Mayo Clinic Internal Medicine Review 2006-2007 SEVENTH EDITION pot

Mayo Clinic
Internal Medicine Review
2006-2007
SEVENTH EDITION
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Editor-in-Chief
Thomas M. Habermann, MD
Co-Editor
Amit K. Ghosh, MD
Associate Editors
Deborah J. Rhodes, MD
Amit Sood, MD
Narayana S. Murali, MD
Randall S. Edson, MD
Dennis K. McCallum, PharmD
Mayo Clinic
Internal Medicine Review
2006-2007
SEVENTH EDITION
MAYO CLINIC SCIENTIFIC PRESS
TAYLOR & FRANCIS GROUP
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ISBN 0849390591
The triple-shield Mayo logo and the words MAYO, MAYO CLINIC, and
MAYO CLINIC SCIENTIFIC PRESS are marks of Mayo Foundation for
Medical Education and Research.
©2006 Mayo Foundation for Medical Education and Research.
Printed in Canada.
All rights reserved. This book is protected by copyright. No part of it may be

reproduced, stored in a retrieval system, or transmitted, in any form or by any
means—electronic, mechanical, photocopying, recording, or otherwise—
without the prior written consent of the copyright holder, except for brief quo-
tations embodied in critical articles and reviews. Inquiries should be addressed
to Scientific Publications, Plummer 10, Mayo Clinic, 200 First Street SW,
Rochester, MN 55905.
For order inquiries, contact Taylor & Francis Group, 6000 Broken Sound
Parkway NW, Suite #300, Boca Raton, FL 33487.
www.taylorandfrancis.com
Catalog record is available from the Library of Congress
Care has been taken to confirm the accuracy of the information presented and
to describe generally accepted practices. However, the authors, editors, and
publisher are not responsible for errors or omissions or for any consequences from
application of the information in this book and make no warranty, express or
implied, with respect to the contents of the publication. This book should not
be relied on apart from the advice of a qualified health care provider.
The authors, editors, and publisher have exerted efforts to ensure that
drug selection and dosage set forth in this text are in accordance with current
recommendations and practice at the time of publication. However, in view
of ongoing research, changes in government regulations, and the constant
flow of information relating to drug therapy and drug reactions, the reader is
urged to check the package insert for each drug for any change in indications
and dosage and for added warnings and precautions. This is particularly impor
-
tant when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food
and Drug Administration (FDA) clearance for limited use in restricted research
settings. It is the responsibility of the health care providers to ascertain the
FDA status of each drug or device planned for use in their clinical practice.
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DEDICATED TO
All students of medicine, whatever their level of experience
and whatever their needs
v
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FOREWORD
he seventh edition of Mayo Clinic Internal Medicine Review 2006-2007 reflects the continued
commitment by the faculty of the Department of Internal Medicine to its mission of scholarship.
One of the key traditions in medicine is the passing of knowledge from physician to physician.
In 1928, William J. Mayo, MD, wrote, “The glory of medicine is that it is constantly moving
forward, that there is always more to learn. The ills of today do not cloud the horizon of tomorrow,
but act as a spur to greater effort.”
*
This edition is a response to these themes. My hope is that this
book will aid in the study of medicine and in the care of patients.
Nicholas F. LaRusso, MD
Chair, Department of Internal Medicine
Mayo Clinic, Rochester, Minnesota
*
Mayo WJ. The aims and ideals of the American Medical Association. Proceedings of the 66th Annual Meeting
of the National Education Association of the United States, 1928. p. 158-63.
vii
T
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PREFACE
cientific observations and clinical advances are moving at a remarkable pace. These changes require physicians to remain abreast
of the latest developments not only in their areas of expertise but also in areas beyond their sphere of expertise. To assist physicians
in this endeavor, the Department of Internal Medicine at Mayo Clinic remains committed to providing continuing medical

education to physicians in a timely manner. Mayo Clinic Internal Medicine Review 2006-2007 is designed to meet the needs of
physicians-in-training and practicing clinicians by updating their knowledge of internal medicine, providing a concise review,
and also helping them prepare for the certifying and recertifying examinations in internal medicine.
The success of the earlier editions of this textbook is exemplified by the number of books published. The positive reaction
to and the success enjo
yed by the earlier editions prompted the Department of Internal Medicine to proceed with the publication
of this, the seventh, edition.
The overall approach to learning medicine can be summed up in two questions. What is it? What do you do for it? Ongoing
efforts have been made to improve the book and its answers to these questions. Each chapter is updated for each edition. Over
time, algorithms and diagrams have been added and changed. The goal is to have an update that is readable and easy to study.
The book is divided into subspecialty topics, each chapter written by an author(s) with clinical expertise in the designated
topic. I
mages and tables have been enhanced. Each chapter has bulleted items that highlight key points. These may be summary
points from previous paragraphs or new points. Bulleted items also address typical clinical scenarios. These scenarios emphasize
classic clinical presentations. Pharmacy tables ar
e included with many of the chapters. The scenarios and pharmacy tables highlight
two key issues. F
irst, the general internist and the subspecialist diagnose diseases in internal medicine. Second, the predominant
type of patient management is pharmacologic. Knowledge of the indications, toxic effects, and drug interactions is of paramount
importance. Multiple-choice questions with a single answ
er follow each chapter. As many clinical cases as possible are included
in the questions. This edition has 360 multiple-choice questions. The answers with explanatory notes follow the questions.
Material in the questions and answers is not included in the index.
I thank everyone who offered important ideas for improvement during the development of this book. I am grateful to the
authors of the previous editions for providing input into this edition and for permitting the use of some of their materials. I am
indebted to all authors for their contributions. I thank the staffs of the S
ection of Scientific P
ublications, D
epar
tment of M

edicine,
and Division of Media Support Services at Mayo Clinic for their contributions to this edition. The support and cooperation of
the publisher, Taylor & Francis Group, are gratefully acknowledged.
I tr
ust that the sev
enth edition of
M
ay
o Clinic Internal Medicine Review
will ser
v
e to update and advance the reader’s knowledge
of internal medicine, as previous editions have done.
I hope that you enjoy this review as much as I have.
Thomas M. Habermann, MD
Editor-in-Chief
ix
S
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Haitham S. Abu-Lebdeh, MD
Consultant, Division of General Internal Medicine, Mayo
Clinic; Assistant Professor of Medicine, Mayo Clinic College
of Medicine; Rochester, Minnesota
Timothy R. Aksamit, MD
Consultant, Division of Pulmonary and Critical Care Medicine,
Mayo Clinic; Assistant Professor of Medicine, Mayo Clinic
College of Medicine; Rochester, Minnesota
Robert C. Albright, Jr., DO
Consultant, Division of Nephrology and Hypertension, Mayo

Clinic; Assistant Professor of Medicine, Mayo Clinic College
of Medicine; Rochester, Minnesota
Thomas J. Beckman, MD
Consultant, Division of General Internal Medicine, Mayo
Clinic; Assistant Professor of Medicine, Mayo Clinic College
of Medicine; Rochester, Minnesota
Thomas Behrenbeck, MD
Consultant, Division of Cardio
vascular Diseases, Mayo Clinic;
Associate Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Eduardo E. Benarroch, MD
Consultant, Department of Neurology, Mayo Clinic; Professor
of Neurology, Mayo Clinic College of Medicine; Rochester,
Minnesota
Peter A. Brady, MD
Consultant, Division of Cardiovascular Diseases, Mayo Clinic;
Assistant Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Robert D. Brown, Jr., MD
Chair, Department of Neurology, Mayo Clinic; Professor of
Neurology, Mayo Clinic College of Medicine; Rochester,
Minnesota
Darryl S. Chutka, MD
Consultant, Division of Preventive and Occupational Medicine,
M
ayo Clinic; Associate Professor of Medicine, Mayo Clinic
College of Medicine; Rochester, Minnesota
Brian A. Crum, MD
Consultant, Department of Neurology, Mayo Clinic; Assistant

Professor of Neurology, Mayo Clinic College of Medicine;
Rochester, Minnesota
Lisa A. Drage, MD
Consultant, Department of Dermatology, Mayo Clinic;
Assistant Professor of Dermatology, Mayo Clinic College of
Medicine; Rochester, Minnesota
Stephen B. Erickson, MD
Consultant, Division of Nephrology and Hypertension, Mayo
Clinic; Assistant Professor of Medicine, Mayo Clinic College
of Medicine; Rochester, Minnesota
Lynn L. Estes, PharmD
Infectious Disease Pharmacist Specialist, Mayo Clinic; Assistant
Professor of Pharmacy, Mayo Clinic College of Medicine;
Rochester, Minnesota
Fernando C. Fervenza, MD, PhD
Consultant, D
ivision of Nephrology and Hypertension, Mayo
Clinic; Associate Professor of Medicine, Mayo Clinic College
of Medicine; Rochester, Minnesota
Amit K. Ghosh, MD
Consultant, Division of General Internal Medicine, Mayo
Clinic; Associate P
r
ofessor of M
edicine, M
ay
o Clinic College
of M
edicine; R
ochester

, M
innesota
W
illiam W
. G
insburg, MD
Consultant, D
ivision of Rheumatology
, M
ay
o Clinic,
J
acksonville, Florida; Associate Professor of Medicine, Mayo
Clinic College of M
edicine; R
ochester
, M
innesota
Thomas M. Habermann, MD
Consultant, D
ivision of H
ematology
, M
ayo Clinic; Professor
of M
edicine, M
ay
o Clinic College of M
edicine; R
ochester

,
Minnesota
C. Christopher H
ook, MD
Consultant, Division of Hematology, Mayo Clinic; Assistant
P
r
ofessor of M
edicine, Mayo Clinic College of Medicine;
R
ochester
, M
innesota
CONTRIBUTORS
xi
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Sheila G. Jowsey, MD
Consultant, Division of Tertiary Psychiatry and Psychology,
M
ayo Clinic; Assistant Professor of Psychiatry, Mayo Clinic
College of Medicine; Rochester, Minnesota
Barry L. Karon, MD
Consultant, Division of Cardiovascular Diseases, Mayo Clinic;
Assistant Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Kyle W. Klarich, MD
Consultant, Division of Cardiovascular Diseases, Mayo Clinic;
Assistant Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Lois E. Krahn, MD

Chair, Department of Psychiatry and Psychology, Mayo Clinic,
Scottsdale, Arizona; Professor of Psychiatry, Mayo Clinic College
of M
edicine; Rochester, Minnesota
Scott C. Litin, MD
Consultant, Division of General Internal Medicine, Mayo
Clinic; Professor of Medicine, Mayo Clinic College of Medicine;
Rochester, Minnesota
William F. Marshall, MD
Consultant, Division of Infectious Diseases, Mayo Clinic;
Assistant Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Marian T. McEvoy, MD
Consultant, Department of Dermatology, Mayo Clinic;
Associate Professor of Dermatology, Mayo Clinic College of
Medicine; Rochester, Minnesota
Bryan McIver, MBChB
Consultant, Division of Endocrinology, Diabetes, Metabolism,
and Nutrition, Mayo Clinic, Rochester, Minnesota
Virginia V
. M
ichels, MD
Consultant, D
epar
tment of M
edical G
enetics, M
ay
o Clinic;
Professor of Medical Genetics, Mayo Clinic College of Medicine;

R
ochester
, Minnesota
Clement J. Michet, Jr., MD
Consultant, D
ivision of Rheumatology
, Mayo Clinic; Associate
Professor of Medicine, Mayo Clinic College of Medicine;
Rochester, Minnesota
Kevin G. Moder, MD
Consultant, Division of Rheumatology, Mayo Clinic; Associate
P
rofessor of Medicine, Mayo Clinic College of Medicine;
Rochester, Minnesota
Timothy J. Moynihan, MD
Consultant, Division of Medical Oncology, Mayo Clinic;
Assistant Professor of Oncology, Mayo Clinic College of
Medicine; Rochester, Minnesota
Paul S. Mueller, MD
Consultant, Division of General Internal Medicine, Mayo
Clinic; Assistant Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Steve R. Ommen, MD
Consultant, Division of Cardiovascular Diseases, Mayo Clinic;
Associate Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Robert Orenstein, DO
Consultant, Division of Infectious Diseases, M
ayo Clinic;
Assistant Professor of Medicine, Mayo Clinic College of

Medicine; Rochester, Minnesota
John G. Park, MD
Consultant, Division of Pulmonary and Critical Car
e Medicine,
Mayo Clinic; Instructor in Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Steve G. Peters, MD
Consultant, Division of Pulmonary and Critical Care Medicine,
Mayo Clinic; Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
John J. Poterucha, MD
Consultant, D
ivision of G
astr
oenter
ology and Hepatology,
Mayo Clinic; Associate Professor of Medicine, Mayo Clinic
College of Medicine; Rochester, Minnesota
Abhiram Prasad, MD
Senior Associate Consultant, Division of Cardiovascular Diseases,
M
ay
o Clinic; Assistant P
rofessor of Medicine, Mayo Clinic
College of Medicine; Rochester, Minnesota
D
eborah J. Rhodes, MD
Consultant, Division of Preventive and Occupational Medicine,
Director, Women’s Health Fellowship, and Director, Women’s
E

x
ecutive Health Program, Mayo Clinic; Assistant Professor
of Medicine, Mayo Clinic College of Medicine; Rochester,
Minnesota
xii
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Frank A. Rubino, MD
Emeritus Member (deceased), Department of Neurology, Mayo
C
linic, Jacksonville, Florida; Emeritus Professor of Neurology,
Mayo Clinic College of Medicine; Rochester, Minnesota
Thomas R. Schwab, MD
Consultant, Division of Nephrology and Hypertension, Mayo
Clinic; Associate Professor of Medicine, Mayo Clinic College
of Medicine; Rochester, Minnesota
Gary L. Schwartz, MD
Consultant, Division of Nephrology and Hypertension, Mayo
Clinic; Associate Professor of Medicine, Mayo Clinic College
of Medicine; Rochester, Minnesota
Robert E. Sedlack, MD
Consultant, Division of Gastroenterology and Hepatology,
Mayo Clinic; Assistant Professor of Medical Education and of
Medicine, Mayo Clinic College of Medicine; Rochester,
Minnesota
Lynne T. Shuster
, MD
Consultant, Division of General Internal Medicine and Director,
Women’s Health Clinic, Mayo Clinic; Assistant Professor of
Medicine, Mayo Clinic College of Medicine; Rochester,
Minnesota

Peter C. Spittell, MD
Consultant, Division of Cardiovascular Diseases, Mayo Clinic;
Assistant Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Karen L. Swanson, DO
Consultant, Division of Pulmonary and Critical Care Medicine,
Mayo Clinic; Assistant Professor of Medicine, Mayo Clinic
College of Medicine; Rochester, Minnesota
Zelalem Temesgen, MD
Consultant, Division of Infectious Diseases, Mayo Clinic;
Assistant P
r
ofessor of M
edicine, M
ayo Clinic College of
Medicine; Rochester, Minnesota
Charles F. Thomas, Jr., MD
Consultant, Division of Pulmonary and Critical Care Medicine,
M
ayo Clinic; Associate Professor of Medicine, Mayo Clinic
College of Medicine; Rochester, Minnesota
Sally J. Trippel, MD, MPH
Consultant, Division of Preventive and Occupational Medicine,
Mayo Clinic; Instructor in Preventive Medicine, Mayo Clinic
College of Medicine; Rochester, Minnesota
Thomas R. Viggiano, MD
Consultant, Division of Gastroenterology and Hepatology,
Mayo Clinic; Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Abinash Virk, MD

Consultant, Division of Infectious D
iseases, Mayo Clinic;
Assistant Professor of Medicine, Mayo Clinic College of
Medicine; Rochester, Minnesota
Gerald W. Volcheck, MD
Consultant, Division of Allergic Diseases, Mayo Clinic; Assistant
Professor of Medicine, Mayo Clinic College of Medicine;
Rochester, Minnesota
Amy W. Williams, MD
Consultant, Division of Nephrology and Hypertension, Mayo
Clinic; Assistant Professor of Medicine, Mayo Clinic College
of Medicine; Rochester, Minnesota
John W. Wilson, MD
Consultant, Division of Infectious Diseases, Mayo Clinic;
Assistant P
r
ofessor of M
edicine, M
ayo Clinic College of
Medicine; Rochester, Minnesota
xiii
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xiv
CONTRIBUTORS FOR PHARMACY REVIEW
Alma N. Adrover, PharmD, MS
Jeffrey J. Armon, PharmD
Sansana D. Bontaveekul, PharmD
Lisa K. Buss, PharmD
Julie L. Cunningham, PharmD, BCPP
Lynn L. Estes, PharmD

Jamie M. Gardner, PharmD
Darryl C. Grendahl, RPh
Anna C. Gunderson, PharmD
Heidi D. Gunderson, PharmD
Thomas M. Habermann, MD
Robert W. Hoel, RPh, PharmD
Todd M. Johnson, PharmD
Philip J. Kuper, PharmD
Jennifer D. Lynch, PharmD
Eric T. Matey, PharmD
Kari L. B. Matzek, PharmD
S
usan V
. McCluskey, RPh
K
evin W
. O
dell, P
harmD
J
ohn G. O’M
eara, P
harmD
N
arith N. O
u, P
harmD
Lance J. Oy
en, P
harmD

M
ichael A. Schwar
z, P
harmD
V
irginia H. Thompson, RP
h
Christopher M. W
ittich, P
harmD, MD
K
elly K. W
ix, P
harmD
R
ober
t C. W
olf
, PharmD
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1. The Board Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Amit K. Ghosh, MD
2. Allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Gerald W. Volcheck, MD
3. Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
K
yle W. Klarich, MD, Thomas Behrenbeck, MD, Peter A. Brady, MD, Abhiram Prasad, MD, Steve R. Ommen, MD,
Barry L. Karon, MD
4. Critical Care Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .147
Steve G. Peters, MD

5. Dermatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .167
Lisa A. Drage, MD, Marian T. McEvoy, MD
6. Endocr
inology
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195
Bryan McIver, MBChB
7. Gastroenterology and Hepatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251
Robert E. Sedlack, MD, Thomas R. Viggiano, MD, John J. Poterucha, MD
8. General Internal Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323
Scott C. Litin, MD
9. Genetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353
Virginia V. Michels, MD
10. Geriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373
Darryl S. Chutka, MD
11. Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .401
Thomas M. Habermann, MD
12. HIV I
nfection
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .465
Z
elalem Temesgen, MD
13. Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .493
Gary L. Schwartz, MD
xv
TABLE OF CONTENTS
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14. Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .531
William F. Marshall, MD, Abinash Virk, MD, Robert Orenstein, DO, John W. Wilson, MD, Lynn L. Estes, PharmD
15. Medical Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .621
C. Christopher Hook, MD, Paul S. Mueller, MD

16. Men’s Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .635
Thomas J. Beckman, MD, Haitham S. Abu-Lebdeh, MD
17. Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .647
Fernando C. Fervenza, MD, PhD, Thomas R. Schwab, MD, Amy W. Williams, MD, Robert C. Albright, Jr., DO,
S
tephen B. Erickson, MD
18. Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .699
Brian A. Crum, MD, Eduardo E. Benarroch, MD, Robert D. Brown, Jr., MD; Frank A. Rubino, MD
19. Oncology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .751
Timothy J. Moynihan, MD
20. Preventive Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .787
Sally J. Trippel, MD, MPH
21. Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .805
Lois E. Krahn, MD, Sheila G. Jowsey, MD
22. Pulmonary Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .825
John G. Park, MD, Timothy R. Aksamit, MD, Karen L. Swanson, DO, Charles F. Thomas, Jr., MD
23. Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .913
Clement J. Michet, Jr., MD, Kevin G. Moder, MD, William W. Ginsburg, MD
24. Vascular Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .977
Peter C. Spittell, MD
25. Women’s Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .999
Lynne T. Shuster, MD, Deborah J. Rhodes, MD
xvi
Front Matter.qxd 6/12/06 1:06 PM Page xvi
Many physicians take the American Board of Internal Medicine
(ABIM) certifying examination in internal medicine (IM) annually.
The total number of candidates who took the ABIM certifying
examination for the first time in 2004 was 7,056. Of these, 92%
passed the examination. Currently, greater importance is being placed
on achieving board certification. Many managed-care organizations

now require board certification before employment. This chapter is
aimed primarily at candidates pr
eparing for the ABIM’s certifying
or maintenance of certification examination in IM. However, can-
didates preparing for non-ABIM examinations also may benefit from
the information, which covers various aspects of preparation for an
examination, strategies to answer the questions effectively, and
avoidance of pitfalls.
Aim of the Examination
The ABIM has stated that the certifying examination tests the breadth
and depth of a candidate’s knowledge in IM to ensure that the
candidate has attained the necessary proficiency required for the
practice of IM. According to the ABIM, the examination has two
goals: the first is to ensure competence in the diagnosis and treatment
of common disorders that have important consequences for patients,
and the second is to ensure excellence in the broad domain of IM.
Examination Format
The examination for ABIM certification in IM requires 2 days to
complete and is divided into four sections of 3 hours each. D
etails
regarding the examination, training requirements, eligibility require-
ments, application forms, and other related information can be
obtained fr
om the ABIM, 510 W
alnut S
treet, Suite 1700,
Philadelphia, PA 19106-3699; telephone numbers: 215-446-3500
or 800-441-2246; fax number: 215-446-3633; e-mail address:
r
; I

nternet addr
ess: .
Almost all of the questions are clinical and based on a correct
diagnosis and management. Because there is no penalty for guessing
the answ
ers, candidates should
answ
er ev
ery question
. M
ar
king
multiple answers for a single question is not allowed and will cause
the question to be scored as incorrect. Most questions are based on
the presentations of patients. Among these, 75% are in the setting
of outpatient or emergency room situations, and the remaining 25%
are in the inpatient setting, including the critical care unit and nursing
home. The ability to answer these questions requires integration of
information provided from several sources (such as history, physical
examination, laboratory test results, and consultations), prioritization
of alternativ
es, or use of clinical judgment. Candidates should know
that a portion of questions are known as field questions, or pretest
questions, and are included for experimental purposes only and to
test the question quality. Although field questions are not scored,
they cannot be identified during the examination. The overall ability
to manage a patient in a cost-effective, evidence-based fashion is
stressed. Questions that require simple recall of medical facts have
essentially been eliminated. The examination is reviewed by practicing
internists to ensure the questions are relevant to a general internal

medicine practice.
• Candidates should answer every question; there is no penalty for
guessing.
• Most questions are based on presentations of patients.
• Questions that require simple recall of medical facts are in the
minority.
A list of normal laborator
y v
alues and illustrativ
e materials (electr
o-
cardiograms, blood smears, Gram stains, urine sediments, chest
radiographs, and photomicrographs) necessary to answer questions
ar
e pr
o
vided. Candidates should interpr
et the abnormal values on
the basis of the normal values provided and not on the basis of the
normal values to which they are accustomed in their practice or train-
ing. Candidates for the cer
tifying examination r
eceiv
e an informa-
tion booklet several weeks before the examination. The booklet
provides a detailed description of the examination, including the
types of questions used. Although much of the information con
-
tained in this chapter is borrowed from the previous information
booklets, candidates for ABIM examinations should read the book-

let that is sent to them because the ABIM may change v
arious com
-
ponents of the format of the examination.
1
1
The Board Examination
Amit K. Ghosh, MD
1_08.qxd 5/17/06 10:44 AM Page 1
• A list of normal laboratory values and illustrative materials nec-
essary to answer questions are provided.
• The information booklet is sent several weeks before the exami-
nation by the ABIM and should be read by candidates.
Scoring
The passing scores reflect predetermined standards set by the ABIM.
Passing scores are determined before the examination and therefore
are not dependent on the performance of any group of candidates
taking the examination.
• Passing scores are set before the examination.
The Content
The questions in the examination cover a broad area of IM. They are
divided into primary and cross-content groups. The subspecialties in
the primary content areas have included cardiovascular diseases,
gastroenterology, pulmonary diseases, infectious diseases, rheuma-
tology/orthopedics, endocrinology/metabolism, oncology, hema-
tology
, nephrology/urology, neurology, psychiatry, allergy/immunology,
dermatology, obstetrics/gynecology, ophthalmology, otolaryngology,
and miscellaneous. The specialties in the cross-content group have
included adolescent medicine, critical care medicine, clinical epi-

demiology, ethics, geriatrics, nutrition, palliative/end-of-life care, occu-
pational/environmental medicine, preventive medicine, women’s
health, and substance abuse. Approximately 75% of the questions
test knowledge in the following major specialties in IM: cardiology,
endocrinology, gastroenterology, hematology, infectious diseases,
nephrology, oncology, pulmonary diseases, and rheumatology. The
remaining 25% of questions cover allergy/immunology, dermatology,
gynecology, neurology, urology, ophthalmology, and psychiatry.
Independent of primary content, about 50% of the questions encom-
pass the cross-content topics. Table 1-1 shows the distribution of the
contents for a recent ABIM certifying examination in IM.
• About 75% of the questions test knowledge in the major specialties.
•
A
bout 25% of the questions co
v
er allergy/immunology, derma-
tology, gynecology, neurology, urology, ophthalmology, and
psychiatry.
•
A
bout 50% of all questions encompass the cr
oss-content topics:
geriatrics, critical care medicine, adolescent medicine, clinical
epidemiology, medical ethics, nutrition, occupational medicine,
pr
ev
entiv
e medicine, substance abuse, and women’s health.
Question Format

Each session contains 90 multiple-choice, single-best–answer questions.
The question may include a case history, a brief statement, a radio-
graph, a graph, or a pictur
e (such as a blood smear or G
ram stain).
Each question has five possible answers, and the candidates should
identify the
single-best answer. More than one answer may appear
correct or partially correct for a question. Also, the traditionally correct
answer may not be listed as an option. In that situation, the one
answ
er that is better than the others should be selected. As noted
above, most questions are based on interactions with patients. Some
questions are progressive; that is, more than one question is based
on information about the same patient. The examples in this
chapter, the questions at the end of each chapter in this book, and
the examples included in the ABIM’s information booklet should
help candidates become familiar with the question format.
Furthermore, the national in-training examination taken by most
second-year residents in IM provides ample opportunity to become
familiar with the question format.
• All questions are of the single-best–answer type.
•
V
arious study guides should be used to become familiar with the
question format.
2 Mayo Clinic Internal Medicine Review
Table 1-1 Contents of the Certification Examination of the
American Board of Internal Medicine
Area % of test

Primary content
Cardiovascular disease 14
Gastroenterology 10
Pulmonary disease 10
Infectious disease 9
Rheumatology/orthopedics 8
Endocrinology/metabolism 7
Medical oncology 7
Hematology 6
Nephrology/urology 6
Allergy/immunology 5
Psychiatry 4
Neurology 4
Dermatology 3
Obstetrics/gynecology 2
Ophthalmology 2
Miscellaneous 3
100
Cross-content
Critical care medicine 10
Geriatric medicine 10
Preventive medicine 6
Women’s health 6
Medical ethics 3
Clinical epidemiology 3
Nutrition 3
Palliative/end-of-life care 3
Adolescent medicine 2
Occupational/environmental medicine 2
Substance abuse 2

From ABIM News Update: 1999 Internal Medicine Certification
Examination. American Board of Internal Medicine, Philadelphia,
Spring 1999. Used with permission.
1_08.qxd 5/17/06 10:44 AM Page 2
Examples
Select the one best answer for each of the following questions.
1. A 56-year-old woman is referred to you for an evaluation of
dyspnea and chest pain of 6 weeks in duration. The chest pain
i
s nonpleuritic, nonexertional, and located along the lower right
lateral chest cage. She has no fever, cough, or chills. During the
past few weeks, she has been experiencing constant low back
pain. The patient underwent right mastectomy 4 years ago
because of carcinoma of the breast with metastatic involvement
of the right axillary lymph nodes. She received radiotherapy
followed by chemotherapy for 24 months. Examination now
shows diminished breath sounds in the right lower lung field.
Results of the remainder of the examination are unremarkable.
A chest radiograph suggests a moderate right pleural effusion.
Which one of the following is most likely to be helpful in
confirming the suspected diagnosis?
a. Bone scan with technetium Tc99m diphosphonate
b. Bone marrow aspirate and biopsy
c. Scalene fat pad biopsy
d. Thoracentesis
e. Mammography
2. A 20-year-old male military recruit returns home from several
weeks of summer training in boot camp. He comes to your
office the following day with a 12-day history of fever (38°C),
coryza, pharyngitis, and cough. Physical examination discloses

a bullous lesion over the right tympanic membrane and scat-
tered crackles in both lung fields. Blood cell count shows mild
thrombocytopenia. A chest radiograph shows patchy alveolar-
interstitial infiltrates in both lungs. Which one of the following
is the best treatment for this patient?
a. Erythromycin
b
.
Penicillin
c.
T
rimethoprim
d. Clindamycin
e.
Ceftazidime
3. A 49-year-old male executive comes to your office with a 6-
month histor
y of cough, shor
tness of breath, and chest tightness
soon after substantial ex
er
tion. H
e notices these symptoms soon
after he finishes a game of racquetball. He is a nonsmoker and
has no risk factors for cor
onary artery disease. Results of physical
examination in y
our office ar
e normal. H
is w

eight is normal
for his height. The chest radiograph is normal. A treadmill test for
ischemic hear
t disease is negative. Which one of the following
diagnostic tests is indicated?
a.
Computed tomography of the chest
b
.
Ar
terial blood gas studies at r
est and after exercise
c. Spirometry before and after exercise
d. Ventilation-perfusion lung scanning
e. Car
diopulmonar
y ex
ercise testing
4. A 43-year-old asymptomatic man has chronic hepatitis C.
Therapy for 12 months with a combination of interferon and
ribavirin failed to clear the virus. Laboratory results are notable
for an alanine aminotransferase value of 65 U/L and normal
v
alues for bilirubin, albumin, and prothrombin time. A liver
biopsy shows a mild lymphocytic portal infiltrate but no fibrosis.
Which one of the following statements about this patient is true?
a. He should be given lamivudine
b. He should have screening for hepatocellular carcinoma and
undergo ultrasonography and
α

-fetoprotein testing every 6
months
c. He should have endoscopy to look for esophageal varices
d. He should be referred for liver transplantation
e. He should receive the hepatitis A and B vaccines if he is not
already immune
5. A 45-year-old man comes to your clinic for evaluation of new-onset
hypertension. Blood pressures obtained elsewhere were 146 to
160/84 to 100 mm Hg, and heart rates ranged from 82 to 96
beats per minute. He does not smoke or drink alcohol. He has no
histor
y of diabetes mellitus. His family history is positive for
hypertension in his father. On physical examination, his blood
pressure is 144/86 mm Hg and body mass index 32 kg/m
2
.
Results of the remainder of the examination are unremarkable.
Laboratory test values are as follows: serum sodium 142 mEq/L,
serum potassium 4.2 mEq/L, serum chloride 104 mEq/ L, serum
bicarbonate 24 mEq/L, glucose 116 mg/dL, blood urea nitrogen
14 mg/dL, serum creatinine 1.0 mg/dL. Which one of the
following is the best initial test in the evaluation of this patient?
a. Renal duplex artery ultrasonography
b. Plasma renin/aldosterone ratio
c. Measurement of plasma metanephrine
d. Overnight oximetry
e. Serum cortisol level
6. A 65-year-old man is referred to your practice for a 4-month
histor
y of swallo

wing difficulties. H
is wife r
eports that the patient
starts coughing and choking immediately after he drinks any
fluid and that he has lost 5 lb. He denies any hematemesis or
melena. H
e denies any histor
y of food “
sticking
” in the supraster-
nal region. His past medical history includes a cerebrovascular
accident with a right-sided hemiplegia 8 months ago, diabetes
mellitus, gastr
oesophageal r
eflux, and hyper
tension. On phys-
ical examination, the patient is alert and cooperative and has
right-sided hemiparesis. His hematocrit value is 42% and blood
glucose 122 mg/dL. What is the next best step in the ev
aluation
of his symptoms?
a.
U
pper endoscopy
b. Upper gastrointestinal barium study
c. Esophageal manometry
d.
M
agnetic resonance imaging of head
e. Computed tomography of neck

Chapter 1 The Board Examination 3
1_08.qxd 5/17/06 10:44 AM Page 3
7. A 68-year-old woman was recently admitted to another hospital
with severe back pain. At that time, magnetic resonance imaging
of the spine showed moderate bulging disks at L3-4 and L4-5
causing moderate compression of the L4 nerve root. Her other
m
edical problems included hypertension and diet-controlled
diabetes mellitus. Medications included hydrochloroiazide 25
mg once a day. On physical examination, the blood pressure was
148/96 mm Hg, and the pulse rate was 78 beats per minute.
On neurologic examination, there was an antalgic gait and the
straight leg raising test was negative. Results of the remainder of
the examination were normal. Laboratory values were hemato-
crit 30%, platelet count 110
×
10
9
/L, blood urea nitrogen 60
mg/dL, creatinine 4.0 mg/dL, serum sodium 132 mEq/L, serum
chloride 112 mEq/L, serum bicarbonate 15 mEq/L, serum
calcium 12.5 mg/dL, serum glucose 120 mg/dL. On urinalysis,
there was trace proteinuria, no ketonuria or glucosuria, and
no casts. Arterial pH was 7.32, and P
CO
2
was 30 mm Hg. What
is the most likely diagnosis?
a. Sarcoidosis
b. Primary hyperparathyroidism

c.
Multiple myeloma
d. Aggressive hydrochlorothiazide therapy
e. Milk-alkali syndrome
8. A patient who is positive for human immunodeficiency virus and
has low CD4 counts is receiving multidrug treatment. He com-
plains of colicky flank pain, and many crystals are subsequently
noted on urinalysis. Which one of the following drugs is most
likely causative?
a. Ribavirin
b. Trimethoprim-sulfamethoxazole
c. Indinavir
d. Acyclovir
e. Ganciclovir
9. A 34-year-old woman comes to your office with a 4-week history
of hemoptysis, intermittent whee
z
e, and generaliz
ed w
eakness.
On examination, her blood pressure is 186/112 mm Hg. She
appears cushingoid and has noted these changes taking place
during the past 12 w
eeks. A
uscultation discloses localiz
ed whee
z-
ing in the left mid lung area. The chest radiograph indicates par-
tial atelectasis of the left upper lobe. The patient is referred to
y

ou for fur
ther ev
aluations. Which one of the following is least
likely to provide useful information for diagnosis and treatment?
a.
S
er
um adrenocorticotropic hormone level
b. 24-Hour urine test for 5-hydroxyindoleacetic acid level
c. Bronchoscopy
d.
Computed tomography of the chest
e. Serum potassium level
10. A 62-year-old woman presents with the onset of eye discomfort
and diplopia. She has not noted any other new neurologic
symptoms. Neurologic examination shows a normal mental
status and neurovascular findings. Reflexes are slightly decreased
in the lower extremities. Gait and coordination are normal.
Cranial nerves show an inability to adduct, elevate, and depress
t
he eye. Pupillary reaction is normal. Motor strength testing is
negative. Sensation is normal, except there is decreased vibratory
and joint position sensation in the feet. What abnormality would
be expected?
a. Saccular aneurysm of the cavernous sinus on computed
tomography
b. Brain stem neoplasm on magnetic resonance imaging
c. Left temporal sharp waves on electroencephalography
d. Increased fasting blood glucose level
e. Increased erythrocyte sedimentation rate

11. A 42-year-old man who is an office worker presents to the
emergency department with acute dyspnea. He has smoked 1
1/2 packs per day for 25 years and had been relatively asymp-
tomatic except for a smoker’s cough and mild dyspnea on
exertion. Physical examination findings are not remarkable
ex
cept for slightly diminished intensity of breath sounds over
the right lung and some prolonged expiratory slowing, consistent
with obstructive lung disease. The chest radiograph shows
extensive infiltrates in the upper two-thirds of the lung fields.
Which one of the following conditions is most likely responsible
for this patient’s symptoms?
a. Pulmonary alveolar pr
oteinosis
b. Silicosis
c. Pulmonary eosinophilic granuloma (histiocytosis X)
d. Idiopathic pulmonary fibrosis
e. Sarcoidosis
12. In a 34-year-old man with acute myelomonocytic leukemia,
fever and progressive respiratory distress develop, and the chest
radiograph shows diffuse alveolar infiltrates. The patient com-
pleted intensive chemotherapy 6 weeks earlier. The total leuko-
cyte count has r
emained less than 0.5
×
10
9
/L for mor
e than 3
weeks. He is currently (for at least 10 days) receiving a

cephalosporin (ceftazidime). Which one of the following is the
most appr
opriate therapy for this patient?
a. Clindamycin
b
.
B
lood transfusion to increase the number of circulating
leukocytes
c. Antituberculous (triple-drug) therapy
d.
Amphotericin intrav
enously
e. Pentamidine aerosol
The answ
ers to the questions ar
e as follows: 1, d (metastatic
pleural effusion); 2, a (
Mycoplasma infection); 3, c (exercise-induced
asthma); 4, e; 5, d (obstructive sleep apnea); 6, b (oropharyngeal
dysphagia); 7, c (multiple my
eloma); 8, c; 9, b (br
onchial carcinoid);
10, d; 11, c (histiocytosis X, or pulmonary eosinophilic granuloma,
4 Mayo Clinic Internal Medicine Review
1_08.qxd 5/17/06 10:44 AM Page 4
with spontaneous pneumothorax); 12, d (disseminated aspergillosis
in a leukopenic patient).
Questions 1 through 3 are examples of questions that are aimed
at evaluating knowledge and judgment about problems that are

f
requent in clinical practice and for which physician intervention
makes a considerable difference. These questions judge the candi-
date’s minimal level of clinical competence. These questions include
descriptions of typical clinical features of metastatic breast carcinoma,
Mycoplasma pneumonia, and exercise-induced asthma, respectively.
Therefore, the decision making is relatively easy and straightforward.
Questions 4 through 12 are more difficult to answer because they
are structured to reflect excellence in clinical competence rather than
just minimal competence. In other words, they require more exten-
sive knowledge (i.e., knowledge beyond that required for minimal
competence) in IM and its subspecialties. Although most of the
questions on the examination are based on encounters with patients,
some require recall of well-known medical facts.
Preparation for the Test
Training during medical school forms the foundation on which
adv
anced clinical knowledge is accumulated during residency training.
However, the serious preparation for the examination actually starts
at the beginning of the residency training in IM. Most candidates
will require a minimum of 6 to 8 months of intense preparation for
the examination. Cramming just before the examination is coun-
terproductive and is unlikely to be successful. Some of the methods
of preparation for the board examination are described below.
Additionally, each candidate may develop her or his own system.
• Preparation for the ABIM examination should start at the begin-
ning of the residency training in IM.
Each candidate should use a standard textbook of IM. Any of those
available should provide good basic knowledge in all areas of IM.
Ideally, the candidate should use one good textbook and not jump

from one to another, except for reading certain chapters that are out-
standing in a particular textbook. The most effective way to use the
textbook is with patient-center
ed r
eading; this should occur thr
ough
-
out the residency program. This book and similar board review syl-
labi are excellent tools for brushing up on important board-relevant
information sev
eral w
eeks to months befor
e the examination. They
,
however, cannot take the place of comprehensive textbooks of inter-
nal medicine. This book is designed as a study guide rather than a
compr
ehensiv
e textbook of medicine. Ther
efore, it should not be
used as the sole source of medical information for the examination.
•
Candidates should thor
oughly study a standar
d textbook of IM.
• This book is designed as a study guide and should not be used as
the sole source of information for preparation for the examination.
The Medical Knowledge Self-assessment Program (MKSAP) prepared
by the American College of Physicians is extremely valuable for
obtaining practice in answ

ering multiple-choice questions. The
questions and answers from the MKSAP are very useful to learn the
type of questions asked and the depth of knowledge expected for
various subjects. By design, the MKSAP is prepared for the continuing
medical education of practicing (presumably ABIM-certified)
internists rather than for those preparing for initial certification by
t
he ABIM. For maintenance of certification examination purposes,
the MKSAP textbook is an excellent aid.
Some candidates find it helpful to prepare for the examination
in study groups. Formation of two to five candidates per group per-
mits study of different textbooks and review articles in journals. The
group should meet regularly as each candidate is assigned reading
materials. Selected review articles on common and important topics
in IM should be included in the study materials. Indiscriminate
reading of articles from many journals should be avoided. In any
case, most candidates who begin preparation 6 to 8 months before
the examination will not find time for extensive study of journal
materials. The newer information in the recent (within 6-9 months
of the examination) medical journals is unlikely to be included in
the examination. Notes and other materials the candidates have
gathered during their residency training are also good sources of
information. These clinical “pearls” gathered from mentors will be
of help in remembering certain important points.
• Study groups may help cover large amounts of information.
• Indiscriminate reading of ar
ticles from many journals should be
avoided.
• Information in the recent (within 6-9 months of the examina-
tion) medical journals is unlikely to be included in the examina-

tion.
Candidates should try to remember some of the uncommon man-
ifestations of the most common diseases (such as polycythemia in
common obstructive pulmonary disease) and common manifesta-
tions of uncommon diseases (such as pneumothorax in eosinophilic
granuloma). The large majority of the questions on the examination
involve conditions most commonly encountered in clinical practice.
Several formulas and points should be memorized (such as the anion
gap equation). The clinical training obtained and the regular study
habits formed during residency training are the most important
aspects of pr
eparation for the examination.
In general, the examination rarely has questions about specific drug
dosages or specific chemotherapy regimens used in oncology. Rather,
questions ar
e gear
ed to
war
d concepts regarding the treatment of
patients. Questions regarding adverse effects of medications are
common on the examination, especially when the adverse effect occurs
fr
equently or is potentially serious. The candidate is also expected to
recognize when a clinical condition is a drug-related event.
•
S
tudy as much as possible about boar
d-eligible topics.
• Learn about the uncommon manifestations of common diseases
and the common manifestations of uncommon diseases.

Day of the Examination
A
dequate time is allo
wed to read and answer all the questions; there-
fore, there is no need to rush or become anxious. You should watch
Chapter 1 The Board Examination 5
1_08.qxd 5/17/06 10:44 AM Page 5
the time to ensure that you are at least halfway through the exami-
nation when half of the time has elapsed. Start by answering the first
question and continue sequentially. Almost all of the questions follow
a case presentation format. At times, subsequent questions will give
y
ou information that may help you answer a previous question. Do
not be alarmed by lengthy questions; look for the question’s salient
points. When faced with a confusing question, do not become
distracted by that question. Mark it so you can find it later, then go
to the next question and come back to the unanswered ones at the
end. Extremely lengthy stem statements or case presentations are
apparently intended to test the candidate’s ability to separate the
essential from the unnecessary or unimportant information. You
may want to underline important information presented in the
question in order to review this information after reading the entire
question and the answer options. You are not allowed to bring a
highlighter to the examination.
• Look for the salient points in each question.
• If a question is confusing, mark it to find it and come back to
the unanswered questions at the end.
Some candidates may fail the examination despite the possession of
an immense amount of knowledge and the clinical competence nec-
essary to pass the examination. Their failure to pass the examination

may be caused by the lack of ability to understand or interpret the
questions properly. The ability to understand the nuances of the
question format is sometimes referred to as “boardsmanship.”
Intelligent interpretation of the questions is very important for
candidates who are not well versed in the format of multiple-choice
questions. Tips on “boardsmanship” include the following:
• All questions whose answers are known should be answered first.
• Spend adequate time on questions for which you are certain of the
answers to ensure that they are answered correctly. It is easy to
become overconfident with such questions and thus you may fail
to read the questions or the answer options carefully. Make sure
you never make mistakes on easy questions.
• Read the final sentence (that appears just before the multiple
answ
ers) sev
eral times to understand ho
w an answ
er should be
selected. Recheck the question format before selecting the correct
answer. Read each answer option completely. Occasionally a
r
esponse may be only par
tially corr
ect. A
t times, the traditionally
correct answer is not listed. In these situations, select the best
alternative listed. Watch for qualifiers such as “next,” “immediately,”
or “initially
.”
• Avoid answers that contain absolute or very restrictive words such

as “always,” “never,” or “must.” Answer options that contain
absolutes ar
e likely incorr
ect.
• Try to think of the correct answer to the question before looking
at the list of potential answers. Assume you have been given all the
necessar
y information to answ
er the question. If the answer you had
formulated is not among the list of answers provided, you may have
interpreted the question incorrectly. When a patient’s case is pre-
sented, think of the diagnosis befor
e looking at the list of answ
ers.
It will be reassuring to realize (particularly if your diagnosis is
supported by the answers) that you are on the “right track.”
• Abnormalities on, for example, the photographs, radiographs,
and electrocardiograms will be obvious.
• If you do not know the answer to a question, very often you are
a
ble to rule out one or several answer options and improve your
odds at guessing.
• Occasionally you can use information presented in one question
to help you answer other difficult questions.
Candidates are well advised to use the basic fund of knowledge accu-
mulated from clinical experience and reading to solve the questions.
Approaching the questions as real-life encounters with patients is far
better than trying to second-guess the examiners or trying to analyze
whether the question is tricky. As indicated above, the questions are
never tricky, and there is no reason for the ABIM to trick the can-

didates into choosing wrong answers.
It is better not to discuss the questions or answers (after the
examination) with other candidates. Such discussions usually cause
more consternation, although some candidates may derive a false
sense of having performed well in the examination. In any case, the
candidates are bound by their oath to the ABIM not to discuss or
disseminate the questions. D
o not study between examination
sessions, particularly the night between the two examination days.
• Approach questions as real-life encounters with a patient.
• There are no trick questions.
Connections
Associations, causes, complications, and other relationships between
a phenomenon or disease and clinical features are important to
remember and recognize. For example, Table 1-2 lists some of the
connections in infectious and occupational entities in pulmonary
medicine. Each subspecialty has many similar connections, and
candidates for the ABIM and other examinations may want to
prepare lists like this for different areas.
Computer-based Testing
Candidates currently can take the computer-based test for the cer-
tification test examination. The computer-based test provides a more
flexible, quiet, and pr
ofessional envir
onment for examination. The
computer-based test is administered by Pearson VUE, a company
with around 200 centers in the United States.
Candidates ar
e encouraged to access the online tutorial at
www.abim.org/cert/cbt.shtm. This tutorial allows the candidate to

become familiar with answering questions, changing answers, making
notes electr
onically
, accessing the table of normal laborator
y values,
and marking questions for review.
Maintenance of Certification
The diplomate certificates issued to candidates who have passed the
ABIM examination in IM since 1990 ar
e v
alid for 10 years. The
total number of candidates who took the ABIM maintenance of
6 Mayo Clinic Internal Medicine Review
1_08.qxd 5/17/06 10:44 AM Page 6
certification examination for the first time in 2004 was 2,022. Of
these, 82% passed the examination.
Enhancements to Maintenance of Certification Program
In January 2006, the ABIM enhanced the maintenance of certifi-
cation program to increase flexibility, incorporate programs developed
by other organizations, and assess performance in clinical practice.
The three general components (credentialing, self-evaluation, and
secure examination) were retained, and all self-evaluation modules
now have a points value.
Every candidate needs to complete a total of 100 points in
self-evaluation modules. Unlike the previous system, renewal of more
than one certificate does not necessitate taking additional self-eval-
uation modules (i.e., the same number of points, 100, satisfies the
requirement to sit for these examinations). Candidates have to
complete at least 20 points in medical knowledge and at least 20
points in practice performance. The remaining 60 points may be

obtained from completion of modules developed by ABIM and
other organizations that meet the ABIM standards (Table 1-3). Thus,
one could combine an ABIM practice improvement module (40
Chapter 1 The Board Examination 7
Table 1-2 Example of Connections Between Etiologic Factors and Diseases
Etiologic factor Agent, disease
C
attle, swine, horses, wool, hide Anthrax
Abattoir worker, veterinarian Brucellosis
Travel to Southeast Asia, South America Melioidosis
Squirrels, chipmunks, rabbits, rats Plague
Rabbits, squirrels, infected flies, or ticks Tularemia
Birds Psittacosis, histoplasmosis
Rats, dogs, cats, cattle, swine Leptospirosis
Goats, cattle, swine Q fever
Soil, water-cooling tower Legionellosis
Military camps Mycoplasmosis
Chicken coops, starling roosts, caves Histoplasmosis
Soil Blastomycosis
Travel in southwestern United States Coccidioidomycosis
Ohio and Mississippi river valleys Histoplasmosis
Decaying wood Histoplasmosis
Gardeners, florists, straw, plants Sporotrichosis
Progressive, massive fibrosis Silicosis, coal, hematite, kaolin, graphite, asbestosis
Autoimmune mechanism Silicosis, asbestosis, berylliosis
Monday morning sickness Byssinosis, bagassosis, metal fume fever
Metals and fumes producing asthma Baker’s asthma, meat wrapper’s asthma, printer’s asthma,
nickel, platinum, toluene diisocyanate (TDI), cigarette
cutter’s asthma
Increased incidence of tuberculosis Silicosis, hematite lung

Increased incidence of carcinoma Asbestos, hematite, arsenic, nickel, uranium, chromate
Welding Siderosis, pulmonar
y edema, bronchitis, emphysema
Centrilobar emphysema Coal, hematite
Generalized emphysema Cadmium, bauxite
Silo filler’s lung Nitrogen dioxide
Farmer’s lung
Thermoactinomyces
,
Micropolyspora
Asbestos exposure Mesothelioma, bronchogenic carcinoma, gastrointestinal
cancer
Eggshell calcification Silicosis, sarcoid
Sarcoid-like disease Berylliosis
Diaphragmatic calcification Asbestosis (also ankylosing spondylitis)
N
onfibr
ogenic pneumoconioses
T
in, emery, antimony, titanium, barium
Minimal pathology in lungs Siderosis, baritosis, stannosis
Bullous emphysema Bauxite lung
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points) with the American College of Physicians MKSAP (3 modules,
60 points), or combination ABIM practice improvement module
(40 points) with 2 ABIM knowledge modules (40 points) and the
ABIM peer and patient feedback module (20 points). All points are
valid for 10 years.
The all-inclusive fee structure started in 2006 allows unlimited
access to ABIM self-evaluation modules and one examination. Thus,

continuous medical education credits can be earned without any
additional fees for 10 years.
The self-evaluation modules evaluate performance in clinical
skills, preventive services, practice performance, fund of medical
knowledge, and feedback from patients and colleagues. Successfully
completed self-ev
aluation modules ar
e v
alid for 10 years. Candidates
may apply to begin the maintenance of certification process any time
after initial certification. The ABIM recommends that completion
of the self-evaluation modules be spread out over time. It is antici-
pated that a candidate will complete one self-assessment module
every 1 to 2 years. The ABIM encourages candidates to enroll within
4 years of certification in order to have adequate time to complete the
program.
• Candidates who passed the ABIM certification examination in IM
in 1990 and thereafter have certificates that are valid for 10 years.
• The maintenance of certification process is called continuous
professional development and consists of a three-step process.
Medical Knowledge and Clinical Skills Self-evaluation
Modules
The medical knowledge module is an open-book examination con-
taining 60 single-best–answer multiple-choice questions regarding
recent clinical advances in IM. This module tests the candidate’s
knowledge of IM and clinical judgment. The questions are written
by board members and ABIM diplomates. Candidates may choose
a module in internal medicine or a subspecialty (focused content).
The module is available on paper, CD-ROM, or the Internet.
Candidates must achieve a predetermined passing score to establish

credit for the module. The module may be repeated as often as
n
ecessary to achieve a passing score.
The clinical skills self-evaluation module consists of an open-book
examination containing audio and visual information pertaining to
physical examination and physical diagnosis and physician-patient
communication skills. The module contains 60 single-best–answer
multiple-choice questions. It is available on a CD-ROM with Web
access. Candidates must achieve a predetermined passing score to
establish credit for the module. The module may be repeated as often
as necessary to achieve a passing score.
Performance-based Practice Improvement Module
This module is a computer-based instrument to help candidates
assess the care they provide to patients and to help them develop a
plan for improvement. Areas of the practice that have potential for
quality improvement are identified. Completion of this module
involves review of patient charts and comparing them to national
guidelines. Data are submitted electronically to the ABIM to provide
feedback. Candidates can implement the changes and measur
e their
impact over a 2-week to 2-year period.
Patient and Peer Feedback Module
Confidential and anonymous feedback regarding the candidate’s
professionalism, physician-patient communication skills, and
overall patient care skills is obtained from colleagues and patients of
the candidate by an automated telephone survey. The candidate
selects 20 colleagues and 40 patients, who are asked to complete a brief,
anonymous telephone survey. The candidate receives a summary of
the survey findings.
Secure Examination

A comprehensive, secure, computer-based examination is offered
two times yearly, currently in May and November. The examination
consists of three modules of 60 single-best–answer multiple-choice
questions. Two of the three modules must be in internal medicine,
and the thir
d may be internal medicine, a medical subspecialty
, or an
area of added qualifications. Successful completion of the self-
evaluation modules is not required before taking this examination.
Q
uestions ar
e based on w
ell-established information and assess
clinical judgment more than pure recall of medical information.
The examination contains clinically relevant questions. To pass the
final examination, the candidate must achiev
e a pr
edetermined
passing score. The examination may be repeated as often as it takes
to achieve a passing score. The blueprint of the number of questions
for the maintenance of cer
tification examination is described at
www.abim.org/moc/im.shtm.
Details of the maintenance of certification program can be obtained
fr
om the ABIM, 510 W
alnut Street, Suite 1700, Philadelphia, PA
19106-3699; telephone numbers: 800-441-ABIM, extension 3598;
fax number: 215-446-3633; Internet address: .
8 Mayo Clinic Internal Medicine Review

Table 1-3 Maintenance of Certification Program: Self-
evaluation Options and Point Values
Module type Point value
Medical knowledge
Any ABIM knowledge module 20
ACP MKSAP 80 (4 modules, 20
points/module)
Practice performance
Any ABIM practice improvement module 40
ABIM peer and patient feedback module 20
New practice performance module TBD
ABIM, American Board of Internal Medicine; ACP MKSAP,
American College of Physicians Medical Knowledge Self-assessment
Program; TBD, to be decided.
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