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Self-Assessment for Board Exam Review

Mayo Clinic

Images in Internal Medicine

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Self-Assessment for Board Exam Review

Mayo Clinic

Images in Internal Medicine

Editor

Furman S. McDonald, MD

Co-Editors

Paul S. Mueller, MD

Gautam Ramakrishna, MD

MAYO CLINIC SCIENTIFIC PRESS

CRC PRESS

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ISBN-0-8493-3079-3

The triple-shield Mayo logo and the words MAYO and MAYO CLINIC are

marks of Mayo Foundation for Medical Education and Research.

©2004 Mayo Foundation for Medical Education and Research.

All rights reserved. This book is protected by copyright. No part of it may be

reproduced, stored in a retrieval system, or transmitted, in any form or by any

means—electronic, mechanical, photocopying, recording, or otherwise—without

the prior written consent of the copyright holder, except for brief quotations

embodied in critical articles and reviews. Inquiries should be addressed to

Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

For order inquiries, contact CRC Press, 2000 NW Corporate Blvd., Boca Raton,

FL 33431.

www.crcpress.com

Care has been taken to confirm the accuracy of the information presented and

to describe generally accepted practices. However, the authors, editors, and

publisher are not responsible for errors or omissions or for any consequences

from application of the information in this book and make no warranty, express

or implied, with respect to the contents of the publication. This book should not

be relied on apart from the advice of a qualified health care provider.

The authors, editors, and publisher have exerted efforts to ensure that

drug selection and dosage set forth in this text are in accordance with current

recommendations and practice at the time of publication. However, in view of

ongoing research, changes in government regulations, and the constant flow of

information relating to drug therapy and drug reactions, the reader is urged to

check the package insert for each drug for any change in indications and dosage

and for added warnings and precautions. This is particularly important when

the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food

and Drug Administration (FDA) clearance for limited use in restricted research

settings. It is the responsibility of the health care providers to ascertain the

FDA status of each drug or device planned for use in their clinical practice.

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DEDICATED TO

Four very special people:

• Charles H. Rohren, MD—the best physical diagnostician I

know. A great physician, teacher, mentor, and friend. You

are the reason I am an internist today. I will always see you

when I think of the physician I want to be.

• Darryl S. Chutka, MD—a great physician and teacher. When

you told me to “make the book as large as you like,” I don’t

think you expected what would come of it. Without your

support and allowance for creative freedom, this book would

never have been written.

• Henry J. Schultz, MD—the greatest single influence on my

professional life. Program director, adviser, friend. I hope

that this book will be useful to the residents you care so

much about, of whom I know I am one.

• Elizabeth S. McDonald, MD, PhD—my devoted wife.

Thanks for putting up with me while I put so much time

into this book.

One very special program:

Proceeds from the book will support the Mayo International

Health Program, which defrays the cost of elective experiences

for Mayo Clinic residents and fellows caring for underserved

patients in international settings.

Furman S. McDonald, MD

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PREFACE

Mayo Clinic Images in Internal Medicine: Self-Assessment for Board

Exam Review was begun in 1998 as an adjunct to a presentation

for the Mayo Internal Medicine Board Review Course. Images

were presented in random order with brief case scenarios. The

reader was encouraged to consider the cases before turning the

page to read a few learning points about each image. That first

book contained 38 cases and 57 images from 6 contributors.

Year by year the work was expanded until now the current

book has 173 cases with 287 images from 28 contributors. As

with the first book, all images are from patients seen at Mayo

Clinic, and the cases have been designed to illustrate important

teaching points. American Board of Internal Medicine–type

board review questions accompany the cases. The references

from which the content for each case scenario was built are

provided so the reader can obtain further information. Cases

are presented in random order to be a more effective review

tool that simulates examination (and clinical practice) condi￾tions. However, with the increase in size, a detailed index was

developed to allow the reader to find cases more efficiently. In

addition, this edition introduces chain referencing, an innova￾tive learning technique that allows the reader to move from

case to case based on specialty designation. With access to

the information in this book through random case review, the

detailed reference index, and specialty chain referencing, Mayo

Clinic Images in Internal Medicine: Self-Assessment for Board Exam

Review is really three effective learning texts bound in one cover.

It is hoped that Mayo Clinic Images in Internal Medicine:

Self-Assessment for Board Exam Review will be an aid for prepa￾ration for board examination certification or recertification

and medical clerkship review and also a useful update for

practicing clinicians.

Furman S. McDonald, MD

Editor

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ACKNOWLEDGMENTS

Many thanks are due to all who helped in the preparation of this

book. There are many, and I will not try to name them all.

This work was supported in part by the Clinical Educator and

Educational Initiative Program, an integral grant program of

Mayo Clinic. We are most appreciative of this support.

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AUTHOR AFFILIATIONS

Furman S. McDonald, MD

Senior Associate Consultant, Division of General Internal

Medicine–Hospital Medicine, Mayo Clinic

Associate Program Director, Internal Medicine Residency, Mayo

School of Graduate Medical Education, Mayo Clinic College of

Medicine

Assistant Professor of Medicine, Mayo Clinic College of Medicine

Rochester, Minnesota

Paul S. Mueller, MD

Consultant, Division of General Internal Medicine, Mayo Clinic

Assistant Professor of Medicine, Mayo Clinic College of Medicine

Rochester, Minnesota

Gautam Ramakrishna, MD

Fellow in Cardiovascular Diseases, Mayo School of Graduate

Medical Education, Mayo Clinic College of Medicine

Assistant Professor of Medicine, Mayo Clinic College of Medicine

Rochester, Minnesota

Image Contributors

Edith M. Andrist

Marc H. Bivins, MD

Emmanouil S. Brilakis, MD

B. Ryan Brady, MD

Darryl S. Chutka, MD

Mark D. P. Davis, MD

Laura A. Diamondopoulos, MD

David Dingli, MD

Jon O. Ebbert, MD

Stephen C. Hammill, MD

Melinda J. Johnson, MD

Patrick S. Kamath, MD

Thomas S. Lin, MD

James S. Mathur, MD

Elizabeth S. McDonald, MD, PhD

Furman S. McDonald, MD

David E. Midthun, MD

Victor M. Montori, MD

Carlos E. Morales, MD

John (Jack) D. Myers, MD

Roger L. Nelson, MD

Julian J. Nicholas, MD

Lynne E. Nowak, MD

David M. Phelan, MD

Jan Stepanek, MD

Craig S. Stump, MD

Wilber W. Su, MD

Farhad Zangeneh, MD

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TABLE OF CONTENTS

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii

How to Use This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

Cases 1-173 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-348

Appendix: Cases by Specialty . . . . . . . . . . . . . . . . . . . . . . . 349

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

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ABBREVIATIONS

The chain references listed at the bottom of the content pages

use the following abbreviations for specialties:

Allergy/Immunol Allergy and Immunology

CAM Complementary and Alternative

Medicine

Crit Critical Care

CV Cardiovascular Diseases

Derm Dermatology

Endo Endocrinology

ENT Ear, Nose, and Throat

Genet Genetics

GI Gastroenterology

Hem Hematology

ID Infectious Diseases

Musc Musculoskeletal Diseases

Neph Nephrology

Neuro Neurology

Ob/Gyn Obstetrics and Gynecology

Oncol Oncology

Ophth Ophthalmology

Pulm Pulmonary Diseases

Rheum Rheumatology

Toxicol Toxicology

Vasc Vascular Diseases

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How to Use This Book

Most atlases of internal medicine and review texts group images

and content by specialty, an order that works well for reference

volumes. However, it does not resemble the random order of

cases in general clinical practice or on examinations. Further￾more, learning styles differ. The editors have endeavored to

make Mayo Clinic Images in Internal Medicine: Self-Assessment for

Board Exam Review useful for examination study, practice, and

reference, realizing that users of the book may have different

needs and different styles of learning. With this understanding,

we suggest the following ways to use this book:

1. Random case review: The order of the cases presented in

this book was determined with a random number generator;

thus, a case does not lend clues to the diagnosis or questions

related to the subsequent case. This most closely simulates

a general practice or examination setting. People who used

the prototypes of this book found this order useful for exam￾ination review.

2. Specialty-specific review with use of chain references:

Some readers may want to review cases in a single special￾ty. The bottom of the content page for each case includes

abbreviations for the specialty classifications of the case

followed by a page number directing the reader to the next

case of that specialty. After the last case in any specialty, the

page numbers refer to the first case in the series. Thus, the

reader can open the book at any page and review specifically

the cases of any specialty by following the chain references.

3. Cases by specialty: To find all the cases of any specialty,

a list of cases categorized by specialty and page number

is provided in the Appendix. Because some cases can be

classified with more than one specialty, these lists may

overlap.

4. Reference by index: For readers who want to find a par￾ticular image or content related to a particular subject, an

extensive index is provided.

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A 37-year-old man received a bone marrow transplant 2 weeks

previously for acute myelogenous leukemia. Two days ago,

itching, diarrhea, pain and numbness in his palms and soles,

and the skin lesions shown here developed. Each of the follow￾ing statements about this condition is true except:

a. Use of HLA-identical grafts eliminates the risk of this con￾dition

b. This condition typically occurs 7 to 21 days after transplan￾tation

c. Increased age is a risk factor for this condition

d. Sex mismatch (female donor, male recipient) is a risk factor

for this condition

e. Values on liver function tests are often increased in this con￾dition

Case 1

1

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