Maintaining Certification in Internal Medicine

Keeping Up with Medical Certification

The American Board of Internal Medicine (ABIM) requires that all internists or specialists who received their internal medicine certification during 1990 or later must complete the certification maintenance program every 10 years. The current fee to maintain your certification is $1135.

The 3 requirements for maintaining certification are:

• Verification of current medical credentials.

• Self-evaluation using at-home components involving medical knowledge modules, medical knowledge learning sessions, and practice performance.

• A secure examination in your discipline.

Practice improvement module demonstrations are now available on the ABIM website www.abim.org/online/pim/demo.aspx

QUESTIONS

1. A 42-year-old man is evaluated after his first episode of renal colic from a ureteral stone. He is presently asymptomatic and has no comorbid conditions. Laboratory analysis of the stone revealed it to be calcium oxalate. The 24-hour urine collection showed a pH level of 6.0, with high oxalate levels and normal levels of calcium, urate, citrate, sodium, phosphate, and creatinine.

In addition to liberal fluid intake to generate a daily urine output of 2 L, which dietary recommendation would reduce his risk for recurrent stones?

A . Decrease purine intake

B . Decrease sodium intake to <3 g/day

C . Increase dietary calcium intake

D . Begin low-dose thiazide diuretic therapy

E . Avoid all calcium supplements

2. A 76-year-old man is evaluated in the nephrology outpatient clinic for refractory anemia. His medical conditions include diabetes mellitus, hypertension, coronary artery disease, and end-stage renal disease requiring maintenance hemodialysis 3 times a week. His medications include aspirin, lisinopril (eg, Prinivil, Zestril), insulin (Novolin R), lovastatin (Mevacor), metoprolol (Lopressor), and sevelamer (Renagel). He also receives 5000 units of subcutaneous erythropoietin (EPO; Procrit) every week. His complete blood cell count shows a hemoglobin level of 9.5 g/dL and hematocrit of 28%, with a normal mean corpuscular volume.

What is the next step in the management of his anemia?

A . Check for antierythropoietin antibodies

B . Obtain a bone biopsy to exclude aluminum-induced toxicity from the dialysate

C . Colonoscopy to look for an occult gastrointestinal source of blood loss

D . Bone marrow aspiration to investigate for a primary hematologic malignancy

E . Check serum iron, ferritin, total iron-binding capacity, and folate levels to estimate iron/folate storages

3. A 23-year-old female ballet dancer presents to her primary care physician with complaints of pain in the sole of her left foot near the heel that first occurred 3 weeks earlier. The pain occurs when she stands up and worsens with walking and dancing. It is especially painful when she takes the first few steps after getting up in the morning or after resting between training sessions. The exam is unremarkable, with the exception of an area with point tenderness on the bottom of her left foot near the heel.

She has recently been selected to dance in her first lead role in a major production. Since rehearsals started 6 weeks ago, she has significantly increased the amount of hours she dances every day.

So far the pain has not limited her ability to perform, but she is worried that it may represent a severe injury and could potentially jeopardize her career.

What is the most appropriate next step?

A . Magnetic resonance imaging (MRI) of her foot and ankle to rule out a stress fracture of the os calcaneum

B . Ordering x-rays of both feet and referral for urgent orthopedic evaluation

C . Reassurance; recommend plantar stretching exercises, nonsteroidal antiinflammatory drugs (NSAIDs) as needed, and schedule a follow-up visit in 2 to 3 weeks

D . Tell the patient she should stop dancing to avoid further injury and that she should immobilize the foot for 4 to 6 weeks

4. A 78-year-old man has biopsy-proven prostate cancer with metastatic lesions to the spine and a serum prostate-specific antigen (PSA) level of 24.2 ng/mL. After 6 months of antiandrogen therapy with leuprolide (Eligard, Lupron), the PSA level becomes undetectable. Leuprolide therapy is continued for 1 year, and the PSA is rising again, currently to 15 ng/mL.

In addition to second-line hormonal therapy and chemotherapy, which agent should be considered to reduce the risk of pathologic spinal fracture?

A . Calcium

B . Vitamin D

C . Calcium and vitamin D

D . Zoledronic acid (Zometa)

E . Hydrocortisone

5. A 55-year-old woman is diagnosed with stage IIIA (T1N2M0) invasive ductal carcinoma of the right breast. Treatment is initiated with 4 cycles of doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan), followed by surgery and radiation. One year after completing her initial treatment, she pre-sents with new-onset right arm weakness. Physical exam confirms a focal weakness of the right arm. A computed tomography scan of the brain is ordered, which reveals a single metastasis in the left frontoparietal lobe.

What is the most appropriate next step?

A . Radiation to the metastatic lesion

B . Radiation to the metastatic lesion, followed by chemotherapy

C . Whole brain irradiation

D . Metastatectomy followed by whole brain radiation

E . Metastatectomy alone

6. A 68-year-old man in your primary care practice presents to the office, reporting he had undergone a PSA screening test at his church, and his PSA level was 2.9 ng/mL. One of his friends was recently diagnosed with prostate cancer, and he is anxious to know how to reduce his risk of developing prostate cancer.

After performing a rectal exam, which is normal, which of the following strategies would you tell the patient is the only approach that has been shown to reduce the incidence of prostate cancer?

A . Random prostate biopsies for early detection of cancer

B . Daily use of saw palmetto

C . Prophylactic therapy with finasteride (Proscar)

D . Weight loss

E . Diet supplemented with flaxseed oil

7. A 60-year-old woman with a history of hypertension presents with episodes of chest pain. She has had 3 episodes in the past 3 weeks, each lasting approximately 5 minutes and occurring spontaneously at a different time of the day. The physical examination findings, electrocardiogram (ECG), and cardiac biomarkers were within normal limits. She was admitted for a 24-hour observation. The following morning she reported having chest pain. Repeat ECG showed 4-mm ST elevation in leads V₁, V₂, and V₃. The patient was given sublingual nitroglycerine, and the pain resolved within 1 minute. The ECG tracing returned to normal after the pain resolved. No rise in cardiac biomarkers was evident. Her fasting lipid profile showed a low-density lipoprotein level of 150 mg/dL. A cardiac catheterization revealed no occlusive disease.

In addition to considering a statin for the patient&#8217;s hypercholesterolemia, what class of medication is likely to help control the patient&#8217;s chest pain?

A . Angiotensin-converting enzyme (ACE) inhibitor

B . Calcium channel blocker

C . Beta-blocker

D . Thrombolytic

8. A 50-year-old woman who is new to your practice comes in for a routine checkup. She reports a history of gastroesophageal reflux disease, as well as a murmur that has never caused her problems. She underwent a stress test 1 year ago to evaluate her epigastric pain, but no evidence of ischemia was found. Physical examination reveals a loud holosystolic murmur in the apex. The patient is referred for an ECG, which shows moderate mitral regurgitation, with a left ventricular (LV) ejection fraction of 45%. What would be the most appropriate treatment strategy for this patient?

A . Vasodilator therapy

B . Biventricular pacemaker

C . Refer for evaluation for mitral valve surgery

D . Reevaluate in 1 year

E . Refer for surgery when she becomes symptomatic

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