Internal Medicine
Certification Exam Review

Educational Objective:

Recognize conditions associated with elevated intraocular pressure.

Key Point:

In addition to glaucoma, iritis and steroid use may be associated with increased intraocular pressure. Subconjunctival hemorrhage does not affect intraocular pressure.

Explanation:

Subconjunctival hemorrhage may be spontaneous (from sneezing or coughing) or traumatic. This condition is not associated with elevated intraocular pressure.

Glaucoma is obviously associated with ocular hypertension. Iritis may present with low, normal, or high pressure. Ocular hypertension and open-angle glaucoma are well-known complications of glucocorticoids.

References:

Aronson JK. Corticosteroids-glucocorticoids. In: Aronson JK, ed. Meyler’s Side Effects of Drugs. 16th ed., 2016:594-657.

Mantravadi AV, Vadhar N. Glaucoma. Prim Care. 2015 Sep;42(3):437-49.

Educational Objective:

Characterize the premalignant condition known as "porcelain gallbladder."

Key Point:

Patients with calcification of the gallbladder wall known as "porcelain gallbladder" should be referred for surgery because this condition is thought to be associated with malignancy.

Explanation:

Calcification of the gallbladder wall, also known as a "porcelain gallbladder," is a premalignant condition and, by some estimates, up to 25% of patients with this finding already have gallbladder malignancy. Repeated episodes of acute or chronic cholecystitis may cause scarring of the gallbladder epithelium, although the pathophysiologic relationship between calcification and oncogenesis is still poorly understood.

It is possible that the statin is causing mild elevations of ALT; however, at this level, neither discontinuation nor liver biopsy is warranted. HIDA imaging would not be of particular help in this situation, as this patient will still require cholecystectomy. Vitamin E supplementation has been shown to be potentially helpful in patients with fatty liver disease, but this condition is not likely in this patient.

Reference:

Sheth S, Bedford A, Chopra S. Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy. Am J Gastroenterol. 2000;95(6):1403-1410.

Educational Objective:

Describe the risks of pregnancy in patients with PCOS.

Key Point:

Patients with PCOS who become pregnant are at risk for hypertension and pre-eclampsia.

Explanation:

Women with PCOS are at risk for gestational diabetes. They also have a 4-fold increase in the risk of hypertension and pre-eclampsia and are at risk for small for gestational age children (SGA).

References:

ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin no. 108: polycystic ovary syndrome. Obstet Gynecol. 2009;114:936-949.

Palomba S, de Wilde MA, et al. Pregnancy complications in women with polycystic ovary syndrome. Hum.Reprod.Update. 2015; 21: 575-592

Educational Objective:

Summarize the appropriate screening for syphilis.

Key Point:

Initial syphilis screening is performed with nontreponemal tests such as VDRL or RPR and positive results are confirmed with treponemal tests.

Explanation:

Antibiotic therapy is highly effective in eliminating the bacteria T pallidum responsible for syphilis. However, due to the low prevalence of syphilis, screening is only recommended for high-risk populations and pregnant women. High-risk populations include men who have sex with men, men who engage in high-risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and incarcerated persons.

Screening for syphilis is a 2-step process. An initial nontreponemal test, VDRL or RPR, has sensitivity rates estimated to be between 78% and 86% for detecting primary syphilis and between 95% and 100% for detecting later stages of the disease. The specificity rate of the nontreponemal test ranges from 85% to 99%. A treponemal test, FTA-ABS or TP-PA, is then performed for confirmation. The confirmatory FTA-ABS test has a specificity rate of 96%.

Late-stage syphilis can involve gummatous, cardiovascular, and neurologic complications. Evidence suggests that screening high-risk adults can decrease the associated morbidity of syphilis.

Reference:

Bibbins-Domingo K, Grossman DC, Curry SJ, et al; US Preventive Services Task Force. Screening for syphilis infection in nonpregnant adults and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(21):2321-2327.

Educational Objective:

Screen for ovarian cancer.

Key Point:

There is not currently a viable screening test for ovarian cancer, and it is unfortunately usually detected on the basis of nonspecific symptoms such as pelvic fullness or vague gastrointestinal complaints.

Explanation:

Ovarian cancer is diagnosed in late stages in nearly all cases because of its insidious onset and vague symptoms. Most ovarian neoplasms grow quickly and painlessly, causing symptoms that may be found in any number of nonmalignant conditions. Much effort is concentrated on finding an effective screening tool because diagnosis during early stages would make the disease more curable and, thus, improve our ability to prevent deaths from ovarian cancer. However, no tool has yet been found that is helpful in the general population. CA-125 is elevated in nearly all cases of ovarian cancer, but it is also elevated in many nonmalignant conditions as well. In addition, performing this costly test on everyone to detect the small percentage of women with ovarian cancer is not cost effective.

Two studies looking at the value of screening ultrasonography showed that 5 cancers were found out of 5000 studies, and 6 cancers were found out of 6470 studies. These numbers are not cost-effective, and, furthermore, they resulted in unnecessary surgeries for many women in whom abnormalities were found that were not dangerous or malignant.

Yearly pelvic examinations may be helpful, but a study showed that 10,000 examinations must be performed to find 1 ovarian cancer. Sedimentation rates are nonspecific and not an effective screening tool for anything. The best chance found for early diagnosis of ovarian cancer is for healthcare professionals to have a high index of suspicion in any patient with persistent, vague gastrointestinal complaints that remain undiagnosed, as these may be initial symptoms of ovarian cancer.

Reference:

Eisenhauer EL, et al. Epithelial ovarian cancer. In: Di Saia PJ, Creasman WT. Clinical Gynecologic Oncology. 8th ed., 2012:285-328.