FIRSTAID
INTERNAL
MEDICINE
BOARDS
Second Edition
TAO LE, MD, MHS
Assistant Clinical Professor of Medicine and Pediatrics
Chief, Section of Allergy and Immunology
Department of Medicine
University of Louisville
Louisville, Kentucky
PETER CHIN-HONG, MD
Assistant Professor, Division of Infectious Diseases
Department of Medicine
University of California at San Francisco
San Francisco, California
THOMAS E. BAUDENDISTEL, MD, FACP
Associate Director, Internal Medicine Residency
Department of Medicine
California Pacific Medical Center
San Francisco, California
New York / Chicago / San Francisco / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / San Juan / Seoul / Singapore / Sydney / Toronto
FOR
THE
®
Copyright © 2008 by Tao Le. All rights reserved. Manufactured in the United States of America. Except as permitted under the United States Copyright Act of 1976,
no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permis-
sion of the publisher.
0-07-164320-6

DEDICATION
To the contributors to this and future editions, who took time to share their
knowledge, insight, and humor for the benefit of residents and clinicians.
and
To our families, friends, and loved ones, who endured and assisted in the
task of assembling this guide.
Copyright © 2008 by Tao Le. Click here for terms of use.
This page intentionally left blank
v
Authors vii
Preface ix
Acknowledgments xi
How to Contribute xiii
Introduction to the ABIM xv
Chapter 1 Allergy and Immunology 1
Raffi Tachdjian, MD, MPH
Marc Riedl, MD, MS
Chapter 2 Ambulatory Medicine 23
Deborah Lindes, MD
Cindy J. Lai, MD
Chapter 3 Cardiovascular Disease 83
Ankush Goel, MD
Sanjiv Shah, MD
Chapter 4 Critical Care 149
Elliott Dasenbrook, MD
Christian A. Merlo, MD, MPH
Chapter 5 Dermatology 161
Tara Miller, MD
Siegrid S. Yu, MD
Chapter 6 Endocrinology 203

Demian Rose, MD, PhD
Amin N. Azzam, MD, MA
Chapter 16 Pulmonary Medicine 599
Elliott Dasenbrook, MD
Christian A. Merlo, MD, MPH
Chapter 17 Rheumatology 629
Mary E. Margaretten, MD
Jonathan Graf, MD
Chapter 18 Women’s Health 665
Deborah Lindes, MD
Linda Shiue, MD
Color insert
715-734
Appendix: Abbreviations and Symbols 689
Index 697
About the Authors 714
DIANA M. ANTONIUCCI, MD
Assistant Professor, Division of Endocrinology and Metabolism
Department of Medicine
University of California, San Francisco
AMIN N. AZZAM, MD, MA
Assistant Professor
Department of Psychiatry
University of California, San Francisco
SCOTT W. BIGGINS, MD, MAS
Assistant Professor, Division of Gastroenterology
Department of Medicine
University of California, San Francisco
THOMAS CHEN, MD, PhD
Staff Physician

Assistant Professor, Division of Nephrology
Department of Medicine
University of California, San Francisco
MARC RIEDL, MD, MS
Assistant Professor, Division of Clinical Immunology and Allergy
Department of Medicine
University of California, Los Angeles
JONATHAN E. ROSENBERG, MD
Assistant Professor, Division of Hematology and Oncology
Department of Medicine
University of California, San Francisco
SANJIV SHAH, MD
Assistant Professor, Division of Cardiology
Department of Medicine
Northwestern University
LINDA SHIUE, MD
Physician, Palo Alto Medical Foundation
Assistant Professor
Department of Medicine
University of California, San Francisco
ROBERT L. TROWBRIDGE, MD
Assistant Professor
University of Vermont College of Medicine
Maine Hospitalist Service
Maine Medical Center
SIEGRID S. YU, MD
Assistant Professor
Department of Dermatology
University of California, San Francisco
SENIOR REVIEWERS

How Is the ABIM Test Structured?
As of August 2006, the ABIM exam is a one-day computer-based test (CBT).
The exam is divided into four two-hour sections with 60 questions in each
section, for a total of 240 questions. Images (blood smears, x-rays, ECGs, pa-
tient photos) are embedded in certain questions. During the time allotted for
each block, examinees can answer test questions in any order as well as review
responses and change answers. However, examinees cannot go back and
change answers from previous blocks. The CBT format (see Figure 1) allows
you to make your own notes on each question using a pop-up box, and it also
permits you to click a box to designate which questions you might wish to re-
view before the end of the session (time permitting).
Please check the ABIM Web site to check for Web demos, updates, and de-
tails about the new format, as well as to identify testing centers nearest to you.
What Types of Questions Are Asked?
All questions are single-best-answer types only. You will be presented with a
scenario and a question followed by four to six options. Virtually all questions
on the ABIM are vignette based. A substantial amount of extraneous informa-
Register early to avoid an
extra $400 late fee.
The majority of your patients
will be aware of your
certification status.
INTRODUCTION
xvii
tion may be given, or a clinical scenario may be followed by a question that
could be answered without actually requiring that you read the case. Some
questions require interpretation of photomicrographs, radiology studies, pho-
tographs of physical findings, and the like. It is your job to determine which
information is superfluous and which is pertinent to the case at hand.
Question content is based on a content “blueprint” developed by the ABIM

TABLE 1.
ABIM Certification Blueprint
PRIMARY CONTENT AREAS RELATIVE PROPORTIONS
Cardiovascular Disease 14%
Gastroenterology 9%
Pulmonary Disease 10%
Infectious Disease 9%
Rheumatology/Orthopedics 8%
Endocrinology/Metabolism 8%
Oncology 7%
Hematology 6%
Nephrology/Urology 6%
Allergy/Immunology 3%
Psychiatry 4%
Neurology 4%
Dermatology 4%
Obstetrics/Gynecology 3%
Ophthalmology 2%
Miscellaneous 3%
Total 100%
CROSS-CONTENT AREAS RELATIVE PROPORTIONS
Critical Care Medicine 10%
Geriatric Medicine 10%
Prevention 6%
Women’s Health 6%
Clinical Epidemiology 3%
Ethics 3%
Nutrition 3%
Palliative/End-of-Life Care 3%
Adolescent Medicine 2%

Source: www.abim.org, 2007.
TABLE 3.
Recertification Performance
YEAR PERCENT PASSED
2002 91%
2003 85%
2004 86%
2005 84%
2006 79%
Check the ABIM Web site for
the latest passing
requirements.
INTRODUCTION
xx
of your studies. Original research articles are low yield, and very new research
(i.e., research done less than one to two years before the exam) will not be
tested. In addition, there are a number of high-quality board review courses
offered around the country. Board review courses are very expensive but can
help those who need some focus and discipline.
Ideally, you should start your preparation early in your last year of residency,
especially if you are starting a demanding job or fellowship right after resi-
dency. Cramming in the period between end of residency and the exam is
not advisable.
As you study, concentrate on the nuances of management, especially for diffi-
cult or complicated cases. For common diseases, learn both common and
uncommon presentations; for uncommon diseases, focus on the classic pre-
sentations and manifestations. Draw on the experiences of your residency
training to anchor some of your learning. When you take the exam, you will
realize that you’ve seen most of the clinical scenarios in your three years of
wards, clinics, morning reports, case conferences, or grand rounds.

■
It’s okay to second guess yourself. Research shows that our “second
hunches” tend to be better than our first guesses.
■
Don’t panic with “impossible” questions. They may be experimental
questions that won’t count. Again, take your best guess and move on.
■
Note the age and race of the patient in each clinical scenario. When eth-
nicity is given, it is often relevant. Know these well, especially for more
common diagnoses.
The ABIM tends to focus on
the horses, not the zebras.
Use a combination of First Aid,
textbooks, journal reviews,
and practice questions.
Never, ever leave a question
blank! There’s no penalty for
guessing.
INTRODUCTION
xxi
■
Questions often describe clinical findings instead of naming eponyms
(e.g., they cite “tender, erythematous bumps in the pads of the finger” in-
stead of “Osler’s nodes”).
TESTING AND LICENSING AGENCIES
American Board of Internal Medicine
510 Walnut Street, Suite 1700
Philadelphia, PA 19106-3699
215-446-3500 or 800-441-2246
Fax: 215-446-3633

Skin-testing wheal-and-flare reactions are measured 15–20 minutes after
placement.
Laboratory Allergy Testing
■
Radioallergosorbent (RAST) serologic testing is performed to confirm the
presence of allergen-specific IgE antibody.
■
Results are comparable to skin testing for pollen- and food-specific IgE.
■
Recommended when the subject has anaphylactic sensitivity to the anti-
gen; useful when skin testing is either not available or not possible owing
to skin conditions or interfering medications (e.g., antihistamine use).
■
RAST testing alone is generally not adequate for venom or drug allergy
testing.
Delayed-Type Hypersensitivity Skin Testing
■
An effective screening test for functional cell-mediated immunity.
■
Involves intradermal injection of 0.1 mL of purified antigen. The stan-
dard panel includes Candida, mumps, tetanus toxoid, and PPD.
■
The injection site is examined for induration 48 hours after injection.
■
Approximately 95% of normal subjects will respond to one of the above-
mentioned antigens.
■
The absence of a response suggests deficient cell-mediated immunity or
anergy.
Allergen Patch Testing

■
C2: SLE.
■
C3: Pyogenic bacterial infections.
■
C5–C9: Neisserial infections.
Humoral (B-Cell) and Cellular (T-Cell) Deficiency Testing
Testing for B- and T-cell deficiency is as follows:
■
CD19: For B-cell immunity.
■
IgG, IgM, IgA, IgD, IgE: For antibody.
■
CD3, CD4, CD8: For T-cell immunity.
■
CD16, CD56: For natural killer cell immunity.
FIGURE 1.1.
The complement reaction sequence.
(Reproduced, with permission, from Brooks GF et al. Jawetz, Melnick, & Adelberg’s Medical
Microbiology, 24th ed. New York: McGraw-Hill, 2004, Fig. 8-9.)
Membrane attack complex
C5b–C9
Cell lysis
C3 convertases
C5b
C6,C7,C8,C9
Factor B
Factor D
Properdin
C4

Neisseria meningitis.
ALLERGY & IMMUNOLOGY
4
GELL AND COOMBS CLASSIFICATION OF IMMUNOLOGIC REACTIONS
The traditional framework that is used to describe immune-mediated reac-
tions. It is not inclusive of all complex immune processes.
Type I: Immediate Reactions (IgE Mediated)
■
Specific antigen exposure causes cross-linking of IgE on mast cell/basophil
surfaces, leading to the release of histamine, leukotrienes, prostaglandins,
and tryptase.
■
Mediator release leads to symptoms of urticaria, rhinitis, wheezing, diar-
rhea, vomiting, hypotension, and anaphylaxis, usually within minutes of
antigen exposure.
■
Late-phase type I reactions may cause recurrent symptoms 4–8 hours af-
ter exposure.
Type II: Cytotoxic Reactions
■
Mediated by antibodies, primarily IgG and IgM, directed at cell surface
or tissue antigens. Antigens may be native, foreign, or haptens (small for-
eign particles attached to larger native molecules).
■
Antibodies destroy cells by opsonization (coating for phagocytosis), com-
plement-mediated lysis, or antibody-dependent cellular cytotoxicity.
■
Clinical examples include penicillin-induced autoimmune hemolytic
anemia and certain forms of autoimmune thyroiditis.
Type III: Immune Complex Reactions

type III
Delayed
hypersensitivity:
type IV
ALLERGY & IMMUNOLOGY
5
tor for the development of asthma. Subtypes include exercise-induced, occu-
pational, aspirin-sensitive, and cough-variant asthma.
SYMPTOMS
Symptoms include dyspnea (at rest or with exertion), cough, wheezing, mu-
cus hypersecretion, chest tightness, and nocturnal awakenings with respiratory
symptoms. Symptoms may have identifiable triggers (e.g., exercise, exposure
to cat dander, NSAIDs, exposure to cold).
EXAM
■
Acute exacerbations: Expiratory wheezing; a prolonged expiratory phase;
↑ respiratory rate.
■
Severe exacerbations: Pulsus paradoxus, cyanosis, lethargy, use of acces-
sory muscles of respiration, silent chest (absence of wheezing due to lack
of air movement).
■
Chronic asthma without exacerbation: Presents with minimal to no
wheezing. Signs of allergic rhinosinusitis (boggy nasal mucosa, posterior
oropharynx cobblestoning, suborbital edema) are commonly found. Exam
may be normal between exacerbations.
DIFFERENTIAL
■
Upper airway obstruction: Foreign body, tracheal compression, tracheal
stenosis, vocal cord dysfunction.

2
-agonists (albuterol), one dose
q 20 min × 1 hour; O
2
to keep saturation > 90%.
■
Good response: With a peak expiratory flow (PEF) > 80% of predicted
or personal best after albuterol, continue albuterol q 3–4 h and insti-
tute appropriate chronic therapy (see below).
■
Incomplete response: With a PEF 60–80% of predicted or personal
best, consider systemic corticosteroids; continue inhaled albuterol q 60
min × 1–3 hours if continued improvement is seen.
The role of a methacholine
challenge is to exclude the
diagnosis of asthma. A
ᮍ challenge can be 2° to
numerous etiologies and thus
may not be definitive.
ALLERGY & IMMUNOLOGY
■
Poor response or severe episode: With a PEF < 60% of predicted or
personal best, give systemic corticosteroids and consider systemic epi-
nephrine (preferably IM), IV theophylline, and/or IV magnesium.
■
Patients with improved symptoms, a PEF > 70%, and O
2
saturation > 90%
for 60 minutes after the last treatment may be discharged home with ap-
propriate outpatient therapy and follow-up. Oral corticosteroids are appro-

PULMONARY FUNCTION RECOMMENDED TREATMENT
Mild intermittent ≤ 2 days per week, ≤ 2 nights PEF ≥ 80% Bronchodilator 2–4 puffs q 4 h
per month. as needed. No daily medications
necessary.
Mild persistent > 2 days per week but < 1 time PEF ≥ 80% Add low-dose inhaled
per day or > 2 nights per month. corticosteroids.
Leukotriene modifiers,
theophylline, and cromolyn
may also be added.
Moderate Daily symptoms or > 1 night per PEF 60–80% ↑ to medium-dose inhaled
persistent week. corticosteroids and add a
long-acting inhaled β
2
-agonist.
Leukotriene modifiers or
theophylline may also be
added.
Severe persistent Continuous symptoms. PEF < 60% ↑ to high-dose inhaled
corticosteroids.
Daily oral corticosteroids may
be added if necessary (60 mg
QD).
a
Dyspnea (at rest or with exertion), cough, wheezing, mucus hypersecretion, chest tightness, and nocturnal awakenings with respi-
ratory symptoms.
6
ALLERGY & IMMUNOLOGY
7
■
All asthma patients should use 2–4 puffs of a short-acting bronchodilator

agonists.
■
Oral corticosteroids at a dosage of up to 60 mg QD may be necessary.
Additional treatment considerations include the following:
■
Recognize the exacerbating effects of environmental factors such as aller-
gens, air pollution, smoking, and weather (cold and humidity).
■
Use potentially exacerbating medications with caution (aspirin, NSAIDs,
β-blockers).
■
Always consider medication compliance and technique as possible com-
plicating factors in poorly controlled asthma.
■
Treatment of coexisting conditions (e.g., rhinitis, sinusitis, GERD) may
improve asthma.
COMPLICATIONS
■
Hypoxemia, respiratory failure, pneumothorax or pneumomediastinum.
■
Frequent hospitalization and previous intubation are warning signs of po-
tentially fatal asthma.
■
A subset of patients with chronic asthma develop airway remodeling, lead-
ing to accelerated, irreversible loss of lung function.
ALLERGIC RHINITIS
The most common cause of chronic rhinitis. Allergic factors are present in
75% of rhinitis cases. May be seasonal or perennial; incidence is greatest in
adolescence and ↓ with advancing age. Usually persistent, with occasional
spontaneous remission.