cancer ............................................................................................................................. 346 Head and Neck Cancers .......................................................................................................... 347 Brain Cancers .......................................................................................................................... 347 Breast Cancer .......................................................................................................................... 348 Lung Cancer ............................................................................................................................ 349 Esophageal Cancer .................................................................................................................. 350 Gastric Cancer......................................................................................................................... 350 Colorectal Cancer.................................................................................................................... 351 Hepatocellular Cancer............................................................................................................. 351 Prostate Cancer ....................................................................................................................... 352 Testicular Cancer .................................................................................................................... 352 Ovarian Cancer ....................................................................................................................... 353 Endometrial Cancer ................................................................................................................ 353 Cervical Cancer....................................................................................................................... 354 Renal Cancer ........................................................................................................................... 354 Blood and Lymph Cancers...................................................................................................... 354 Key Takeaways ....................................................................................................................... 355 Quiz ......................................................................................................................................... 355 Chapter 20: Nephrology ........................................................................................................... 362 Basic Anatomy and Physiology of the Kidneys ..................................................................... 362 Acute Pyelonephritis ............................................................................................................... 362 Renal Tubular Acidosis........................................................................................................... 363 Interstitial Kidney Disease ...................................................................................................... 364 Diabetic Nephropathy ............................................................................................................. 366

Acute Glomerulonephritis....................................................................................................... 367 Nephrolithiasis ........................................................................................................................ 369 Acute Kidney Injury ............................................................................................................... 371 Chronic Renal Failure ............................................................................................................. 372 Dialysis ................................................................................................................................... 374 Key Takeaways ....................................................................................................................... 374 Quiz ......................................................................................................................................... 375 Chapter 21: Pulmonology......................................................................................................... 382 Acid Base Disorder ................................................................................................................. 382 Signs and Symptoms of Acid-Base Disorders ........................................................................ 383 Anion Gap Calculation ........................................................................................................... 383 Respiratory Failure.................................................................................................................. 383 Acute Respiratory Distress Syndrome .................................................................................... 385 Bacterial Pneumonia ............................................................................................................... 386 Typical Bacterial Pathogens ................................................................................................... 387 Treatment of Bacterial Pneumonia ......................................................................................... 387 Specific Types of Pneumonia ................................................................................................. 387 Viral Pneumonia ..................................................................................................................... 388 Prognosis in Pneumonia.......................................................................................................... 389 Chronic Obstructive Pulmonary Disease (COPD) and Chronic Bronchitis ........................... 390 Asthma .................................................................................................................................... 391 Cystic Fibrosis ........................................................................................................................ 393 Pneumoconiosis and Asbestosis ............................................................................................. 393 Mechanical Ventilation ........................................................................................................... 394 Key Takeaways ....................................................................................................................... 395 Quiz ......................................................................................................................................... 395 Summary .................................................................................................................................... 402 Course Questions and Answers .............................................................................................. 404

Preface This USMLE step II Course is designed to provide information regarding clinical subjects that are tested as part of the USMLE II examination. This includes the study and practice of internal medicine, preventative care, obstetrics, gynecology, ophthalmology, psychiatry, dermatology, sports medicine, pediatrics, emergency medicine, and radiology. Each topic is designed to cover the common clinical diseases associated with these medical specialties, including their treatment. Medical students are expected to understand the causes of disease, risk factors, and treatment. The more theoretical topics of ethics, biostatistics, and epidemiology will also be discussed as part of this course.

The focus of chapter one is internal medicine, which is a broad subject involving the care of adult patients with problems related to the heart, lungs, kidneys, brain, endocrine system, and gastrointestinal tract. While there are hundreds of possible illnesses an adult can have, the internist will deal primarily with common diseases affecting adult patient in an internal medicine clinic.

Chapter two discusses preventive medicine. Preventive medicine involves evaluations, screening tests, and recommendations that are intended to decrease the incidence of a disease before it occurs, identify disease in high risk patients, and decrease the complication rates of disease the patient may already have. The use of preventive medicine applies to patients of all ages.

Chapter three in the course involves the various dermatological conditions that an internist deals with on a regular basis. The skin is the largest organ of the body with hundreds of possible disorders and manifestations of disease elsewhere in the body. The main focus of this chapter includes benign skin lesions, skin cancers, acne, and less common skin-related conditions.

Chapter four in the course discusses various types of surgeries and surgical techniques seen in a variety of surgical fields. While many surgeons are general surgeons, some surgical specialties focus on certain areas of surgery, such as orthopedic surgery, neurosurgery, and gynecological surgery. This chapter will cover some of the most common surgical techniques utilized in the surgical realm.

The focus of chapter five in the course is sports medicine. The provider involved in sports medicine will deal with healthy or “normal” patients that seek assistance to lose weight or become more fit. They will also deal with common sports-related injuries, in particular, musculoskeletal injuries, mild traumatic brain injuries, and major injuries. The use of anabolic steroids is covered in this chapter as this is a common problem in among competitive athletes.

Chapter six covers common ENT (Ear, Nose, and Throat) conditions. These types of disorders are common in any emergency department and general practice clinic. Providers need to understand the most common diseases of the head and neck including acute diseases and infections, as well as chronic ENT problems. Head and neck cancers are usually managed by the ENT specialist but can be diagnosed by any provider of older adults, so these are included as part of the discussion.

The topic of chapter seven is pediatrics and the different pediatric conditions that might be seen by the primary care physician. Many children do not have access to pediatricians and are seen by the general practitioner for most of their medical needs. Caring for children involves caring for their acute and chronic conditions so this will be the focus of this chapter.

Chapter eight involves the topic of obstetrics. While pregnancy care can be given by an obstetrician, it is often a part of healthcare that is provided by the general or family practitioner. Care of the pregnant woman begins before she becomes pregnant and continues with the prenatal visit. The women will have several prenatal visits during the pregnancy. Labor and delivery ends with either a vaginal delivery or a cesarean section in some cases. Prenatal care and birth are o discussed in this chapter.

Gynecology is the topic of chapter nine in the course. It involves the care and management of diseases that affect women of all ages with regard to their pelvic structures. Women can be affected with sexually transmitted infections, abnormal uterine bleeding (AUB), polycystic ovarian syndrome, and endometriosis. Gynecological cancers and menopause are also covered in this chapter.

The topics of chapter ten is radiology. Radiology includes the basic x-ray, which is the basis of everyday radiology. There are many other types of radiological tests and procedures besides the basic x-ray.

Patients can undergo ultrasounds, CT scans, MRI scans, PET scans, and SPECT scans, which are specialized radiologic tests. Radiologists may also perform interventional procedures and radiotherapy.

Each of these topics are discussed in this chapter.

Chapter eleven involves the subject of ophthalmology. While the eye is a small organ, it is crucial to every patient’s life, with a variety of illnesses and disorders that can affect it. The chapter will talk about the many common diseases affecting the eye, including glaucoma and cataracts, retinal diseases, uveitis, refractive errors, and eye trauma. An ophthalmologist treats many of these diseases, but they should also be identified and managed, to a limited degree, by the general practitioner or emergency room specialist.

The topics covered in chapter twelve is psychiatric disorders. Psychiatric disorders are extremely common and can affect people of all ages. There are several broad categories of psychiatric disorders that are covered in this chapter. They include things like mood disorders, psychoses, anxiety disorders, amnestic disorders, dissociative disorders, somatoform disorders, and personality disorders. Substance use disorders are considered psychiatric and included as part of the discussion of psychiatry in this chapter.

Chapter thirteen discusses common problems seen in emergency medicine. Emergency medicine physicians will see patients with fever, sometimes caused by Bacteremia or even septic shock. Other problems seen in the emergency department include chest pain, acute coronary syndrome, respiratory arrest, and cardiac arrest. Abdominal pain and the acute abdomen are seen in emergency medicine as well as trauma. Major traumatic diseases seen include head trauma, chest trauma, and abdominal trauma. These are discussed in this chapter as part of common issues seen in emergency medicine.

Medical ethics is the topic of chapter fourteen. There are many issues involved in medical ethics, including the doctor-patient relationship, conflicts of interest in medical practice, and patient confidentiality. Areas of medicine surrounded in ethical issues are those involved in reproductive medication and the care of the dying patient. The ethics of euthanasia in the dying patient are discussed as part of this chapter. Issues around human testing are also covered as these are important ethical issues in medical research.

Biostatistics and epidemiology are related topics that are the focus of discussion in the fifteenth chapter of the course. Much of epidemiology relates to research, although it is important to know the

epidemiology of various diseases in clinical practice. Many topics of biostatistics are purely related to research; however, in clinical practice, statistical issues like the mean, median, mode, and prevalence versus incidence of diseases are important to understand in clinical practice. For these reasons, they are covered in this chapter.

The sixteenth chapter of this course will be a comprehensive discussion of cardiology. Congenital heart diseases will be discussed as part of this chapter as well as the major types of heart-related diseases, including heart failure, acute myocardial infarction, valvular diseases, and cardiomyopathies that can affect the heart.

The seventeenth chapter of the course primarily covers the topic of gastroenterology. This starts with disorders of the pharynx and esophagus, including cancers of these tissues. Diseases of the stomach, liver, gallbladder, small intestine, and colon will be discussed as part of this chapter. Nutritional diseases like gluten insensitivity and malabsorption disorders will also be covered in this chapter.

The eighteenth chapter of this course will involve a comprehensive discussion of hematology. This includes disorders of the red blood cells, including anemia and polycythemia. There are diseases that affect the white blood cells, which will be covered in this chapter as well as diseases affecting platelets, such as thrombocytopenia and thrombocytosis. Disorders of the bone marrow and hematological cancers will also be discussed as part of this chapter.

The nineteenth chapter discusses oncology. This will include coverage of the major etiologies behind cancer and overviews of all of the major cancer types seen in adults and children, some of which have hereditary components, while others are considered purely acquired cancers.

The twentieth chapter of the course will be a discussion of the diseases of the kidneys. The basic structure and function of the kidneys will be covered along with the diseases of the glomeruli, the tubules, and the collecting system of the kidneys. Genetic and acquired kidney disorders will be discussed in this chapter.

The twenty-first chapter of this course is a comprehensive discussion of pulmonology and diseases of the lungs. The major acquired disorders of the lung will be covered, including chronic obstructive pulmonary disease, chronic bronchitis, and acute pneumonia. The different cancers of the lung are also discussed as part of this chapter.

Chapter 1: Internal Medicine The focus of this chapter is internal medicine, which is a broad subject including the care of adult patients with problems related to the heart, lungs, kidneys, brain, endocrine system, and gastrointestinal tract. While there are hundreds of possible illnesses an adult can have, an internist will primarily treat common diseases affecting adult patients presenting to an internal medicine clinic.

Cardiovascular Disease The vast majority of cardiovascular diseases in adults stems from atherosclerosis or atherosclerotic cardiovascular disease (ASCVD), which is a buildup of plaque material in the main vessels. The areas of the body most affected by this problem include locations with minimal collateral circulation, such as the heart, kidneys, brain (resulting in stroke), and the peripheral vessels (particularly the lower extremities).

These diseases are mainly asymptomatic until the individual reaches middle age and beyond.

The main risk factors for atherosclerosis include obesity, male gender, advanced age, dyslipidemia, smoking, diabetes, family history, and hypertension. In some cases, a poor diet (high in trans fats) can cause atherosclerosis. The actual plaque is made from calcium, cholesterol, and proteins in the bloodstream. The plaque builds up, resulting in a narrowing of crucial blood vessels. The physical examination, Doppler flow ultrasounds, electrocardiogram, stress testing, and angiography are all common ways to diagnose ASCVD. The related terms arteriosclerosis and arteriolosclerosis involve “hardening of the arteries” and “hardening of the arterioles”, respectively. Anything that leads to hardening of the arteries and atherosclerosis is called “atherogenic”.

The signs and symptoms of atherosclerosis do not show up for several decades as the body can survive with decreased blood flow to a degree. The symptoms develop when the narrowing of the artery is very severe or when there is a plaque rupture that leads to thrombosis in the affected artery. The first signs of ASCVD is usually a stroke or heart attack. Other symptoms depend on which organ is being affected by poor circulation.

The usual time of onset of symptoms is the 50s or 60s, although the disease begins in childhood. Men are more commonly affected when compared to women; however, except when it comes to the cerebral arteries, which affects men and women equally. Typical symptoms of ASCVD include dyspnea or chest pain on exertion, arrhythmias, and light-headedness (when the coronary arteries are affected).

When the cerebral (mainly carotid) arteries are affected, the typical symptoms involve blurry vision, hemiparesis, loss of consciousness, dizziness, speech abnormalities, and focal numbness.

When the peripheral arteries are involved, the main thing seen is coolness of the extremities, leg pain with walking, ulcerations of the legs, and decreased peripheral pulses. Numbness of the legs may be present with severe disease. Plaques can also affect the kidneys, leading to kidney failure and hypertension, particularly in the late stages. The disease leads to sudden cardiac death or heart attack in about half of all females and in about two-thirds of all males.

After formation, plaques are detectable as vessel narrowing as indicated with angiography. This and related techniques only detect severe disease. However, the rupture of the plaque and arterial occlusion from thrombosis can occur within seconds or minutes with less than severe cases of atherosclerosis. Ruptured plaques are known as complicated plaques because the extracellular matrix that separates the lesion from the lining of the arterial wall is disrupted and blood flow is impaired by debris or by thrombus formation. The obstructed artery is what causes the symptoms of heart attack or stroke.

Serious disease is not indicated by a certain degree of stenosis but by having an unstable or vulnerable plaque with any degree of stenosis but is vulnerable to occlusion. Things like carotid intimal media thickness measurement (by ultrasound), calcium scoring of the coronary arteries by CT scanning, and lab tests, such as a homocysteine level, hs-CRP level, lipid levels, and Hgb A1c levels will detect disease before angiography can show a significant lesion. Certain imaging that are not commonly used (such as the PET scan and the SPECT scan) can detect the severity of plaque formation.

The main preventative measures in ASCVD is the avoidance of modifiable risk factors (such as smoking, obesity, and poor dietary habits). Exercise improves circulation and will decrease the patient’s chances of obesity. Statins will lower cholesterol levels and antihypertensives will decrease blood pressure.

Aspirin taken daily will prevent blood clots that lead to arterial occlusion. Surgical or interventional strategies are used as prevention of complications when drugs and lifestyle modifications do not control the atherosclerosis.

Treatments of ASCVD are not as effective as preventative measures. Combined approaches are more effective than singular treatments. Treatments include anticoagulation measures, anti-diabetic drugs, statin drugs, and antihypertensive drugs. Behavioral methods include increasing fruits and vegetables in the diet. Dairy product reduction has no effect. Serious cases require bypass or cardiovascular intervention procedures.

Chronic Lung Disease Chronic lung diseases are primarily secondary to smoking, although there are other causes of these diseases. The most common classification of chronic lung disease is COPD or chronic obstructive pulmonary disease, of which there are two types: chronic bronchitis and emphysema. These are terms used for different manifestations of this disease state and have slightly different symptoms. In chronic bronchitis, a productive cough must be present for two years and for at least three months each year.

Tobacco smoke combined with things like air pollutions, occupational exposures, and genetics to create the disease state. Poor ventilation and cooking fires contribute to COPD in the developing part of the world. While lung testing (spirometry) is the gold standard for testing for COPD, it can mimic asthma but doesn’t improve when beta-agonists are given.

About 2.4 percent of people throughout the world have COPD, primarily in patients who are older than 40 years and who smoke. More than 90 percent of deaths come from people in developing countries, where there is limited access to treatment. The incidence is increasing in developing countries because of higher smoking rates and increased longevity.

There are several characteristic symptoms associated with COPD including dyspnea, productive cough, and sputum production. They are present for a long period of time and have exacerbations. The cough is the first symptom to develop. There is usually sputum production but it can be dry. The patient also has an increase in respiratory infections. Dyspnea starts with exertion and progresses to dyspnea at rest, often with pursed lips breathing. There is prolonged outflow breathing and chest tightness, which is less common. Barrel-chestedness and clubbing can be signs of the disease, but these are less common. Cor pulmonale is the end stage of the disease. This involves hypertension of the arteries of the lungs, associated with leg edema, ascites, and distention of neck veins.

Figure 1 shows hyperinflation of the lungs consistent with COPD:

Figure 1

Because of shared risk factors, there can be other diseases linked to COPD, including type 2 diabetes, hypertension, coronary artery disease, lung cancer, anxiety disorder, depression, osteoporosis, and sexual disorders. Severely affected patients will have fingernail clubbing and chronic disease.

Exacerbations are common and involve increased sputum (that becomes yellow or green), increased cough, and increased dyspnea. The patient may have cyanosis, tachypnea, diaphoresis, and tachycardia.

The major risk factor for COPD is tobacco smoke. About 20 percent of smokers will develop COPD with half of lifelong smokers at risk for the disease. About 80-95 percent of patients with COPD have been or

are already smokers. The longer one smokes, the greater is their chances of COPD. Women have a more severe reaction to cigarette smoke and have an increase in secondhand smoke as a cause of the disease. Besides cigarettes, other smoking can cause COPD, including pipes, cigars, and marijuana.

Women who smoke in pregnancy can confer a risk of COPD to the child.

Air pollution causing COPD is usually indoor pollution, such as cooking fires indoors (which is the case 80 percent of the time in places like sub-Saharan Africa, China, and India). Urban air pollution plays a much smaller role in the disease process. Certain occupational exposures will lead to COPD, including cotton textile industrial exposure, gold mining, and coal mining, as well as agricultural exposure and exposure to welding. Exposure to silica and fiberglass dust can cause COPD. Genetics play a small role in COPD. People born with alpha-1-antitrypsin disease or AAT (an autosomal recessive disease) have an increased risk of emphysema. This disease accounts for 1-5 percent of cases of COPD and occurs in about 0.4 percent of people. Other genetic factors are likely present but have not yet been identified. Poverty increases the risk of COPD and having other diseases, like HIV/AIDS and tuberculosis, will increase the risk.

Exacerbations are caused by infections, lack of medications, or exposure to pollutants. Infections are the primary cause of COPD exacerbations (causing 50-75 percent of cases). Environmental pollutants, smoking, and secondhand smoke are less likely to cause exacerbation. Cold outdoor temperatures account of a small percentage of exacerbations. Severely affected patients will have up to 4 exacerbations per year, mostly in the winter months. A pulmonary embolism can also cause an exacerbation.

COPD should be considered in anyone of middle age or older who has the symptoms of the disease.

Several tests can be done that include spirometry (the gold standard of testing), chest x-ray, and CT of the chest. Spirometry involves forcefully blowing into a tube, obtaining the FEV1 (forced expiratory volume in 1 second) as well as the forced vital capacity (FVC) and FEV (force expiratory volume). Patients with COPD will have a prolonged FEV1. A bronchodilator should be used to look for reversibility. The patient with COPD will have an FEV1/FVC ratio that is less than 70 percent. The FEV1 will be less than 80 percent of predicted. Peak flow measurements do not diagnose the patient with COPD. GOLD grading of COPD includes mild disease (GOLD 1), with an FEV1/FVC of less than 80 percent and leads to GOLD 4 (very severe disease), with an FEV1/FVC of less than 30 percent. There is a British questionnaire for COPD, called the COPD assessment test (CAT), that can determine disease severity.

Things like muscle weakness and weight loss will also determine the severity of the disease. ABGs can also determine disease severity.

The differential diagnosis of COPD includes things like a pneumothorax, asthma, pneumonia, pulmonary artery disease, and heart failure. The main difference between COPD and asthma is that beta-agonists improve spirometry readings with asthma, which is not the case for COPD. Chronic bronchitis without spirometry changes is not suggestive of COPD. When treating COPD, the patient should have a pneumococcal vaccination and an annual influenza vaccination. Smoking cessation is the most important treatment for COPD. It is the only known way of decreasing disease progression. There are many ways to stop smoking, including nicotine replacement methods, varenicline (Chantix), or bupropion. Decreasing exposure to occupational dusts or fumes will

decrease the progression of the disorder. Using respirators on the job will be helpful. Reducing exposure to indoor cooking smoke will help the disease.

COPD has no cure and is generally not reversible, even with treatment. The only two things that reduce mortality in COPD is supplemental oxygen and smoking cessation. Patients should also have annual flu shots, pneumococcal vaccination, morphine for shortness of breath, and medication inhalers such as anticholinergics and beta agonists. Both short-term and long-term drugs can be used. Exercise will, in general, improve lung function. Those patients who are malnourished can increase calories and nutritional benefits. Corticosteroids tend to decrease the frequency of exacerbations but don’t affect overall mortality. Erythromycins can be used long-term to decrease bacterial infection rates.

Theophylline and caffeine are not recommended. Mucolytics can help in chronic bronchitis; however, cough medicines will not help.

Surgical options include lung transplantation and lung volume-reduction surgery. Lung transplant will help in cases of patients who have stopped smoking. Lung volume reduction surgery will decrease the amount of air in the lungs that goes to dead spaces.

COPD exacerbations are treated by increasing the dosages of short-acting bronchodilator medications.

A nebulizer or metered-dose-inhaler is recommended. Oxygenation is also recommended although COPD patients often have hypoxia as their drive to breathe (O2 levels) and will stop breathing if oxygen is given in high doses. A short course of corticosteroids can be helpful as will antibiotics to treat possible infection. Drugs of choice for infection include doxycycline, amoxicillin, and azithromycin (fluoroquinolones are contraindicated secondary to side effects). Those with hypercarbia can be manage with positive pressure ventilation (non-invasive). Home care is recommended for those who don’t have acidosis (from acute respiratory failure). Those with respiratory acidosis are at risk for respiratory failure and require hospital admission.

Acute and Chronic Renal Failure Renal failure or end-stage kidney disease is a condition where the kidneys don’t function. The practitioner may be dealing with acute or chronic renal failure. Complications of acute disease include hyperkalemia, volume overload, confusion, or elevated BUN.

AKI or Acute Kidney Injury Acute renal injury is a rapid decline in renal function with obvious oliguria (less than 400 milliliters per day) along with imbalances of electrolytes, such as hyperkalemia. It can result from a variety of causes, which can be prerenal, intrinsic, or postrenal. Temporary dialysis may be necessary to bridge the gap necessary for managing the renal function until the cause can be managed. Chronic disease, on the other hand, develops slowly and exhibits few obvious symptoms. Patients may have acute renal failure in the presence of preexisting chronic renal failure. This can be difficult to diagnose and should be based on prior (baseline) bloodwork.

The symptoms of acute disease are based on azotemia (elevated BUN), which can lead to uremia (the pathological manifestations of severe azotemia). The major signs of uremia include hematuria, weight loss, vomiting, diarrhea, nausea, increased/decreased urination, muscle cramps, and itching.

Hyperkalemia can lead to paralysis of the muscles and arrhythmias. Fluid buildup can cause obvious edema.

Crush syndrome to the muscles can cause myoglobulin in the urine. Prolonged ischemia with reperfusion can lead to muscle breakdown products, such as phosphorus, potassium, and myoglobulin to enter the bloodstream (this is called rhabdomyolysis). The metabolites of myoglobulin injure the kidneys for reasons that aren’t clear.

In some cases of acute kidney injury or AKI, there is hypotension (for a variety of reasons, such as blood loss or other causes of low blood pressure) that contributes to the renal injury. Drug overdoses or excesses of drugs like antibiotics or chemotherapy drugs can cause acute damage to the kidneys. Bypass surgery to the heart may cause hypotension and acute renal injury. This is a possibly temporary problem that is reversible when the acute insult is reversed.

Chronic Renal Insufficiency Patients with chronic renal failure may have hypertension, anemia, and heart disease as complications.

The disease may be asymptomatic with the most common symptoms being secondary to anemia (fatigue, shortness of breath, dizziness, weakness, poor memory, and poor concentration).

The main causes of acute renal failure are different from chronic renal failure and include urinary tract obstruction, hypovolemia, myoglobin in the blood, hemolytic uremic syndrome, and medications. On the other hand, diabetes, nephrotic syndrome, hypertension, and polycystic kidney disease are common causes of chronic renal insufficiency.

The most common cause of CKD (chronic kidney disease) is diabetes mellitus. Other causes are uncontrolled hypertension and polycystic kidney disease. Overuse of acetaminophen and ibuprofen can cause chronic kidney disease as well. Certain viruses (hantavirus) can result in chronic renal insufficiency. People of African descent can have CKD from the APOL1 gene in the absence of other causes. HIV disease can cause nephropathy and CKD. There are five stages of CKD that depend on the glomerular filtration rate. Stage 1 disease is mild, while stages 2-3 will require increased monitoring and a reduction in the use of nephrotoxic drugs. Stages 4 and 5 diseases are more serious with stage 5 disease resulting in kidney dialysis or renal transplant as they cannot maintain an adequate excretion of toxins.

Figure 2 describes the five stages of chronic kidney disease:

Figure 2

The diagnosis of these kidney diseases is different depending on the disease type. Acute renal insufficiency is diagnosed by the presence of oliguria and decreased serum creatinine levels. The diagnosis of chronic disease is based on having decreased glomerular filtration rate (less than 15).

Stage 1 disease has a normal or high GFR (GFR > 90 mL/min); Stage 2 disease (Mild CKD) has a slight reduction in GFR (GFR = 60-89 mL/min); Stage 3A disease is called moderate CKD (GFR = 45-59 mL/min); Stage 3B disease is called moderate CKD (GFR = 30-44 mL/min);Stage 4 disease is called severe CKD (GFR = 15-29 mL/min); Stage 5 disease requires dialysis and is called end stage CKD (GFR <15 mL/min).

The treatment of acute renal insufficiency is cause-dependent. Chronic disease is treated with kidney transplant, peritoneal dialysis, or hemodialysis. The dietary treatment of chronic renal disease is a low protein diet (in type 1 diabetes) and a whole food, plant-based diet in other causes of CKD. High protein from whatever source is detrimental to kidney disease. Patients with kidney disease must avoid nephrotoxic drugs and things like contrast dye. The incidence of acute renal failure is about 0.3 percent per year, with the prevalence of about 0.1 percent.

Chronic Neurological Diseases Most acute neurological diseases are treated by neurologist, while chronic neurological diseases are often seen by primary care medical specialists, like internists and family medicine doctors. The two most common chronic brain diseases seen by primary care doctors are dementia and Parkinson’s disease.

Dementia Dementia can be caused by several kinds of disorders, each of which is long-term and results in a gradual decline in the patient’s ability to remember things, think clearly, and function in their daily tasks.

Emotional problems are common and patients have a decreased level of motivation. Eventually language is affected (but not consciousness, which is one of the main differentiating factors to delirium).

In most countries, the most common etiology of dementia is Alzheimer’s disease (causing 50-70 percent of dementia cases), followed by vascular dementia (in 25 percent of cases), and Lewy body dementia (15 percent of cases). Less common causes of dementia are syphilis, Parkinson’s disease, normal pressure hydrocephalus, frontotemporal dementia, and Creutzfeldt-Jacob disease. Rare causes of dementia are genetic in nature.

Memory loss is the symptom most commonly seen in the beginning of dementia. The secondary symptoms commonly seen include deficits in memory, language, visual-spatial functioning, problemsolving ability, and attention. The disease of dementia (as a whole) is progressive and does not progress very quickly so that many patients aren’t identified until the disease has progressed for a long time.

About ten percent of patients will have more than one underlying etiology for their disease (with mixed symptoms). Other things often seen in dementia include tremor, dysphagia, dysarthria or other speech problems, balance problems, confusion, restlessness, visual disorders, and psychological issues, such as agitation, anxiety, depression, irritability, delusional thinking, difficulty sleeping, appetite changes, apathy, and abnormal motor function. Psychosis may develop in severe cases.

There are four reversible causes of dementia including vitamin B12 deficiency, neurosyphilis, Lyme disease, and hypothyroidism. If dementia is suspected and it is not clearly an Alzheimer’s dementia, these other causes should be ruled out.

Alzheimer’s disease is the major cause of dementia. There is initial findings of short-term memory loss and word-finding problems. There are difficulties such as lack of judgment, reasoning, and insight, and problems of frequently getting lost. These people repeat themselves often and will have problems with complex tasks. The hippocampus is the part of the brain affected first and most severely.

Vascular dementia is the second most common cause of dementia that isn’t reversible. The symptoms vary as they are caused by mini-strokes that collectively affect brain function. The patient will have step-wise changes in mental functioning. There will be CT or MRI changes that show vascular strokes in different areas of the brain. Risk factors include tobacco use, diabetes, hyperlipidemia, atrial fibrillation, and hypertension. Other vascular diseases like heart disease may be present.

Patients with Lewy body dementia have Parkinsonian symptoms and hallucinations that are usually visual and occur around the time of sleep. Other symptoms include problems with visuospatial functioning, problem-solving difficulties, disorganization, and attention difficulties. It can be diagnosed clinically or after a PET scan or SPECT scan of the brain, showing typical hypoperfusion of the occipital lobe.

Frontotemporal dementia is seen as a drastic change in the personality and language functioning. They have social dysfunction early in the disease as well as poor insight. Memory difficulties are not a major factor in this type of dementia. There are three kinds of frontotemporal dementia, which include a behavioral type (called behavioral-variant disease), temporal variant disease (losing the meaning of words and having difficulty naming things), and progressive non-fluent aphasia type, which affects the person’s speech muscles and ability to say words.

Early stage Alzheimer’s dementia is called mild cognitive impairment. Patients can stay at this stage or progress to more advanced symptoms of dementia. The patients may have just memory problems but will have a normal mental status examination. Those that progress to advanced dementia will have

“early stage dementia” with mild impairment of the mental status examination. They may have difficulty functioning in complex daily activities. There may be social withdrawal and personality changes that are most noticeable to people near them.

Moderate dementia involves progression of the disease. Patients may have severe impairment in activities of daily living, particularly complex ones and will have noticeable problems with the mental status examination. They can’t function outside a limited environment and cannot be left alone.

Patients with late stage disease require 24-hour assistance and have difficulty with things like dressing, eating, and sleeping. They have frequent wandering behaviors and are at a risk of falling. Bladder and bowel dysfunction are common.

The major diagnostic testing in dementia include having a consistent history and physical examination, abnormal cognitive testing, and possible abnormalities in brain imaging. Screening is not recommended; however, patients with symptoms can be evaluated with the above diagnostic testing.

Dementia has no cure. For Alzheimer’s disease, patients can be treated with cholinesterase inhibitors (like donepezil and galantamine). Both donepezil and memantine are used in all stages of Alzheimer’s disease (AD). Rivastigmine is used in all stages of AD and galantamine is reserved for mild to moderate disease. Memantine is a N-methyl-D-aspartate (NMDA) blocker rather than a cholinesterase inhibitor.

Non-drug treatments include behavioral interventions and things like proper diet and exercise can improve the state of the disease. Antipsychotics are commonly used for behaviors but aren’t actually recommended as they increase the risk of death.

The lifetime incidence of dementia is about ten percent, increasing with age. About half of people older than 85 years will have dementia. About 1.7 million people die from dementia every year, with an increased incidence because of an increase in the number of elderly people in the world. It is perhaps the most common mental disability in the aged population.

Parkinson’s Disease Parkinson’s disease or PD is a progressive neurodegenerative disorder of the CNS affecting primarily the motor system. The main motor symptoms include rigidity of the muscles (cogwheel rigidity), tremor, difficulty ambulating, postural instability, and slow movements (bradykinesia). It can affect both behavior and thinking, thus dementia is part of the advanced stages of the disease. Patients will have sleep difficulties, social and emotional problems, and some sensory difficulties. The collection of symptoms is referred to as “parkinsonism”.

Other symptoms of PD unrelated to movement include daytime tiredness that can progress to narcolepsy, REM sleep disturbances, orthostatic hypotension, excessive sweating, gastric dysmotility, constipation, urinary incontinence, perceptive disturbances, and paresthesias.

The cause of PD is not known but is believed to be partially genetic and partially environmental. People with a positive family history of PD have an increased incidence of the disease. Exposure to pesticides and history of head injury increase the risk (as is seen in boxers and other athletes). The major part of the brain affected is the substantia nigra (part of the midbrain) resulting in a lack of necessary dopamine and a buildup of Lewy bodies inside the neurons.

Unlike Alzheimer’s disease, which involves a buildup of tau proteins in the brain, people with Parkinson’s disease have a buildup of alpha-synuclein in the brain. The dementia doesn’t develop until the patient is severely affected and memory is not always the first sign of the dementia. PD is more closely linked to Lewy body dementia, which has a similar buildup of alpha-synuclein in the brain.

The patient may have a history and physical that is suggestive of the disease. Imaging will rule out other causes of the problem but will not rule in Parkinson’s disease, except for an MRI, which may or may not show abnormalities in the substantia nigra. Substantia nigra Lewy bodies are seen at autopsy but cannot be used to diagnose the disease in life. Parkinsonism unrelated to true PD is less helped with antiParkinson’s drugs. There are both autosomal dominant and autosomal recessive patterns of Parkinson’s disease.

There is no known cure for PD; however, there are many treatments. The main treatment is exogenous L-dopa and other dopamine agonists (used secondary to L-dopa). The medications gradually lose effectiveness over time so that involuntary movements are prevalent. Severe cases are treated with deep brain stimulation.

The disease affects males more than females and tends to affect people older than sixty years of age.

The life expectancy of the patient with PD is about 7-14 years after initial diagnosis. The most common form of parkinsonian symptoms is PD, which is completely idiopathic. Other causes include strokes, multiple head trauma, infections, metabolic disease, and drug toxicity. Atypical parkinsonism is evident in diseases that are related to PD but have other symptoms, such as progressive supranuclear palsy, Lewy body dementia, cortico-basilar degeneration, and multiple system atrophy.

When giving L-dopa or levodopa for PD, the treatment is always given with a dopa decarboxylase inhibitor and sometimes with a catechol-O-methyl transferase (COMT) inhibitor. MAO-B inhibitors can be used as well as dopamine agonist drugs (if L-dopa fails to work). L-dopa is the most effective treatment but there are side effects related to its use and it does not work forever. L-dopa is used instead of dopamine because dopamine doesn’t cross the blood-brain barrier. Carbidopa and benserazide are dopa carboxylase inhibitors that “deactivate” levodopa outside of the brain.

COMT Inhibitors like tolcapone will block the enzyme that degrades dopamine and is used as a complement to L-dopa. Several dopamine agonists can be used that will help patients to delay the onset of disease including apomorphine, cabergoline, piribedil, ropinirole, pramipexole, pergolide, and bromocriptine. MAO-B inhibitors include selegiline, safinamide, and rasagiline. These block MAO-B (an enzyme that breaks down dopamine).

Type 2 Diabetes Type 2 diabetes is the most common endocrine disorder in humans, resulting in insulin resistance, high blood pressure, and later, a lack of insulin. Typical symptoms include increased frequency of urination, weight loss that cannot be explained, and increased thirst/hunger. Patients have open sores that don’t heal after an injury and fatigue. The symptoms of diabetes happen only when it is severe. Some patients will have itching, peripheral neuropathy, blurry vision, and recurrent fungal infections. Fatigue is a common symptom, although most patients are not symptomatic at the time of their diagnosis.

Long term complications include renal failure, retinopathy, hypertension, and heart disease. Poor blood flow can lead to amputations late in life. While diabetic ketoacidosis tends not to occur, patients can have hyperosmolar hyperglycemic coma if the blood sugar is remarkably high. Type 2 diabetes is a chronic disease that has numerous long-term complications. The main complication is ischemic heart disease, followed by stroke, amputations, kidney failure, blindness, and vascular dementia.

The main causes of type 2 diabetes (which accounts for 90 percent of all diabetics) is obesity, genetics, and lack of exercise. It is not an autoimmune disease as is the case with type 1 diabetes. It is preventable by exercising, eating properly, and maintaining a healthy weight. It can be treated with a variety of medications (particularly metformin) along with bariatric surgery to attain a better weight in obese individuals. Type 2 diabetes is mostly polygenetic with a high twin concordance rate. There are rare monogenetic causes of type 2 diabetes, including maturity onset diabetes of the young, RabsonMendenhall syndrome, and Donohue syndrome.

There are three main ways to diagnose type 2 diabetes. The first is a 2-hour glucose tolerance test, which involves drinking a glucose solution and having blood sugars checked afterward. Any elevation above 200 mg/dL after drinking the glucose solution will indicate diabetes. A fasting blood sugar of 126 mg/dL or more indicates diabetes, and a Hemoglobin A1c of at least 6.5 indicates diabetes. There are no mass screening recommendations for type 2 diabetes, although it should be considered in people with risk factors, including family history.

Chronic GI Diseases There are multiple chronic diseases affecting adults that affect the gastrointestinal system. Some of the more common diseases are gastroesophageal reflux disease, functional bowel disorders (like irritable bowel syndrome), and inflammatory bowel diseases. Some of these are discussed in this section.

Gastroesophageal Reflux Disease or GERD GERD is primarily known as acid reflux. It is a chronic condition involving the reflux of stomach contents up into the esophagus, mainly after meals. Typical symptoms include acid in the back of the mouth, chest pain, heart burn, vomiting, wheezing, and enamel erosion of the teeth. The main complications include an esophageal stricture, esophagitis, and Barrett’s esophagus. The major risk factors for the disease include pregnancy, obesity, hiatal hernia, smoking, Zollinger-Ellison syndrome, hypercalcemia, scleroderma (which causes esophageal dysmotility), and taking of antidepressants, sleeping medications, calcium channel blockers, and antihistamines. The main problem with GERD is the failure of the proper closure of the lower esophageal sphincter at the base of the esophagus.

Figure 3 depicts the changes seen with Barrett’s esophagus:

Figure 3

GERD has the potential to injure the esophagus. Besides the obvious symptoms, the different injuries to the esophagus include reflux esophagitis (inflammation), esophageal strictures (narrowing of the esophagus), and Barrett’s esophagus (precancerous changes at the base of the esophagus). Esophageal cancer may develop after a lifetime of severe GERD. About 20 percent of patients will have Barrett’s esophagus.

GERD can be diagnosed with clinical symptoms alone or can come from a barium swallow study. Upper GI endoscopy might help diagnose GERD. Esophageal pH monitoring is recommended for people with no improvement after taking proton pump inhibitors. The least likely diagnostic test helpful in GERD is esophageal manometry which is recommended only after surgery. H. pylori testing is not recommended as it does not affect the outcome, even when treated. A trial of PPI (proton pump inhibitors) can be diagnostic.

The treatment of GERD can be lifestyle factors, drugs, and surgery. Lifestyle factors include weight loss, avoiding fatty and acidic foods, and not lying down after meals. Smoking cessation can help. Proton pump inhibitors like omeprazole are the treatment of choice, although antacids and histamine-2 blockers can be effective. The surgical treatment most often used is the laparoscopic Nissen fundoplication, which forms a wrap around the LES (lower esophageal sphincter). A newer procedure called the LINX has been approved, which involves placing a metal band around the LES to tighten up the sphincter. The LINX has similar outcomes to the Nissen procedure.

Inflammatory Bowel Diseases Inflammatory bowel diseases involve a variety of inflammatory disorders of the small and large intestines. Ulcerative colitis involves an inflammation of the colon only, while Crohn’s disease involves inflammation of any part of the GI tract (from the mouth to the anus).

The signs and symptoms of Crohn’s disease include steatorrhea and loose stools, fevers, weight loss, and various kinds of fistulas. In ulcerative colitis (UC) there is bloody, mucus-filled stools, tenesmus, fever (in severe cases), and an increased risk for colon cancer. The biggest complication for UC is colon cancer; however, anemia is a common complication.

Figure 4 shows the difference between ulcerative colitis and Crohn’s disease:

Figure 4

Crohn’s disease, if present in the colon, is mainly on the right side of the colon with common involvement of the terminal ileum. UC involves primarily left-sided colonic involvement. The rectum is almost always involved in UC but not anal involvement. There is a higher rate of primary sclerosing cholangitis with UC but not in Crohn’s disease. There are no skip lesions in UC and snake-like ulcerations on endoscopy with Crohn’s disease that aren’t seen in UC. The disease depth is deep with Crohn’s disease but superficial in UC. Stenosis is seen with Crohn’s disease but not with UC. Crypt disease/granuloma formation is seen only with Crohn’s disease.

IBD is associated with certain genetic factors that aren’t completely clear and various environmental factors. Some feel it is an autoimmune disease; however, the autoimmune nature of the disease is not yet known. The diseases are diagnosed with colonoscopy and biopsies of the terminal ileum and colon.

The treatments vary according to the type of IBD. In Crohn’s disease, the treatments include antibiotics and possible surgery to remove lesions, fistulas, and abscesses. The treatment of UC includes a colectomy (at some point) and mesalazine. The surgery is curative for UC but is not curative for Crohn’s disease as other lesions can always develop.

Immunosuppression can help in both Crohn’s disease and UC, including azathioprine, 6-mercaptopurine, methotrexate, TNF inhibitors, and prednisone. First line treatment involves prednisone, with other immunosuppressive drugs that are useful when treating stable disease that has been managed with initial prednisone use.

Key Takeaways •

Internal medicine plays emphasis on treating chronic diseases.

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Acute diseases cared for in internal medicine are usually exacerbations of preexisting chronic diseases.

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The most common cardiorespiratory diseases include atherosclerotic blood vessel diseases and chronic obstructive lung disease.

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Diabetes mellitus type 2 is the most common endocrine disease.

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Common neurological diseases treated by internists include dementia and Parkinson’s disease.

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GI diseases commonly seen in internal medicine include GERD and inflammatory bowel disease.

Quiz 1. What body area is least likely to be affected by atherosclerotic cardiovascular disease? a. Lungs b. Heart c. Brain d. Kidneys

e. Lower extremities Answer: a. The lungs are generally unaffected by atherosclerotic cardiovascular disease; however, the other body areas are affected by atherosclerosis.

2. What is not considered a risk factor for atherosclerosis? a. Hypertension b. Type 2 diabetes c. Obesity d. Smoking e. Alcohol consumption Answer: e. Each of these is a risk factor for atherosclerosis except for alcohol consumption, which is not a risk factor for the disease.

3. Which would not be a symptom of cerebral arterial involvement in atherosclerosis? (list all that apply) a. Leg pain b. Hemiparesis c. Speech deficits d. Cold extremities e. Focal numbness Answer: a. d. The findings of leg pain and cold extremities would be likely seen in peripheral arterial atherosclerosis rather than cerebral atherosclerosis.

4. How long do the symptoms of chronic bronchitis need to be present to confirm the diagnosis? a. Three months b. Six months c. One year d. Two years e. Five years Answer: d. The symptoms of chronic bronchitis must be present for a minimum of two years before it can be diagnosed.

5. What is the initial symptom you can expect to see in patients who have COPD? a. Dyspnea on exertion

b. Dyspnea at rest c. Cough d. Clubbing of fingers e. Wheezing Answer: c. The cough is the most common first symptom of COPD, occurring in most patients before other symptoms develop.

6. What is the end result of severe COPD? a. Cor pulmonale b. Asthma c. Lung cancer d. Cyanosis e. Acute MI Answer: a. The final result in end-stage COPD is cor pulmonale, which involves pulmonary vasculature hypertension.

7. In evaluating the patient with COPD using spirometry, what will the FEV1/FVC be in terms of percentage? a. 50 percent b. 60 percent c. 70 percent d. 80 percent e. 90 percent Answer: c. The FEV1/FVC will be less than 70 percent when doing spirometry on these patients.

8. What of the following will decrease the rate of mortality in patients with COPD? (list all that apply) a. Supplemental oxygen b. Smoking cessation c. Long-term corticosteroids d. Long-term beta agonists e. Pulmonary exercises

Answer: a. b. The only two interventions that will decrease the mortality rate in patients with COPD include smoking cessation and supplemental oxygen.

9. A COPD patient has hypercarbia and respiratory acidosis from an exacerbation. What treatment is least recommended for this? a. Antibiotic therapy b. Steroids c. High dose oxygen d. Positive pressure ventilation e. Short-acting beta-agonist nebulizer Answer: c. High dose oxygen is not recommended as it can decrease the patient with COPD’s drive to breathe.

10. What is considered the most common cause of chronic kidney disease? a. Polycystic ovarian syndrome b. Hypertension c. Diabetes mellitus d. NSAID use e. Anemia Answer: c. The most common cause of CKD is diabetes mellitus.

11. At what GFR does the patient with chronic kidney disease first need dialysis? a. 50 b. 35 c. 25 d. 15 e. 5 Answer: d. At a GFR of fifteen or less, the patient has end-stage renal disease and begins to need dialysis.

12. The most common cause of dementia is Alzheimer’s disease. What is the second most common type of dementia? a. Creutzfeldt-Jakob disease b. Vascular dementia

c. Syphilis d. Frontotemporal dementia e. Lewy Body dementia Answer: b. About 25 percent of dementia cases are from vascular dementia, making this the second most common cause of dementia.

13. Which part of the brain is the first and most deeply affected part seen in Alzheimer’s dementia? a. Hippocampus b. Thalamus c. Hypothalamus d. Parietal lobe e. Temporal lobe Answer: a. The hippocampus is the first and most deeply affected part of the brain in Alzheimer’s disease and is involved in the production and sustenance of memory.

14. What is not considered a risk factor for having vascular dementia? a. Hypertension b. Tobacco use c. Renal insufficiency d. Diabetes e. Atrial fibrillation Answer: c. Each of these is a risk factor for vascular dementia except for renal insufficiency, which is not a major risk factor for the disorder.

15. What symptoms would not likely be seen in “parkinsonism”? a. Rigidity of the muscles b. Spasticity and hyperreflexia c. Tremor d. Difficulty ambulating e. Slow movements Answer: b. Each of these are present with parkinsonism except for spasticity and hyperreflexia.

16. Which of the following indicates type 2 diabetes? (list all that apply) a. Postprandial glucose of 185 mg/dL

b. Post-glucose solution testing of 220 mg/dL c. Hgb A1c of 5.7 d. Hgb A1c of 6.8 e. Fasting blood sugar of 115 mg/dL Answer: b. d. Diabetes mellitus can be diagnosed in several ways, including a fasting blood sugar, Hgb A1c, and post-glucose solution testing (2-hour GTT).

17. Which drug is not associated with the development of GERD symptoms? a. Antidepressants b. Sleeping medications c. Metformin d. Calcium channel blockers e. Antihistamines Answer: c. Each of these is associated with GERD except for metformin.

18. What is the least helpful diagnostic test when evaluating GERD symptoms? a. Upper GI endoscopy b. Esophageal pH monitoring c. Barium swallow d. Trial of PPIs e. Esophageal manometry Answer: e. Esophageal manometry does not diagnose GERD but is recommended in cases where surgery is indicated for GERD. 19. What is not considered a finding in ulcerative colitis? a. The presence of skip lesions b. Superficial mucosal ulcerations c. Bloody diarrhea d. Rectal involvement e. Increased risk of colon cancer Answer: a. Each of these is seen in UC except for the presence of skip lesions, which is present with Crohn’s disease.

20. What part of the intestinal tract is likely involved in Crohn’s disease but not in UC?

a. Rectum b. Descending colon c. Transverse colon d. Ascending colon e. Terminal ileum Answer: e. The terminal ileum is affected by Crohn’s disease but is not ulcerative colitis.