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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
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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
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Mr. Renaldo managed to keep on the Half-hearted
good side of most of his pupils, but he fell Coöperation
from his pinnacle of power when he made the following
announcement:
“Now, if any of you want to go to Delevan to attend the baseball
meet I’ve nothing to say. I don’t believe our team is going to do
much, but we’ll see.
“If the people outside hadn’t butted in and tried to run our sports
we would have come out all right.
“I know you want to win the state championship. We came so near
it last year that we should have a good chance for it under favorable
circumstances. But we haven’t much of a team. I could have picked a
winning team, I believe; but town folks wanted to run the thing, so
we’ll see what comes of it.”
After this vent of pique a big buzz of criticism arose. However,
when the contest came off at Delevan the superintendent made the
trip and shouted as loud as anyone. Through some strange
characteristic quality he was able to throw cold water one day and
build up fires of enthusiasm the next.
Later in the spring came this announcement:
“We’ll not have any more baseball games with out-of-town teams
this season. Our athletics are absorbing too much attention; too
many people are trying to run things up here.”
Of course the crack pitcher went to the board of education and got
consent of the board to continue the series of games as had
previously been the custom. Later the superintendent said, “Well,
now, let me see who wants to play.... All right, then, if these are your
players, go ahead.”
CONSTRUCTIVE TREATMENT
One simple rule applies here: develop a consistent policy and cling
to it. If grades are low, get behind the team in every way and you can
usually swing the backward students into line on their studies, even
when there is no danger of losing place because of lame lessons.
Move the players around and use substitutes frequently so that no
one will fasten on a given post as personal property.
A strong man can organize the town folks so that their support will
be always helpful. In any case the appearance of a milk and water
policy must be avoided.
COMMENTS
Athletics is as difficult to manage as a church choir. A light-

fingered touch is dangerous, as schoolboy passions are not sensibly
controlled many times. A disciplinarian may lose his influence and
position merely through carelessness at this point. The appearance of
an autocratic control of games by the superintendent is highly
undesirable. The whole affair should be just as democratic as
possible.
Pupils know pretty well what is necessary for the good of the
school and if their good judgment is appealed to by a respected and
trustworthy superintendent or principal, the best policies can usually
be carried out.
ILLUSTRATION (HIGH SCHOOL)
In the Bellevue High School a wise principal had assisted in

organizing some six entertainment companies for appearance in the
auditorium at stated intervals during the season. Their programs
were made up of dramatic, musical or literary numbers, as the
members of each company decided. The Schwartz-Ensign Concert
Company made its appearance on November 10, and won the
plaudits of a large house. Friends in neighboring towns, relatives of
some of the performers, requested a reproduction of the
entertainment. After consultation with her colleagues, Velma
Schwartz gave a favorable answer to two invitations.
Loretta met Velma afterwards and said, Meeting Half
“Velma, did we make a mistake in saying Way
nothing to Miss Pringle about these out-of-town trips? What will she
say?”
“Why should she say anything? Our folks at home are willing and I
don’t see that we are getting in her way. It makes no difference one
way or the other what she says.”
Naturally, the news finally reached Miss Pringle, high school
principal and general overseer of the entertainment programs. Two
currents of thought passed through her mind.
“I don’t see why, after all my care, they have taken up their out-of-
town trips without saying anything to me. I’ll just nip this in the bud
and tell them they can’t go.” But a different notion drove out the
earlier one. “They have done no real wrong. It’s a compliment to my
training for them to receive these invitations. I don’t see what harm
can come from it.” But a fragment of the former line of argument
would persist:
“Yes, Velma is the girl who did it. She starred the night of the
program. Her friends are determined to show her off elsewhere. No
doubt she wanted to add to her glory by keeping her scheme out of
my fingers. I have a notion to say to her that she might better have
talked the matter over with me.”
Then good sense ruled her and what she actually said was: “Why,
Velma, I heard just lately that some of your friends are planning to
have you out at Beecham Springs to give a program of music. What a
fine thing that is! It comes Friday night, I believe; that makes it safe
for your studies, so it’s going to turn out well. Your father and
mother are going with you, I suppose? Well, then, that will be fine.”
CASE 96 (HIGH SCHOOL)
“I just want to say in closing that there is Bluffing on

some doubt about two of the boys getting to Scholarship
play on the football team next week—their grades are very low, and
in fact as matters stand now they would be shut out.”—
(Superintendent’s announcement in the assembly room.)
“He’s bluffing. If our team doesn’t win he’ll be cut up as bad as any
of us.”—(First pupil.)
“His voice was weak when he made that speech. He won’t carry out
his threat.”—(Second pupil.)
“If, after all our team has done, he pulls Tom and the Giant off the
team, he’s a goner and he knows it. He might as well save all this
talk.”—(Third pupil.)
“Just lie low, my boy. We’ve got him fixed. He’ll jump a hundred
feet in the air, if he falls into our trap. Every man of us is out if one
drops out, no more games this year. No, he doesn’t know. But it’ll get
to him.”—(Member of the football team.)
“I thought I’d best tell you so you could be prepared for it. The
boys have it all made up that they’ll strike and call all the games off if
you keep any one or more of them from playing. They may be bluffin’
you; but I rather think not, for they don’t believe they can beat Upper
Kensington unless they can have the boys they want to play on the
team. Do as you think best.”—(Citizen.)
“Seems as though things are going a little crooked some way. I
wonder where I blundered. I didn’t expect to set them going this way.
Why don’t they get to their books; they might know I’m going to do
the square thing by them. Probably I’ll have to ease up their minds
some way.”—(Worried superintendent.)
Quit the bluff game; it’s playing with fire. Call in the boys who are
behind in their work and settle up the matter of studies without any
reference to playing. Talk very little about what you are going to do
in checking up deficiencies. Do a few of these things and let the talk
come the other way. Hold out natural inducements to good work and
spare the threats for rare occasions. “Barking dogs seldom bite,” is an
old saying that applies to those fearsome teachers who forecast a
terrible punishment and then let the matter pass without further
attention. Each occurrence of a situation such as this is a loosened
spoke in your wheel of fortune. Don’t put yourself in the hands of a
conspiracy by playing a loose game in discipline.
COMMENTS
Shrewd pupils can catch a rash superintendent and trip him into a
heavy fall.
ILLUSTRATION (HIGH SCHOOL)
Miss McCord, of the Benton High School, was very unpopular one
winter because she had failed two star basketball performers, and
thus kept them from remaining on the team. These players were in
her advanced algebra class, with about twenty other students, all
ardent basketball enthusiasts. One day she said to Coith Burgess,
who was not one of the players, but who had been especially
indignant at her firmness, “I should like to see you for a moment,
Coith, after class.”
“Oh, would you?” Coith shaped the words Sacrificing
with his mouth, but uttered no sound, and Scholarship
Miss McCord did not see the disrespectful response. When the class
was dismissed he started to go with the rest. Miss McCord, seeing
him go and thinking he had forgotten her request, said to him, “Don’t
forget, Coith,” and went on with her conversation with another pupil.
When she had finished it, Coith was nowhere in sight. He had gone
on to the assembly room, where he was explaining to all the
disaffected his reasons for not doing as “the old crank” had asked
him.
Miss McCord had no mind to pass over the matter lightly. She
talked at once to the principal, and the two arranged a plan of
treatment. Nothing was said to Coith, but he was not asked to recite
the next day, nor did Miss McCord appear to hear him when he
volunteered. The next day the same thing happened; Miss McCord
did not seem to hear or see him at all. That afternoon, Coith met Mr.
Stacey, the principal, in the hall. “How’s this, Burgess?” he inquired,
“You’re reported absent two days in succession in advanced algebra.”
“Absent? Not a bit of it. I’ve been there all right, but Miss McCord
hasn’t asked me to recite. She doesn’t give a fellow a chance.”
“Were you there?... All right.” Mr. Stacey was looking gravely at
Coith. “What reason could Miss McCord have had for not paying any
attention to you?”
Coith began to flush and stammer. Finally, he told the story of his
disobedience, rather sullenly but frankly.
“Why did you do it?”
“I don’t know. Just natural meanness, I guess.”
“I’ll tell you why you did it, Coith. You thought it would make a
little hero of you with all the basketball crowd to be rude and
insubordinate to Miss McCord, just now when they all dislike her,
because she had the courage to stand by her guns in that affair. It
was a case of posing, and the thing has happened to you that does
happen sometimes to the poseur—she took you at your word. If you
chose to put an end to your relations as teacher and student, she
agreed to accept the situation. As I see it, you are out of the class and
your own fault it is, too.”
Of course in the end Coith came back into the class, after making
all due apologies. He had learned the lesson of coöperation; he had
learned, too, to subject his love of approbation to a standard of
fairness and reciprocity.
The instinct for self-gratification often takes the form of a
pathological fondness for prominence and the approval of others. In
Coith’s case his sense of fairness, courtesy, and submission to
rightful authority had all become subordinate to promptings of his
vanity and resentment. The course of Mr. Stacey and Miss McCord
restored in him the proper sense of the relative importance of the
admiration of his fellows and a sound working relation with his
teacher.
CASE 97 (RURAL SCHOOL)
Miss Jackman of the Ellensburg rural Preparing for

school and her pupils were having a picnic Picnic
in the woods.
She said: “Who would like to carry my basket?”
“I want to.”
“I can.”
“Let me,” came the response from various pupils.
“You may carry it, Tom,” said the teacher.
After getting the pupils thoroughly interested in the project you

are planning, name at once those who are to assist you. Distribute
the work so that as many as possible may have a share in the
responsibility.
COMMENTS
Those who had offered their services were hurt at not being
chosen. Had the teacher said: “Will you please carry my basket,
Tom?” there would have been a less poignant feeling among the
others that favoritism had been shown by the teacher.
ILLUSTRATION (RURAL SCHOOL)
Mr. Merryman was the jolliest teacher the Organize

children of the Concord rural school ever Carefully
had had. No other teacher gave the children so many “outings”; no
other ever placed so much responsibility upon the pupils on such
vacations, and never before had responsibility seemed so delightful
as since Mr. Merryman came to the school. “He’s just like his name,”
declared the children.
One reason why Mr. Merryman had such success in organizing
little excursions which to other teachers were most unwelcome
bugbears, was that he announced them long enough beforehand to
give himself and the children ample time to prepare for details.
“One week from today,” said Mr. Merryman one Friday afternoon,
“we will all go on an excursion to get materials for our aquarium. I
will appoint Joseph and Henry to look up, sometime between now
and Wednesday, the best route for the school to take down to the
creek. Remember, we want a dry path, for the children must not get
wet feet. Lucy and Ellen, James and William may arrange for drag
nets. Perhaps we shall have to make some of them. You may find out
whether we can borrow them or not, and how much the material will
cost if we need to make them ourselves. Henrietta and Edward may
be sure that there are suitable dishes for bringing home our trophies.
Find out just what we need.
“Some of the little children won’t want to go so far as the creek,
where they have to be so still, so I will appoint the sixth grade girls to
form an entertainment committee to find a pleasant place at some
little distance from the creek where the little ones can play. You will
have a stock of games ready to entertain them while some of us are
busy at the creek and when we have enough things, animals, plants,
etc., for our aquarium, we will all come to the same place and there
we will have our lunches together. Doris, Frieda and May of the girls,
and Thomas, Fayette and Wilbur of the seventh and eighth grade
boys may be the refreshment committee. The different committees
may get together next Monday and talk over their plans. Make up
your minds between now and then just what you need to talk about.
Have everything planned and ready before the day of our excursion.
Meanwhile all of us, in the nature class, will study about the
aquarium and the animals that live in it. Our first lesson will be on
Monday, about ‘How to make the aquarium.’ That is all for this
afternoon.”
It is needless to add that for a week the excursion and the studies
and talks connected with it furnished many an hour of innocent and
instructive diversion for the eager children. When the day came
every detail had been thought out and prepared for so carefully that
the event was entirely successful. Looking forward in expectation to
the pleasure, filled the children’s minds too full to leave much room
for mischief, and “discipline” in the sense of punishments sank into
its legitimate place, far into the background.
Conferences with the teacher about matters which were puzzling to
the children brought teacher and pupils into a close and delightful
relationship which made unkindly feeling toward the teacher or
insubordination almost out of the question. Once or twice earlier in
the year, when planning the excursion, Mr. Merryman had been
obliged to say, “But only those will be invited whose work and
conduct in school have been satisfactory.” But even this precaution
was now unnecessary; he simply took the precaution to place the
more troublesome of the pupils on whatever committee would have
to consult most frequently with himself. In this way the feeling of
coöperation between himself and them grew stronger with each
succeeding school “event.”
(5) Play and truancy. There is no better preventive of truancy than
just such outings as that above described, especially if the teacher is
wise enough and tactful enough to utilize some part of the day’s
experiences in the regular school work, nature study, geography,
history, etc. This is by no means difficult to do. Such a course would
have prevented entirely the unfortunate situation of the following
case.
CASE 98 (SEVENTH GRADE)
Darrow King deliberately planned the Play and Truancy

truancy of his classmates one bright May
day, although he did not actually suggest it to them. He had been
good a long time, nothing exciting had happened since cold weather,
and he wanted to get out-of-doors and away from the stuffy school-
room. There was no fun in playing truant alone, or he might have
done that; he had no grudge against Miss Haynes except as she
represented an irksome educational system of which he did not
approve. When he grew eloquent of fishing lines and a warm sunny
swimming hole out by Pike’s Mill, every boy within sound of his voice
felt the primal impulse to take to the fields. So they did, leaving
seventeen girls and three righteous quitters to take care of Miss
Haynes and Grade Seven.
“This is Darrow King’s work,” said Miss Haynes to herself. “If I
don’t conquer that boy he’ll be running the school before long. I’m
fearing he’s on the downward path.” So Darrow King was called
before the bar and arraigned. It was a private session after school.
“Darrow, I believe you planned that truancy, and I want you to tell
me the truth about it. Didn’t you tell the other boys to skip school
last Friday afternoon?”
“No, ma’am, I didn’t. I just said there was a good place to fish out
there, and that Mr. Pike would let us swim below the dam, and all the
fellows said they wanted to go. I didn’t say they should, they just
wanted to.”
“Perhaps that’s true, but it was you who planned it, wasn’t it?”
“No’m, I didn’t plan it. I just remarked how nice it would be for us
all to go together if it wasn’t a school day, and Bob Darcy he said let’s
go anyway, and I guess they all wanted to, for they did—except the
two Jones boys and the Righter kid.”
“Nevertheless it was you that started it, wasn’t it? Tell the truth,
Darrow.”
“Well, yes, I s’pose I started it. I guess it was me, all right.”
“Oh, Darrow, don’t you realize what an influence you have over the
other boys? There is nothing so great as the power of influence. I
remember I wrote my graduating theme upon The Power of
Influence, and I’ve noticed it ever since. You knew that playing
truant is one of the worst things you can do, and yet you led those
boys into temptation. What do you think will be the end of a boy who
enters into such sin? You know that when we begin to sin we go from
bad to worse, and I hate to think of your going on the downward
path, Darrow.”
By this time Miss Haynes had reduced herself to tears at the image
she was conjuring up of Darrow sliding down the moral toboggan.
Darrow, catching his cue from her, began to look contrite and
sorrowful.
“Darrow, think of the power for good you might be, if only you’d
use your influence rightly. Instead of teaching the boys to do wicked
things, why not become a great uplift in their lives? Had you ever
thought of that?”
“No, ma’am. But I’ll try to do better, Miss Haynes.”
This rapid conversion to righteous resolutions completely melted
Miss Haynes. “I’m sure you will, Darrow. That is all—I won’t punish
you this time, for I expect you to use your personal influence to bring
these thoughtless and perverse boys into better ways of thinking and
doing. Only think of the power for good that you have!”
Darrow left the room with a step that fairly sang of a chastened
soul resolved to bring all its erring kind into the fold of holy
endeavor. He kept this up until he was well away from the
schoolhouse, when he broke into a mad run and was soon with the
other boys in Farrell’s pasture, where they were playing ball. Here he
recounted his interview with Miss Haynes, not omitting the pathetic
passages, amid shouts of laughter. Needless to say, his “great
influence over the boys” was not exerted in the interests of good
order that year. The boys continued to do what they had done before,
and Darrow led them as of old.
Talk with two or three of the leading boys, including Darrow, and
ask them about the fishing trip. Show them that you understand “the
call of the wild” that comes with May sunshine. But “put it up to
them” if playing truant is the square thing to do, either to the school
or to their parents. Why should one attend school regularly? Is it
honorable to sneak off without permission? What is to be done about
it? Assume that of course the boys will do something about it. Who
can suggest a fair way of making this wrong right? Probably some
one will suggest that the time be made up, or that the lessons missed
be written out and handed in. Arrange with this small group what is
to be suggested to the larger group. As to Darrow, without telling him
that he is the leader, enlist him in some project that will identify him
with school interests. Perhaps he can plan an outdoor gymnasium,
lay out a tennis court, or superintend the putting up of bird-houses.
By this means get him gradually to work with you until you and he
have formed a solid friendship. Identify him with your own
leadership; form a partnership with him. Truancy will disappear
under such conditions, for real friendship will develop between
teacher and pupils.
Some pupil leaders are useful allies, others are worthy enemies
who may outgeneral the ranking officer. A wise teacher sets himself
first of all to win to his loyal support the natural leaders of the pupils.
This is done by first winning their admiration and respect, then by
stressing some interest which the teacher and student leaders have in
common, thus making common cause with them until sympathetic
relations are established. Study your leading pupils; find out their
hobbies, their friends, their ambitions.
COMMENTS
Children instantly detect the mawkish note in a teacher’s dealings

with them, and appreciate it keenly if they have any sense of humor.
The most of them have. Miss Haynes was over-emotional, and made
the blunder of appealing to feelings which Darrow did not possess.
Never talk to a child leader about his leadership. To do so either
makes him vain, or robs him of his ability through the development
of self-consciousness. Miss Haynes did not appeal to a boy’s
interests. A boy does not usually care to lead his companions to
moral heights. He does not like “Sunday language.” He does not
think he is slipping into perdition when he plays truant; and many
grown people think he is right. Miss Haynes failed because she did
not know enough about boy nature to make a real appeal to a boy.
She had so little sympathy with the play spirit that she did not even
sympathize with the boys’ response to the call of a swimming hole.
Because she could not appeal to the leader, his leadership continued
to be against her authority and against the best interests of the
school.
ILLUSTRATION 1
A teacher in an orphan asylum won the Indulge the

friendship and support of a boy who had Hobby
caused much trouble, by discovering that he was very fond of
animals, and that he had a tame opossum and several trained dogs.
The teacher could not afford to buy and give him books, but he
brought him, each Monday, from the public library, a new book
about animals. Through a discussion of Cy de Vry and his methods,
the teacher convinced the boy that he had a real interest in dumb
creatures, and after that there was no more trouble with the group
who were under this boy’s influence.
ILLUSTRATION 2 (HIGH SCHOOL)
Mr. Claud Jakeway of the Williamstown Camera Club

rural high school was much annoyed by the
frequent absences of two or three members of the Freshman class.
The excuses given him were: “Didn’t feel well enough to study,” “Had
to help father,” etc. A little private investigation convinced Mr.
Jakeway, however, that the real cause in each case was truancy,
generally, for the purpose of either hunting or fishing. Mr. Jakeway
studied over his problem for some days, then one morning made the
following announcement.
“I noticed a few days ago in one of my periodicals that certain
magazines devoted to country life and its interests are advertising for
original photographs of wild animals taken in their native habitat. I
am greatly interested in this myself, for I am exceedingly fond of wild
life, and immensely enjoy a day in the woods now and then. I wonder
if some of you older boys wouldn’t like to join with me to form a
Camera Club. We’ll go out on Saturdays and take our lunches. Only a
few can associate together effectively in work which must be done so
quietly, so I shall limit the membership to four besides myself.
Hunting wild animals with a camera is sport enough for anybody, but
we’ll take our fish poles along in case we don’t happen to strike
‘game.’ By the end of the month the birds will be here and the
hibernating animals will be out of their winter’s sleep. Please think
this matter over and see how many of you would like to spend your
Saturdays in the way I have indicated. Beside the limitation in
numbers, I shall place only one restriction upon the membership of
the club, that is, that we can accept in it only those whose attendance
in school has been regular. I realize of course that those who have
lost time in school will need their Saturdays in order to make up back
work, so please keep that also in mind between this and the end of
the month. Then we will decide who is eligible for membership.”
Mr. Jakeway’s plan was effective. Initiative in coöperation and
substitution accomplished the needed reform.
3. Curiosity, Legitimate, and Otherwise
Curiosity is the beginning of all knowledge.
—Plato.
Curiosity is the intellectualized form of the adaptive instinct.

Children who lack it are subnormal; and yet some teachers seem to
think that curiosity is a sin and should be inhibited. Like all other
instincts, it must be controlled; and part of every child’s education is
the acquiring of ability to control his curiosity, to know when to give
it free rein and when to curb it. It must not be indulged at the
expense of the right of others to quiet, or to the undisturbed
possession of their property, or to the opportunity of doing their
work; in short, the legitimate satisfaction of curiosity stops where the
rights of other people begin.
Curiosity is not, then, a vice to be conquered, but a fundamentally
healthful, natural, and progress-bringing instinct. The greater part of
the curiosity of children is about matters which they need to know,
and it can be utilized in motivating work; a fact which, once
understood, changes an annoyance into an asset.
But sometimes children are inquisitive about things which should
not concern them; their curiosity conflicts with good taste and a true
sense of propriety, or with the rights of others. Moreover,
unrestrained curiosity often interferes with the fulfillment of duty, or
it develops unwholesome appetites and precocious sophistication.
Children are also often curious about many things which can not
properly be explained to them until a fuller knowledge gives them an
interpretative basis; and for this curiosity the wisest treatment is
postponed satisfaction, with a clear explanation for the reason. Such
an answer to questions which can not well be answered at once is far
better than the evasive or lying replies with which too many parents
and some teachers put off children. Boys and girls will usually accept
a postponement of the answer, if they are convinced that if given
they could not understand it, and they will set themselves to the
mastery of the prerequisites. But they easily and soon discover lies in
the answers given them (usually these lies are too clumsy to deceive a
bright child very long), and then, knowing they can not depend upon
the lawful and natural source of information, they set about finding
answers by whatever means offers. Questions of religion and sex
especially, should be answered with a definite promise of satisfaction
when the time comes, rather than with a misleading or evasive reply.
Teachers should analyze the nature of the curiosity of their pupils.
They will find that it will fit one of these four cases:
1. Legitimate curiosity, which should be satisfied at once, and in

such a way as to stimulate further interest in the things
concerned.
2. Legitimate curiosity, which can not wisely be satisfied at once,
but which should be put off with a frank statement that when
the child is older and can understand the knowledge sought
for, it will be given.
3. Curiosity which is pathological or idle, or the satisfaction of
which interferes with the rights of others.
4. Curiosity not harmful in itself, but which interferes with the
child’s own wholesome development.
(1) Curiosity stimulated by novelty or by spirit of investigation.
This is the form of curiosity which Plato so much admired, yet most
parents and teachers dub it just plain “meddling.” Perhaps they have
not realized the possibilities for growth in it that Plato saw.
CASE 99 (SECOND GRADE)
Louis Gannin came into his first year of Meddling

school life with a surplus of interest in
whatever struck his senses. His movements were very rapid, his
attention was fluctuating and his hand deft in opening boxes and
other receptacles for articles of any sort.
“Louis, is that you?” said his teacher one morning. He was visible
only as a mass of child’s garments, for he stood doubled up over a
pile of rubbish in a hall closet.
And so it was on many occasions, until Miss Vanderlip broke down
in despair:
“Louis, I think you must have looked at everything there is in this
whole school building by this time. I have told you not to get into
things and still you do it. What shall I do with you, anyway?”
Louis looked down at his shoes in undisturbed innocence.
“I know what I’ll do with you. I’ll just tie your hands together for a
long time, so as to teach you not to get into things. How’ll you like
that? Then you’ll be like a prisoner with handcuffs.”
Louis did not know very much about handcuffs or prisoners, nor
could he help but wonder how it would feel to have his hands tied
together. He meekly let the matter rest because teacher was
apparently not in a very good mood.
We advise Miss Vanderlip to substitute permissible investigations

for forbidden ones; provide something every day which will absorb
attention and if possible exhaust the inquiring impulses of this boy.
Give him privileges, not punishment. Get an old clock, bring flowers,
an old book, a skeleton of a small animal or bird. Bring out one at a
time. Watch his reactions, after receiving them; note what appeals to
him most. Connect these extras with his lessons as far as possible so
that he may see no dividing line between work and play. Avoid
scolding but drive hard on the search for facts. Saturate him with
discoveries, so that he will not have time to pry into forbidden things.
COMMENTS
Louis had no more need of punishment than a fledgling when first

he tries to fly. Boys’ hands were made to open up things, not to be
handcuffed. He has an appetite; the way to satisfy it is to feed, not
disappoint it.
He is subject to direction. If let alone he will go far wrong; if
coerced he will go wrong the sooner; if helped he may become a
famous scholar.
ILLUSTRATION (THIRD GRADE)
Miss Frederick never let her wits fail Busy Work

when it came to providing interesting
material for children. Stories—she could tell them by the hour and
make her children laugh or cry as she would. Something to do,
delightful little tasks that were play, not work, an unlimited
assortment of these she had always at hand.
For some of the most eager ones she kept on hand a supply of busy
work which was brought out as a special reward for diligence.
For Janie and Rhoda, the two irrepressibles, she had a small
collection of Chinese paper dolls, no two alike, or some needle-work,
or a specimen from the woods. At times she sent Janie out to bring
natural objects.
“See how many different things you can bring in to me from that
maple tree, and Rhoda, bring as many different kinds of parts from
the rose-bush as you can find. They must be tiny and no two alike.”
At another time she called for different kinds of soil, stone, cloth,
pictures, and when the list seemed exhausted, she repeated items on
it without any loss of interest because some new characteristic
concerning them was brought to the attention of the curious,
wondering, little investigators.
The child that pays too much attention to what other pupils are
doing needs only to be interested in his own work. He should not be
punished. The teacher should discover what in his schoolmate’s work
interests him and then give him the same kind of work. Such a pupil
should cause a teacher no trouble. It is a matter of keeping him
interested and busy, and that is not a difficult task for the skillful
teacher.
ILLUSTRATION 2 (FIFTH GRADE)
Mildred Trott spent all her time listening Listening to

to the recitations of other classes, which Other
caused her to fail in her own. Her teacher, Recitations
Miss Ware, had often talked to her about this, and Mildred had often
resolved to do better; but when the fascinating recitations began in
front of her, she listened to them in spite of good resolutions.
Finally, one day, Miss Ware saw her watching the class at the front
of the room, while her own small geography lay closed on her desk.
She smiled, stood up, and said in a clear voice:
“Mildred Trott, Mildred Trott,

Hears that which concerns her not!”
The other children laughed a little, Mildred opened her book
hastily, and the incident passed. But at recess Miss Ware heard
Mildred’s playmates repeat the bit of doggerel, and Mildred did not
seem to like it. The next day Mildred held her book open, but she still
slyly listened to the recitation instead of studying. Miss Ware again
stood up, and repeated clearly—
“Open book availeth not;

You must study, Mildred Trott.”
This time the children laughed more, and two or three put down
the couplet before they forgot it, in the flyleaves of their books. Again
they teased Mildred at recess, and Mildred began to see that she
must overcome her curiosity or endure continual teasing. The next
day and the next she studied assiduously, and had good lessons. On
the next day, feeling very sure of herself, she fell from grace. When
Miss Ware saw her leaning forward eagerly to hear the advanced
spelling lesson, she stopped long enough to chant—
“Mildred’s class is not in session;

Mildred, work upon your lesson!”
This was the last bit of doggerel that was needed.
COMMENTS
The illustration given above was sent to the president of the

International Academy of Discipline with the following comment,
which was intended to justify the method employed:
The correction came in a friendly way, but its form enlisted the
whole school (for children love rhymes and will repeat them in and
out of season) in the corrective process. The need for well-prepared
lessons had not been an incentive strong enough to induce Mildred
to overcome her instinctive curiosity, but the ridicule of her
schoolmates gave enough additional incentive to stir her will to
action.
In spite of the fact that the method is supposed to have been
effective in dealing with “Mildred Trott,” we can not believe that the
method is good enough to recommend. On the contrary, we believe
that, in most instances, any such attempt on the part of the teacher
to bring ridicule to bear on one pupil is sure to rouse resentment.
Hostility between pupil and teacher is likely to cause more trouble to
the teacher and be more harmful to the pupil than the habit of
listening to others recite.
If the teacher finds it necessary to speak to the child at all about
the habit of listening to others recite, after she has already made the
attempt to interest the child in his own work, she should take the
matter up with the child, individually. An effective way to apply the
principle of initiative in coöperation is to approach the child with a
smile on your face, when he is alone, and in the same breath that you
speak of his habit of listening to others, mention the fact that you
used to have trouble, too, keeping your mind concentrated. Do not
say this unless it is true. But it is true of most of us, and to tell this to
the child gets results in most cases. Suggest that he try to concentrate
daily. Approve him now and then upon his progress.
In dealing with curiosity, the general truth that ideals clearly
defined help immensely in gaining control of natural tendencies,
holds. Fine and high ideals of the rights of others, of what is
appropriate and just, must constantly be kept before young people to
help them in directing and mastering their instincts.
CASE 100 (FOURTH GRADE)
The children in Valley Grove School had “Trying on”

an insatiable curiosity concerning Clothing
unfamiliar things, which annoyed Miss Freeman, their teacher,
exceedingly. She was a city woman, with no idea of the restricted
lives her pupils lived. They were crudely inquisitive, coming from
homes which were morally wholesome, but uncultured or even
boorish in manners. Miss Freeman was anxious to help them, but
was very young and not well prepared. She went home every week-
end, and every day the carrier left a letter for her at the schoolhouse.
She wore pretty clothes, which the little girls admired greatly. One
day Maggie Linton touched the silken sweater which they all liked so
much, and then Erna wondered how it felt to wear such a garment;
and the result was that Ollie Bain put on sweater, hat and gloves, and
was turning around in a small circle of admiring femininity when
Miss Freeman came into the hall.
“Why, you naughty girls!” she exclaimed. “You mustn’t touch other
people’s things. Take them off, Ollie. You may look at them, but you
mustn’t handle them; hasn’t your mother taught you that? Look how
dirty your hands are, Ollie. I’ll have to have my gloves cleaned.”
She was not angry, for she liked the children and had a good
disposition. But she failed to use the girls’ curiosity, and she failed to
generalize the principles that teach children when curiosity may be
satisfied and when it must be controlled.
“Teacher, why do you get a letter every day, and who writes it?”
Carl Voegling asked the question one rainy recess, while all the
other children stood at ecstatic attention to hear what the answer
would be.
“Carl, that’s not any of your business, and you are not to ask me
personal questions,” Miss Freeman answered. The children saw her
cheeks grow pink, and, having been brought up to think it legitimate
fun to tease people, they continued slyly to refer to the letters
throughout the year.
One day, the teacher came into the hall to Watching Mail
find George Funk examining the envelope
of the letter that had come that morning. She was very angry this
time, and told George, a boy of twelve, to stay in at recess for a week.
She thought she had come just in time to prevent his opening and
reading the letter, and told him that after this she would keep her
mail in the desk, since she could not trust her pupils out of her sight.
George had not really meant to read the letter, and feeling that her
remarks were unjust, became very sullen.
When the week was almost up, Miss Freeman herself had an
impulse of curiosity. “Why did you want to read my letter, George?”
she asked.
“I didn’t want to read your letter,” he answered. “I just wanted to
see the postmark.”
“But what good would that do you?”
“Well, I wanted to know where it was from.”

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Essential Learning for the Internal

Medicine Clerkship 1st Edition Conrad

Master the Boards USMLE Step 2 CK Conrad Fischer

Master the Wards Surgery Flashcards Dec 3 2015 1st

A Free Book For Emergency Medicine Clerkship Students

Internal Medicine 5th Edition Eugene Toy

Pocket Medicine The Massachusetts General Hospital

First Aid for the Surgery Clerkship 4th Edition Latha

First Aid for the Psychiatry Clerkship, Fourth Edition

Essentials of Internal Medicine Ardhendu Sinha Ray

eBook conversion by codeMantra

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,

T e goal is to increase vaccination rates or pertussis by giving it every time a

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

T is occurs in response to medication, chemical agents, insect venoms, or the

• Rash, urticaria, itching, ushing

T e best initial steps in management are: