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Steven S. Agabegi FOURTH EDITION
Elizabeth D. Agabegi

•• •
Step-Up
®Wolters Kluwer SE RIE S
STEP-UP to

MEDICINE
FOURTH EDITION

ED I TORS
Steven S. Agabegi, MD
Elizabeth D. Agabegi, MD
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ISBN 978-1-4963-2147-3 (alk. paper)
I. Agabegi, Steven S., editor. II. Agabegi, Elizabeth D., editor.
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10 9 8 7 6 5 4 3 2 1
Advisory Board
WADE R. BARKER, DDS AUSTIN IVEY, DDS
Medical Student Resident Physician
School of Medicine Oral and Maxillofacial Surgery
Texas Tech University Health Sciences Baylor University Medical Center
Center Dallas, Texas
Lubbock, Texas
HAWNYEU MATTHEW MOY, MPH
RYAN BOLTON, MD Medical Student
Assistant Professor of Medicine Chicago Medical School
Division of General Internal Medicine Rosalind Franklin University
University of Illinois Hospital & Health Chicago, Illinois
Sciences System
Chicago, Illinois JAMES MURCHISON, MBA
Medical Student
LANCE W. CHAPMAN, MD, MBA School of Medicine
Resident Physician Texas Tech University Health Sciences
Department of Dermatology Center
UC Irvine Medical Center Lubbock, Texas
Irvine, California
GITA S. RAO
MARK D. DUNCAN, MD Medical Student
Resident Physician, Internal Medicine School of Medicine
Department of Medicine Texas Tech University Health Sciences
UCLA Medical Center Center
Los Angeles, California Lubbock, Texas

AHSAN S. FAROOQI, MD, PhD

School of Medicine
Texas Tech University Health Sciences
Center
Lubbock, Texas

iii
 Reviewers
MOHAMMED ARAFEH ABIGAIL GOODMAN, MD
Medical Student Resident Physician
Ross University School of Medicine Department of Pathology
Dominica, West Indies Midwestern University
Downers Grove, Illinois
DANA BAIGRIE, DO
Medical Student KRISTA JOHANSEN, MD
Edward Via College of Osteopathic Assistant Professor of Anatomy and Physiology
Medicine Edward Via College of Osteopathic
Spartanburg, South Carolina Medicine
Blacksburg, Virginia
DAVID BALLARD, MD
Medical Student ASHLEY JONES, MD
Louisiana State University Health Sciences Resident Physician
Center Department of Surgery
Shreveport, Lousiana Palmetto Health
Columbia, South Carolina
JANELLE BLOCKER
Medical Student Soor Kothari
University of Sint Eustatius School of Medical Student
Medicine St. George’s University School of Medicine
Sint Maarten, Caribbean Grenada, West Indies

F. BRIAN BOUDI, MD, FACP STEVEN MCAFEE, MD

Assistant Professor of Medicine Resident Physician
University of Arizona College of Medicine Department of Anesthesiology
Phoenix, Arizona University of Missouri
Columbia, Missouri
MARIA CANNAROZZI, MD
Associate Professor of Internal Medicine and LUIS CARLOS MEJIA-RIVERA, MD
Pediatrics Associate Professor of Clinical Pharmacology
University of Central Florida College of San Juan Bautista School of Medicine
Medicine Caguas, Puerto Rico
Orlando, Florida
NATE MOORE
JIMMY DEMEO Medical Student
Medical Student Edward via College of Osteopathic
Lake Erie College of Osteopathic Medicine Medicine
Erie, Pennsylvania Blacksburg, Virginia

MATTHEW FITZ, MD SHERYL RECINOS, MD

Associate Professor Resident Physician
Clerkship Director, Internal Medicine Department of Family Medicine
Loyola University Stritch School of Riverside County Regional Medical Center
Medicine Moreno Valley, California
Chicago, Illinois
KARA RONCIN
BRIANNA FOX Medical Student
Medical Student Medical University of the Americas
Ross University School of Medicine Nevis, West Indies
Dominica, West Indies

iv
 Reviewers ● v

LESLIE SEIJO Michael Sostok, MD

Medical Student Professor of Medicine
San Juan Bautista School of Medicine University of Cincinnati College of Medicine
Caguas, Puerto Rico Cincinnati, Ohio

ARCHANA SHAH CHRISTINE TRAN

Medical Student Medical Student
Texas Tech University Health Sciences Mayo Clinic College of Medicine
Center School of Medicine Rochester, Minnesota
Lubbock, Texas
BRIAN WU, MD
VISHAL SHAH Medical Student and PhD Candidate
Medical Student Keck School of Medicine
University of Vermont College of Medicine University of Southern California
Burlington, Vermont Los Angeles, California
 PREFACE
We wrote the first edition of Step-Up to Medicine during our third year of medical school
because we could not find a review book that was concise, yet covered the breadth of pathol-
ogy encountered during the internal medicine clerkship and the corresponding NBME shelf
examinations. Our goal was to create a single “study tool” to spare medical students the hassle
and expense of trying to extract pertinent information from multiple sources.
Now in its fourth edition, Step-Up to Medicine has been completely revised based on exten-
sive feedback by both faculty and students. In addition, we welcomed an Advisory Board
of students and residents to the team that worked collaboratively to enrich the content and
ensure that the most tested topics were covered. And, since we know that medical students
and interns have no time to waste, we retained and enhanced the high-yield outline format,
Quick Hits, and Clinical Pearls. Finally, to pull it all together, we added a new 100-question,
clinically-oriented practice exam at the end of the book for self-assessment. Before looking at
the answers, take time to answer these questions because these are the questions you will be
faced with in clinical practice.
We hope that the new edition of Step-Up to Medicine continues to be a valuable tool for
students during the clinical years of medical school. However, we recognize the changing
nature of science and medicine and encourage you to send comments or suggestions to www.
lww.com.
We would like to thank the Advisory Board, and all the reviewers for their efforts in
improving the content for this edition. In particular, we would like to give special thanks
to Stacey Sebring, with whom we worked for the last eight years, for her tireless efforts and
­dedication in bringing this and previous editions of Step Up to Medicine to fruition.

Steve and Liz Agabegi

vi
Contents
Advisory Board iii
Reviewers iv
Preface vi

1 Diseases of the Cardiovascular System

Ischemic Heart Disease 1
Congestive Heart Failure 15
Acute Decompensated Heart Failure 21
Arrhythmias 22
Tachyarrhythmias 23
Bradyarrhythmias 31
Diseases of the Heart Muscle 33
Pericardial Diseases 36
Valvular Heart Disease 40
Congenital Heart Diseases 49
Diseases of the Vasculature 52
Cardiac Neoplasms 62
Shock 63

2 Diseases of the Pulmonary System

Obstructive Lung Diseases 68
Lung Neoplasms 77
Diseases of the Pleura 81
Interstitial Lung Disease 87
Respiratory Failure 93
Diseases of the Pulmonary Vasculature 101
Miscellaneous Topics 108

3 Diseases of the Gastrointestinal System

Diseases of the Colon 113
Diseases of the Liver 120
Diseases of the Gallbladder and Biliary Tract 132
Diseases of the Appendix 138
Diseases of the Pancreas 139
Gastrointestinal Bleeding 144
Diseases of the Esophagus 148
Diseases of the Stomach 154
Diseases of the Small Intestine 159
Inflammatory Bowel Disease 162

4 Endocrine and Metabolic Diseases

Diseases of the Thyroid Gland 167
Diseases of the Pituitary Gland 176
Diseases of the Parathyroid Glands 181
Diseases of the Adrenal Glands 183
Diseases of the Pancreas 190 vii
viii ● Contents

5 Diseases of the Central and Peripheral Nervous Systems

Cerebrovascular Disease (Stroke) 207
Movement Disorders 214
Dementia 217
Altered Mental Status 220
Demyelinating Disease 223
Neuromuscular Diseases 226
Neurocutaneous Syndromes 228
Spinal Cord Diseases 229
Miscellaneous Conditions 230

6 Connective Tissue and Joint Diseases

Connective Tissue Diseases 244
Crystal-induced Arthritides 256
Myopathies and Pain Syndromes 260
Seronegative Spondyloarthropathies 263
Vasculitis 265

7 Diseases of the Renal and Genitourinary System

Renal Failure 269
Proteinuria and Hematuria 280
Glomerular Disease (Glomerulonephropathies) 283
Tubulointerstitial Diseases 287
Renal Cystic Diseases 289
Renal Vascular Disease 292
Stones and Obstructions 293
Neoplasms 298
Miscellaneous Conditions 302

8 Fluids, Electrolytes, and Acid–Base Disorders

Volume Disorders 303
Sodium 306
Calcium 310
Potassium 313
Magnesium 316
Phosphate 318
Acid–base Disorders 319
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 Contents ● ix

9 Hematologic Diseases and Neoplasms

Anemias 325
Microcytic Anemias 328
Normocytic Anemias 331
Macrocytic Anemias 332
Hemolytic Anemias 333
Platelet Disorders 341
Disorders of Coagulation 344
Anticoagulation 349
Plasma Cell Disorders 354
Lymphomas 356
Leukemias 360
Myeloproliferative Disorders 363

10 Infectious Diseases
Infections of the Upper and Lower Respiratory Tracts 365
Infections of the Central Nervous System 373
Infections of the Gastrointestinal Tract 376
Infections of the Genitourinary Tract 380
Sexually Transmitted Diseases 384
Wound and Soft Tissue Infections 395
Infections of the Bones and Joints 398
Zoonoses and Arthropod-borne Diseases 401
Common Fungal Infections 404
Other Fungal Infections 407
Common Parasitic Infections 407
Fever and Sepsis 407
Miscellaneous Infections 412

11 Diseases of the Skin and Hypersensitivity Disorders

Common Dermatologic Problems 415
Inflammatory, Allergic, and Autoimmune Skin Conditions 415
Skin Conditions Related to Microbial Infection 422
Precancerous and Cancerous Diseases of the Skin 426
Miscellaneous Skin Conditions 429
Allergic Reactions 432
Drug Allergy 433
Food Allergy 434
Insect Sting Allergy 434
Dermatology-related Key Terms 435
x ● Contents

12 Ambulatory Medicine
Cardiovascular Diseases 436
Headache 444
Upper Respiratory Diseases 447
Gastrointestinal Diseases 451
Musculoskeletal Problems 461
Overview of Musculoskeletal Examination Maneuvers 461
Diseases of the Eye 473
Sleep Disorders 478
Miscellaneous Topics 479

APPENDIX
Radiographic Interpretation 492
Electrocardiogram Interpretation 496
Physical Examination Pearls 508
Workup and Management of Common Problems 511
Basic Statistics and Evidence-based Medicine 516
End of Life Issues and Informed Consent 520

Questions 523
Answers 552
Index 572
Diseases of the
Cardiovascular
System
1

Diseases of the Cardiovascular System

Ischemic Heart Disease
Stable Angina Pectoris
A. General characteristics
1. Stable angina pectoris is due to fixed atherosclerotic lesions that narrow the major
Quick HIT
coronary arteries. Coronary ischemia is due to an imbalance between blood supply CAD can have the following
clinical presentations:
and oxygen demand, leading to inadequate perfusion. Stable angina occurs when • Asymptomatic
oxygen demand exceeds available blood supply. • Stable angina pectoris
2. Major risk factors • USA pectoris
a. Diabetes mellitus (DM)—worst risk factor • MI—either NSTEMI or
b. Hyperlipidemia—elevated low-density lipoprotein (LDL) STEMI
• Sudden cardiac death
c. Hypertension (HTN)—most common risk factor
d. Cigarette smoking
e. Age (men >45 years; women >55 years)
f. Family history of premature coronary artery disease (CAD) or myocardial
infarction (MI) in first-degree relative: Men <55 years; women <65 years
Quick HIT
g. Low levels of high-density lipoprotein (HDL) In a patient with CAD, goal of
3. Minor risk factors (less clear significance) include obesity, sedentary lifestyle (lack LDL is less than 100 mg/dL.
of physical activity), stress, excess alcohol use.
4. Prognostic indicators of CAD
a. Left ventricular function (ejection fraction [EF])
• Normal >50% Quick HIT
• If <50%, associated with increased mortality Typical Anginal Chest Pain
b. Vessel(s) involved (severity/extent of ischemia) • Substernal
• Left main coronary artery—poor prognosis because it covers approximately • Worse with exertion
• Better with rest or nitro-
two-thirds of the heart
glycerin
• Two- or three-vessel CAD—worse prognosis

B. Clinical features
1. Chest pain or substernal pressure sensation
a. Lasts less than 10 to 15 minutes (usually 1 to 5 minutes)
b. Frightening chest discomfort, usually described as heaviness, pressure,
­squeezing, tightness; rarely described as sharp or stabbing pain
c. Pain is often gradual in onset
2. Brought on by factors that increase myocardial oxygen demand, such as exertion
or emotion
3. Relieved with rest or nitroglycerin
4. Note that ischemic pain does NOT change with breathing nor with body posi-
tion. Also, patients with ischemic pain do not have chest wall tenderness. If any of
these are present, the pain is not likely to be due to ischemia

1
 2 ● STEP-UP TO MEDICINE

CLI NICAL PEARL 1-1

There Are Two Conditions Termed Syndrome X
1. Metabolic Syndrome X
• Any combination of hypercholesterolemia, hypertriglyceridemia, impaired glucose tolerance, diabetes,
hyperuricemia, HTN.
• Key underlying factor is insulin resistance (due to obesity).
2. Syndrome X
• Exertional angina with normal coronary arteriogram: Patients present with chest pain after exertion but
have no coronary stenoses at cardiac catheterization.
• Exercise testing and nuclear imaging show evidence of myocardial ischemia.
• Prognosis is excellent.

C. Diagnosis (of CAD)

Diseases of the Cardiovascular System

1. Note that physical examination in most patients with CAD is normal (see Clinical
Pearl 1-1)

Quick HIT 2. Resting ECG

a. Usually normal in patients with stable angina
Best initial test for all forms b. Q waves are consistent with a prior MI
of chest pain is ECG. c. If ST segment or T-wave abnormalities are present during an episode of chest
pain, then treat as unstable angina (USA)
3. Stress test—useful for patients with an intermediate pretest probability of CAD
based upon age, gender, and symptoms.
Quick HIT a. Stress ECG
Stress testing is used in the • Highest sensitivity if patients have normal resting ECG, such that changes
following situations: can be noted.
• To confirm diagnosis of • Test involves recording ECG before, during, and after exercise on a treadmill.
angina • 75% sensitive if patients are able to exercise sufficiently to increase heart rate
• To evaluate response of to 85% of maximum predicted value for age. A person’s maximum heart rate
therapy in patients with
documented CAD is calculated by subtracting age from 220 (220—age).
• To identify patients with • Exercise-induced ischemia results in subendocardial ischemia, producing ST
CAD who may have a segment depression. So the detection of ischemia on an ECG stress test is
high risk of acute coro- based on presence of ST segment depression.
nary events • Other positive findings include onset of heart failure or ventricular arrhyth-
mia during exercise or hypotension.
• Patients with a positive stress test result should undergo cardiac catheterization.
b. Stress echocardiography
Quick HIT • Performed before and immediately after exercise. Exercise-induced ischemia
is evidenced by wall motion abnormalities (e.g., akinesis or dyskinesis) not
Exercise stress ECG is present at rest.
ideal initial test if able to
• Favored by many cardiologists over stress ECG. It is more sensitive in detect-
exercise and normal resting
ECG (readily available and ing ischemia, can assess LV size and function, can diagnose valvular disease,
relatively inexpensive). and can be used to identify CAD in the presence of pre-existing ECG abnor-
malities (see Clinical Pearl 1-2).
• Again, patients with a positive test result should undergo cardiac catheterization.

Quick HIT
A stress test is generally
CLI NICAL PEARL 1-2
considered positive if the
patient develops any of the Types of Stress Tests
following during exercise:
ST segment depression,
Test Method of Detecting Ischemia
chest pain, hypotension, or Exercise ECG ST segment depression
significant arrhythmias. Exercise or dobutamine echocardiogram Wall motion abnormalities
Exercise or dipyridamole perfusion study (thallium/ Decreased uptake of the nuclear isotope during
technetium) exercise
 dise a ses o f t h e c a r dio v a scu l a r s y stem ● 3

c. Information gained from a stress test can be enhanced by stress myocardial per-
fusion imaging after IV administration of a radioisotope such as thallium 201
during exercise.
• Viable myocardial cells extract the radioisotope from the blood. No radioiso-
tope uptake means no blood flow to an area of the myocardium.
• It is important to determine whether the ischemia is reversible, that is, whether
areas of hypoperfusion are perfused over time as blood flow eventually equal-
izes. Areas of reversible ischemia may be rescued with percutaneous coronary
intervention (PCI) or coronary artery bypass graft (CABG). Irreversible isch-
emia, however, indicates infarcted tissue that cannot be salvaged.
• Perfusion imaging increases the sensitivity and specificity of exercise stress
tests, but is also more expensive, subjects the patient to radiation, and is
often not helpful in the presence of a left bundle branch block.
4. If the patient cannot exercise, perform a pharmacologic stress test.
a. IV adenosine, dipyridamole, or dobutamine can be used. The cardiac stress
induced by these agents takes the place of exercise. This can be combined with

Diseases of the Cardiovascular System

an ECG, an echocardiogram, or nuclear perfusion imaging.
b. IV adenosine and dipyridamole cause generalized coronary vasodilation. Since
diseased coronary arteries are already maximally dilated at rest to increase
blood flow, they receive relatively less blood flow when the entire coronary sys-
tem is pharmacologically vasodilated.
c. Dobutamine increases myocardial oxygen demand by increasing heart rate,
blood pressure, and cardiac contractility.
5. Holter monitoring (ambulatory ECG) can be useful in detecting silent ischemia
(i.e., ECG changes not accompanied by symptoms). The Holter monitor is also
used for evaluating arrhythmias, heart rate variability, and to assess pacemaker and
implantable cardioverter-defibrillator (ICD) function.
a. Continuously examines patient’s cardiac rhythm over 24 to 72 hours during
normal activity
b. Useful for evaluating unexplained syncope and dizziness as well
6. Cardiac catheterization with coronary angiography (see Clinical Pearl 1-3, Figure 1-1)
a. Coronary angiography—definitive test for CAD. Often performed with concur-
rent PCI or for patients being considered for revascularization with CABG.

CLINICAL PEARL 1-3

Cardiac Catheterization
1. Most accurate method of determining a specific cardiac diagnosis.
2. Provides information on hemodynamics, intracardiac pressure measurements, cardiac output, oxygen
s­ aturation, etc.
3. Coronary angiography (see below) is almost always performed as well for visualization of coronary arteries.
4. There are many indications for cardiac catheterization (generally performed when revascularization or other
surgical intervention is being considered):
• After a positive stress test.
• Acute MI with intent of performing angiogram and PCI.
• In a patient with angina in any of the following situations: When noninvasive tests are nondiagnostic,
angina that occurs despite medical therapy, angina that occurs soon after MI, and any angina that is a
diagnostic dilemma.
• If patient is severely symptomatic and urgent diagnosis and management are necessary.
• For evaluation of valvular disease, and to determine the need for surgical intervention.

Coronary Arteriography (Angiography)

1. Most accurate method of identifying the presence and severity of CAD; the standard test for delineating
coronary anatomy.
2. Main purpose is to identify patients with severe coronary disease to determine whether revascularization
is needed. Revascularization with PCI involving a balloon and/or a stent can be performed at the same time
as the diagnostic procedure.
3. Coronary stenosis >70% may be significant (i.e., it can produce angina).
Diseases of the Cardiovascular System 4 ● STEP-UP TO MEDICINE

Figure
1-1 Coronary angiogram. Injection of the right coronary artery shows a stenosis in the midportion
of the vessel, indicated by the arrow.
(From Lilly LS. Pathophysiology of Heart Disease. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2011:152,
Figure 6.8; Courtesy of Dr. William Daley.)

b. Contrast is injected into coronary vessels to visualize any stenotic lesions. This
defines the location and extent of coronary disease.
c. Angiography is the most accurate test for detecting CAD.
d. If CAD is severe (e.g., left main or three-vessel disease), refer patient for s­ urgical
revascularization (CABG).

D. Treatment
1. Risk factor modification
a. Smoking cessation cuts coronary heart disease (CHD) risk in half by 1 year
after quitting.
b. HTN—vigorous BP control reduces the risk of CHD, especially in diabetic
patients.
c. Hyperlipidemia—reduction in serum cholesterol with lifestyle modifications
and HMG-CoA reductase inhibitors (statins) reduce CHD risk.
d. DM—type II diabetes is considered to be a cardiovascular heart disease equiva-
Quick HIT lent, and strict glycemic control should be strongly emphasized.
e. Obesity—weight loss modifies other risk factors (diabetes, HTN, and hyperlip-
Standard of care for stable idemia) and provides other health benefits.
angina is aspirin and a f. Exercise is critical; it minimizes emotional stress, promotes weight loss, and
β-blocker (only ones that helps reduce other risk factors.
lower mortality), and
nitrates for chest pain. g. Diet: Reduce intake of saturated fat (<7% total calories) and cholesterol (<200 mg/
day).
2. Medical therapy
a. Aspirin
• Indicated in all patients with CAD
• Decreases morbidity—reduces risk of MI
b. β-Blockers—block sympathetic stimulation of heart. First-line choices include
Quick HIT atenolol and metoprolol.
• Reduce HR, BP, and contractility, thereby decreasing cardiac work (i.e.,
Side effects of nitrates: β-blockers lower myocardial oxygen consumption)
• Headache • Have been shown to reduce the frequency of coronary events
• Orthostatic hypotension c. Nitrates—cause generalized vasodilation
• Tolerance
• Syncope • Relieve angina; reduce preload myocardial oxygen demand
• May prevent angina when taken before exertion
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