Internal Medicine
Certification Exam Review

Educational Objective:

Describe the appropriate treatment of patients with Lyme arthritis.

Key Point:

Confirmed Lyme arthritis should be treated with doxycycline for 28 days. If arthritis persists after treatment, then an additional course of 28 days of doxycycline or treatment with intravenous antibiotics (eg, ceftriaxone) is appropriate.

Explanation:

This patient has established Lyme disease based on her history and positive serum titers. Synovial fluid cultures are usually negative in patients with Lyme disease. Treatment with doxycycline for 28 days is standard care for patients with Lyme arthritis. If arthritis persists in this patient after this treatment, then she may be treated with an additional 28 days of doxycycline. An alternative regimen is intravenous ceftriaxone for 14 to 28 days. Because this patient already has an established history of Lyme disease, resending the serum antibody titer is unnecessary.

References:

Raukar NP, Zink BJ. Bone and joint infections (chapter 128). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1693-1709.

Wormser GP. Lyme disease (chapter 321). In: Goldman L, Schafer A. Goldman-Cecil Medicine. 25th ed., 2016:2021-2027.

Educational Objective:

Appropriately treat erectile dysfunction.

Key Point:

First-line for treatment of erectile dysfunction is an phosphodiesterase type 5 inhibitor (eg, sildenafil).

Explanation:

Phosphodiesterase type 5 inhibitors prolong nitric oxide–induced vasodilation and are effective in producing an erection. The American College of Physicians guidelines recommend treating these patients with a phosphodiesterase type 5 inhibitors such as sildenafil, as first-line therapy for erectile dysfunction in men without contraindications (eg, increased cardiovascular risk).

References:

Qaseem A, Snow V, Denberg TD, et al. Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline From the American College of Physicians. Ann Intern Med. 2009;151:639-649.

Wincze JP. Erectile dysfunction. In: Ferri FF. Ferri’s Clinical Advisor. 2018:466-467.

Educational Objective:

Identify amaurosis fugax.

Key Point:

Amaurosis fugax is a transient ischemic attack causing the transient loss of vision, due to the lack of blood flow to the optic nerve.

Explanation:

This is a classic case of Amaurosis fugax (ocular ischemic syndrome) caused by a transient lack of blood flow to the optic nerve; essentially a transient ischemic attack. The lesion causing the ischemic sign is usually in a larger vessel such as the carotid artery. Since the retinal artery is small, it tends to be the most compromised among vessels branching off the carotid.

In addition to sudden visual loss as the result of thrombotic or embolic ischemia, Amaurosis fugax may also be the result of a vasculitis such as temporal arteritis or a manifestation of hyperviscosities such as sickle cell crisis or polycythemia vera. Malaria is not a cause of transient blindness. Patients who experience an episode of amaurosis fugax have a 10 to 15 percent chance of subsequently developing a central retinal artery occlusion within a year.

Initial evaluation should include a complete blood count and, sedimentation rate, Depending on the patient’s past medical history, imaging studies of the carotid and/or heart could be in order in addition to the possibility of a temporal artery biopsy.

References:

Jean E. Klig, “Ophthalmologic Complications of Systemic Disease” Emergency Medicine Clinics of North America - Volume 26, Issue 1 (February 2008)

Wu, T, Amaurosis Fugax. Ferris’s Clinical Advisor. 2017: 60

Educational Objective:

Know the clinical features of the abdominal compartment syndrome.

Key Point:

The abdominal compartment syndrome may occur after abdominal trauma.

Explanation:

The patient is critically ill after surviving a motor vehicle collision. Abdominal compartment syndrome (acute abdominal hypertension) usually occurs in critically ill patients, particularly those with abdominal trauma, recent surgery, burns, or severe infections. The most common precipitating factor is the excessive use of crystalloid-based fluids.

Affected patients are usually unable to communicate; however, if they are able, they may complain of abdominal pain and shortness of breath. The most prominent finding on physical examination is abdominal distention. Hypotension, tachycardia, oliguria, respiratory distress, and elevation of the central venous pressure can all occur. Imaging of the abdomen is not typically helpful. The best way to confirm the diagnosis is by direct measurement of intra-abdominal pressure. An excellent surrogate measure of intra-abdominal pressure is intravesical pressure, which is relatively accurate except in cases of local pelvic pathology (eg, abscess, hematoma). Exploratory laparotomy may be required for treatment purposes, but the first step is confirming the diagnosis.

References: 

Maluso P, Olson J, Sarani B. Abdominal compartment hypertension and abdominal compartment syndrome. Crit Care Clin. 2016;32(2):213-222.

Sugrue M, De Waele JJ, De Keulenaer BL, Roberts DJ, Malbrain ML. A user's guide to intra-abdominal pressure measurement. Anaesthesiol Intensive Ther. 2015;47(3):241-51.

Educational Objective:

List the 4 cardinal signs of Parkinson Disease.

Key Point:

The cardinal features of Parkinson’s disease are resting tremor, rigidity, bradykinesia and postural instability. Postural instability may be a late manifestation of Parkinson Disease.

Explanation:

The 4 cardinal manifestations of PD can be remembered using the TRAP mnemonic:

• Tremor: A resting, pill-rolling motion (typically 4-6 Hz)
• Rigidity: Cogwheel type
• Akinesia/bradykinesia: Slowness of movement
• Postural instability: Failure of postural "righting" reflexes that lead to poor balance and falls Many nonmotor features are present in PD, including orthostasis, depression, and constipation.

References:

Ferri FF. Parkinson's disease. In: Ferri FF. Ferri's Clinical Advisor. 2016.

Scottish Intercollegiate Guidelines Network. Diagnosis and Pharmacological Management of Parkinson's Disease: A National Clinical Guideline. Accessed April 4, 2016.

Lees AJ, Hardy J, Revesz T. Parkinson's disease. Lancet. 2009 Jun 13;373(9680):2055-66.