Maintaining Certification in Internal Medicine

QUESTIONS

A 73-year-old black woman presents to your office complaining of dysphagia and a 20-lb weight loss during the preceding 6 months. She has a 40 pack/year smoking history, drinks 1 shot of bourbon daily, and has had a longstanding history of gastroesophageal reflux disease (GERD) but has not complied with proton pump inhibitor (PPI) therapy. She is obese and has tried to lose weight in the past, but her current weight loss is unintentional. Upon review of her chart, you discover that she also has a history of achalasia. You suspect that she may have esophageal cancer. In addition to her cigarette smoking and alcohol use, which of her risk factors suggests that she has a squamous-cell carcinoma rather than an adenocarcinoma?
1. Obesity
2. GERD symptoms
3. Noncompliance with PPI therapy
4. History of achalasia
5. Older age
A 70-year-old man presented with itching and flaking of his skin (Figure 1 below). Which of the following statements is not true?

Figure 1
1. The diagnosis is seborrheic dermatitis
2. The optimal treatment is a potent topical steroid
3. Associated systemic conditions to consider are Parkinson's disease and HIV/AIDS
4. Topical ketoconazole or ciclopirox are appropriate treatments for this condition
Which of the following values increases as the prevalence of a disease declines in a population?
1. Positive predictive value of a test
2. Specificity
3. Sensitivity
4. None of the above
A 56-year-old man fell off the ramp of a truck he was unloading and hit the back of his head on the ground. His coworker noticed some muscle twitching right after the man fell. He remained unresponsive for about 1 minute and vomited twice upon awakening. Physical examination in the emergency department shows he is awake and fully oriented and only complains of a headache. His scalp has a small laceration and contusion at the site of impact. The neurologic examination is normal. The patient is otherwise healthy and does not take any medication. What would be the most appropriate next step in management?
1. Computed tomography (CT) of the head without contrast
2. Plain x-rays of head to rule out fracture, and admit for 24-hour observation
3. Discharge home and recommend rest for 48 hours
4. No imaging studies, but admit for 24-hour observation
A 33-year-old, otherwise healthy woman presents to her primary care physician complaining of a cough productive of thick, yellow sputum for the past 3 days. She had rhinorrhea with clear discharge, a sore throat, myalgias, and mild headaches for 2 to 3 days before the onset of cough. Her 2 children, ages 5 and 8 years, have had similar symptoms during the past week. The cough is worse when she is active, and it interrupts her sleep at night. She has not had fevers, chills, sinus drainage, or chest pain. Physical examination shows her vital signs are normal, and findings are unremarkable, with the exception of a few scattered wheezes at the bases of both lungs and her coughing several times during the examination that produced thick, yellow sputum. She has tried some over-the-counter cold medications, with only minimal relief. What is the most appropriate next step in management?
1. Antibiotic treatment with a quinolone
2. Order a chest x-ray
3. Treatment with a beta₂-agonist inhaler and an antitussive for symptom control
4. Send sputum sample for culture and Gram's stain
What are the most likely twin diagnoses for this patient (Figure 2)?

Figure 2
1. Osteoarthritis and eczema
2. Rheumatoid arthritis and eczema
3. Rheumatoid arthritis and rheumatoid nodules
4. Psoriasis and psoriatic arthritis

ANSWERS

1—D. Risk factors that lead to esophageal irritation predispose patients to squamous-cell esophageal carcinoma. In addition to smoking and alcohol use, which are synergistic risk factors for squamous-cell carcinoma, achalasia is another important risk factor. Other risk factors include Plummer-Vinson syndrome, long-term ingestion of hot beverages, tylosis, and a history of head and neck cancer. Obesity, GERD symptoms, and noncompliance with PPI therapy can lead to Barrett's esophagus (which this patient does not have), a well-known risk factor for esophageal adenocarcinoma.

Source: Enzinger PC, et al. Esophageal cancer. N Engl J Med. 2003;349:2241-2252.

2—B. Erythema, crusting, and greasy flaking in the creases of the skin, as seen in this patient, are the classic presentation of seborrheic dermatitis. In addition to the creases of the nose shown in Figure 1, other sites likely to be involved are the scalp, eyebrows, beard, midsternum, and creases behind the ears. New-onset or worsening seborrheic dermatitis is a common finding in Parkinson's disease and related neurologic conditions. It is also one of the earliest and most frequent findings in patients with HIV infection. The pathophysiology of seborrheic dermatitis involves an inflammatory response to the presence of Malassezia yeast on the sebum-rich areas of the skin; thus, long-term treatment with ketoconazole or ciclopirox is appropriate and safe. Long-term use of high-potency corticosteroids on the face should be avoided, because of the risks of inducing skin atrophy and/or rosacea, absorption, and dyspigmentation.

Source: Gupta AK, et al. Skin diseases associated with Malassezia species. J Am Acad Dermatol. 2004;51:785-798.

3—B. The negative predictive value is the proportion of persons with a negative test result who indeed do not have the disease.

Negative predictive value is the true-negative tests divided by the true- and false-negative tests.

With a decrease in the prevalence of the disease, the negative predictive value increases, while the positive predictive value decreases (ie, inverse relationship). The sensitivity and specificity values usually do not change.

Source: Sackett DL, et al, eds. Clinical Epidemiology: A Basic Science for Clinical Medicine. 2nd ed. Boston, Mass: Lippincott Williams & Wilkins; 1991.

4—A. This man experienced a concussion complicated by an impact-related seizure, but his neurologic examination is normal. The decision to perform cranial CT should be based on the New Orleans Criteria and Canadian CT Head Rule. The patient's 2 episodes of vomiting and scalp bruises indicate the need for a CT scan of his head. If the scan is normal, he could be discharged to the care of a person who is given written instructions to check on him several times during the next 24 hours and to bring him back to the emergency department immediately if drowsiness, vomiting, confusion, weakness, or increased headache occurs. A non-narcotic analgesic may be given.

The patient should be informed about common sequelae of concussion, including the possibility that headache, dizziness, or mild difficulty with concentration may persist for days or weeks. A temporary leave from his work, or a change to less-taxing assignments, may be appropriate.

Source: Ropper AH, Gorson KC. Clinical practice. Concussion. N Engl J Med. 2007;356:166-172.

5—D. This otherwise healthy patient has symptoms that are most consistent with an episode of acute bronchitis, a disorder that affects approximately 5% of US adults annually, more often during the winter and fall than in the summer and spring. The term "acute bronchitis" implies a self-limited inflammation of the large airways of the lung. It is characterized by cough without pneumonia. The condition is caused by viruses, such as influenza A or B, parainfluenza, respiratory syncytial virus, coronavirus, adenovirus, or rhinovirus. Cough in the absence of fever, tachycardia, and tachypnea suggests bronchitis rather than pneumonia. Normal vital signs and the absence of rales and egophony on chest examination make pneumonia unlikely. Thus, further diagnostic testing is usually unnecessary.

Antibiotics are not recommended in most cases of acute bronchitis. Systematic analysis of several clinical trials has suggested that antibiotics may reduce the duration of symptoms, but only very modestly. A meta-analysis of 8 clinical trials involving patients with acute bronchitis suggested that symptoms were reduced by a fraction a day with the use of erythromycin (Ery-Tab, PCE Dispertab), doxycycline (eg, Adoxa, Doryx, Periostat), or trimethoprim/sulfamethoxazole (TMP/SMX; Bactrim, Septra). Although statistically significant, the results were clinically trivial.

For wheezing and cough or wheezing with activity, clinical experience suggests that a beta₂-agonist, such as albuterol (Proventil), may provide relief, but data from clinical trials are inconsistent. Also on the basis of clinical experience, patients with persistent cough may benefit from the short-term use of codeine or a hydrocodone-containing antitussive or inhaled corticosteroids, but data to support their use are lacking.

Sources: Bent S, et al. Antibiotics in acute bronchitis: a metaanalysis. Am J Med. 1999;107:62-67.
Macfarlane J, et al. Reducing antibiotic use for acute bronchitis in primary care. BMJ. 2002;324:91-94.

6—D. Well-demarcated, erythematous plaques with silvery scale on the elbows, knees, scalp, umbilicus, and gluteal cleft are characteristic of psoriasis. Eczema would generally be less discretely localized and have lichenification or serous crusting. The elbows would be a typical location for rheumatoid nodules, but they would be deeper under the surface, and without the silvery scaling. Up to 30% of patients with psoriasis develop psoriatic arthritis, with the most common forms being asymmetrical poly- or oligo-articular and distal interphalangeal joint involvement, as in this patient. Another common cutaneous sign, albeit absent in this patient, would be pitting of the nails associated with the arthritis. Rheumatoid arthritis and osteoarthritis are usually symmetrical.

Sources: Schön MP, et al. Psoriasis. N Engl J Med. 2005;352:1899-1912.
Zachariae H, et al. Quality of life and prevalence of arthritis reported by 5,795 members of the Nordic Psoriasis Associations. Data from the Nordic Quality of Life Study. Acta Derm Venereol. 2002;82:108-113.

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