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TOP SH ELF
Essential Learning
for the Internal
Medicine Clerkship
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes
in treatment and drug therapy are required. he authors and the publisher o this work have checked with sources
believed to be reliable in their e orts to provide in ormation that is complete and generally in accord with the
standard accepted at the time o publication. However, in view o the possibility o human error or changes in
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ration or publication o this work warrants that the in ormation contained herein is in every respect accurate or
complete, and they disclaim all responsibility or any errors or omissions or or the results obtained rom use o
the in ormation contained in this work. Readers are encouraged to con irm the in ormation contained herein
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included in the package o each drug they plan to administer to be certain that the in ormation contained in this
work is accurate and that changes have not been made in the recommended dose or in the contraindications or
administration. his recommendation is o particular importance in connection with new or in requently used
drugs.
TOP SH ELF
Essential Learning
for the Internal
Medicine Clerkship
Conrad Fische r, MD
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
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Ab o u t t he Au t h o r
Conrad Fischer, MD, is a Program Director in Internal Medicine in New York

City. He is also a clerkship director or the third year internal medicine rota-
tion. Dr. Fischer is Associate Pro essor o Medicine, Physiology and Pharma-
cology at ouro College o Medicine. In addition he holds a Master’s degree in
T eology rom Union T eological Seminary in New York.
v
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t Ab l e o f Co n t e n t s
How to Use this Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii
CHAPTER 1: General Internal Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

CHAPTER 2: Allergy and Immunology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CHAPTER 3: Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
CHAPTER 4: Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
CHAPTER 5: Endocrinology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
CHAPTER 6: Gastroenterology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
CHAPTER 7: Geriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
CHAPTER 8: Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
CHAPTER 9: In ectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
CHAPTER 10: Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
CHAPTER 11: Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
CHAPTER 12: Women’s Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
CHAPTER 13: Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
CHAPTER 14: Pulmonology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
CHAPTER 15: Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
APPENDIX: Abbreviations and Mnemonics . . . . . . . . . . . . . . . . . . . . . . . . . . 423

INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
vii
how to u se t h is book
It is my sincere hope that I have created a unique and use ul book to prepare
you or your shel examination or or greater depth o study in internal med-
icine. Initially, the volume o in ormation you must absorb will seem over-
whelming. All I can tell you or sure is:
• While the knowledge you must eventually acquire seems in nite, it isn’t.
• T e amount you need or this standardized test is certainly nite.
T e ormat this book ollows is the pattern o the most requently asked
questions on the exam:
1. What is the most likely diagnosis?

2. What is the best initial test?
3. What is the most accurate test?
4. Which o the ollowing physical ndings is most likely to be ound in this
patient?
5. What is the best initial therapy?
In addition, we will show you the most likely results o EKGs, x-rays, and C
and MRI scans to be ound on the test.
Studying a lot can eel hard and pain ul. It is an e ort. I will share with you,
then, the solvent or pain ul e orts in the area o medicine.
• Everything you are learning here is use ul to help people.

• T e “smartest” or most knowledgeable that most people are in medicine in
third year is the day they walk into their Shel . T is is, there ore, a high point
or peak experience. Don’t waste it.
• You can always rest later; you can’t study or your Shel later
My suggestion on how to use this book is:
1. Study one subject as a time.

2. Read it in multiple (3 to 4) di erent sources.
3. Use a book o practice questions only a er you have studied the subject.
Don’t start with practice questions.
ix
To p S h e l f : Es s e n t i a l Le a r n i n g f o r t h e In t e r n a l Me d i c i n e Cl e r k s h i p
I you study a small number o subjects repetitively, it will provide more depth
and you will develop a greater sense o satis action. It may eel slower, but it is
more ocused and you become more con dent.
What Do I Do if I Hate Certain Subspecialties?

Not to worry! Say you love pulmonary and hate hematology, or the other way
around. You actually can pass the Shel examination by picking your avorite
subjects and studying them really, really well.
Ah yes! For those with limited attention, it is better to study the things you like
really well than to be super cial over every subject. I mysel studied this way.
Only later did I ully learn the other subjects.
Your “Calling”
I have spent 30 years in the classroom. I taught my rst class, physiology, by
accident as a 19-year-old college junior. I spent another year teaching physics
to college students. I was never sick and I had no sick relatives. How, then, did
I know to go to medical school? Because it is a calling. A calling means you try
to grasp where your great passion and the world’s great need meet.
As a physician, you are di erent rom the other healthcare providers. No other
branch o caregivers needed a law to limit them to 80 hours a week o work.
Anyone can do a job i it is easy. T e reason we are “pro essional” is that we get
the job done. We are done when the job is done. We are not done when our
shi is done. We are done when people are taken care o , not when the clock
hits a certain hour. I was on rounds today, a Saturday morning on a 3-day
holiday weekend. T e resident had been up all night and was tired and hungry.
He wanted to stop and to leave. But he did not. He took care o patients. He
started to develop a nose bleed and had to sit down, and continued to present
patients and do the right thing, despite bleeding.
We do not seek su ering or ourselves. We do not create pain or make the pro-
cess needlessly dif cult. When pain comes in the process o our mission, our
goal, our duty, however, we do not avoid it. T is is the process o our training
that makes us, as physicians, better than the other pro essions.
In a homogenized world where everyone is supposed to be the same, we as

doctors and medical students are simply not the same. We work harder, study
longer, and stay past any arbitrary outside clock until our duty is ul lled.
T is book is the culmination and the result o decades o classroom experience

and thousands o patients seen. I hope you will nd it use ul. I you use it cor-
rectly, you will relieve su ering.
And that is a mighty ne thing to do in this li etime!
x
Ho w t o Us e Th i s Bo o k
Is My Ro t a t io n Exper ienc e Eno ugh ?

Let us say you went to a busy, well-run hospital where you had enormous clini-
cal exposure and great teaching. Is it enough to prepare or your Shel ?
ABSOLU ELY NO !
It doesn’t matter i you do a 300-year-long rotation in a great school. It is not

enough. T ere are simply too many subjects that you need to cover. T ere are
too many diseases that you never see because they are never admitted to the
hospital where the majority o teaching occurs. T ere are more than 25,000
primary test takers a year o the Shel exam, and there are only a ew hundred
cases o Brugada syndrome in the history o the world’s literature. Even i every
case were seen by 10 students. It still would not be enough. Did you see Alport
syndrome? Liddle syndrome? Is there a case o Churg-Strauss syndrome or
every morning report or every hospital?
T e answer is: You need to study or the Shel to supplement your experience
because there are just too many unusual diseases you will not see or a long
time. T e good news is: T ere are many, many things you will study just or
Shel that you will later diagnose and recognize simply because you learned
them or a test.
Fa ir ness
Is the test air?
ABSOLU ELY!
No one designing the Shel exam is trying to ool you or make you ail. T ere is
a rigorous intellectual honesty to the test. Your e orts are not lost. I you ollow
the blueprint or the exam, all you need is honest study and rigorous e ort or
a short period o time. And you will succeed.
Dr. Conrad Fischer

New York City
xi
P r e f ACe
Top Shelf: Essential Learning for the Internal Medicine Clerkship is not a
textbook—it is a review book: a review o the in ormation that you need to
know or this exam.
T e layout is primarily presented as an outline, mostly with the use o short

phrases either in paragraph orm or in bulleted or numbered lists. Comparative
material is presented in tables, and there are images that represent some o the
issues discussed in the text. In each chapter, the emphasis is on presentation,
etiology, diagnostic tests, and treatment. In addition, key words in making a
diagnosis; major associations with the disease; and choosing the best initial
test, the most accurate test, the best initial therapy, and the most e ective ther-
apy are covered. ips and sidebars direct you to targeted in ormation and can
help you complete a brie nal review prior to taking your exam.
For those who are seeking a multimedia approach to issues covered in this
text, I have developed a video course available at http://www.medquestreviews.
com/store/top-shel -internal-medicine that can be purchased separately.
Dr. Conrad Fischer

New York City
xiii
Ge n e r a l I n t e r n a l 1
Me d Ic In e
In t r o d u c t Io n
General internal medicine, which includes all screening, is one o the most
highly tested areas o the boards. Although this chapter is brie , nearly every What screening tests lower
mortality? Mammography,
act is eligible to be tested. T e Shel examination is meant to test the basic PAP smears, and
competence o the general internist. As such, the level o oncology tested, colonoscopy.
or example, always includes the current screening recommendations or cancer,
whereas speci c types o chemotherapy or a disease such as multiple
myeloma may not be tested at all. You do not need to go to medical school
to know that screening tests detect cancer, but you do have to go to medical
school to know which ones will lower mortality.
TIP
Do not walk into the exam without knowing the most current screening
recommendations.
Whose Recommendations Are You Tested On?

Shel and all board examinations predominantly use the recommendations o
the United States Preventive Services ask Force (USPS F), an independent
panel that has no nancial incentive or its recommendations.
For example, USPS F states clearly that there is no de nite recommenda-

tion to screen men or prostate cancer with prostate speci c antigen (PSA).
On the other hand, the American Urological Association may recommend
screening with PSA and a digital rectal examination. You are not tested on
the recommendations o private organizations with a strong nancial interest There is no de nite
in the outcome o a test. T e National Cancer Institute permissively recom- mortality bene t with
mends screening PSA starting at the age o 50. “Permissively” means they the use o PSA. PSA is not
recommended as a general
acknowledge the controversy and let you know Medicare will pay or the test screening test.
at age 50.
1
T is book will not engage in lengthy pro and con discussions; rather, it will give
direct recommendations on what you should answer i the question comes up.
Although the exam includes a number o challenging and complicated sub-
jects, this book’s purpose is to give you an answer with the minimum number
o acts to memorize. T is does not mean this book is super cial or incomplete;
it simply means it will jump to the bottom-line answer.
How Does the Test Handle Controversial or Unclear Areas o

Medicine?
T e est is absolutely not the place where controversies will be worked out. I a
question seems controversial or the answer unclear based on your understand-
ing o the best current data, you may want to consider that a number o ques-
tions on your examination are experimental. T is means they are being tested
to see how many people get them right.
T e est have a simple solution to controversial issues: T e right answer will be
the one that is most broadly supported by current research.
For example:
Which o the ollowing statements concerning prostate cancer is correct?

a. PSA should be of ered routinely at age 40.
b. PSA should be of ered routinely at age 50.
c. Digital rectal examination should be of ered routinely at age 40.
d. Screening with PSA lowers mortality.
e. A rapidly rising level o PSA is associated with an increased risk o prostate cancer.
Answer: The correct answer is (e). This statement is correct. The question is intelligently
put because it sidesteps the issue o whether you should be doing the test in avor o a
statement that everyone can agree upon. Another correct statement could have been: “I
a man ully understanding the risks and bene ts o PSA testing is requesting the test, then
the test should be per ormed.”
How Do I Answer Questions Concerning Recommendations

that Have Recently Changed?
Never try to “time” the exam in terms o answering based on what was correct
when you think the question was written. Rather, answer based on the current
recommendation at the time o your exam.
c a n cer Scr een In G

Breast Cancer
T e strongest evidence shows that screening or breast cancer is most e ective
beginning a er age 50. T ere is controversy surrounding screening between
the ages o 40 and 50. However, the shel has never engaged in this controversy.
T e greatest bene t o screening with mammography has always been in those
above the age o 50.
2
Ch a p t e r 1 : G e n e r a l In t e r n a l Me d i c i n e
Which o the ollowing is most likely to bene t a patient with breast cancer?
a. Screening with ultrasound
b. Screening with MRI
c. Tamoxi en in those with 2 rst-degree relatives with breast cancer
d. Soy diet
e. Exercise
. Low- at diet
g. BRCA testing
Answer: The correct answer is (c). Estrogen inhibition is an underutilized therapy to pre-
vent breast cancer. Tamoxi en and raloxi ene are not routinely recommended in those
with an average risk o cancer, but having relatives with breast cancer markedly increases
the risk o cancer. Ultrasound helps distinguish cystic rom solid lesions, particularly in
younger women. MRI as a screening method is not yet o clear value. Although soy diets
and exercise may have some bene t, it is not nearly as clear as that o antiestrogen
therapy. In women with a strong amily history suggestive o a mutation, BRCA testing
will detect an increased risk o breast and other cancers, such as ovarian. However, it is
not clear what the right therapeutic intervention in those with a positive test is.
BRCA Testing
BRCA is associated with an increased risk o cancer, especially with a amily
history o cancer. It is not enough just to
detect an increased risk o
• T e intervention or a positive test is not clear. cancer. To intervene, you
must detect an increased
• Prophylactic mastectomy (and oophorectomy) or a positive test is not risk o cancer that you can
clearly recommended or all who test positive. do something about.
• T ere is no clear mortality benef t to routine BRCA testing.
• BRCA is associated with an increased risk o ovarian cancer, in addition to
numerous other cancers, such as prostate and pancreas.
Prophylactic Tamoxifen and Raloxifene Prevent Breast Cancer

First-degree relatives =
amoxi en and raloxi ene reduce the risk o breast cancer by 50% to 70%. siblings and parents
When a patient has multiple rst-degree relatives with breast cancer, tamoxi en
is FDA-approved or prevention o breast cancer in premenopausal women; in
postmenopausal women, either tamoxi en or raloxi ene should be used to pre-
vent the development o breast cancer. T e best age at which to start treatment Tamoxi en and raloxi ene
is not precisely known. T ere is no clear bene t when starting be ore age 40. will also treat osteoporosis
in addition to decreasing
T e greatest bene t is in those above age 50. reatment should be continued the risk o breast cancer.
or at least 5 years.
T e most common adverse e ects o tamoxi en are:
• Hot ashes
• Leg cramps
• Endometrial cancer (unusual)
• Deep vein thrombosis
• Cataracts
3
TIP
Shel questions have to be clear. The shel exam will not provide a scenario
in which the patient’s age is equivocal or unclear.
T e bene ts o the prophylactic use o tamoxi en were clearly measurable even

a er 10 years o use. T e adverse e ects did not persist or occur a er 5 years.
In addition to markedly reducing the risk o breast cancer, there was a 30%
reduction in the risk o osteoporotic ractures.
Li etime Risk o Developing Breast Cancer in a Woman with No Children

No a mily One rst -d egree Two rst -d egree
Age hist ory relat ive relat ives
40 10% 18% 29%
50 9% 16% 26%
60 6.5% 13% 21%
T is table demonstrates the enormous increase in risk because o a amily

history o breast cancer.
I , or a 40-year-old woman with 2 relatives with cancer, we add in:
• Giving birth be ore age 20

• Menarche at age 11
T e li etime risk o breast cancer rises to 43%.
Colon Cancer
• Screening or colon cancer should begin by age 50.
• Colonoscopy is superior to all other modalities.
• Colonoscopy is per ormed every 10 years in the average risk population.
• Virtual (or C ) colonoscopy is never the right answer.
• Barium enema, ecal occult blood testing, and sigmoidoscopy are in erior to
colonoscopy.
Cervical Cancer
• Pap smears start at age 21, irrespective o the age o onset o sexual
Chlamydia screening is activity.
routine or all sexually
active women. • No screening is necessary or those above age 65.
• T ere is no need or Pap smear in those who have had a hysterectomy.
• Pap every 3 years or every 5 years combined with HPV testing.
4
Special Circumstances or Colon Cancer Screening

Three a mily
memb ers,
2 generat ions, Fa milia l Juvenile p olyposis,
One a mily memb er 1 p remat ure a d enomatous Inf a mmat ory and Peutz-Jeghers
wit h colon ca ncer (b e ore a ge 50) p olyp osis (FAP) b owel d isea se (IBD) syndrome
Start at age 40 or Start at age 25 with Screening Colonoscopy a ter No additional
10 years earlier colonoscopy every sigmoidoscopy 8–10 years screening.
than the age the 10 years. every 1–2 years o colonic
amily member starting at age 12. involvement. Test
was diagnosed, Gardner syndrome is every 1–2 years.
whichever is screened like FAP.
earlier. Screen at It is an FAP variant
regular intervals
a terward.
Which o the ollowing results in the greatest bene t?

Cervical screening: Pap
a. Pap smear
and HPV testing every
b. Colonoscopy 5 years.
c. Mammography
d. Annual chest x-ray in heavy smokers
e. PSA
Answer: The correct answer is (c). The changes in screening recommendations have not
changed the answer to the most requently asked cancer screening question. The mam-
mogram has always been the most bene cial o all the cancer screening methods, and
women above the age o 50 have always been the group that bene ts the most rom
screening. Three cancer screening methods lower mortality: Pap, mammography, and
colonoscopy. Mammography is simply the best o these. This is an example o a question
that sidesteps controversy, since breast cancer kills more people than both cervical and
colon cancer. Annual screening chest x-rays have never been ound to be bene cial in any
group, including smokers.
Cancer Tests That Are Never the Right Answer

No blood test has ever been ound to lower cancer mortality. T is includes Annual screening chest
carcinoembryonic antigen (CEA), alpha- etoprotein (AFP), CA-125, and PSA. x-ray is not recommended
or any group.
• Screening chest x-rays or high-resolution C scans
• Pelvic examination
• Breast sel -exam
• esticular examination
• Anal Pap smear
• Skin examination or melanoma
• Any blood or radiologic test or pancreatic, ovarian, or bladder cancer
5
d Ia bet eS, Hyper t en SIo n , Hyper l IpId eMIa ,

a bd o MIn a l a o r t Ic a n eu r ySM, a n d o St eo po r o SIS
Diabetes
Screen or ype 2 diabetes in those with blood pressure above 140/90 mg/dL.
The BP cutof or diabetes Diabetes is diagnosed with 2 asting blood glucoses above 125 mg/dL or a
screening is a unique
number or this hemoglobin A1c above 6.5%. T e goal o LDL cholesterol levels is at least
circumstance, at only <100 mg/dL in diabetics.
135/80 mg/dL.
Hypertension
Screen or hypertension at every of ce visit in those over the age o 18.
Hyperlipidemia
• Screen men above age 35 every 5 years.
• Screen women above age 45 every 5 years.
• Screen persons above 20 years o age who have additional cardiovascular
risk actors (H N, DM).
Abdominal Aortic Aneurysm

• Screen all men aged 65 to 75 who have ever smoked.
• Use ultrasound above age 65.
Osteoporosis
Screening
• Screen women above age 65 (or above 60 with risk actors such as chronic
Hip racture in an elderly steroid use or weight less than 70 kg) with bone densitometry (DEXA scanning).
woman is atal ar more
o ten than a myocardial • A -score 1 to 2.5 standard deviations below normal is osteopenia.
in arction. • A -score more than 2.5 standard deviations below normal is osteoporosis.
• Screen every 2 years.
• T e -score is a measure o a woman’s bone density as compared to that o
a healthy young woman.
Treatment
1. Vitamin D and calcium supplementation are routinely indicated in all
patients with either osteopenia or osteoporosis.
2. Bisphosphonates (alendronate, risendronate, ibandronate, zolendronic
acid): T ese medications will reduce the likelihood o hip and vertebral
racture by 50% in those with decreased bone density. Adverse e ects are:
• Osteonecrosis o the jaw
• Esophagitis i not taken with adequate uid intake
6
3. Exercise with high-impact physical activity. Running, stair-climbing, and

weight training all increase bone density.
Alt er n At e t h er Apy (l ess evid en ce t h An Bisph o sph o n At es )

Several other therapies exist that would be the correct answer only i bisphos-
phonates were not in the choices or there was a contraindication or complica-
tion o bisphosphonate use.
• eriparatide: an analogue o P H that increases new collagenous bone

matrix ormation
• Calcitonin: decreases vertebral ractures, but does not clearly reduce hip
ractures
• Raloxi ene: a selective estrogen receptor modi er that also decreases the
risk o breast cancer
• Estrogen replacement: limited bene t with severe osteoporosis
• Denosumab: a RANKL inhibitor that stops osteoclasts
Diseases Not to Be Routinely Screened (The Wrong Answers)

• T yroid disease
• Hemochromatosis
• Carotid artery stenosis
• Glaucoma
IMMu n Izat Io n S
Hepatitis A and B Vaccines
Although hepatitis A and B vaccinations have both been added to the routine
vaccinations in childhood, adults should be vaccinated in the ollowing Hepatitis vaccine is o
greatest bene t to patients
circumstances: with chronic liver disease.
• Chronic liver disease

• Men who have sex with men
• Injection drug users
• Household contacts o those with the active disease
Hepatitis A vaccine is recommended or those traveling to countries with an

unsa e ood and water supply. Routine hepatitis B vaccine is recommended in
healthcare workers.
Inf uenza Vaccine

In uenza vaccine is recommended annually or all adults. T e question,
however, may account or possible reversal in this recommendation back to
7
high-risk groups by asking: “Which o the ollowing groups is most likely to

Flu vaccine is not benef t rom in uenza vaccine?” T e answer to this is:
contraindicated in egg
allergy. • Patients with chronic disease o the heart (CHF), lung (COPD and asthma),
or kidney
• Diabetic patients
• Patients with HIV/AIDS
• Pregnant women
• Immunosuppressed patients such as those with hematologic malignancy or
users o glucocorticoids
• Healthcare workers
• Obese patients
Pneumococcal Vaccine
T is vaccine is indicated in those above age 65. Generally healthy individuals
HIV testing should be require only a single vaccination at age 65. A second vaccine is given to those
universal, not based on risk
actors. whose rst injection was be ore age 65 and in those with underlying illness such as:
• obacco smoking
• Patients with chronic disease o the heart (CHF), lung (COPD and asthma),
or kidney
• Diabetic patients
• Immunosuppressed patients such as those with hematologic malignancy,
users o glucocorticoids, or patients with HIV/AIDS
T e rst type o pneumococcal vaccine to be administered is the 13 polyvalent

pneumococcal vaccine (PCV13). T is is what should be given rst at age 65. A
second injection o pneumococcal vaccination should be given a year later. T e
second vaccine is the 23 polyvalent pneumococcal vaccine.
I the patient got the 23 polyvalent at age 65 or earlier in li e, then the PCV13
should be given a year a er the rst injection. T e bottom line is that everyone
needs to get both injections.
Never vaccinated? Give the PCV13 rst, and the 23 a year later. Vaccinated
with the 23 already? Give the PCV13 at least a year a er the rst shot.
Meningococcal Vaccine
Although this vaccine has now been added to the routine age 11 visit, adults
should be vaccinated i they are:
• Functionally (sickle cell) or anatomically asplenic

• Living in dormitories or military barracks
• De cient in terminal complement
8
Papilloma Virus Vaccine

• Routine or all women between ages 9 and 26
• Acceptable to give in men as well
• Give to nonvirgins to protect against carcinogenic subtypes o papillovirus
Varicella Vaccine
Shingles or the reactivation o varicella, also called herpes zoster, is extremely
common in elderly patients, a ecting as many as 5% o patients above age 60.
Varicella vaccine is a version o the vaccine given in children, but at higher
dose. T is is indicated in all individuals at the age o 60. Contraindica-
tions are the use o steroids and AIDS with less than 200 CD4 cells/µL, preg-
nancy, or any immunosuppression (AIDS, malignancy, immunosuppressant
medications).
l o w b a ck p a In
Low back pain is so common as to be considered an expected nding in the
general population. T e most requently tested point is about in which patients
x-rays are use ul. T e vast majority o individuals are not su ering rom cord
compression or spinal stenosis. Hence, unless there are additional severe nd-
ings described in the case, the most likely answer is:
• No x-rays
• No bed rest
• Yes to moderate exercise and stretching such as yoga
I there is evidence o cord compression such as ocal neurological ndings,

vertebral tenderness, or a sensory level de cit, the “most appropriate next A positive straight leg raise
does not count as a “ ocal
step in the management o the patient” is to give steroids and obtain an MRI neurological de cit.”
or C .
I there is ever in addition to ocal neurological ndings, vertebral tenderness,
or a sensory level de cit, then you should add antibiotics that are active against
staphylococcus, such as vancomycin, to the steroids. Fever with signs o cord
compression suggests a spinal epidural abscess.
TIP
Unless there are ocal neurological indings, vertebral tenderness,
incontinence, or a sensory level de cit, do not per orm imaging studies o the
spine.
Fever + cord compression = epidural abscess
9
Tetanus/Acellular Pertussis
A booster o tetanus toxoid is given every ten years. etanus toxoid acellular
pertussus ( dap) is the pre erred orm. I the wound is soiled or “dirty,” the
Expect Tdap questions! interval is 5 years. Give a booster in the orm o dap.
T e goal is to increase vaccination rates or pertussis by giving it every time a

tetanus booster is needed.
dap is sa e in pregnancy. A tetanus booster should be given with every

pregnancy.
10
Al l e r g y An d 2
immu n o l o g y
An Aph yl Axis
In anaphylaxis, the causative agent is not as important as the response o the
host. Anaphylaxis is de ned as:
• Hypotension
• achycardia
• Respiratory distress
T is occurs in response to medication, chemical agents, insect venoms, or the

ingestion o a ood. In addition, the patient may have:
• Rash, urticaria, itching, ushing

• Bronchospasm
• Swelling o the lips, tongue, or throat
• Stridor
• GI symptoms (diarrhea, nausea/vomiting)
T e best initial steps in management are:
• Epinephrine intramuscularly (1:1,000 solution)

• Antihistamines (diphenhydramine)
• Intravenous uids (normal saline)
• Oxygen
• Corticosteroids
• Inhaled bronchodilators such as albuterol
• H 2 blockers
Epinephrine
Epinephrine will work the most rapidly and will restore central per usion
pressure. In addition, epinephrine will reverse bronchospasm and laryngospasm.
11
When anaphylaxis occurs, especially with hypotension and any orm o respir-
Epinephrine sel -injection atory distress, there are no contraindications to the use o epinephrine. Steroids
(epi-pen) is given when
repeat anaphylaxis may will take 4 to 6 hours to work, whereas epinephrine will work instantly. Anti-
occur. histamines do not have the same decrease o e cacy as steroids or epinephrine.
When an insect sting may recur a er anaphylaxis, the best initial management
is desensitization and epi-pen.
TIP
Epinephrine is used as a 1:1,000 solution intramuscularly in anaphylaxis. It is
used as a 1:10,000 solution intravenously or cardiac resuscitation.
Epinephrine Use in Asthma

In an acute exacerbation o asthma, there are contraindications to the use o
There are no epinephrine. T is is because in asthma there is:
contraindications to
epinephrine when there • Ef ective alternative therapy such as albuterol
is any concern that
anaphylaxis may be • Potential harm in those with a history o coronary artery disease
li e-threatening.
u r t ic Ar iA An d An g io ed emA
Def nition/Presentation/Etiology
Urticaria is de ned as eruptions o itchy, red wheals or hives with sharp
borders, commonly af ecting the trunk and extremities but sparing palms and
soles.
Acute urticaria may be caused by bugs (insect bites), drugs (e.g., penicillin),
Urticaria can be caused by or oods, but requently there is no known cause. Chronic urticaria is caused
in ection.
by pressure, cold, and vibration. Chronic urticaria is de ned as lasting longer
than 6 weeks. Nearly hal o those with chronic urticaria never have a speci c
etiology identi ed.
Angioedema is a severe, li e-threatening orm o urticaria. Angioedema

Itching is not always implies swelling o deeper subcutaneous tissues such as the lips, ace, and eye-
present with urticaria and
angioedema. lids. Both urticaria and angioedema can be associated with laryngeal edema
and hypotension.
Diagnostic Tests
Acute urticaria is a clinical diagnosis and needs no diagnostic testing, and
Icatibant is a bradykinin there should be no delay in administering treatment. Chronic urticaria is
antagonist used or
hereditary angioedema. best managed by trying to identi y and eliminate the trigger. A CBC is done
to look or eosinophilia. Food, pollen, and latex allergies can be identi-
ied with radioallergosorbent (RAS ) testing. Skin testing con irms the
presence o allergen-speci ic IgE. RAS is done when skin testing is not
possible.
12
Ch a p t e r 2 : Al l e r g y a n d Im m u n o l o g y
Common Causes o Acute Urticaria

Aspirin and other NSAIDs
Bugs Drugs Food s Ot her Cont a ct can worsen urticaria due to
• Bee stings • Penicillin • Shell sh • Hereditary • Latex mast cell degranulation.
• Feathers • Aspirin • Tomatoes
• Animal • NSAIDs • Strawberries
dander • Morphine and • Nuts, especially
codeine peanuts
• ACE inhibitors • Eggs
(presents • Chocolate
without hives)
• Sul a drugs
• Contrast agents
Treatment
Severe urticaria is treated with antihistamines such as hydroxyzine or cypro-
heptadine, although these are sedating; occasionally a ew weeks o steroids are
required. Milder urticaria can be controlled with newer, nonsedating antihis-
tamines such as:
• Fexo enadine
• Loratadine
• Cetirizine
Chronic Urticaria
• Eliminate the trigger i one is identi ed.
Venom immune therapy
• Doxepin is a nonspeci c histamine and serotonin blocker that is used or desensitizes patients when
chronic urticaria. the insect sting cannot be
• Avoid systemic steroids or chronic urticaria. avoided.
• Use venom immune therapy (desensitization).
Prevention o Contrast Allergy

Radiologic procedures requiring iodinated contrast material are o en una-
voidable even in those with an allergy to this material. T ese patients should
receive corticosteroids and antihistamines prior to receiving the contrast.
A 43-year-old man comes to the emergency department with severe swelling o his ace,
lips, and scrotum. No hives are ound. He has recently been started on lisinopril or hyper- C2: decreased in SLE
tension not responsive to hydrochlorothiazide. His complement levels, speci cally C2 and C3: decreased in pyogenic
C4, are decreased. bacterial in ection
C5–C9: Neisseria in ection
What is the best initial therapy or this patient?
a. Fresh rozen plasma
b. Loratadine
c. Diphenhydramine
d. Furosemide
e. Prednisone
. Epinephrine
13
Answer: The correct answer is (a). Fresh rozen plasma (FFP) will replace C1 esterase inhibi-
CH50 is the initial test or the tor. Epinephrine will not be e ective in those with C1 esterase inhibitor de ciency. This
complement pathway. case has given clear evidence o C1 esterase inhibitor de ciency. In this condition, C2 lev-
els are decreased during acute attacks. C4 is decreased both during acute attacks and
between attacks.
C1 esterase inhibitor de ciency can also be treated with replacement with C1 esterase
inhibitor concentrate and by giving anabolic steroids. Ecallantide is an inhibitor o
kallikrein used or hereditary angioedema.
Al l er g ic r h in it is
Def nition/Etiology
Allergic rhinitis is an extremely common hypersensitivity reaction to inhaled
allergens. Inhaled allergens include pollens, grasses, ragweed, molds, house-
hold mites, or pets. Symptoms can be provoked by cold air, odors, or dust. It is
associated with a history o atopic disorders such as eczema, asthma, and ood
allergy.
Presentation
Allergic rhinitis presents with:
Nasal polyps are associated
with chronic rhinitis. • Rhinorrhea
• Sneezing
• Eye irritation with redness, itching, and tearing
• Occasional cough and bronchospasm
Diagnostic Tests
With severe symptoms, an investigation should be made to identi y speci c
environmental allergens in order to avoid them. T e most sensitive test is allergen-
speci c IgE levels. RAS testing and skin testing are also use ul.
Treatment
T e best initial therapy is intranasal corticosteroids.
Intranasal steroids such as beclomethasone, unisolide, budesonide, or

uticasone are all superior to oral antihistamines such as exo enadine,
desloratadine, or cetirizine. Steroids are also less expensive than antihista-
mines. T ere are also antihistamine eye drops or treatment o local ocular
symptoms.
Recurrence o allergic A 34-year-old woman is seen in the o ce or a chronic runny nose, cough, and itchy eyes.
rhinitis is more likely with She has these symptoms or several weeks every spring. On physical examination, her
oral antihistamines than nasal mucosa is hypertrophic, edematous, and pale. A polyp is detected. You prescribe
with intranasal steroids. intranasal f uticasone. She returns 3 days later because her symptoms have not resolved.
She insists she is ully adherent to the f uticasone.
14
What is the most appropriate management?
a. Stop intranasal steroids and switch to oral desloratadine

b. Prescribe a short course o oral prednisone
c. Tell her to temporarily leave her home
d. Tell her to continue the f uticasone
e. Switch to oral montelukast
. Switch to inhaled cromolyn
Answer: The correct answer is (d). Intranasal steroids will take 2 weeks to reach a ull e ect
and she has only been using it or 3 days. Antihistamines may work acutely, but you should
not stop the steroids, which are ultimately associated with ewer recurrences as well as
the chance to shrink her polyp. Cromolyn and montelukast are not as e ective as steroids.
Patients Not Controlled with Intranasal Corticosteroids and

Oral Antihistamines
For a patient with persistent symptoms a er weeks o steroids and antihista-
mines, the answer to the question “What is the most appropriate next step in
the management o this patient?” is:
• Leukotriene inhibitors (e.g., montelukast)
Intranasal steroids need
or 2 weeks to work.
• Intranasal anticholinergic medications (ipratropium)
or
• Intranasal mast cell stabilizers (cromolyn or nedocromil)
A patient comes to the emergency department with persistent rhinorrhea, sneezing,

and ocular itching despite weeks o treatment with intranasal budesonide, ipratropium,
nedocromil, oral exo enadine, and oral montelukast. Her symptoms are worse at night
and on weekends. IgE testing is speci c or environmental allergens.
What is the most e ective management?

a. Change jobs
b. Use dustproo covers on pillows and mattress
c. Vacuum the rugs
d. Hire a pro essional cleaning service
e. Begin oral steroids
Answer: The correct answer is (b). Dustproo covers on pillows and mattresses decrease
exposure to environmental allergens. This is more e ective than just washing these items.
Vacuuming is not strong enough to remove mites rom the environment. Oral steroids
are never the right answer or allergic rhinitis. There is no point in changing jobs or an
allergen that happens at night and weekends at home.
Management o Environmental Allergens

• Remove household items containing dust (rugs, drapes, bedspreads).
• Use air puri ers and dust lters.
15
• Flush out allergens using nasal irrigation with saline.

• Keep household items, such as pillows, in dustproo covers.
p r imAr y immu n o d ef icien c y d is eAs es

Common Variable Immunodef ciency
Etiology
Common variable immunode ciency (CVID) is a de ect in the productive
capacity o B cells. B cells are present in normal numbers, but they do not pro-
duce e ective immunoglobulins. T is leads to a panhypogammaglobulinemia,
although you will nd a normal number o cells on CBC. Lymph nodes and
adenoids are present in either normal or enlarged size. IgG, IgM, and IgA all
become decreased over time. T e onset may occur at any time in adulthood,
hence the word “variable” in the name.
Presentation
Look or an adult o either gender with requent episodes o sinopulmonary
in ections such as:
• Sinusitis, otitis media, and pharyngitis

• Bronchitis and bronchiectasis
• Pneumonia (bacterial or nonbacterial; a ew develop Pneumocystis species
or other ungal pneumonia without HIV)
Gastrointestinal disorders such as celiac disease occur, as does chronic in ec-

CVID is associated with tion with Giardia. Giardia is the classic enteric pathogen. Look or malabsorp-
autoimmune diseases.
tion with steatorrhea.
Diagnostic Tests
T e B cell count is normal, but serum protein electrophoresis SPEP shows a
Beware o lymphoma in marked decrease in antibody production o all types. IgG is depressed more
CVID.
than IgA or IgM.
Treatment
Besides using antibiotics as in ections arise, patients should get monthly intra-
venous immunoglobulin injections (IVIG). With IVIG, the patient’s immune
unction is relatively normal.
X-Linked (Bruton) Agammaglobulinemia

Because this disorder is X-linked, it presents exclusively in male children.
T e clinical mani estations o increased sinopulmonary in ection are the same
as or CVID. T e main dif erence, besides the age o onset, is that this is a
16
def ciency in B cells, rather than a B cell de ect in production o immunoglobulins.

T e CBC will show a low WBC count because o low lymphocyte count.
Physical Examination
Lymph nodes, spleen, tonsils, adenoids, and all other machinery or the pro-
duction o B cells will be markedly diminished.
Treatment
reatment includes antibiotics or in ections and monthly intravenous
immunoglobulin.
DiGeorge Syndrome
his is an isolated cell de iciency, occurring as a result o a deletion in
chromosome 22. T e thymus is hypoplastic. T ere are also:
• Cardiac de ects (classically tetralogy o Fallot)

• Hypocalcemia rom ailure o parathyroid development
B cells and
• Facial abnormalities (including cle palate) immunoglobulins are
normal in DiGeorge
reat in ections as they arise. PCP prophylaxis with trimethoprim/ syndrome.
sul amethoxazole is given. IVIG in usion helps.
Severe Combined Immunodef ciency

In severe combined immunode ciency (SCID), both B cell and T cell immunity
are def cient. Patients are pro oundly immunosuppressed, leading to bacterial,
ungal, and viral in ections. reat with bone marrow transplantation.
IgA Def ciency

IgA de ciency is the most common primary immunode ciency. Patients
requently survive into adulthood and may not exhibit any symptoms. Some have
requent respiratory in ections and some progress to bronchiectasis.
With IgA de ciency, look or:

Blood donations to IgA-
• Asthma de cient patients must be
rom IgA-de cient donors.
• Atopic disease
• Autoimmune disorders
• Anaphylaxis with blood trans usion
reatment is symptomatic since we do not have the ability to replace IgA.
Hyper IgE Syndrome

Look or increased number o skin and lung in ections with Staphylococcus.
Folliculitis and boils, or carbuncles, occur requently. reat the in ections as they
arise.
17
Chronic Granulomatous Disease

Chronic granulomatous disease (CGD) is a de ect in the granules o neutro-
phils. T ere is a de ect in the oxidative burst that allows neutrophils to destroy
bacteria. It is like having a match that won’t light: T ere is a de ect in the pro-
duction o hydrogen peroxidase. Patients present with in ections with catalase-
positive organisms such as:
• Staphylococcus aureus
• Burkholderia cepacia
• Aspergillus
T is gives recurrent, severe in ections o the skin, ears, lungs, liver, and bone.
Look or “suppurating
lymph nodes” with CGD.
Diagnostic Tests
Nitroblue tetrazolium is the test that shows decreased superoxide or
hydrogen peroxide production by neutrophils. he dihydrorhodamine 123
(DHR) oxidation test is another test or CGD. Immunoblot or genotype
con rms the disease.
Dihydrorhodamine measures NAPH oxidase in CGD as a diagnostic test.
Treatment
reat in ections as they arise. Use trimethoprim/sul amethoxazole or PCP
prophylaxis as you would in AIDS. Gamma inter eron is used to prevent
in ection.
18
Ca r Di o l o g y 3
Co r o n a r y a r t er y Dis ea s e
Risk Factors
T e major, and clearest, risk actors or the development o coronary artery
disease (CAD) are:
• Diabetes mellitus
• Hypertension
• obacco smoking
• Hyperlipidemia
• Age o the patient
• Family history
Risk actors or coronary artery disease are important because:
1. T ey answer the “What is the most likely diagnosis?” question when the
history and physical examination are equivocal.
2. T ey are used to lower mortality, especially in those with established
coronary artery disease.
I the question describes an older male patient with chest pain, risk actors
have less importance; coronary artery disease or a myocardial in arction can
be present without major risk actors. Risk actors are critical or the “what is
the most likely diagnosis?” question when a patient is younger than 55 or is a
premenopausal woman.
De ning the Risk Factors

Dia bet es Mel l it u s
• wo asting blood glucose levels above 125 mg/dL
• One asting blood glucose above 200 mg/dL with symptoms
19
• wo hemoglobin A1c levels above 6.5%

• Abnormal glucose tolerance test
TIP
The question will most o ten simply state that the patient has a history o
diabetes.
Hyper t en sio n
• Blood pressure above 140/90 mm Hg
• Blood pressure above 140/90 in diabetic patients or those with end organ
damage such as renal insu ciency
• 150/90, age >60
Hyper l ipiDeMia
Hyperlipidemia is generally de ned according to the level o LDL. Although an
increased triglyceride level con ers some increased risk o CAD and vascular
disease in general, this is not as clear as the risk associated with an increased
LDL level. Questions involving high levels o LDL can be challenging because
the level that is dangerous or needs to be modi ed varies based on the number
o other risk actors present and the presence o coronary disease itsel .
“T e management o hyperlipidemia is con using, and it is hard to give a goal-

directed answer or a standardized test. In those with coronary disease the goal
o therapy is an LDL at least under 100 mg/dL. In those with diabetes the goal
is also at least under 100 mg/dL. I you have both coronary disease and diabetes,
the goal is better at under 70 mg/dL. In those presenting with an acute coronary
syndrome, every patient should be put on a statin regardless o the LDL.
T ese are the answers or a national standardized examination like the shel
exam.
However, your attending may say that every diabetic or every person with cor-
onary disease should be on a statin. T is is your answer or your rotation.
In all circumstances, the two most e ective statins are atorvastin and rosu-
vastatin. At maximum dose these are also both re erred to as ‘high intensity
statins.’
In those with very high risk such as diabetes and coronary disease who can-
not tolerate a statin use proprotein convertase subtilisin kexin 9 antibody
(PCSK9-ab).”
For example:
A 51-year-old woman comes to the o ce to see her primary care provider or a routine
visit. Her only past medical history is hypertension that is well controlled on hydrochloro-
thiazide. Her LDL level is 145 mg/dL.
20
Ch a p t e r 3 : Ca r d i o l o g y
What is the best management o her lipid level?

a. No management needed
b. Fat-restricted diet
c. Cholestyramine
d. Niacin
e. Atorvastatin
Answer: The correct answer is (a). This is a di cult question or many test takers. The goal
o therapy or this patient is an LDL below 160 mg/dL. The patient has only a single risk
actor and no coronary artery disease equivalents such as diabetes. The risk actors that
are used in terms o hyperlipidemia are hypertension, tobacco smoking, amily history,
and older age, de ned as above age 45 or a man and above age 55 or a woman. This
woman has only a single risk, hypertension, and there ore does not need to be main-
tained at an LDL below 100 mm/dL as you would with CAD or one o its equivalents.
a g e o f t He pat ien t
Patients are at increased risk o CAD with increasing age. T is is de ned as:
• Above age 45 or a man

• Above age 55 or a woman
f a Mily Hist o r y
In order or a amily history to be considered signi cant or a patient, it has
to be a history o premature coronary disease. I all o the patient’s relatives
developed CAD at the age o 80, it is not considered signi cant or the patient.
T e age cuto or premature disease is speci cally de ned as:
• Under age 55 or a male relative

• Under age 65 or a emale relative
T e question o age in terms o amily history is one o the most requently

misunderstood issues in terms o CAD. est takers requently take amily Only a amily history o
premature coronary
history into account when they should not because the question describes disease is considered
older amily members with CAD. signi cant or a patient.
Minor Risk Factors

T ere are several risk actors that have less clear pathological signi cance or
are hard to de ne.
o besit y
Obesity is a risk or increased mortality in general, but it is not universally
accepted as a risk or CAD. Obesity exerts its risk or CAD primarily through
increasing the prevalence o diabetes, hypertension, and hyperlipidemia.
Obesity separate rom these diseases exerts only a small increase in the risk o
CAD. T is increased risk can also be neutralized by increased physical activity
and exercise.
21
pHysica l in a c t ivit y
Just as physical activity is protective against all-cause mortality, physical inac-
tivity increases the risk o CAD. T is is predominantly through the e ect that
physical inactivity has in increasing obesity and its subsequent increase in
hypertension, hyperlipidemia, and diabetes.
in cr ea sin g a g e a n D Ma l e g en Der
T e e ect o male gender on the risk o CAD is generally help ul only in those
o middle age (45 to 55). By the time a woman is 5 to 10 years postmenopausal,
most o the protective e ects o menstruation have worn o .
TIP
Age is not very use ul in helping to answer questions about CAD, since it is
unlikely you will be presented with a 20-year-old and asked to identi y CAD
in that age group.
eMo t io n a l s t r ess
T is risk is nearly impossible to measure and de ne.
t a ko t su bo c a r Dio Myo pat Hy

T is is a sudden ballooning o the le ventricle o the heart rom severe emo-
Severe emotions + sudden tional or physical stress and is sometimes called transient apical ballooning
ventricular ballooning =
Takotsubo cardiomyopathy syndrome. akotsubo cardiomyopathy is not ischemic in nature, and there is
no way to predict who is at risk or the disorder. T e patient develops severe
chest pain or symptoms o acute congestive heart ailure. T e EKG shows
changes consistent with anterior wall myocardial in arction. T ere is no clearly
a VR V1 V4
a VL V2 V5
a VF V3 V6
Figure 3.1: Anterior wall myocardial in arction. ST segment elevation in V2–V5.

Used with permission from Philip Veith.
22
e ective therapy, and most patients have a complete recovery over time. It is
thought to occur rom an unpredictable massive catecholamine release.
Presentation
CAD leading to ischemia presents with chest pain that is described as:
• Dull
• Squeezing
• Pressure-like
• ightness or heaviness
• “Sore like being punched”
T e pain o ischemia is exacerbated by physical exertion and relieved by rest.

However, pain that occurs at rest can imply extremely severe ischemia.
Duration
T e duration o pain that is worrisome or CAD lasts or more than a ew
seconds or minutes, but less than several hours. Ischemic pain can radiate to Pain that lasts only or
seconds or persists
the neck, arm, or shoulder, but non-radiating pain does not exclude anything. unchanged or hours is not
T e pain o typical ischemic episodes lasts 20 to 30 minutes. as ischemic in nature.
Location
T e pain o ischemia rom CAD localizes to being “substernal” or “retrosternal.”
Pain that is described as right-sided is rarely rom ischemia. Even though the The more lateral the pain
is, the less likely it is to be
heart is directed anatomically more toward the le than the right, pain that is ischemic in nature.
described as being on the le side o the chest is not ischemic in nature 90% o
the time.
Overall, the quality and location o the pain is the most important eature that
allows us to answer the “what is the most likely diagnosis?” or “what is the most
appropriate next step in management?” question.
Nonspeci c Features o Chest Pain

A number o associated symptoms occur with many di erent causes o chest
pain but do not help establish a diagnosis. Many di erent causes o chest pain
are associated with dyspnea, pallor, anxiety, diaphoresis, nausea, and ever. T e
presence or absence o these eatures will neither exclude nor prove the pres-
ence o CAD/ischemia as the cause o the patient’s chest pain.
Features That Help Exclude Ischemia as the Diagnosis

Over 90% o patients coming to the emergency department with chest pain
ultimately do not have a myocardial in arction. Without an EKG and cardiac
enzymes, it is o en impossible to know the diagnosis, either in real li e or
23
your test. T e ollowing eatures will allow you to know that the answer on
the test, at least, is not ischemia. We know that the answer is not ischemia i
the question describes pain that:
• Changes with respiration

• Changes with bodily position
• Is associated with chest wall tenderness
It is not necessary to have all 3 o these eatures present to exclude CAD. Each
Pain that changes with o them alone has a very high negative predictive value or CAD. On your test,
position, respiration, or
palpation is non-ischemic a 95% negative predictive value is acceptable. In clinical practice, a 5% alse
95% o the time. negative rate is not acceptable.
Other key descriptors that help exclude ischemia as the cause o the chest pain:
• Kni elike or sharp

• Point-like
• Lasting or a ew seconds
TIP
The entirety o initial management is based on history + EKG in most cases.
Physical Examination
T e vast majority o patients with CAD have a normal physical examination.
T is includes those with stable angina, unstable angina, acute coronary syn-
drome, and even S segment elevation myocardial in arction.
T ere is a huge potential di erence between “physical ndings most likely to

occur” and “complications that may occur.”
T e physical ndings most likely to occur are basically none.
Potential complications are:
S4 gallop: T is is rom an ischemic le ventricle that becomes sti and

noncompliant. An S4 gallop by itsel is not an indication or additional
therapy.
Murmurs o mitral or aortic regurgitation: Myocardial in arction (MI)
is associated with death o papillary muscles, which can rupture and cause
acute mitral or aortic regurgitation. Patients will present with tachycardia
and rales and possibly hypotension. T is may need an intraaortic balloon
pump and surgical repair.
S3 gallop: Extension o an in arction can cause acute ventricular ailure
and volume overload. An S3 gallop needs a erload reduction with an ACE
inhibitor or angiotensin receptor blocker (ARB).
24
Hypotension
Bradycardia
Rales/crepitations: An ischemic myocardium does not pump e ciently
and rales can develop due to pulmonary congestion.
Di erential Diagnosis/”What Is the Most Likely Diagnosis?”

Since the majority o causes o chest pain that bring a patient to the hospital are
not myocardial in arctions or even ischemic in nature, recognizing the eatures
o the other causes o chest pain is essential. Many causes o chest pain can
present with dyspnea, nausea, diaphoresis, or ever, so the best way to divide
them up is by whether the pain changes with respiration or bodily position, or
there is chest wall tenderness.
Pleuritic Pain (Changes with Respiration)

Et iology Dist inct ive feat ure
Pneumonia Cough, sputum
Pneumothorax Dyspnea, sharp pain, tracheal deviation i tension
pneumothorax
Pleuritis Friction rub
Pulmonary embolus Sudden in onset, clear lungs
Pericarditis Changes with bodily position: improves with sitting
orward, worse when lying at
Other Causes o Chest Pain

When a patient has chest pain and it is not rom the heart, the most common
etiology is in the gastrointestinal system.
g a st r o in t est in a l Diso r Der s

T e most common gastrointestinal disorders with chest pain are ref ux disease,
ulcers, hiatal hernia, and gallbladder disease.
Mit r a l v a l ve pr o l a pse
T e pain o mitral valve prolapse is atypical in nature in that:
• It is not related to exertion.

• Palpitations are common.
• It is requently present in young women who are menstruating.
• Auscultation reveals a midsystolic click.
a o r t ic a n eu r ysM
• Pain radiates to the back in between the shoulder blades
• Di erence in blood pressure between arms
• Wide mediastinum on chest x-ray
25
c o st o cHo n Dr it is
Musculoskeletal pain originating rom the ribs and the costochondral
junctions is an extremely common cause o chest pain. Chest wall tender-
ness is present, and the patient is best treated with NSAIDs and other anti-
inf ammatory medications.
Diagnostic Tests
ekg
T e “best initial diagnostic test” or all orms o chest pain is an EKG. S segment
The main drive in initial elevation is indicative o an in arction 75% o the time; S segment depression
therapy is based mostly on
the presence or absence o is indicative o an in arction only 25% o the time. For acute coronary syn-
ST elevation. drome in the emergency department, the presence o S segment elevation is
the main eature driving the use o thrombolytics and angioplasty. I the story
is typical or ischemic disease, the only truly important nding is whether there
is S elevation or not. I the EKG is abnormal and shows S depression or
wave inversion, or is normal, it has limited importance in driving immediate
therapy.
c a r Dia c en zyMes
Cardiac enzymes such as CK-MB, troponin, or myoglobin are used in evaluating
CK-MB is the best method acute coronary syndromes in the emergency department. Cardiac enzymes are
o con rming a rein arction
within several days. not use ul in the stable patient in the o ce.
Time Course o Cardiac Enzymes

First b ecomes
Na me of enzyme a b norma l Durat ion
Myoglobin 1–4 hours 12 hours
CK-MB 4–6 hours 1–2 days
Troponin 4–6 hours 1–2 weeks
TIP
LDH is never the correct answer or diagnosing an acute coronary syndrome;
it takes too long to become positive.
Treatment
Each speci c coronary syndrome will be addressed separately because there is
considerable variation in therapy. In the absence o contraindications, there are
several medications that are used in all the syndromes. All orms o CAD are
treated with:
• Aspirin
• Beta blockers (metoprolol)
26
• Nitrates
• Statins
Specif c Medications
Prasugrel has greater
Na me of med icat ion Circu mst a nces for use e cacy than clopidogrel
Clopidogrel, prasugrel, o Acute myocardial in arction, angioplasty with in MI.
ticagrelor stenting, intolerant o aspirin
Statins All acute coronary syndromes, CAD to an LDL
goal < 100 mg/dL
ACE inhibitors Ejection raction < 40%, acute ST elevation MI
ARBs Same as or ACE inhibitors i intolerant o ACE
inhibitors
Heparin, low molecular weight Acute coronary syndromes, especially with
(LMW) ST segment depression
Fondaparinux or bivalirudin Alternative to LMW heparin
GP IIb/IIIa inhibitors Acute coronary syndromes, especially those
undergoing angioplasty
Eplerenone or spironolactone ST elevation MI with ejection raction < 40%
and heart ailure symptoms
Stable Angina
Stable angina is usually evaluated in the o ce or ambulatory setting. Physical
examination is generally not help ul in guiding the “most likely diagnosis” or
“best initial therapy” questions. Although an EKG is always per ormed as the
best initial test, the EKG lacks sensitivity between episodes o acute ischemia.
TIP
Do not answer CK-MB or troponin in the stable patient in an o ce or clinic
setting.
Diagnostic Tests
A er the EKG is done, the most likely answer to the “best initial test” ques-
tion is the exercise tolerance (stress) test. Imaging can be added to the EKG
interpretation o a stress test either with echocardiography or by nuclear
imaging (typically single photon emission computed tomography or SPEC ).
A standard exercise tolerance test is based on 2 eatures:
• T e patient can exercise to a target heart rate.

• T e EKG will be able to detect ischemia.
“Maximum” stress test means the patient exercises until he or she achieves a
target heart rate above 80% o his or her predicted maximum level. A person’s
maximum heart rate is calculated by subtracting his or her age rom 220.
27
T e detection o ischemia on standard exercise tolerance testing is based on

Exercise by exertion is being able to see S segment depression. I the patient cannot exercise, a phar-
pre erred to pharmacologic
simulation o exercise. macologic alternative to exercise is used, such as dobutamine with echocardiog-
raphy, or dipyridamole or adenosine with a nuclear isotope such as thallium.
Types o Stress Tests

Test Met hod of d etect ing ischemia
Exercise tolerance test ST segment depression
Exercise or dobutamine Wall motion abnormalities
echocardiography
Exercise or dipyridamole thallium Decreased uptake o the nuclear
isotope during exercise
c a r Dia c en zyMes , ecHo ca r Dio g r a pHy, a n D a n g io g r a pHy

Cardiac enzymes such as troponin, CK-MB, and myoglobin are always a wrong
answer or diagnosing stable angina with the case described as being in the
o ce or clinic. Echocardiography is use ul in patients with stable chest pain
syndromes. It is used to determine the presence o several anatomic abnormali-
ties that can result in pain, such as:
• Aortic stenosis
• Hypertrophic cardiomyopathy
• Mitral valve prolapse
Angiography is used to determine the need or bypass surgery.

Angiography is the only
way to determine i the
patient has Prinzmetal Treatment
(variant) angina. T e standard o care or angina is:
• Aspirin
• Beta blockers such as metoprolol
In stable angina,
clopidogrel, prasugrel, • Nitrates or ongoing chest pain
and ticagrelor are used
as alternatives in those
intolerant o aspirin.
Additional Medical Therapy or Stable Angina
Med icat ion Ind icat ion
ACE inhibitors Low ejection raction (<35%) on
echocardiography
Angiotensin receptor Low ejection raction, intolerant o ACE inhibitors
blockers
Ranolazine Persistent pain despite maximum medical therapy
Statin LDL above 70 (everyone with coronary disease
should be on a statin unless intolerant.)
28
TIP
Anticoagulants (such as LMW heparin) other than antiplatelet medications
are always wrong treatments in stable angina.
a n g io pl a st y a n D b ypa ss s u r g er y
Angioplasty does not o er a mortality bene t in those with stable angina.
Angioplasty does, however, help control angina in those who have persistent Statins are acceptable
coronary disease.
symptoms despite maximal medical therapy. T e use o angioplasty automati-
cally implies that a diagnostic angiography has been done, although this can
certainly be done at the same time as the percutaneous coronary intervention
(PCI).
T e strongest indications or bypass surgery, or a coronary artery bypass gra

(CABG), are:
• T ree-vessel coronary disease with >70% stenosis in each vessel

• Le main coronary disease with >50% stenosis
• Le ventricular dys unction
Other potential indications are 2-vessel disease in a diabetic patient or severe

le anterior descending disease.
Which o the ollowing is the strongest indication or angioplasty (PCI)?

a. 80% right coronary stenosis
b. 90% circum ex and 70% right coronary stenosis
c. Three-vessel disease with greater than 70% stenosis
d. Le t anterior descending stenosis greater than 75%
e. Acute ST segment elevation MI
Answer: The correct answer is (e). The greatest mortality bene t o PCI is not based on a
particular anatomy o stenosis. The greatest bene t o PCI is obtained in the particular In stable angina, PCI is
acute presentation o an acute ST segment elevation in arction. Although PCI is requently not better than medical
done in those with 1- and 2-vessel coronary disease, the main bene t o percutaneous therapy, which includes
revascularization in chronic stable angina is or more rapid relie o symptoms and not or aspirin, beta blockers,
nitrates, weight loss,
a mortality bene t. Maximal medical therapy as the initial treatment option in chronic
smoking cessation, and
stable angina of ers the same symptomatic and mortality bene t as percutaneous coronary
statins.
intervention as an initial revascularization strategy.
Acute Coronary Syndrome

T e acute coronary syndromes (ACS) are:
• Unstable angina
• Non-S segment elevation myocardial in arction (NS EMI)
• S segment elevation myocardial in arction (S EMI)
T e major di erence in the management o ACS compared with stable angina

is the use o morphine, additional antiplatelet therapy, thrombolytics, anti-
coagulant therapy, and revascularization. When the patient presents to the
29
emergency department, initial treatment decisions are based primarily on the

Ticagrelor is used with history and the EKG. Enzyme levels are not available at the time that the initial
aspirin or ACS; alternative
to prasugrel and treatment decisions are made. T ere is nothing in the physical examination
clopidogrel. that can establish the presence o S elevation or depression, or whether the
enzymes will be elevated.
Treatment
All patients with angina should receive aspirin and beta blockers. T e main
di erence in the management o ACS compared with stable angina is the addi-
tion o :
• Clopidogrel, prasugrel, or ticagrelor
• ACE inhibitors
• Statins
• Morphine and nitrates
• Anticoagulants
• T rombolytics
Although morphine, oxygen, and nitrates are o en given rst in the temporal
sequence o management, they are not as important as additional antiplatelet
medications because o mortality bene t.
TIP
Answer “What is the most appropriate next step in management?” questions
based on mortality bene t. Let the mortality bene t drive you.
Unstable Angina and Non-ST Segment Elevation MI

You cannot tell the di erence between unstable angina and NS EMI rom
the history, physical, or EKG. T e distinction is based entirely on whether the
patient develops an elevated level o troponin or CK-MB. Enzymes do not
begin to elevate or 4 to 6 hours a er the start o chest pain and may still be
normal as long as 12 to 18 hours a er the onset o pain. Enzyme testing reaches
greater than 95% sensitivity at 12 hours, with a hand ul o patients developing
an elevation a er that.
T e main di erence in treatment between unstable angina and myocardial

Thrombolytics are not in arction (NS EMI or S EMI) is the use o :
use ul in NSTEMI.
• Heparin (yes in unstable angina)
• Glycoprotein IIb/IIIa inhibitors (epti bitide, tiro ban, abciximab)
Both o these agents work rapidly to prevent the progression or development

o a clot in the coronary artery. T ey are used routinely prior to or simul-
taneously with the use o PCI. Neither o them will dissolve a clot that has
30
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of the outside world set down in the midst of military activities. There
mother, wife, sister, sweetheart, friend could meet her soldier or
sailor lad, could spend the night if necessary and have good,
inexpensive meals. It was the scene of many impromptu weddings,
the hostess of the house and her assistants taking charge of the
arrangements, when lovers decided suddenly to be married before
the ocean and the chances of battle should separate them. The Y.
W. C. A. carried its work to France, and in its Hostess Houses there
looked after the welfare of the women workers for the American
Expeditionary Force and its canteens followed the American troops
even to north Russia, where they were established in Murmansk and
Archangel.
All of the great religious bodies of the country joined at once in the
effort to lessen for the army and navy men the hardships of war, to
surround them with as many as possible of the comforts of civilized
life and to uphold them physically, mentally and morally. People of
Protestant faith gave their support mainly to the long established and
widely reaching organization of the Y. M. C. A., members of the
Catholic Church, working through the National Catholic War Council,
supported the endeavors of the Knights of Columbus, and the
Jewish Welfare Board, with American Jewry behind it, turned its
attention especially to soldiers of that faith. And the Salvation Army,
with its years of experience in caring for the needs of humanity and
upholding morale, was early in the field. All these organizations
coöperated in the most cordial way, supplementing one another’s
effort and joining their endeavors whenever the best results could be
gained in that way, two or more of them sometimes using the same
building. The friendly hand, the good cheer, the comforts each had to
offer were ready for any man in uniform without a thought as to his
religious affiliations. Each held its religious ministrations in reserve
for those who asked for them and, for the rest, based its abundant
and many-sided service solely on the desire to help the American
Army fight the battle of justice and liberty. Their one purpose was to
big-brother the fighting forces of the nation and, whether in training
camp or debarkation port, on transport or battleship, behind the lines
in France or at the very front, to be ready with whatever help and
cheer and comfort it was in their power to give when it was wanted.
In a Red Triangle Hut in the Battle Zone
The Jewish Welfare Board was the youngest of all these
organizations, having been formed after our entrance into the conflict
for the purpose of helping to win the war by carrying out the policies
of the War Department with regard to the welfare and the morale of
the soldiers. Behind it were three and a half million citizens of the
Jewish faith and, while it functioned on its religious side for the
benefit of the 175,000 men of the Jewish religion in the Army and
Navy, in all its other activities it was nonsectarian and worked as
generously and cordially for one as for another. In the training camps
of the Army and the Navy in the United States it had many huts and
nearly three hundred field workers who arranged entertainments,
classes and study groups, provided religious services, and taught
the English language and the principles of American citizenship to
men new to America. In two hundred communities near training
stations the representatives of the Welfare Board coöperated with
the War Camp Community Service in all the phases of its activities.
Overseas it had headquarters in Paris and at the end of hostilities it
was preparing to establish others at debarkation ports and in cities
near the large camps of the A. E. F. and was ready to send a
hundred men and women workers to take charge of them. Its club
rooms in Paris were equipped with books, music, games and other
means of social enjoyment and the organization, by coöperation with
a French society, arranged to have Jewish soldiers entertained in
French homes of their own faith. Through the suggestion of the
Welfare Board a number of rabbis were commissioned as chaplains
with the fighting forces, each of them being provided with a monthly
allowance to expend upon small comforts for his boys. They held
Jewish holyday services back of and almost in the front line
trenches, in cities and villages, once in the ruins of a Roman Catholic
Cathedral and again in a large Y. M. C. A. hut. At one service, at
which the rabbi, coming from another sector, arrived a little late, he
found that the local Knights of Columbus Chaplain had kept the
meeting together for him and opened it with a preliminary prayer.
The National Catholic War Council, organized to direct the war-
aiding activities of all Catholic forces, operated a million-dollar chain
of Visitors’ Houses at army and navy training camps and of service
clubs in communities and embarkation ports, where it worked in
coöperation with the War Camp Community Service. Under its
supervision was the society of the Knights of Columbus which, at the
close of hostilities, had in the United States several hundred
buildings and 700 secretaries and overseas more than a hundred
buildings and huts, with many more in preparation, and over 900
workers. It had service clubs in London and Paris which provided
reading, lounging and sleeping rooms, and all such club comforts,
while its huts behind the lines furnished centers of comfort, cheer,
entertainment and small services of many sorts. It operated a great
fleet of motor trucks which carried supplies up to the firing line and
into the front trenches. Nothing was more welcome to the battle-
weary soldiers relieved from front line duty than these “K. C.” rolling
canteens with their hot drinks, cigarettes and other comforts. The
organization shipped to the other side and gave to soldiers and
sailors many tons of supplies, including cigarettes by the hundreds of
millions and huge amounts of chewing gum, soap, towels, stationery,
candy and chocolate. It had more than a hundred voluntary
chaplains on service with the troops, many of whom carried money
furnished by the society to aid in providing comforts for the welfare of
the soldiers.
The Salvation Army won a peculiar place in the hearts of our
fighting men by the simple hominess and complete self-abnegation
of its service. Its huts and hostels were in all the important training
camps at home, while overseas the Salvation Army uniform in some
kind of a structure or dugout welcomed the army lad in the big camp
areas, in the supporting lines and in the forward troop movements up
to the rear of the front line forces and trenches. It had overseas more
than 1200 officers, men and women, operating 500 huts of one sort
or another, rest rooms and hostels. It had forty chaplains serving
under Government appointment and it supplied nearly fifty
ambulances. Its method was to put a husband and wife in charge of
a canteen or hut, the man making himself useful in any way that
offered, the woman making doughnuts and pies, chocolate and
coffee for the ever hungry doughboys, and doing for them whatever
small motherly service was possible. In their huts the men could
always find warmth and light and good cheer, music and games and
good things to eat that were touchingly reminiscent of boyhood and
home. Shells screamed overhead, gas floated back from the front
and the earth shook with the roar of battle, but the Salvation Army
workers stood to their self-imposed duties regardless of their own
comfort or danger and had ready for the long lines of soldiers coming
and going a smiling, heartfelt welcome and huge quantities of pies
and doughnuts and hot drinks. Its canteens were always open, day
and night, and none of its workers was sent overseas without special
training.
By far the largest, oldest and most important of these welfare
organizations was the Young Men’s Christian Association, which
expanded a total of nearly $80,000,000 on a system of war service
so vast that the sun was rising upon it through every hour of the day.
Within a few hours after the United States entered the war the Y. M.
C. A. offered its entire resources to the Government. At the end of
hostilities it had overseas over 7,000 workers, of whom 1,600 were
women; in the American Expeditionary Forces it had 1,900 war
service centers, nearly 1,500 in the French armies, several hundred
in Italy, with more in Russia and Siberia; in the United States it had
950 of these centers and 6,000 workers and it was represented in
every cantonment and training camp for Army or Navy from end to
end of the country. On this side, it paid for its huts and their
equipment a total of more than $6,000,000, while overseas the
similar expenditure went beyond $5,000,000, making a total of well
over $11,000,000 invested in the equipment with which to give our
soldiers and sailors rest and cheer, entertainment and comfort. The
cost of the operation of these centers amounted, for the duration of
the war, to over $6,550,000.
In the home camps and cantonments the “Y” centers had an
average of nearly 20,000,000 visits from soldiers and sailors per
month, while in them at the same time were written letters on free
Red Triangle stationery numbering more than 14,000,000 and its
entertainments, lectures and motion picture shows were attended by
5,000,000 men. It established and carried on thousands of
educational classes, French being the most popular study. Its work
was especially valuable in the education of illiterates and of
foreigners who did not understand English. Some 50,000 who could
not read or write when they entered the training camps received in
this way the rudiments of a common school education. On troop
trains and transports the “Y” workers were present, giving whatever
service the conditions made possible.
Overseas the hut of the Red Triangle was to be found wherever
there were American fighting men—in England, Ireland, Scotland, in
France and Italy, Russia and Siberia, from Gibraltar to Vladivostok,
from the Caucasus to the Murman coast. Sometimes the “hut” was a
dugout, sometimes a ruined chateau, again it was a freight car on a
siding, or a temporary shack, or a substantial building. But, whatever
its form and appearance, it stood for home, for the democratic social
fabric for which the men were fighting, and within it they could
always find light and warmth, cheer and good fellowship, books,
games, music, entertainment, smokes and toothsome dainties.
Motion picture films for the Y. M. C. A. to the average length of
fifteen miles were shipped every week, and at its moving picture
shows there was an average weekly attendance of 2,500,500.
Scores of actors and actresses canceled their engagements and
went overseas to interest and amuse the soldiers and sailors with
performances of all kinds on the hut circuit, organized and directed
by the Over-There Theater League, under the Y. M. C. A. During the
latter months a hundred performances daily, on the average, were
put on in the various camps. None of the players received a salary
and shows of all kinds were free. There were concerts, lectures,
readings, as well as movies and every kind of theatrical
performance. A department of plays and costumes maintained in
Paris sent out to the camps facilities for amateur performances and
fifty professional coaches went from the United States to encourage
and train the soldiers to produce entertainments of their own. Violins,
banjos, mandolins, ukeleles and cornets were sent over by the
thousands, to say nothing of smaller instruments and sheets of
music.
To provide for athletics and physical recreation for the soldiers and
sailors overseas the Y. M. C. A. expended more than a million and a
half dollars. It sent over 1,200 sports leaders and its shipments
included huge quantities of baseballs and bats, boxing gloves,
footballs, ping-pong balls, racquets, nets, tennis balls, running
shoes, and all the paraphernalia of indoor and outdoor sports, to the
value of $2,000,000, which were free for the asking.
The post canteens of the army were taken over by the Y. M. C. A.,
at the urgent request of the commander of the American forces and
against its own desire, and operated throughout the war. This
entailed the running of a huge merchandising proposition foreign to
its customary activities and the work was assumed in addition to its
chosen program of fostering the morale and cherishing the welfare of
the fighting forces. For this post exchange service it furnished
buildings and service without charge and sold to the soldiers at cost
goods to the value of $3,000,000 per month. Its workers often
carried packs of goods into the trenches and distributed them freely.
Because it was all a question of service the organization itself bore
the very considerable loss at which it operated the canteens.
A system of “leave-areas” conducted by the Y. M. C. A. provided
recreation for the men on the seven days’ furlough given to each one
after four months of service. It was not thought desirable by the
military authorities to turn the men loose for their holiday and
therefore several resorts were taken over to furnish interesting
places for them to visit and were put into the hands of the Y. M. C. A.
as hosts and entertainers. Aix-les-Bains was the first and twenty-five
others were added until the men had a wide range of selection
ranging from famed resorts in the Alps to others on the shores of the
Mediterranean. It was a kind of entertainment that had to be created,
for it was entirely without precedent. Largely in the hands of women
workers in the Y. M. C. A., they and their men helpers and advisers
bent their utmost endeavor, resourcefulness and loving care to the
work of giving the men a good time and sending them back to their
duties at the end of their leaves physically and mentally refreshed.
Each area had its athletic field in which every day there were sports
going on and there were mountain climbs, picnics, bicycle rides, and,
in the evening, movies, theatrical entertainments, concerts, music
and dancing.
The women’s contingent of the Y. M. C. A. did effective work both
in these leave areas and in the canteens. Their service was not
enlisted until a year after our entrance into the conflict, but at the end
of hostilities a thousand women were engaged in it, and so insistent
was the call for them that they were recruited as rapidly as possible,
a thousand more being sent over during the next three months. They
were given a week or more of intensive training before sailing to fit
them for the duties they would have to undertake.
Unique in all army as well as in all educational history was the
great educational system which the Y. M. C. A. undertook to
establish, under the authority and with the coöperation of the War
Department. Beginning in the home camps, it was carried across the
sea, developed more and more as time went on, and found its climax
in the “Khaki University.” The final and complete plans were ready
only in time for use with the Army of Occupation in Germany and in
the camps abroad and at home in which the men waited for
demobilization, when $2,000,000 worth of text-books had been
ordered for the work. Some of the foremost educational experts of
the United States, numbering several hundred, were engaged in the
organizing and supervision of the system and many hundreds of
others, members of the alumni and faculties of American educational
institutions who were enrolled among the fighting forces, undertook
the work of instruction. The scheme enabled soldiers and sailors to
continue their studies without expense, whether they desired
elementary, collegiate or professional instruction or agricultural,
technical or commercial training. The scheme, which was finally
taken over by the Army, is described at more length in the chapter on
“The Welfare of the Soldiers.”
So successful and important was the work of the Y. M. C. A. with
the American forces that both the French and the Italian
Governments requested it to establish service centers with their
respective armies. This it did, the American workers who initiated
and supervised the program of recreation and fostering of morale
being assisted, in the respective armies, by French and Italians.
A Pleasant Evening in a Hostess House

Salvation Army Lassies at the Front
The prodigious program of the Y. M. C. A. with the American
forces, which it has not been possible to more than outline, was
carried through largely by volunteer workers who wished to
undertake it as the best way in which they could help to win the war.
Men who were too old to fight or were physically unfit for military
service joyfully welcomed the opportunity to do something that would
aid the fighting men. Many gave up large salaries and left their
situations for the sake of this important service. Others who were
financially unable to leave dependents accepted for them an
allowance much smaller than they could have earned themselves
and gladly took up the work upon the mere payment of their
expenses.
The “Y” workers were on the troop trains that carried the men from
their homes to the training camps and the Red Triangle was at the
fighting man’s side from that moment until he was ready to go over
the top. And sometimes the “Y” worker even went forward in the
charge with the men for whose welfare he was giving his service.
Shell fire not infrequently destroyed the trucks upon which the goods
of the Y. M. C. A. were being carried to the front, its huts were
sometimes shattered in the same way and nine of its workers, two of
them women, were killed by bursting shells. Fifty-seven died in the
service, most of them from wounds, over-work and exposure.
Twenty-three were seriously injured or gassed. Of its workers 152
received official recognition for distinguished services, to thirteen of
whom was awarded the Croix de Guerre and to fifty more other
famous decorations.
The American Army was a reading and thinking army and that one
of the seven great big-brothering organizations which undertook to
supply it with reading matter, the American Library Association, was
kept busy. The Library War Service of the Association had in each of
forty-eight large army and navy training camps and in seventy
hospitals in the United States a central library building, or library
quarters, with branches and stations radiating all over the camp or
hospital area to render its volumes easy of access. It had collections
of books in nearly two hundred hospitals and Red Cross Houses. It
equipped with these collections over five hundred military camps and
posts and aviation fields, schools and repair depots. It supplied with
libraries 260 naval and marine stations and 750 vessels. It had
nearly 2,000 branches and stations placed in Y. M. C. A. and K. of C.
huts, barracks and mess halls. It shipped overseas 2,000,000 books
and 64,000 magazines and distributed 5,000,000 magazines
donated by the public through the mails. In its war service libraries
there were over 5,000,000 volumes. Three hundred and forty trained
librarians supervised its service. Accepted books to the number of
4,000,000 were given by the American people, who provided also
the money with which were bought 1,300,000 more. Book donations
were well sifted before the books were accepted for war service and
the authorities of the association estimated that probably twice as
many were given as were finally used.
But even these enormous quantities of books and magazines were
no more than sufficient to meet the desire for reading shown
throughout the Army and the Navy. The Library War Service of the
Association did its best to supply to every fighting man in the training
camps at home, on the transports, on the cruisers and battleships, in
the stations overseas, in the camps and rest billets, the book he
needed when he wanted it, whether it was light fiction, or a technical
treatise, or a work of history, economics, philosophy or travel. It
supplied books in practically all the modern languages—about forty
were represented in each of the large camps—for both study and
reading and its lists were filled with titles of scientific, technical and
other works that covered the whole range of modern knowledge and
activity, philosophy, literature, history, biography, poetry, art, music,
fiction, drama, economics, sociology, business, travel. There was
demand for them all. Toward the end of the war and after the
armistice the Library War Service bent its energies to meeting the
greatly increased call for vocational books that would enable the
fighting man to become more efficient in his special job or to get a
better one when he should presently be returned to civil life.
To support this vast enterprise of big-brothering the Army the
American people gave without stint to the organizations by which the
work was systematized and carried through. They gave money and
effort and thought and love, because it was for “our boys.” They
responded with more than was asked by each organization in its
separate appeals made during the first year and a half of our war
effort. Then, in order that the appeal for funds might be made more
efficiently and economically, the seven chief organizations united in a
great, nation-wide drive, the money that was subscribed to be
divided proportionately among them. They asked for $170,000,000.
All the preparations had been made for it before the armistice was
signed and it began on that day. Every one believed that the war was
over, but because “our boys” were still overseas and for many weeks
to come would need care, recreation, comforts and entertainment,
no hand withheld its gift. When the week’s drive was over it was
found that $203,179,000 had been subscribed to continue the work
of big-brothering the fighting forces.
CHAPTER XXXII
RUNNING THE RAILROADS
During the first nine months of our participation in the war the
railroads did their best to meet the unusual and mounting demands
upon their facilities and methods. But the entire railroad system had
developed under the principle of competition and, composed as it
was of so many diverse parts and divergent interests, all
accustomed by theory, tradition and practice to competitive methods,
it presently became evident that the coördinated management and
coöperative effort demanded by the emergency would be impossible
under continued private control. The immense increase in traffic
caused by war conditions had strained the existing system to its
utmost effort, and had resulted by the autumn of 1917 in hopeless
congestion of freight at eastern terminals and along the railway lines
far inland. There had been such rapid increase in operating
expenses that the financial situation of the railroads was very bad,
and, under the general financial conditions of the time, had become
a serious menace. The country was at war and its first and most
pressing duty was to prosecute that war to early and complete
victory, which it could not do under the paralysis that was threatening
the transportation system.
For the Government to take control of the railroads was an almost
revolutionary procedure, so opposed was it to American economic
theory, conviction and practice. But the problem was rapidly being
reduced to the bare alternatives of governmental railroad control or
the losing of the war, or, at least, its long-drawn out continuance. But
one solution was possible, and, disregarding all theory and all deeply
rooted custom, the President, in accordance with powers already
conferred upon him by Congress, took possession and assumed
control of the entire railroad system of the United States at the end of
December, 1917.
Management of transportation by rail and water was thereupon put
into the hands of a Director General of Railroads, who thus found
himself at the head of more than 265,000 miles of railway, many
times the mileage of any other nation, and of 2,300,000 employees.
There were about 180 separate operating companies having
operating revenues of $1,000,000 or more per year each and several
hundred more with less than that yearly revenue. The Railroad
Administration, which decentralized its work by dividing the country
into districts, each under a regional director, began its task in the
face of weather conditions without parallel in the history of the
country, which had already almost paralyzed transportation and were
to continue for ten weeks longer.
There was a shortage of freight cars and of locomotives and the
railroads, in common with all the country, were menaced with a
shortage of coal, due mainly to the immensely increased demand
and the breakdown of transportation. So great was the congestion of
freight that in the area north of the Potomac and Ohio Rivers and
east of Chicago and the Mississippi there were 62,000 carloads
waiting to be sent to their destination, while along the lines west and
south of that area there were over 85,000 more carloads held back
by this congestion. Nearly all of it was destined for the eastern
seaboard north of Baltimore.
In addition to the usual transportation business of the country,
hundreds of thousands, mounting into the millions, of soldiers had to
be carried from their homes to cantonments and from cantonments
to ports of debarkation and billions of tons of munitions, food,
supplies and materials of many kinds had to be carried from all parts
of the country upon lines that converged toward eastern ports, while
the immense war building program of the nation—cantonments,
camps, munition plants, shipyards and ships, warehouses, structures
of many sorts—called for the transportation of vast quantities of
material.
By the first of the following May practically all of this congestion
had been cleared up and through the rest of the year there was no
more transportation stringency, although traffic grew constantly
heavier until the end of hostilities. It will illumine the conditions under
which the Railroad Administration achieved its results to mention a
few of its items of transportation. During the ten months ending with
October it handled 740,000 more cars of bituminous coal than had
been loaded during the same period of the previous year. From the
Pacific Northwest there were brought, from April to November, for
the building of airplanes, ships and other governmental activities and
for shipment overseas, 150,000 cars of lumber. During the year
630,000 cars of grain were carried to their destination, the increase
from July to November over the previous year being 135,000 cars.
Livestock movement was especially heavy, showing in all kinds a
large increase. Five hundred and sixty thousand carloads of material
were moved to encampments, shipyards and other Government
projects. From the middle of May to the end of the year the car-
record office showed a total movement of 1,026,000 cars, an
average of 5,700 daily.
Comparison of the physical performance of the roads during the
first ten months of 1918 with that of the similar period in 1917,
reduced to fundamentals, showed an increase in the number of ton-
miles per mile of road per day, in number of tons per loaded car, in
number of tons per freight train mile, in total ton-miles per freight
locomotive per day. The constant purpose was to keep each
locomotive and car employed to its capacity and to make each
produce the maximum of ton-miles with the minimum of train,
locomotive and car miles.
Highly important among the achievements of the Railroad
Administration was the movement of troops. From the first of the
year until November 10th there were transported over the roads
6,496,000 troops, an average of 625,000 per month, the troop
movements requiring 193,000 cars of all types, with an average of
twelve cars to the train. Outstanding features of the troop movement
were that 1,785,000 men were picked up from 4,500 separate points
and moved on schedule to their training camps, that 1,900,000 were
brought into the crowded port terminals for embarkation without
interference with the heavy traffic of other kinds already being
handled there and in the adjacent territory, that 4,038,000 were
carried an average distance of 855 miles, undoubtedly the largest
long distance troop movement ever made. During one period of thirty
days over twenty troop trains were brought each day into the port of
New York. During the entire period from January to November
including these huge troop movements there were but fourteen train
accidents involving death or injury to the men.
To all the necessities of the wartime effort of the railroads—the
enormously increased quantities of freight that had to be moved
expeditiously and the transportation of troops—was added a
considerable increase in the ordinary passenger traffic.
Notwithstanding the earnest and repeated requests of the Railroad
Administration that only necessary journeys should be taken by
civilians, a request that was, indeed, very generally heeded, and the
increase in passenger rates, the passenger traffic all over the
country was much heavier than in any previous year, the increase
amounting in the region east of Chicago to twenty-five per cent.
The efficient handling of all this enormous freight and passenger
traffic was made possible by the policies that were adopted. The
handling of the whole vast network of railroads as one system
eliminated competition and the wasteful use of time, effort and
equipment. The previous usage of the roads in accepting freight at
the convenience of the consignor without regard to the ability of the
consignee to receive it had resulted in the appalling congestion of
terminals and lines in the autumn of 1917. The Railroad
Administration based its policy upon the principle that the consignee
must be considered first and that if he could not receive the freight it
was worse than useless to fill up switches and yards with loaded
cars. In order thus to control traffic at its source a permit system was
adopted which prevented the loading of traffic unless there was
assurance that it could be disposed of at its destination. This policy
proved to be the chief factor in the ability of the transportation
system to meet the enormous demands upon it.
Modification of demurrage rules and regulations induced more
rapid unloading of cars and their quicker return to active use.
Consolidation of terminals, both freight and passenger, greatly
facilitated the handling of cars. Locomotives that could be spared
were transferred from all parts of the country to the congested
eastern region. Coördination of shop work increased the amount of
repairs upon equipment that could be done and kept locomotives
and cars in better condition while new ones were ordered and work
upon them speeded. Rolling stock and motive power were
economized by doing away with circuitous routing of freight and
sending it instead by routes as short and direct as possible, a policy
which saved almost 17,000,000 car miles in the Eastern and
Northeastern Region.
A plan was devised for making up solid trains of live stock and of
perishable freight and also consolidated trains of export freight at
Western points and forwarding them on certain days of the week
directly and rapidly to their destinations. Passenger trains that had
been mainly competitive and such others as could be spared were
dropped, resulting in the elimination during the first seven months of
Federal control of 47,000,000 passenger train miles—an economy in
motive power and equipment without which the successful
movement of troops would have been impossible. Equipment was
standardized, making possible its universal use, and freight cars
were more heavily loaded. In place of the separate ticket offices
made necessary by private and competitive ownership consolidated
ticket offices were opened in all large cities, 101 of these doing the
work of the former 564. The result aimed at was both economy and a
better distribution of the passenger traffic.
The Railroad Administration saw in the inland and coastal
waterways and the coastwise shipping service an important possible
aid in its task of making transportation equal to wartime needs, and
so mid-Western rivers and Eastern canals were brought into
coöperation with railway service and several coast-wise lines of
steamships were made a part of its facilities.
The rental, or return, guaranteed to the railroad companies
amounted for the year approximately to $950,000,000. Upon the
advice of a commission appointed to investigate the matter of wages
and living costs among railroad employees, wages were raised and
threatened labor trouble thereby averted, the increase amounting to
between $600,000,000 and $700,000,000 for the year. In the ten
months ending November 1st the railroad receipts from freight,
passenger and other sources aggregated over $4,000,000,000 and
were almost as large as for the whole of the previous year. The
receipts were greater by 20 per cent, but operating expenses also
had increased by more than $1,000,000,000, the year 1918 breaking
all records for both revenues and expenses. The increase in wages,
in cost of coal, and in all maintenance and operating costs was
responsible for the increase of expenses, which would have been
much greater but for the economies introduced. Freight rates were
raised during the year to help meet the raise of wages, while a
substantial increase in passenger rates was put in force both to help
in that result and to discourage unnecessary passenger traffic during
wartime conditions. There was a final balance against the
Government, as between the net income of the roads and the
guaranteed return to their owners, of between $150,000,000 and
$200,000,000.
The sole purpose of the Government in taking over control of the
railroads was to achieve a more efficient prosecution of the war by
more rapidly forwarding our own war effort and by giving more
effective coöperation to our war associates. Thus, early in the winter
of 1918 the Western Allies made it known to the United States
Government that unless the food promised by the Food
Administration could be delivered to them very soon they could not
continue their war effort. This was immediately after the Railroad
Administration had taken charge of the railroads and was struggling
with the freight congestion extending through the eastern half of the
country, with coal shortage and blizzard weather. Every possible
facility of the Railroad Administration and of the roads it was
operating was brought to the emergency, and railroad officials and
employees worked day and night, with the results that by the middle
of March all the available vessels of the Allies had been filled with
food and dispatched across the Atlantic, while at Eastern seaports
were 6,000 more carloads ready for later shipment.
In carrying out this war-furthering purpose the Railroad
Administration coöperated constantly with the other war
administrative and war prosecuting agencies of the Government, the
Food and Fuel Administrations, the War Trade and War Industries
Boards, the Shipping Board, the Army and Navy Departments. Just
as food, fuel, trade, industry, labor were each and all mobilized for
war effort and all brought into harmonious and effective teamwork,
so the transportation agencies were all bent, first of all, to the same
purpose. Roads, motive power, freight and passenger equipment
were devoted first to the necessities of carrying men from homes to
cantonments and camps and thence to ports of embarkation and of
moving food, munitions, supplies and raw materials to camps, to
shipment points and to places of manufacture for war purposes.
After these war needs were met whatever remained of transportation
facilities was at the disposal of the ordinary commercial traffic of the
country.
In order that the public might better understand the situation and in
order also to better the service of the roads there was instituted a
Bureau of Complaints and Suggestions which dealt with all
dissatisfactions and considered suggested improvements. A very
large number of the railroad employees of all kinds, efficient through
years of service, joined the fighting forces of the nation or engaged
in work more directly concerned with the war and so made it
necessary to fill their places with untrained help. To remedy this
condition training schools were established with successful results.
In the summer of 1918 all express companies were combined and
placed under the management of the Railroad Administration and a
little later telegraph and telephone companies, because of their
refusal to accept an award of the War Labor Board, were unified and
placed under the control of the Postmaster General, as, in the
autumn, was done also with the cable companies.
CHAPTER XXXIII
THE WORK OF WOMEN FOR THE WAR
While the women of the United States did not enter war service by
means of work in industries and auxiliary organizations to the extent
of their enlistment in England, because the man-power problem had
not yet, at the end of hostilities, become serious in this country, the
many and varied kinds of work for the war in which they did engage
was of great importance and it had the devoted and enthusiastic aid
of almost every woman and girl throughout the land. From the
mother who sent her sons across the ocean to the little Girl Scout
who ran errands for a Red Cross chapter, they were ready for any
sacrifice it should be necessary for them to make and any service
they could render. Their spirit was as high, their patriotism as ardent
and their wish to serve as keen as that of their husbands, fathers
and brothers, and their spirit and their service were essential factors
in the war achievements of America. Their spirit was always the
same, but their services were of the greatest variety, being, for the
greater part, such as they could render without leaving their homes.
Being undertaken in addition to their usual duties in the care of
homes and families, their war labors were less outstanding and
much less likely to impress the superficial observer than if they had
been detached from woman’s usual environment. But they were
none the less essential.
The shutting down or curtailment of non-essential industries and
the rapid expansion of those directly or indirectly engaged in war
production shifted many women already possessing some degree of
industrial training into war work plants of one sort or another, while
the need for workers and the desire to give service of direct
consequence led many women to enter factories who had not before
undertaken industrial work. Among the latter class were many of
collegiate education, or of independent means, or engaged in office
work who were moved by patriotism to undertake factory work for the
war. The flow of women into war industrial work increased steadily
throughout the year and a half of our participation and would have
been very greatly augmented if the war had continued long enough
to call the men of the second draft from their situations.
By the end of September, 1918, women were working in munition
plants of many kinds, making shells, grenade belts, fuses, gas
masks, metal parts of rifles, revolvers and machine guns, and many
other sorts of the direct supplies of war. Accurate statistics of their
numbers made in the early summer of 1918 showed that about
1,500,000 women were engaged in the industrial work directly or
indirectly connected with the Government’s war program, while
subsequent estimates added about 500,000 to that number to cover
those entering such work down to the signing of the armistice.
Woman’s Land Army Members Sorting and Grading

Potatoes

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Essential Learning for the Internal

Medicine Clerkship 1st Edition Conrad

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Conrad Fischer, MD, is a Program Director in Internal Medicine in New York

How to Use this Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix

CHAPTER 1: General Internal Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

APPENDIX: Abbreviations and Mnemonics . . . . . . . . . . . . . . . . . . . . . . . . . . 423

1. What is the most likely diagnosis?

• Everything you are learning here is use ul to help people.

My suggestion on how to use this book is:

1. Study one subject as a time.

What Do I Do if I Hate Certain Subspecialties?

In a homogenized world where everyone is supposed to be the same, we as

T is book is the culmination and the result o decades o classroom experience

And that is a mighty ne thing to do in this li etime!

Is My Ro t a t io n Exper ienc e Eno ugh ?

It doesn’t matter i you do a 300-year-long rotation in a great school. It is not

Dr. Conrad Fischer

T e layout is primarily presented as an outline, mostly with the use o short

Dr. Conrad Fischer

Whose Recommendations Are You Tested On?

For example, USPS F states clearly that there is no de nite recommenda-

How Does the Test Handle Controversial or Unclear Areas o

Which o the ollowing statements concerning prostate cancer is correct?

How Do I Answer Questions Concerning Recommendations

c a n cer Scr een In G

Prophylactic Tamoxifen and Raloxifene Prevent Breast Cancer

T e bene ts o the prophylactic use o tamoxi en were clearly measurable even

Li etime Risk o Developing Breast Cancer in a Woman with No Children

T is table demonstrates the enormous increase in risk because o a amily

I , or a 40-year-old woman with 2 relatives with cancer, we add in:

• Giving birth be ore age 20

T e li etime risk o breast cancer rises to 43%.

Special Circumstances or Colon Cancer Screening

Which o the ollowing results in the greatest bene t?

Cancer Tests That Are Never the Right Answer

d Ia bet eS, Hyper t en SIo n , Hyper l IpId eMIa ,

Abdominal Aortic Aneurysm

3. Exercise with high-impact physical activity. Running, stair-climbing, and

Alt er n At e t h er Apy (l ess evid en ce t h An Bisph o sph o n At es )

• eriparatide: an analogue o P H that increases new collagenous bone

Diseases Not to Be Routinely Screened (The Wrong Answers)

• Chronic liver disease

Hepatitis A vaccine is recommended or those traveling to countries with an

Inf uenza Vaccine

high-risk groups by asking: “Which o the ollowing groups is most likely to

T e rst type o pneumococcal vaccine to be administered is the 13 polyvalent

• Functionally (sickle cell) or anatomically asplenic

Papilloma Virus Vaccine

I there is evidence o cord compression such as ocal neurological ndings,