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Internal Medicine Board Review - ABIM Exam / Internal Medicine Shelf Exam Review

Updated on October 22, 2014

Medical Mnemonics - Causes of Anion Gap Metabolic Acidosis

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Alcohol Poisoning: What you Need to Know for the ABIM and USMLE exams

If most of your clinic duties are in primary care, you may only rarely encounter alcohol poisoning. However, this topic is a favorite of the boards in the Nephrology section and one that does certainly arise in emergency departments and on the inpatient wards. For the USMLE and ABIM examinations, it is important to know the specifics of alcohol poisoning, including how to differentiate among Ethanol, Methanol, Isopropyl alcohol, and Ethylene glycol. In fact, in a patient suspected of having consumed too much alcohol, these will be the answer choices rather than simply “alcohol poisoning.” So how do we arrive at the correct diagnosis?


First of all, you won’t be able to consider alcohol poisoning without first calculating an osmolal gap, the difference between the measured (seen on labs) and the calculated osmolality. The former is seen on the lab value list provided in the clinical vignette; the latter is determined by the following equation: Plasma Osmolality = 2 x serum [Na+] + [BUN]/2.8 + [Glucose]/18




A normal osmolal gap is 10mosm/kg H2O. A larger than 10mosm/kg H2O value suggests that the unmeasured osmoles is attributable to an alcohol.


Now, how do we differentiate the different types of alcohol? Using a few simple clinical clues…



  • Of the 4 causes, only isopropyl alcohol does not have an anion gap metabolic acidosis. In fact, the patient will likely feature a normal acid-base status despite being so severely ill that they are in a coma or at least hypersomnolent.
  • Vision abnormalities or abdominal pain suggest methanol due to this alcohol’s effects on the retina and the pancreas.
  • While the eyes and pancreas are damaged by methanol, the kidneys are the main organ affected by ethylene glycol due to its breakdown to oxalic acid that can cause nephrolithiasis, especially calcium oxalate stones.
  • Ketoacidosis is primarily seen in ethanol poisoning (the most common type of alcoholic poisoning).



The ABIM and USMLE exams are known for testing both the diagnosis and treatment of various conditions. Alcohol poisoning is no different. You will either be asked what the most likely diagnosis is in a patient with an overdose of some type or what the best next step is in his or her management.



Isopropyl alcohol treatment is dependent on the intensity.

  • -Mild intensity: IV fluids and gastric lavage
  • -Severe intensity (featuring shock and low blood pressure): Hemodialysis



Methanol and Ethylene glycol have similar treatment (isn’t that nice?):

  • Fomepizole and Hemodialysis



Ethanol poisoning has the most basic management: IV fluids including glucose.


Now, that you’ve reviewed alcohol poisoning for the ABIM and USMLE boards, let’s give you all the info in one simple Knowmedge visual.



Thanks in advance for sharing your thoughts below if you have additional tips for the other users in the Knowmedge community.


Knowmedge Medical Mnemonics Platform

It’s coming! A revolutionary, new medical mnemonics platform!

Medical Mnemonics: Causes of Hypercalcemia – “CHIMPANZEES”

Medical Mnemonics: Causes of Hypercalcemia

It’s Medical Mnemonics Monday! Hypercalcemia (Elevated calcium levels) is a commonly tested condition on any medical exam board including the internal medicine boards. Often, in mild hypercalcemia, there are no signs or symptoms on the condition. In more severe cases, you may see symptoms such as nausea / vomiting, muscle weakness, confusion, loss of appetite, excessive thirst, and constipation. Causes of hypercalcemia can be remembered by the mnemonic “CHIMPANZEES”

  • C – Calcium supplementation
  • H – Hydrochlorothiazide
  • I – Iatrogenic, immobilization
  • M – Multiple myeloma, milk-alkali syndrome, medication (e.g Lithium)
  • P – Parathyroid hyperplasia or adenoma
  • A – Alcohol
  • N – Neoplasm (e.g breast cancer, lung cancer)
  • Z – Zollinger Ellison syndrome
  • E – Excessive vitamin D
  • E – Excessive vitamin A
  • S – Sarcoidosis

Check out the list of the previous Medical Mnemonics here.

Internal Medicine Board Review Topic: JNC8

Perhaps no topic is as difficult to categorize into the appropriate section of the ABIM Board, NBME Shelf, or USMLE Step exams as is hypertension.

Is elevated blood pressure a topic for General Internal Medicine (we see it more than any other speciality)? Cardiology (where the patients with difficult-to-control hypertension go)? Or is it related to Nephrology (where most of the anti-hypertensive medications act)? Fortunately, agreeing on the perfect location in the syllabus is not for you to worry about. Nor do you need a deep understanding of each previous iteration of the somewhat fickle hypertension guidelines. When it comes to hypertension for the sake of the boards and the wards, all you need to do is master the latest recommendations regarding blood pressure management.

In December 2013, the 8th edition of the Joint National Committee (JNC 8) hypertension guidelines released after multiple delays, leading some critics to dub it “JNC Late.”

Despite their tardiness, the JNC 8 guidelines serve as the gold standard for determining the goal systolic and diastolic blood pressure levels in our patients, taking into account age and comorbid conditions.

  • Patients age 60 years or older who do not have diabetes or chronic kidney disease (CKD) should be targeted to have a goal blood pressure of less than 150mmHg systolic and less than 90mmHg diastolic.
  • Patients age 18 to 59 years have a goal of less than 140mmHg systolic and less than 90mmHg diastolic.
  • Patients of any age with diabetes or CKD also have a goal of less than 140mmHg systolic and less than 90mmHg diastolic.

One of the best changes of the JNC8 over JNC7 for board exam purposes is the simplification of the goal diastolic blood pressure. All patients, based on age or the presence of diabetes/CKD are managed to a goal of less than 90mmHg.

Much of the focus of the JNC 8 is on the target blood pressure readings. However, it also provides recommendations to promote the safer use of specific anti-hypertensive agents. Preferred medications to be used as first-, second-, and third-line agents include the following four drugs:

  • Angiotensin converting enzyme (ACE) inhibitors
  • Angiotensin receptor blockers (ARBs)
  • Calcium channel blockers (CCBs)
  • Thiazide diuretics

With the exception of concurrent ACE inhibitors and ARBs, other combinations of the 4 agents can be administered to titrate to goal blood pressure. Note that missing from the above list are beta blockers, which are no longer considered top candidate medications for hypertensive patients in the absence of comorbidities (patients with prior myocardial infarction or congestive heart failure).

ACE inhibitors or ARBs are an essential part of hypertensive management in patients up to age 75 with CKD, regardless of ethnic background. Meanwhile, in patients greater than age 75 with CKD there isn’t evidence supporting renin-angiotensin system inhibitor treatment. While ACE inhibitors or ARBs can be used, CCBs and thiazide diuretics are also an option.

Lastly, the ethnicity also plays a role in determining the preferred anti-hypertensive agent. When initiating blood pressure lowering medication in patients of African descent, ACE inhibitors should be avoided in favor of CCBs or thiazides.

One of our Twitter followers asked when the December 2012 guidelines would appear on board exams, partly given their controversy.Despite an outreach attempt to the folks at ABIM, the response I got was a generic “…We advise test takers to answer all questions according to their current understanding of clinical principles and practice. If ABIM determines that any question has been compromised by new information, that question will not be counted in your overall examination score. This information appears in the instructions at the start of every ABIM examination…”

My recommendation is that given the adoption of these guidelines by large medical organizations such as Kaiser Permanente, you should start to use the updates for both the boards and the wards. Drop a note below giving your take on the JNC 8 guidelines.

Internal Medicine Board Review: Ring-Enhancing and Non-Enhancing Lesions

A favorite of the USMLE Steps, NBME Internal Medicine Shelf, and ABIM Internal Medicine Board Exams seems to be those ring-shaped lesions picked up on imaging studies. Often, the scenario is a ring lesion identified on a CT head scan in an immunocompromised patient (particularly one with HIV or AIDS). These can be challenging because the clinical vignette focuses on the description of the lesion without providing detailed serologies. So let’s use an efficient approach to identifying the most commonly encountered ring lesion etiologies on medical exams.


The first step is to determine whether the lesion presented on the CT scan is ring-enhancing or non-enhancing.


If it is a ring-enhancing lesion, the most commonly seen etiologies are

  • Cerebral toxoplasmosis (50%)
  • Primary central nervous system (CNS) lymphoma (30%)
  • Less commonly, Bacterial or Fungal abscess (e.g. Cryptococcosis, Histoplasmosis, Aspergillosis, Tuberculosis and Trypanosomiasis)


Cerebral Toxoplasmosis is the most common cause of ring-enhancing cerebral lesions. Often, multiple lesions are seen, usually located in the basal ganglia. It is unlikely to be seen in a patient who is already receiving prophylactic trimethoprim-sulfamethoxazole (TMP-SMX). Patients with AIDS and CD4 count less than 100/microL are at increased risk. It’s very important to remember that Toxoplasmosis serologies are non-specific but patients with cerebral toxoplasmosis are seropositive for T. gondii IgG antibody.


Primary CNS Lymphoma is the second most common cause of a ring-enhancing cerebral lesion. Unlike cerebral toxoplasmosis, primary CNS lymphoma may be solitary. Thus, if a solitary lesion is detected, even if toxoplasma serology is positive, CNS lymphoma is the more likely diagnosis than toxoplasmosis. The location of CNS lymphoma is more commonly in the periventricular areas. Lesions greater than 4cm in diameter are more likely to be primary CNS lymphoma rather than cerebral toxoplasmosis. Epstein-Barr virus (EBV) DNA in the cerebrospinal fluid (CSF) is quite specific for primary CNS lymphoma.


And the ring non-enhancing lesions are typically due to…


Progressive Multifocal Leukoencephalopathy (PML), which is attributed to the JC virus. It presents with multiple demyelinating lesions. It predominantly affects the white cerebral matter, in particular the brainstem and the cerebellum. Other patients at risk of developing PML are those receiving natalizumab therapy for relapsing-remitting multiple sclerosis, efalizumab for psoriasis, and brentuximab for Hogkin’s lymphoma.


I hope you find this review helpful in rapidly identifying the cause of each brain-ring lesion you may encounter on the USMLE Steps, NBME Internal Medicine Shelf, and ABIM Internal Medicine Board Exams.

Medical Mnemonics: Causes of Papillary Necrosis

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Medical Mnemonics - Causes of Papillary Necrosis

Mnemonic for causes of Papillary Necrosis _ “POSTCARDS”

It’s Medical Mnemonics Monday!


Renal Papillary Necrosis is a form of nephropathy characterized by coagulative necrosis of the renal medullary pyramids and papillae. Causes of Papillary Necrosis can be remembered by the mnemonic “POSTCARDS”.

  • Pyelonephritis
  • Obstruction of the urogenital tract
  • Sickle cell disease
  • Tuberculosis
  • Chronic liver disease,
  • Analgesia/alcohol abuse,
  • Renal transplant rejection
  • Diabetes mellitus
  • Systemic vasculitis

Medical Mnemonics - Cause of Microcytic Anemia

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Medical Mnemonics: Felty Syndrome

Medical Mnemonics: Felty Syndrome


Felty syndrome is a rare condition that involves rheumatoid arthritis, decreased white blood cell count, and a swollen spleen. It can develop into a serious and life-threatening infection.


Unfortunately, there is not much known about the condition. The underlying cause is unknown and treatment generally focuses on controlling the underlying RA.


Components of Felty Syndrome can be remembered by the mnemonic: SANTA

  • S – Splenomegaly
  • A – Anemia
  • N – Neutropenia
  • T – Thrombocytopenia
  • A – Arthritis (Rheumatoid)

Check out the list of the previous Medical Mnemonics here.

Medical Mnemonics - Recognizing Features of Melanoma

Medical mnemonic for the recognizing features of Melanoma It is important to recognize the moles and growths that might cancerous early in the process. A mole exhibiting the following ABCDE features should be at least suspected for Melanoma.

  • A: Asymmetry – Asymmetric moles are particularly suspicious
  • B: Border – Irregular borders are more likely to be cancerous
  • C: Color – Different colors within a mole are suspicious
  • D: Diameter – Moles with a diameter > 6mm are especially suspicious
  • E: Evolving – A mole that is enlarging or begins to feel itchy is another suspicious sign

A special distinction is made for Nodular Melanoma, which is often smaller in size and symmetrical. It is also often even in color. The mnemonic EFG is often used for the recognizing features of Nodular Melanoma.

  • E: Elevated
  • F: Firm to touch
  • G: Growing progressively for more than a month

Check out the list of the previous Medical Mnemonics here.

Knowmedge and Docphin announce collaborative agreement for Internal Medicine Board Review Questions

Knowmedge – Docphin Internal Medicine Questions Collaboration Press Release


Docphin, an evidence-based medicine content management platform for hospitals and healthcare providers, to feature content from the Knowmedge Internal Medicine Question Bank on its web and mobile platforms


Feb. 11, 2014 - COLUMBUS, Ohio Knowmedge, an internal medicine board review question bank provider, and Docphin, an evidence-based content management platform for hospitals and healthcare providers, are excited to announce a collaborative agreement for ABIM exam content. Under this agreement, Docphin will feature Knowmedge’s ABIM Board Exam practice questions on its web and mobile platform for medical residents and physicians to test their internal medicine knowledge. The agreement also lays the groundwork for further collaboration and opportunities to enhance medical education. Dr. Ravi Bhatia, co-Founder of Knowmedge, states “Docphin is a valuable data aggregation platform for residents and physicians. Their web and mobile platforms are an excellent resource for physicians to stay on top of all the relevant news in medicine. We are excited about the opportunity to work with the Docphin team to provide Internal Medicine questions and content to enhance medical education.”


Dr. Mitesh Patel, CEO of Docphin, states “Incorporating Knowmedge’s high yield ABIM Internal Medicine Board Exam style questions on to the Docphin platform will provide us an additional resource to further improve medical education. Docphin and Knowmedge share a similar vision to improve medical education and this collaboration sets the groundwork for our companies to continue working together to help residents and physicians build their medical knowledge.”


Docphin’s (www.docphin.com) provider platform streamlines access to medical research from over 5000 journals and recommends content that’s relevant to your interests and trending among your peers. Docphin’s hospital platform enables departments and residency programs to upload clinical guidelines, hospital protocols, and decision-making references for mobile access and provides detailed engagement metrics to help accelerate the implementation process within the healthcare system. Docphin is used at over 350 institutions in more than 15 countries by all types of providers and students including physicians, nurses, pharmacists, engineers, and scientists. Docphin is available for iPhone, iPad, Android, and Web.

Knowmedge (www.knowmedge.com) is a medical exam prep provider focused on Internal Medicine board review questions. The Knowmedge Internal Medicine question bank contains over 900 board review questions. The question bank has been used by physicians and residents at over 100 institutions. The question bank is used by physicians preparing for the numerous exams, including ABIM Board exam, In-training Exam, Internal Medicine Shelf exam, and the USMLE Step 3 exam.

Internal Medicine Board Review Courses

Are you studying for the ABIM Internal Medicine Board Exam? We’ve touched upon our suggestions for studying for the ABIM exam including a brief overview of the independent internal medicine board review courses.

There are a lot of internal medicine board review course options. We’ll cover the ones we’re aware of here. If you know of one we’ve missed, please post a comment or send us a note at support@knowmedge.com.


Independent Internal Medicine Board Review Courses


iMedicine Review


iMedicine Review – Shahid Babar


Website: www.imedicinereview.com


Taught by: Shahid Babar, MD FACP FHM


Overview: Dr. Babar has been conducting Internal medicine board review courses at various academic centers since 2007. He founded iMedicine Review in 2010 and in addition to continuing his live courses, he created educational apps for residents and physicians preparing for ABIM Internal medicine board exam. His courses are 3 ½ days long and take place in various cities around the country.


Locations / Dates: Dr. Shahid Babar’s will be teaching his iMedicine Review course at five different locations in 2014.

University of Pennsylvania, Perelman Quadrangle

Philadelphia, PA
May 15, 16, 17 & 18, 2014 (Thursday – Sunday)


    • PinnacleHealth Hospital Program

Harrisburg, PA

May 29, 30, 31 & June 1, 2014 (Thursday – Sunday)

University of Connecticut

Farmington, CT
June 12, 13, 14 & 15, 2014 (Thursday – Sunday)

AMA Executive Conference Center

New York, NY
July 9, 10, 11 & 12, 2014 (Thursday – Sunday)

The George Washington University

Washington, DC
July 24, 25, 26 & 27, 2014 (Thursday – Sunday)

Cost

The cost of the iMedicine Review course varies depending on a few factors:

  • Physicians – $695.00
  • Residents – $595.00
  • Groups of 2 or more – $545.00
  • Chief Residents – $245.00

Contact

You can contact iMedicine Review through the website or directly by emailinginfo@imedicinereview.com.


Note: Dr. Shahid Babar is an advisor to Knowmedge .


Awesome Review


Awesome Review – Habeeb Rahman


Website: www.tutormd.com


Taught by: Habeeb Rahman, MD


Overview: This Internal Medicine Board Review course taught by Dr. Habeeb Rahman is a popular option for residents. While more expensive than some of the other review courses, the high-yield animations and notes presented by Dr. Rahman make this a worthwhile experience for many who take his Awesome Review course.


Locations / Dates: Dr. Habeeb Rahman will be teaching his Awesome Review course at ten different locations in 2014.

Maimonides Medical Center

Brooklyn, NY
January 22 – March 13 (Weekday nights)


Roosevelt Hospital

    • New York, NY


    • January 21 – February 27 (Weekday nights)


North Shore University Hospital

Manhasset, NY
February 8 – February 23 (Saturday and Sunday)


Newark Beth Israel Medical Center

Newark, NJ
March 1 – March 16 (Weekends)


Advocate Christ Medical Center

Oaklawn, Illinois
March 21 – March 30 (Friday, Saturday, Sunday)


New York Hospital of Queens

Flushing, NY
April 5 – April 20 (Saturday, Sunday)


Crowne Plaza Phoenix Airport Hotel

Phoenix, AZ
April 25 – May 4 (Friday, Saturday, Sunday)


Hilton Hotel

East Rutherford, NJ
June 1 – June 6 (Sunday – Friday)


Holiday Inn Hotel

Long Beach, CA
June 13 – June 22 (Friday, Saturday, Sunday)


Empire Meadowlands Hotel

Secaucus, NJ
July 14 – July 19 (Monday – Saturday)

Cost

The cost of the Aweome Review course varies depending on the size of the group:

  • Group of less than 10 people: $1,045.00
  • 10 or more people: $995.00

Contact

You can contact Awesome Review through the website or directly by emailinginfo@awesomereview.com or by calling 201-905-0102 or 201-888-1002.


Unique Review Course


Unique Course – Satish Dhalla


Website: www.uniquecourse.com


Taught by: Satish Dhalla, MD FACP


Overview: Of the three Internal Medicine Board Review independent courses, this is the oldest. Dr. Dhalla has been director of the Unique Course Board Review since 1995.


Locations / Dates: Dr. Satish Dhalla will be teaching his Unique Course twice in 2014.

Double Tree Hilton

Fort Lee, NJ
June 23 – June 28 (Monday – Saturday)

Double Tree Hilton Fort Lee, NJ
July 14 – July 19 (Monday – Saturday)

Cost

The cost of the Unique Course is $1,095.00.


Other Internal Medicine Board Review Courses

There are a lot of other Internal Medicine Board Review courses. We’ll go through the ones we’re aware of here:


Mayo Clinic Internal Medicine Board Review

  • Website: Mayo Clinic Internal Medicine Board Review (IMBR)
  • Dates: June 16 – June 20
  • Location: Rochester, MN
  • Cost: $1,299.00

Cleveland Clinic Internal Medicine Board Review

  • Website: Annual Intensive Review of Internal Medicine
  • Dates: June 1 – June 6
  • Location: Cleveland, OH
  • Cost: $825 – $1,475

American College of Physicians (ACP)

  • Website: Intensive Review of Internal Medicine
  • Dates: June 1 – June 6
  • Locations: New York, NY
  • Cost: $865 – $1,465

Columbia University Internal Medicine Board Review

  • Website: Intensive Review of Internal Medicine
  • Dates: June 1 – June 6
  • Locations: New York, NY
  • Cost: $350 – $950

GoFrontRunners

  • Website: Internal Medicine Board Review
  • Dates: August 2 – August 3
  • Locations: Laguna Hills, CA
  • Cost: $575

MedStudy Internal Medicine Board Review

  • Website: ABIM Certification Board Review Course
  • Dates: May 21 – May 30
  • Locations: Dallas, TX
  • Cost: $1,245 – $1,545

American Physician Institute for Advanced Professional Studies (The Pass Machine)

  • Website: Internal Medicine Review Course
  • Dates: March 21 – March 23 / June 13 – June 15 / August 15 – August 17
  • Locations: Chicago, IL
  • Cost: $1,297

If you know any internal medicine board review courses we have missed, please let us know.


If you have used an internal medicine live course to study, please share your feedback with us in the comments section. We all benefit from learning about the various internal medicine board review courses that are offered.

ABIM Maintenance of Certification Requirements Changes in 2014

The American Board of Internal Medicine (ABIM) has implemented changes to the Maintenance of Certification (MOC) requirements. Like the 24 other specialty boards, ABIM will have a 4 Part Process:

  • Part I: Professional standing (licensure)
  • Part II: Lifelong learning and self-assessment
  • Part III: Cognitive expertise (examination)
  • Part IV: Practice performance assessment (performance improvement project)


Parts I and III are essentially unchanged. However Parts II and IV are new additions. Part II is the lifelong learning and self-assessment component. It includes continuing medical education (CME) and online modules for most boards.


Starting in 2014, the ABIM now maintains a report indicating if ABIM Board Certified physicians are “meeting MOC requirements”.


The ABIM has detailed the changes in the MOC requirements. It’s a bit of a maze to try to follow all the details so we’ll give you the high level bullets here.


What has changed?

Previous: You were required to maintain your Internal Medicine Board Certification by “simply” passing the ABIM Board Exam every 10 years.


ABIM MOC Changes: In order to be “meeting MOC requirements”, you will still need to pass the ABIM Board Exam every ten years. In addition, you will need to:

  • Complete at least one ABIM-approved MOC activity every two years
  • Earn at least 100 ABIM MOC points every five years with:
    • At least 20 points in medical knowledge
    • At least 20 points in practice assessment
  • Fill out a patient safety and a patient experience survey requirement every five years


Why the changes?

We are certainly no experts in this area. The ABIM argues that “There is growing recognition and agreement from the public, consumer groups and medical organizations that assessing knowledge and performance every 10 years is not sufficient.” Others could certainly argue this is all about money and power (after all, ABIM isn’t implementing these changes without a financial benefit).


There are certainly those that think the MOC changes are helpful and for the better. Then there are those that take a more cynical, yet popular – and perhaps accurate – view of the changes. Regardless, these are the rules, at least for now, that you have to play by if you want to maintain your Internal Medicine Board Certification.


What’s the cost of this?

Fees (currently) for the Internal Medicine MOC are $194 annually or $1,940 on a 10-year basis. You can choose to pay annually or pre-pay for 10 years. If you maintain certification for other specialties, the fees are different.


What if I just got certified? What if I need to certify in 2014? What about 2015? What if I’ve been “Grandfathered” in?

Almost universally, regardless of when you need to certify, you will be impacted by the changes. Even for those grandfathered in and not having to meet any requirements previously, you will now be listed as “not meeting MOC requirements” (If you are grandfathered in, you will still maintain your certification but you will be listed as “not meeting requirements”)


In order to understand your specific situation, you should review the MOC requirements website where it details the actions you will need to take depending on when you need to recertify.


Does the ABIM know my contact information?

Make sure you update it if you have not provided them with the most current information. You can update your contact information online.


What medical knowledge modules / products can I complete to earn points?

You can earn medical knowledge points through the ABIM directly or from other professional organizations. A list of ABIM’s medical knowledge modules can be found on their website.


You can see a list of medical knowledge modules products developed by professional organizations at the ABIM website.


How can I earn practice assessment points?

You can earn practice assessment points by completing ABIM PIMs Practice Improvementmodules or through the Approved Quality Improvement (AQI) pathway.


What if I need help?

With all the rules and requirements that are needed to make this transition, it can get confusing. If you do need help, you can contact the ABIM at 1-800-441-ABIM or email them atMOC2014@abim.org


The bottom line

The ABIM Maintenance of Certification requirements have changed. To maintain Board Certification, you have to play by their rules. It can be confusing and it will cause problems, especially in the first few years of this transition, but the change is here to stay.


To learn more about the ABIM Maintenance of Certification (MOC) requirements, visit the ABIM MOC website.

MKSAP 16 Books Review

MKSAP 16 Review

You may have already come across Knowmedge’s coverage of several other ABIM Internal Medicine Board Review books. Today, we explore the “big daddy of them all”—the Medical Knowledge Self-Assessment Program (MKSAP), created by the venerable American College of Physicians (ACP). Ask any Internal Medicine resident—1st, 2nd, or 3rd year—how they plan on studying for the Internal Medicine board exam, and their response will surely include “MKSAP.” Furthermore, residency chiefs have developed a tendency of using MKSAP questions for board review at morning report, noon conference or even afternoon educational sessions. There is a reason for its vast utility: MKSAP is truly an authoritative guide to reviewing the curriculum covered in the ABIM Internal Medicine Board Review Blueprint.

In its 16th iteration, the MKSAP content has been refreshed as well as the user interface on the app/desktop versions creating a better learning experience.

Let’s begin with the many plusses of MKSAP 16:

  • First and foremost, with dozens of contributors in each of the major internal medicine sub-specialties, the medical content in the text and 1,200 questions is well-researched with bibliographic citations.
  • Lots of tables and figures help break up the text which can otherwise be cumbersome to stay engaged while reading. Later in your studying, revisiting these tables is a good approach.
  • One of my favorite features is the High-Value Care Recommendations that opens each book. Here’s why: the folks behind the ABIM, like the healthcare policy makers, are concerned about the overuse/inappropriate use of tests in the diagnostic work-up of commonly encountered symptoms. Thus, these points which emphasize unnecessary tests/treatments may be commonly tested on the actual exam. Furthermore, I’ve referred back to this section during patient care to determine if a test is actually necessary or extraneous before initiating treatment.
  • Dermatology contains vivid photos of the skin lesions commonly encountered on the exam. However, it would be nice if they had had a separate section with just images so you can quiz yourself near the end of your exam preparation.
  • Same goes for EKGs on the cardiology section and chest xrays on the pulmonary sections.
  • A Key Points highlighted box contains high-yield nuggets that help summarize major topics
  • Each subject area is a separate book (in the print version) or a separate heading in the digital version making it very easy to handle physically. I recall using MKSAP 15 on my specialty rotations. I’d carry the appropriate book around but they wouldn’t unfortunately fit in my white coat pocket. The MKSAP online version solves this problem as many residents have found.

Now for some areas that could be improved in MKSAP 16:

  • While the figures and photos do break up the monotony of the text portions, the question explanations are still too long. I can understand the need to have lengthy text in the syllabus (MKSAP 16 is a powerful clinical tool and a nice reference to have when reviewing a patient’s diagnosis), for questions, it’s not high-yield and efficient to have to read 4 or 5 paragraphs after each question. In fact, this was the reason Knowmedge was created. We felt that in the 21st century, the Internet allows better methods to facilitate knowledge retention such as audio-visual explanations.
  • An H icon highlights topics that address “the learning needs of the increasing number of physicians who work in the hospital setting.” Since this feature is mentioned in the letter from Dr. Patrick Alguire (Editor-in-Chief ) at the beginning of each book, I initially thought it was beneficial. But then it occurred to me that for someone not studying for the Hospital Medicine Maintenance of Certification, it’s not entirely clear what to do with the icon. Surely, I don’t just skip over the blue text sections like porphyria cutanea tarda diagnosis and constipation management, which are just as likely to be on either exam. Instead, it ended up just being a distraction.
  • A final minor point (literally): the index on the print version of MKSAP is in the smallest type I have ever come across. It must be 8 point or less. I don’t have any near vision problems and I felt tempted to reach for a magnifying glass.
  • MKSAP Online: The digital version is much improved from the previous iterations such as MKSAP 15. While it now allows better analytics of your question responses, its interface is not as user friendly as one would hope. For instance, unlike most websites/ apps the menu toolbar appears on the upper right side of the screen rather than the left side. On the app, overlays should have been utilized for Normal Lab Values and Bibliography and Key Points rather than forcing the user to leave the current topic.

While there are areas of improvement that could be made, overall, the MKSAP 16 Books are a valuable and authoritative source for Internal Medicine Board Review.

Medical Mnemonics: Hypersensitivity Reactions

Medical Mnemonics / Internal Medicine Board Review: Types of Hypersensitivity Reactions: "ACID"
Medical Mnemonics / Internal Medicine Board Review: Types of Hypersensitivity Reactions: "ACID" | Source

Medical Mnemonics - Major and Minor Criteria for Rheumatic Fever: "JONES CAFE PAL"

Mnemonic for the Major and Minor Criteria for Rheumatic Fever - "JONES CAFE PAL"
Mnemonic for the Major and Minor Criteria for Rheumatic Fever - "JONES CAFE PAL" | Source

Book Review: The John Hopkins Internal Medicine Board Review

The John Hopkins Internal Medicine Board Review


Publication Date: April 25, 2012


Editors: Bimal H. Ashar, Redonda G. Miller, Stephen D. Sisson


Overview:


The John Hopkins Internal Medicine Board Review, 4th edition book, published by Elsevier, is a review guide for those preparing for the ABIM Internal Medicine Board Exam. The book contains over 600 pages and covers all the major aspects of the Internal Medicine Board Exam.


The book also contains a companion website for additional information.


Breakdown of Book (Chapters):

  • Pre-Read: Maximizing Test Performance: Effective Study and Test-Taking Strategies (3 pages)
  • Section I: Cardiology (64 pages)
  • Section II: Infectious Disease (58 pages)
  • Section III: Pulmonary and Critical Care Medicine (56 pages)
  • Section IV: Gastroenterology (45 pages)
  • Section V: Nephrology (33 pages)
  • Section VI: Endocrinology (40 pages)
  • Section VII: Rheumatology (33 pages)
  • Section VIII: Hematology (38 pages)
  • Section IX: Oncology (39 pages)
  • Section X: Neurology (24 pages)
  • Section XI: Selected Topics in General and Internal Medicine (106 pages)

Price:

  • List price: $94.12
  • Current Amazon price: $94.12
  • eBook (Kindle): $56.97


Amazon average reviews (as of 12/16/2013): 4.2 out of 5


Amazon Best Sellers Rank (as of 12/16/2013): #59,506


Our opinion as a book for Internal Medicine Board Exam Review:


The Cleveland Clinic Intensive Review of Internal Medicine is a fantastic review book for those preparing for the Internal Medicine Boards. The book contains all the major categories you would expect to find on the ABIM Internal Medicine Board Exam. Each section is broken into chapters (75 in total) detailing many of the subcategories found in the ABIM Internal Medicine Exam Blueprint. The book, despite being over 600 pages, is easy to carry around and relatively light weight.


The use of tables and images, many in color, in this book is second-to-none! It’s an often overlooked factor but with the amount of information that needs to be digested for the ABIM exam, a user-friendly book can be an extremely valuable learning tool.


An additional item that we believe can be of value for a lot of people is the online access that is provided with the book. This allows users to search topics within the book and even practice questions online.


This is one of the best review books you can find for the internal medicine boards – a concise, high-yield review of the topics important for the boards in a user-friendly book.

Book Review: The Cleveland Clinic Intensive Review of Internal Medicine

The Cleveland Clinic Intensive Review of Internal Medicine


Publication Date: April 9, 2009


Editor: James K Stoller, Franklin Michota Jr, Brian Mandell


Overview:


The Cleveland Clinic Intensive Review of Internal Medicine, 5th edition book, published by Lippincott Williams & Wilkins, is a review guide for those preparing for the ABIM Internal Medicine Board Exam. The book contains over 900 pages and covers all the major aspects of the Internal Medicine Board Exam. The book also contains 200 Board Style questions and has a companion website. Breakdown of Book (Chapters):

  • Section I: Multidisciplinary Skills for the Internist (170 pages)
  • Section II: Infectious Disease (64 pages)
  • Section III: Hematology and Medical Oncology (102 pages)
  • Section IV: Rheumatology (52 pages)
  • Section V: Pulmonary and Critical Care Medicine (81 pages)
  • Section VI: Endocrinology (72 pages)
  • Section VII: Nephrology and Hypertension (64 pages)
  • Section VIII: Gastroenterology (100 pages)
  • Section IX: Cardiology (178 pages)
  • Section X: Mock Board Simulation (63 pages)

Price:

  • List price: $104.99
  • Current Amazon price: $99.74
  • eBook (Kindle): $54.99


Amazon average reviews (as of 12/16/2013): 3.8 out of 5


Amazon Best Sellers Rank (as of 12/16/2013): #313,209


Our opinion as a book for ABIM Exam Board Review:


The Cleveland Clinic Intensive Review of Internal Medicine is an excellent resource for Medical Students, Residents, and Internists. The information is well organized and displayed in a user-friendly format. Each chapter contains a list of high-yield “Points to Remember.” At the end of each chapter there are several review questions to test your knowledge of the subject. In addition, following the questions in each chapter, there is a “suggested reading” list for additional information.


The editors have done a fantastic job of using pictures, many in color, and tables in order to condense information in a user friendly format. In addition, the book, while being over 900 pages isn’t uncomfortably big to handle (unlike The Mayo Clinic Internal Medicine Review). The pages are lighter though there is risk of highlighter bleed.


There is very little to complain about this book as it has everything you’d want for your board review – high-yield, accurate information presented in a user-friendly manner. The sample practice questions and “Points to Remember” are extremely valuable for review. If we had to pick a downside, it’s that the book hasn’t been updated since 2009. For many textbooks, this is generally not an issue but Internal Medicine board material is always evolving and certainly some of the studies cited in the book have been updated and new information has come out.


Overall, this is a wonderful resource for the ABIM Internal Medicine Boards.

Book Review: Mayo Clinic Internal Medicine Board Review

Mayo Clinic Internal Medicine Board Review

The Mayo Clinic Internal Medicine Board Review, 10th edition book, published by Oxford University Press, was developed as a comprehensive review guide specifically for those preparing for theABIM Internal Medicine Board Exam. Edited by Dr. Amit Ghosh, this approximately 800 page book is used by residents and internists, both as a reference tool and a book for internal medicine board review.

Publication Date: June 27, 2013

Editor: Robert Ficalora MD


Breakdown of Book (Chapters):

  • ABIM Exam Overview (8 pages)
  • Part I: Cardiology (121 pages)
  • Part II: Gastroenterology and Hepatology (63 pages)
  • Part III: Pulmonary Diseases (55 pages)
  • Part IV: Infectious Disease (107 pages)
  • Part V: Rheumatology (50 pages)
  • Part VI: Endocrinology (61 pages)
  • Part VII: Oncology (19 pages)
  • Part VIII: Hematology (41 pages)
  • Part IX: Nephrology (39 pages)
  • Part X: Allergy (30 pages)
  • Part XI: Psychiatry (10 pages)
  • Part XII: Neurology (39 pages)
  • Part XIII: Dermatology (20 pages)
  • Part XIV: Cross-Content Areas (101 pages)

Price:

  • List price: $99.99
  • Current Amazon price: $89.37
  • eBook: Book is currently not available in eBook format


Amazon average reviews (as of 12/16/2013): N/A

Amazon Best Sellers Rank (as of 12/16/2013): #70,188


Our opinion as a book for Internal Medicine Board Exam Review:

The Mayo Clinic Internal Medicine Board Review is a great resource for Medical Students, Residents, and Internists. The information is up-to-date and the editor has done a great job bringing all the pieces together. The book is well-written, thorough and comprehensive for board review. The authors have done an excellent job of ensuring the information is properly cited throughout the book. The use of images and tables in this book is also fantastic! The book is extremely high-yield and we could certainly see someone highlighting much of the book.

After complaints of the size of the previous edition book (~1,000 pages), this book has been redesigned, updated and condensed slightly 801 pages. The biggest reason for the reduction is size is that this book no longer contains questions & answers. The 168-page Mayo Clinic Board Review Questions and Answers book can be purchased separately (currently $40.22 on Amazon). The book is now much more user friendly than the previous version and the long chapters have been broken into smaller sections.

Unfortunately, there are some downsides – including the size and weight (almost 6 lbs!) of the book. While we like how the book is broken up into different sections, it can still be a significant struggle for someone who has difficulty reading a lot of text and retaining information. In addition, while the tables and images are great, they are largely in black and white. Use of vivid imagery would have helped the pictures be more memorable. We believe the book also would have been strengthened with strong summaries or key concept boxes throughout the book. At the end of some chapters is a brief summary, though this could have been expanded to every section. We would also add that there are certain sections of the book that simply don’t seem like they cover enough content (e.g., Oncology is only 20 pages while the ABIM exam blueprint indicates it is ~7% of the exam)

If you are a text reader and can get through this book – we applaud you! If you can retain the information – by all means, this is a wonderful book! However due to its size and small font, we would almost categorize this more as a reference book that can be bought early in residency or post residency as a reference resource. While not as comprehensive as Harrison’s Principles of Internal Medicine, this is still a significant amount of text to digest and effectively retain for the ABIM Internal Medicine Board Exam.

High-Yield Internal Medicine Board Exam Pearls


The Knowmedge High Yield Internal Medicine Board Exam Pearls eBook is now available! This eBook brings together all the high-yield pearls you’ve seen on our blog over the past year covering all the major categories you will see on the ABIM Exam or the NBME Internal Medicine Shelf Exam. There are 17 chapters covering:

  • Cardiovascular Disease
  • Endocrinology & Metabolism
  • Gastroenterology
  • General Internal Medicine
  • Hematology
  • Infectious Disease
  • Nephrology / Urology
  • Oncology
  • Neurology
  • Dermatology
  • Pulmonary Disease & Critical Care
  • Rheumatology / Orthopedics


Enrich your internal medicine exam prep and build your Knowmedge! Download your free copy and pass it on to a friend!


Also, if you haven’t seen and downloaded our first eBook (Internal Medicine Practice Questions), you can still do so! It’s also available for iTunes, Google Play, and Kindle.

High Yield Internal Medicine Board Exam Pearls by Knowmedge

How to Study for the NBME Internal Medicine Shelf Exam

Internal Medicine Clerkship: Study Plan for the Shelf Exam

The NBME Internal Medicine Shelf Exam is challenging especially from the standpoint that it occurs during your internal medicine clerkship – a period that you are likely spending a lot of time at the hospital. This means whatever precious time you have, it needs to be focused on high-yield exam preparation. While there is no one way to study for the NBME Internal Medicine Shelf Exam, here we present some of the best practices we’ve picked up over time. As is the case with any board exam, the best tried and true overall method is to “study early and study often.”

1. Take a sneak peek at the shelf exam outline even before your rotation starts, if you can.

Unbeknownst to many medical students, the NBME publishes an Internal Medicine content outline of the covered subjects on the Internal Medicine shelf exam. As you review the list of systems, take a few moments to browse through the review book of your choice (more on this later) and familiarize yourself with the major diagnoses you can expect to see during your rotation.

As is the case with many medicine exams, Cardiovascular Disease is the basis for more questions than any other organ system. A large percentage (35% – 50%) of the exam is comprised of Cardiovascular Disorders, Disease of the Respiratory System, and Nutritional & Digestive Disorders.

2. Get a study guide–digital or print–to prepare for the NBME exam and your clerkship

It’s important to have a good study guide that is tailored for the exam while also preparing you for the patients you’ll encounter on the wards. Some of the more popular and effective guides we’ve come across that cover both objectives are: Master the Wards Internal Medicine Clerkship: Survive Clerkship and Ace the Shelf Exam and Step-Up to Medicine

The former is written by Dr. Conrad Fischer who has decades of experience teaching medicine at all levels–med school, residency, etc–and it shows in this book. His emphasis on clinical features, diagnostic workup and management of commonly encountered diseases is fairly comprehensive and yet easy to follow. Most students seem to find that by reading the relevant sections/chapters of this book related to their patients, they are able to answer just about any question an attending or resident asks them on rounds. Over the course of the clerkship, that serves as a huge confidence boost that can translate into a better performance on the shelf exam.

Step-Up to Medicine is especially strong because it covers diseases in such detail that even in the absence of another reference, you should be able to confidently learn the material needed to take care of your patients in the hospital or clinic and also pass the Shelf Exam. Easy-to-follow, colorful flow charts are an added bonus. If you’re asked by your attending to present a diagnosis related to one of your ward patients, don’t be surprised if Step Up is the first book you find yourself browsing. It’ll systematically cover the signs, symptoms, diagnosis, treatment and potential complications. While I hesitate to say that any resource is a “must-have” while you are on a medical rotation since there are so many ways to succeed, this book is the closest you get to a mandatory reference..

Undoubtedly, however, you will come across many of your medical student colleagues carrying First Aid for the Medicine Clerkship book. I myself used a previous edition of this book during my Internal Medicine rotation and felt that it didn’t go into enough details to lead to a mastery of the material clinically or for the shelf exam. Even if the shelf exam doesn’t ask minute details, the reference book you choose should provide some context to each disease rather than concentrating too much on mnemonics, which is what I feel First Aid focused on. It also wasn’t easily applicable to the patients one might expect to see while on rotation. Perhaps, folks still gravitate to this title because of the fact that First Aid for the USMLE Step 1 — an absolutely priceless resource–is fresh in the mind of third year medical students on their IM rotation, having taken the Step 1 exam just months earlier.

Lastly, since 2000, one book has become more recognizable on the Internal Medicine wards than any other: Pocket Medicine, which proudly states that it is “Prepared by residents and attending physicians at Massachusetts General Hospital.” From a marketing standpoint, the book is brilliant. The collective knowledge of the world’s premier institution in the pocket of my white coat? Who can say no to that?

Like the strategy behind the iPhone, each new edition of Pocket Medicine is easy to identify. When you discover that the “latest, latest” edition is colored purple, you start to feel that your green Pocket Medicine book handed down from a recent graduate seems grossly inadequate. It feels as uncool and antiquated as carrying around a BlackBerry phone. Pocket Medicine works for some folks; it has to or it wouldn’t still be around after a decade and a half. However, I found the tiny print to be incredibly difficult to navigate. Because the emphasis is on cramming information into the limited space, the content does not flow nearly as well as Step Up. While there are ample citations, given that the study can’t be clicked, it isn’t convenient. To better view cited material, I would use UpToDate, which your medical center likely offers, at least for computers on the premises.

3. Thriving on the Internal Medicine rotation doesn’t guarantee success on the NBME Exam… but it sure helps!

Your weeks-long rotation in inpatient and outpatient Internal Medicine is not designed to prepare you for the end of the clerkship NBME shelf exam. Plain and simple. It is intended instead to familiarize you with the common (and some not-so-common) conditions that internists can expect to see. By knowing those diagnoses like the back of your hand, you can better spend your study time reviewing the more esoteric diagnoses you probably won’t come across in the patients on your census.

Treat each and every patient you admit from the emergency room, write a SOAP note on in the general medicine floors, and see in the exam room of a clinic as an incredible learning opportunity. Don’t forget that as a student you put in early mornings and late nights to study human pathophysiology, anatomy, genetics, ethics, etc to be given the privilege of seeing live patients. This is your chance to not only be a part of an actual patient care team but also finally correlate the tons of medical lectures to a real patient, not a synthesized PBL case.

As a senior resident, I recall often starting my third year medical students with admissions that on the surface seemed relatively basic: an alcoholic with acute pancreatitis, an obese middle-aged man with chest pain after consuming a fatty meal, an 80-year-old female with a 60-pack-year smoking history presenting with her third COPD exacerbation of the year. But they were easy admissions only on the surface because it was easy to get fooled into thinking that identifying the diagnosis was the goal of our trade. In fact, these admissions were chock full of medical knowledge, provided you successfully opened your mind. Even though the diagnosis is screaming out at you (often the case with the thorough work-up our Emergency Medicine colleagues perform and the promptness of imaging reads by our Radiology friends), maintaining a broad enough differential allows you to be prepared for the next patient who may have an atypical presentation of a common diagnosis. That, of course, is the type of patient that one finds presented on the NBME exam.

I’ve noticed that with the truncated work-hour schedule in residency, education of residents and medical students alike has been cut substantially. Even if this means you’re not “getting pimped” by your attending or senior, read up on each patient’s complaints. In other words, that patient with pancreatitis should send you on an exploration of the differential diagnosis based on the location of the abdominal pain. Even within pancreatitis, use the “I GET SMASHED” mnemonic to branch out and learn about each of those topics separately. For instance, the G stands for Gallstones, which should lead to a review of the diagnosis, treatment, and complications of cholelithiasis.

Rather than trying to serve as an additional intern and take care of as many patients as possible (remember medical student doesn’t equal workhorse), use the experience of taking care of a reasonable number of patient to learn about them and their conditions as well as you can. Ultimately, that will serve you well for developing a solid fund of knowledge and experience you’ll be able to apply for years while better preparing you for the NBME exam at the same time.

4. Join a study group or at least get a study partner

It may seem impossible to find the time on your third-year Internal Medicine clerkship to coordinate your schedule with other students. Having been in those shoes before, I can tell you that it can be done. Often, students are given either a Saturday or Sunday off. If you look around at the beginning of your clerkship orientation, you should be able to find another student with a similar work schedule.

There’s nothing quite like learning from your colleagues. How do you find a partner who matches your intelligence? It doesn’t matter what their IQ is relative to yours. You simply need a partner who shares your passion for learning. Even if you come across questions for which neither you nor your partner have an answer to, a textbook, reliable website (and most likely Knowmedge) surely will. And if you find that you actually know more than the person you are studying with, you’ll be happy to know that nothing reinforces concepts than teaching them to others. An additional benefit of having a study buddy: A few minutes (not much longer than that) can be spent debriefing your fellow medical student on the quirkiness of your attending, idiosyncrasies of your senior attending, and coolness of your intern, etc. Nothing is quite as soothing as having someone who can relate to your situation.

In the event that you’ve been stationed in some remote location far far away from your other class members, don’t despair. Fortunately, we live in a digital age where being part of a study group is much easier. You can connect with colleagues through Skype, Google Hangout or a number of other channels. One of our favorite approaches is to remain informed and learn through the power of social media – in particular Twitter. In a previous post, we highlighted excellent Twitter handles to follow for internal medicine board review. If Twitter is not your cup of tea, you can also connect with colleagues through the High-Yield Internal Medicine community on Google+. Regardless of what approach you decide to use, studying alongside others preparing for the same exam is a great motivational tool for success.

5. Get a question bank that fits your personal needs What is the value of an Internal Medicine question bank? This is a discussion near and dear to our heart, of course. Question banks have become a popular tool because they bring together a lot of material in a question format and help create a test taking environment. There are a lot of question banks to choose from – so what should you look for in an NBME qbank?

  • High quality NBME-style questions in a format similar to the exam:The exam is mostly filled with clinical vignettes and has straightforward questions as well. At a minimum, your NBME exam question bank should have both of these types of questions. Quantity is important – but the quality of the questions and explanations is much more important.


  • Detailed explanations that review why the incorrect choices were wrong: A question bank that does not provide you detailed explanations is probably not worth the money and time spent. As you review questions, you will inevitably get some wrong – your choice of NBME question bank should detail why your choice is incorrect and the reasoning behind the correct choice.
  • Ability to track your personal performance:Your choice of NBME qbank should be able to tell you your performance overall and by category. Most – not all – question banks provide you a dashboard broken down by category. The Knowmedge question bank has gone an additional step to break the categories into subcategories as seen on the NBME exam blueprint. This allows you to review your strengths and weaknesses at a granular level. Knowing you are weak at cardiovascular disease is great – knowing you are weak at arrhythmia questions is more valuable.


  • Add-ons – Notes, Lab values, Highlighting: Depending on how you study, these may be valuable features. NBME exam questions straight talk:

No question bank – not MKSAP for Students, not Knowmedge, not any – knows what will be on the actual NBME exam. However, the NBME blueprint helps to understand the areas that are emphasized the most. Granted, you still are going to need to study the whole curriculum, but it can certainly alleviate some of the anxiety when down the stretch, you are unsure of one of the topics that forms a smaller percentage of the questions. With limited time to study, you can better choose which high-yield subject areas to study. During the development of Knowmedge’s qVault, the entire team focused our energy not on trying to give the exact questions that will be on the exam. Instead, we look at the sign of an excellent question bank as teaching important medical concepts that also is useful for the exam.

High-quality NBME exam review questions can be found in many places – question banks are not the only place. There are study guides, books, and even free sources. So don’t simply base your decision on question bank on the questions. In addition to the quality of the questions, what truly differentiates one NBME exam question bank from another is whether it will truly help you build a broad base of knowledge and help you retain information for the exam. If you are not comfortable reading a bunch of text – it won’t matter how great the questions are. If you are not an audio-visual learner, the Medstudy or Knowmedge videos won’t do anything for you (As clarity, the Knowmedge qbank contains text and audio-visual explanations for this exact reason). If you are an “old-fashioned” learner that prefers printouts – USMLEWorld is definitely not for you – those who have used them are well aware their software will block you from taking print screens or copying of their content. In short… don’t follow the herd – each one of us learns differently and you need to pick the best method for you.

6. Review our suggested NBME test taking strategies

The NBME exam questions are not intended to trick you – they are intended to challenge your knowledge and ability to bring together your understanding of many different concepts and topics. As mentioned above you will see atypical presentations of common diagnoses or typical presentations of the uncommon diagnoses. Below are some of the tactics you can use as you are practicing questions and/or taking the actual NBME exam:

  • For clinical vignettes, read the question (last line) first and then go back and read the scenario. This way you’ll know what to look for as you are reading the scenario.
  • Try to answer the question even before peeking at the answer choices.
  • Watch for key demographic information – geography, ethnicity, gender, age, occupation.
  • The NBME test is not intended to be tricky but we are all human so we miss keywords sometimes – such as “least likely” – pay attention to these. Fortunately, exams have cut down on including these but you may still come across them.
  • If you are challenged by a longer clinical vignette, note the key items and develop your own scenario – this may trigger an answer.


Most medical students I’ve spoken with say time is generally not an issue – 100 questions in 2 ½ hours means 90 seconds per question–but be sure to maintain the pace recognizing that it’s not uncommon to find yourself slowing down towards the end. Get off to a steady start to save time for the home stretch. We cannot stress enough the mantra “study early and study often.” The exam is challenging due to the breadth of Internal Medicine topics but it can be conquered with diligence and proper preparation.

7. Understand and be prepared for Shelf exam day

Be prepared and confident. No matter how you have chosen to study, on test day – confidence is critical! Get a good night’s rest – last minute cramming and staying up late is only going to stress you out more. Get there early – don’t risk getting caught in traffic. It’s much better to be a little early than be aggravated in traffic.

Take an extra layer of clothing. The last thing you want to do is be uncomfortable and cold because someone decided to turn on the air conditioner too high.

That’s a basic overview of how to study for and pass the NBME Internal Medicine Board Exam. As mentioned, there is no secret sauce or method to this – you simply need to have a broad base of knowledge. There is no substitute for studying early and studying often! If you are in the middle of your Internal Medicine rotation or about to start, we wish you well – we’re here to help so let us know if you have any questions! Happy learning!

Dr. Shahid Babar, Founder of iMedicine Review, joins Knowmedge Advisory Board

Dr. Shahid Babar, founder of iMedicine Review – an internal medicine live course – joins Knowmedge as an advisor

The Knowmedge team is excited to announce the addition of Shahid Babar, MD FACP FHM, to our advisory board. Dr. Babar is a Clinical assistant professor of Medicine and Associate director of hospitalist program in Lancaster General Health. He has conducted Internal medicine review courses in various academic centers since 2007. He founded iMedicine Review in 2010 in order to help residents and internists prepare for the internal medicine boards. Thousands of students have benefitted from his three-and-a-half day live course.

Dr. Babar’s internal medicine board review course offers a comprehensive review of all topics relevant to the ABIM exam. In 2014, Dr. Babar’s internal medicine board exam review course will be offered five times between May – July in various academic centers in Philadelphia (PA), Harrisburg (PA), Farmington (CT), New York City (NY), Washington D.C.

Dr. Babar states “I started iMedicine Review as a way to help residents and internists prepare for the internal medicine boards through an engaging, live lecture format. That’s why I’m excited about joining Knowmedge – their vision for an interactive and engaging high-yield internal medicine question bank is something that is appealing to me as an educator and should be appealing to students looking for an audio-video question bank.”

Dr. Ravi Bhatia, co-founder of Knowmedge states “I am thrilled to have Dr. Babar join the Knowmedge advisory board. I attended his live course for preparation of my board exam. His educational experience and commitment to helping residents and internists learn through a live internal medicine course is something I personally admire and will be of great benefit to the Knowmedge team. I look forward to working with Dr. Babar and helping more physicians through our affiliation with iMedicine Review.”

iMedicine Review is a leader in internal medicine education. Under the leadership of Dr. Shahid Babar, thousands of students have benefitted from the ABIM exam review course offered at iMedicine Review. For more information about iMedicine Review, please visit:http://www.imedicinereview.com/

Knowmedge is a provider of internal medicine board questions for students preparing for the internal medicine ABIM board exam. The Knowmedge platform contains over 900 high-yield questions with video explanations from 12 different medical categories and over 100 subcategories. For more information about Knowmedge, please visit:http://www.knowmedge.com/

Internal Medicine ABIM Exam Blueprint: Initial Certification vs. Maintenance of Certification

One of the more common questions we get asked is regarding the difference between the ABIM internal medicine initial certification exam vs. the Maintenance of Certification (MOC) exam. Specifically, we are often asked whether our platform is more tailored towards those striving for initial certification or those taking the ABIM Maintenance of Certification exam.

In actuality, there is very little difference between the exams. The types of questions you can expect to see on both exams are the same. The ABIM exam certification and Maintenance of Certification web pages both describe the type of questions you can expect to see as:

The exam consists of single best answer questions only. This type of question consists of a brief statement, case history, graph, or picture followed by a question and list of possible options. You must choose the one answer that is better than the others; note that other options may be partially correct.

When you compare the ABIM internal medicine board exam certification blueprint andMaintenance of Certification blueprint, you notice they’re almost carbon copies of each other! The breakdown of what you can expect to be tested on the exam is identical.

Internal Medicine Board Exam Content

So is there any difference between the ABIM initial certification exam and the Maintenance of Certification exam? Yes, there is one important distinction – the length of the exam:

  • Initial certification exam: Approximately 10 hours (Four 2-hour sessions with a maximum of 60 questions per session) + breaks

  • Maintenance of Certification exam: Approximately 8 hours (Three 2-hour sessions with a maximum of 60 questions per session) + breaks


If you are preparing for the internal medicine board exam and have not yet reviewed the ABIM exam blueprint, we highly urge you to do that! It’s important to have an overview of the test and understand the specific categorization of questions you can expect to see. While our ABIM question bank does detail questions down to the diagnostic level, it’s important for you to review this on your own.

For other tips on how to study for the ABIM board exam – initial certification or maintenance of certification – be sure to check out our post title How to study for and pass the ABIM board exam.

8 Pulmonary & Critical Care Pearls for the Internal Medicine Shelf and ABIM Board Exam

Pulmonary disease and critical care are an extremely important part of the Internal Medicine Medical Clerkship and ABIM Board exam. According to the ABIM exam blueprint, questions testing pulmonary disease topics comprises ~10% of the exam. That places it second only to cardiology’s 14% in terms of relative percentage.


1. ABGs do not need to stand for AnyBody’s Guess


The next time you see an arterial blood gas (ABG) on a practice or actual exam question, don’t start searching for the “Panic” (or “Skip”) button. Determining diagnoses based on ABGs can seem daunting at first but by following a simple yet systematic approach, we can tackle these questions without difficulty. Click on the link to our previous “How to Handle ABGs on the ABIM Board Exam”and after reviewing the 5 easy steps, it won’t be long before you look forward to ABG questions on the exam.


2. Obstructive or Restrictive? That is the question surrounding Lung Disease


To distinguish between obstructive and restrictive lung disease, the first value to look at on the pulmonary function test (PFT) report is the Total Lung Capacity (TLC), which is defined as the volume of air contained in the lungs at the end of a maximal inspiration.

    • Obstructive Lung Disease: TLC will be increased (example: asthma and COPD)
    • Restrictive Lung Disease: TLC will be decreased. Restrictive Lung Disease is further sub-divided into intra-thoracic and extra-thoraciclung disease.
      • Intra-thoracic lung Disease (FEV1/FVC normal or increased above 80%, DLCO decreased, Residual Volume decreased)
        • Sarcoidosis
        • Idiopathic Pulmonary Fibrosis
        • Hypersensitivity Pneumonitis
        • Pneumoconiosis
        • ABPA
        • Churg-Strauss Syndrome
        • Asbestosis
        • Silicosis
        • Berylliosis


    • Extra-thoracic Lung Disease (FEV1/FVC normal or increased above 80%, DLCO normal, Residual Volume increased)
      • Obesity
      • Kyphosis
      • Myasthenia Gravis
      • Guillain-Barre Syndrome
      • Muscular dystrophy


3. The Mnemonic “CHAD PARS” helps recall the major causes of bronchiectasis.


  • C – CYSTIC FIBROSIS
  • H – HYPOGAMMAGLOBULINEMIA
  • A – ALPHA 1 ANTITRYPSIN DEFICIENCY
  • D – DYSKINETIC CILIARY SYNDROME
  • P – PNEUMONIA
  • A – ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA)
  • R – RHEUMATOID ARTHRITIS
  • S – SJOGREN’S SYNDROME


4. Not all that wheezes is asthma…but it sure is important for the ABIM boards and medicine shelf exam


Frequency of asthma symptoms provides the necessary information for proper classification of this reversible obstructive lung disease (defined by greater than or equal to 12% increase in the FEV1 after use of an albuterol inhaler). Only then can we determine the best treatment for the affected patient in an exam vignette.


This slide (click on it for enlarged view) conveniently depicts the criteria for intermittent, mild persistent, moderate persistent, and severe persistent asthma, along with their recommended treatments.



5. Similarly, mastering COPD classification (using the GOLD criteria) and treatment is essential


Unlike asthma, COPD is an irreversible condition. Administering the bronchodilator albuterol will not increase FEV1.


GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria is the primary method used to diagnose and identify the severity of COPD. A diagnosis of COPD should be considered for any patient over the age of 40 who has any of the following conditions:

  • Dysnea that is persistent, worsens over time and gets worse with exercise
  • Chronic cough
  • Chronic sputum production
  • History of exposure to risk factors (Tobacco smoke, smoke from home cooking, occupational dust, chemicals)
  • Family history of COPD


FEV1/FVC ratio less than 70% is an indication that there is an airflow limitation and, thus, COPD. The spirometric criteria for a diagnosis of COPD is a post-bronchodilator FEV1/FVC ratio less than 70%.


FEV1 will tell us the intensity of the COPD which can be characterized into four stages:

  • Stage I (Mild): FEV1 > 80% of predicted value; Rx: Short acting Bronchodilator as needed with or without Ipratropium
  • Stage II (Moderate): 50% ≤ FEV1 < 80% of predicted value; Rx: Short acting Bronchodilator as needed with long acting bronchodilator around the clock with or without pulmonary rehab
  • Stage III (Severe): 30% ≤ FEV1 < 50% of predicted value; Rx: As above for moderate COPD plus Inhaled steroids
  • Stage IV (Very severe): FEV1 < 30% of predicted value (or FEV1 < 50% of predicted value plus chronic respiratory failure); Rx: As above for severe COPD plus Long-term oxygen therapy for at least 15 hours daily. Surgical intervention should be considered.


The slide below (click for enlarged view) reveals the cut-off criteria for the different stages.


Other indications for Oxygen therapy in COPD patients are:

  • PaO2 less than 55 mm Hg or Oxygen saturation less than 88% OR
  • PaO2 less than 59 mm Hg or Oxygen saturation greater than 88% with evidence of Cor pulmonale (Right ventricular dysfunction) or secondary erythrocytosis (hematocrit greater than 55%)


6. IgE and Eosinophil levels help us distinguish ABPA, Hypersensitivity pneumonitis, and Churg-Strauss syndrome


ABPA → Increased IgE levels and increased peripheral eosinophils >10% → Rx with steroids


HYPERSENSITIVITY PNEUMONITIS → IgE levels and peripheral eosinophils are normal → Remove offending agent


CHURG-STRAUSS SYNDROME → IgE levels are normal, peripheral eosinophils >10% → (Clue: asthmatic patient with increase peripheral eosinophils and a foot drop) → Management with steroids


7. Light’s criteria will guide you to correctly identifying Pleural Effusions as either exudative or transudative


Broken down into Transudative and Exudative effusion. Remember that for Transudate, all of the following need to be met. If all are not met, then the patient has an exudative effusion.

  • Transudate effusions include conditions such as: CHF, Nephrotic syndrome, Cirrhosis, Hypothyroidism
  • Exudative effusions include conditions such as: Neoplasm, Infection, RA, SLE, Esophageal perforation, Pancreatitis, and Dressler Syndrome


8. Bronchoalveolar lavage (BAL) findings can help narrow down, if not nail, the diagnosis.

  • Increased Neutrophils → think Idiopathic Pulmonary Fibrosis
  • Increased CD8>CD4 → think Hypersensitivity Pneumonitis
  • Increased CD4>CD8 → think Sarcoidosis
  • Increased Eosinophils → think Eosinophilic pneumonia
  • Positive Silver Methanamine Stain → think Pneumocystis Jiroveci in patients with HIV
  • Inclusion bodies → think CMV pneumonia

Once again, the folks who write the Internal Medicine licensing exams don’t expect you to have the depth of knowledge regarding lung conditions that a pulmonologist possesses. However, topics such as the ones mentioned in the slides and pearls above should assist you with the pulmonary section of the med school clerkship and ABIM Board Exams.

Internal Medicine Boards Review: Neurology pearls

Neurology is an extremely important part of the Internal Medicine Medical Clerkship and ABIM Board exam. According to the ABIM Exam Blueprint, Neurology comprises ~4% of the exam.


1. In Neurology questions on the medical school clerkship and ABIM board exam, nothing helps narrow the diagnosis than the reflexes mentioned in the vignette


Review the slide below (click to enlarge) for the most high-yield conditions associated with hyperreflexia, normal reflexes, hyporeflexia, and delayed reflexes and absent reflexes.



2. We’re not trained ophthalmologists but remembering these eye conditions can add points to your ABIM score

  • Optic nerve lesion → can lead to complete blindness in the ipsilateral eye (monocular blindness of the ipsilateral eye)
  • Optic chiasm lesion → Bitemporal hemianopiacommon in pituitary tumors that compress the optic chiasm
  • Optic tract lesion → contralateral homonymous hemianopia
  • Optic radiation lesion → contralateral homonymous quadrantanopia

Lack of an ipsilateral adduction to a contralateral gaze is a Medial Longitudinal Fasciculus (MLF) lesion. This condition, which is also known as intranuclear ophthalmoplegia, is seen in patients who have Multiple Sclerosis.


In normal individuals, if asked to look the right, the right eye should abduct and the left eye should adduct. If a patient with MS is asked to look to the right (for example), he/she will be able to abduct the right eye but fails to adduct the left eye → Lesion is Left MLF.


Same concept applies when asked to look to the left. Normally, the left eye will abduct and the right eye should adduct. In patients with MS, patients lose the ability to adduct the right eye →Lesion is Right MLF.


Argyll Robertson Pupil → eyes will be able to constrict when the patient focuses on a near object (eg. bringing fingers to the nose). This is known as accommodation. However, patients with an Argyll Robertson pupil lose the ability to constrict the eyes when bright light is shined into their eyes. In a nutshell, the eyes can’t react to light but can accommodate. This condition is often seen in patients with syphilis.


Marcus Gunn Pupil → This condition is also known as Relative Afferent Pupillary Defect (RAPD). In normal individuals, when a swinging flashlight test is performed, both the direct and consensual eye should constrict to light.


With Marcus Gunn pupil, let’s suppose the left eye is affected. If light is shined into the right eye, both the direct and consensual will constrict. When light is shined into the left eye, both the direct and consensual eye will seem dilated (lack of constriction) → Shows damage to the ipsilateral optic nerve.


3. Know the indications and contraindications of use of t-PA.


Indications:

  • Ischemic stroke as seen on CT head with CLEARLY defined onset of symptoms
  • Time of onset of symptoms to administration of t-PA should be no later than 3 hours (180 minutes)

Major Contraindications:

  • Blood pressure greater than or equal to 185/110mmHg
  • CT head indicates a hemorrhagic stroke rather than an ischemic stroke
  • Major trauma to the head within the past 3 months
  • Major surgery within the past 14 days
  • Current use of anticoagulants as administering t-PA with anticoagulants increases risk of major bleeds
  • Platelet count of less than 100,000/uL
  • PT>15 seconds
  • Glucose 400 mg/dl


Or in slide form…



4. Identifying buzzwords is key for selecting the correct neurological diagnosis when CT/MRI findings are included in the vignette.

  • Multiple Sclerosis → increased T2 signal and decreased T1 signal. There will be increased enhancement of active lesions with gadolinium.
  • Multi-infarct dementia → multiple hypo-dense areas without enhancement.
  • Toxoplasmosis, brain abscess, and lymphoma → Ring enhancing lesions seen on CT scan
  • Cerebral atrophy → dilated ventricles with dilated sulci
  • Normal pressure hydrocephalus → dilated ventricles without dilated sulci. Patient is “wet, wobbly, and weird.” (urinary incontinence, ataxia, and dementia triad is often seen in these patients)
  • Alzheimer’s DiseaseBrain atrophy with or without periventricular white matter lesions

5. Differentiating Myasthenia Gravis and Eaton-Lambert Syndrome can seem challenging at first. That’s why they’re on the ABIM.Ever find yourself second-guessing whether it’s Eaton-Lambert or Myasthenia Gravis that improves with repetitive movements? And, which one is associated with thymoma? Before letting your head spin or do cartwheels, take a few minutes to learn the difference between these two neuromuscular disorders. The concise yet useful categorization will make it difficult to get the two mixed up.


Myasthenia gravis

  • Antibodies to post-synaptic acetylcholine receptors
  • Ptosis and diplopia can be presenting symptoms
  • Can be associated with thymoma
  • Reflexes are normal
  • Power decreases with repetition

Eaton-Lambert Syndrome

  • Antibodies to pre-synaptic acetylcholine receptors
  • Ptosis and diplopia are usually absent
  • Usually associated with oat cell carcinoma (small cell carcinoma) of the lung
  • Reflexes are decreased (hyporeflexia)
  • Power improves with repetition (“As you EAT, you get stronger”)

Once again, the folks who write the Internal Medicine med school clerkship shelf and ABIM board exams don’t expect you to have the depth of knowledge regarding neurological conditions that a neurologist possesses. However, topics such as the ones mentioned in the slides and pearls above should assist you with the neurology section of these exams.

High-Yield Internal Medicine Boards Review: Rheumatology

Rheumatology is a subject that comes up daily in clinical practice, and is a favorite on the ABIM Internal Medicine board exam. According to the ABIM Internal Medicine exam blueprint, Rheumatology / Orthopedics represents 8% of the exam. Here we cover five evidence-based high-yield pearls that will help you be better prepared for the Internal Medicine ABIM certification exam!

1. Rheumatoid Arthritis is a systemic, inflammatory and symmetrical condition

  • Systemic means that it not only involves joints but also will affect different parts of the body like the lungs, heart, blood vessels, skin, kidneys, and the hematological system.
  • Inflammatory means that the joints that are affected will be erythematous, warm, swollen, and tender to touch. Since it is an inflammatory condition, ESR and CRP (inflammatory markers) will also be elevated.
  • Symmetrical condition means that both sides of the body will be affected. The main joints that are affected are the wrist, MCP, and PIP joints.
  • DIP joint and lower back is usually not affected.
  • Most specific antibody for RA is anti-CCP.
  • The most common extra-articular manifestation of RA is subcutaneous nodules.
  • Poor prognostic factors for RA include:
    • Progressive synovitis
    • Vasculitis (ulcers of fingers and toes)
    • Subcutaneous nodules
    • HLA-DR4 marker
    • Elevated ESR
    • Elevated Rheumatoid Factor
    • Erosive lesions on X-ray
  • Patients with syncope symptoms or numbness/tingling in the upper extremities or weakness may have atlanto-odontoid subluxation. MRI of the cervical spine is the diagnostic test of choice. Surgical compression is warranted if patient has symptoms or the size is greater than 8 mm in diameter
  • Certain medications used in the management of RA are: NSAIDs, Hydroxychloroquine, Sulfasalazine, Methotrexate with Folic Acid, Leflunomide, Steroids, and anti-TNF alpha inhibitors
    • Hydroxychloroquine → frequent eye exams required
    • Methotrexate → Check CBC and Liver function tests every 6-8 weeks
    • Leflunomide → Contraindicated in pregnancy. Reverse with cholestyramine X 11 days
    • Anti-TNF alpha inhibitors → PPD testing needs to be checked before starting medication. NEVER give two anti-TNF alpha inhibitors concurrently as this increases the risk of infections. Usually if one is not working, another anti-TNF alpha inhibitor will work.

2. Osteoarthritis is a chronic, progressively debilitating disease that is non-inflammatory and non-systemic

  • Non-inflammatory means that this condition does not present with erythema or warmth to a joint but can have swelling. Since it is a non-inflammatory condition, the inflammatory markers (ESR and CRP) are also normal.
  • Non-systemic means that only joints get affected without compromising the integrity of the entire body.
  • Pathophysiology is based on progressive destruction of cartilage that surrounds bone that leads to “bone on bone” phenomenon.
  • Some of the major risk factors for Osteoarthritis include obesity, repetitive use, older age, and trauma to a joint.
  • Joint involvement can be mono-articular or asymmetrical, chronic poly-articular.
  • Major joints that are involved are the hip joint, knee joint, lower back, PIP (Bouchard’s nodes), and DIP joints (Heberden nodes). Usually MCP joint is spared.
  • Mainstay of treatment is non-pharmacological, pharmacological, or surgical.
    • Non-pharmacological intervention includes weight reduction and weight resistance training.
    • Pharmacological intervention includes NSAIDS and narcotics.
    • Surgical intervention includes steroid injections or knee replacement therapy.

3. Knowing antibodies and their associated conditions are very high yield for the ABIM board examination

  • ANA → screening test for SLE. Most specific for SLE is anti-Smith, followed by anti- ds-DNA.
  • Anti-ds-DNA is often seen in patients with lupus nephritis.
  • Anti-histone → Drug induced lupus (most common drugs are Procainamide, Hydralazine, INH, PTU, Minocycline, and Methyl-Dopa)
  • Anti-CCP → most specific antibody for Rheumatoid Arthritis
  • Anti- SSA (Ro) and Anti SSB (La) → commonly seen in Sjogren’s Syndrome. NOTE: Anti-SSA (Ro) can lead to a newborn having complete heart block
  • Diffuse systemic sclerosis (Scleroderma) → anti-SCL 70 (anti-topoisomerase 1)
  • CREST syndrome → anti-centromere
  • Polymyositis/Dermatomyositis → anti Jo-1
  • Mixed Connective Tissue Disease → anti RNP

4. Interpretation of joint effusion plays a critical role in establishing diagnosis

  • WBC of 200-2000 in joint effusion-non-inflammatory conditions like Osteoarthritis
  • WBC of 5000-50,000 in joint effusions-inflammatory conditions like RA, gout, pseudogout, or trauma
  • WBC >50,000 → likely septic arthritis
  • With gout, inflammatory joint effusion will be seen. Additionally, monosodium urate crystals will be present and negative birefringence is present
  • With pseudogout, inflammatory joint effusion will be suspected. Calcium pyrophosphate crystals will be seen and positive birefringence will be present
  • With septic arthritis, if patient is less than 40 years of age, the likely causative agent is Neisseria gonorrhea and treatment is with Ceftriaxone. In patients more than 40 years of age, likely causative agent is Staph aureus and treatment is with Nafcillin for MSSA or Vancomycin for MRSA.
  • NOTE: Never start uric acid lowering agent in an acute gouty attack AND never discontinue uric acid lowering agent if patient already on a uric acid lowering agent in an acute attack.
  • Goal uric acid level to prevent further attacks of gout should be less than 6 mg/dl.
  • In an acute attack, checking a uric acid level has no diagnostic value.

5. Seronegative Spondyloarthropathies (HLA B27+ and Rh factor negative)

  • HLA B27 is NEVER used in the diagnosis of the seronegative spondylarthropathies
  • Mnemonic to remember the different seronegative spondyloarthropathies is “PEARR”
    • P – Psoriatic arthritis
    • E – Enteropathic arthritis
    • A – Ankylosing Spondylitis
    • R – Reactive arthritis
    • R – Reiter Syndrome → causative agent is Chlamydia. Triad of urethritis, uveitis, and arthritis (Can’t pee, can’t see, can’t climb a tree)

As stated, these are high-yield pearls that are “must know” as you study for the ABIM exam. Best of luck in your preparation for board certification (or as you prepare for maintenance of certification)!

How to study for and pass the ABIM Internal Medicine Boards

As the ABIM internal medicine certification exam approached, we received a large number of emails from our subscribers asking for suggestions on the best way to study for the boards. The truth is there is no one path to success though there are certainly ways to increase your likelihood of passing. Regardless of whether you are preparing for board certification or trying to achieve maintenance of certification (MOC), the best tried and true overall method is to “study early and study often.” Below we lay out possible strategies and tactics (in no particular order) for passing the ABIM board exam:


1. Know the basics of the internal medicine board examThis is obvious but a lot of people simply don’t review this prior to starting their exam preparation and instead rely on their ABIM study source of choice to provide the information.

  • Review the ABIM exam blueprint and understand the topics covered on the exam
  • A large percentage (33%) of the exam is comprised of Cardiovascular Disease, Gastroenterology, and Pulmonary Disease
  • Over 75 percent are based on patient presentations – most take place in an outpatient or emergency department; others are primarily in inpatient settings such as the intensive care unit or a nursing home.
  • While it’s not a big part of the exam, be prepared and expect to interpret some pictorial information such as electrocardiograms, radiographs, and photomicrographs (e.g., blood films, Gram stains, urine sediments).


2. Use the in-training exam as a starting gaugeIf you are a resident, the Internal Medicine in-training exam is a good starting point to see where you stand. It’s simply that – a barometer of where you stand. It will give you an idea where you may be weak and where you may be pretty strong. It will also give you an idea of how you compare with your peers. Don’t alter your ABIM study plan simply based on it but it does give you an early metric of the areas you need to focus on.


3. Get a study guide to prepare for the ABIM examIt’s important to have a good study guide that is tailored for the exam. Some of the more popular and effective guides we’ve come across are the MedStudy Internal Medicine Board Review books and Harrison’s Principles of Internal Medicine Board Review.


4. Join a study groupStudy groups, if utilized properly, are particularly effective because they allow you to learn from your colleagues and other exam takers. Oftentimes, people will form study groups with their colleagues (ideally limited to 3-4 people) at their residency program. Tactics to use in ABIM study groups may include:

  • Focus on a new internal medicine category by week. For example, focus one week on cardiology and the next on pulmonary care. The exam can be broken into a dozen or so categories (see the ABIM exam blueprint). The majority of the subspecialty questions on the Internal Medicine board exam will focus on cardiology, gastroenterology, and pulmonary care. However, do not neglect the other areas as the ABIM wants to ensure that internists have a broad base of medical knowledge.
  • Test each other with internal medicine questions you have written yourself. We are firm believers in the philosophy that the best way to learn is to teach. If you help others learn, your knowledge of medical concepts will be greatly strengthened.

We recognize that joining a study group is often not feasible – especially for those no longer in residency programs where everyone is preparing the boards. Fortunately, we live in a digital age where being part of a study group is much easier. You can connect with colleagues through Skype, Google hangout or a number of other channels. One of our favorite approaches is to remain informed and learn through the power of social media – in particular Twitter. In a previous post, we highlighted excellent Twitter handles to follow for ABIM exam review as you prepare for certification. If Twitter is not your cup of tea, you can also connect with colleagues through the Knowmedge ABIM community on Google+. Regardless of what approach you decide, studying alongside others preparing for the same exam is a great motivational tool for success.


5. Get a question bank that fits your personal needsWhat is the value of an Internal Medicine question bank? This is a discussion near and dear to our heart, of course. Question banks have become a popular tool because they bring together a lot of material in a question format and help create a test taking environment. There are a lot of question banks to choose from – so what should you look for in an ABIM qbank?

  • High quality ABIM-style questions in a format similar to the exam: The exam is mostly filled with clinical vignettes and has straightforward questions as well. At a minimum, your ABIM exam question bank should have both of these types of questions. Quantity is important – but the quality of the questions and explanations is much more important.
  • Detailed explanations that review why the incorrect choices were wrong: A question bank that does not provide you detailed explanations is probably not worth the money and time spent. As you review questions, you will inevitably get some wrong – your choice of ABIM question bank should detail why your choice is incorrect and the reasoning behind the correct choice.
  • Ability to track your personal performance: Your choice of ABIM qbank should be able to tell you your performance overall and by category. Most – not all – question banks provide you a dashboard broken down by category. The Knowmedge question bank has gone an additional step to break the categories into subcategories as seen on the ABIM exam blueprint. This allows you to review your strengths and weaknesses at a granular level. Knowing you are weak at cardiovascular disease is great – knowing you are weak at arrhythmia questions is more valuable.
  • Add-ons – Notes, Lab values, Highlighting: Depending on how you study, these may be valuable features.

ABIM exam questions straight talk:

  • No question bank – not MKSAP, not Knowmedge, not any – knows what will be on the actual ABIM exam. Based on the ABIM Blueprint, you can make assumptions on what are the most high-yield areas to study. The point of a question bank is not to give you the exact questions that will be on the exam – it is to hopefully teach you concepts you may see on the exam and how to reason through what you don’t know immediately.
  • High-quality ABIM exam review questions can be found in many places – question banks are not the only place. There are study guides, books, and even free sources. So don’t simply base your decision on question bank on the questions. In addition to the quality of the questions, what truly differentiates one ABIM exam question bank from another is whether it will truly help you build a broad base of knowledge and help you retain information for the exam. If you are not comfortable reading a bunch of text – it won’t matter how great the questions are. If you are not an audio-visual learner, the Medstudy or Knowmedge videos won’t do anything for you (As clarity, the Knowmedge qbank contains text and audio-visual explanations for this exact reason). If you are an “old-fashioned” learner that prefers printouts – USMLEWorld is definitely not for you – those who have used them are well aware their software will block you from taking print screens or copying of their content. In short… don’t follow the herd – each one of us learns differently and you need to pick the best method for you.


6. Consider whether a review course is right for youThere are pros and cons to taking a review course for your ABIM exam prep. The pros are that it gives you a serious dose of review in a short period of time. It gets you focused if you weren’t focused and some courses are absolutely excellent – we know some internists are ardent supporters of some of the professors that teach these courses. The three most popular independent courses we are aware of are:

  • Awesome Review by Dr. Habeeb Rahman – The best known and most popular independent course. Dr. Rahman has a very unique style of teaching and accompanies his lectures with his own videos. During this six day course (Sunday - Friday), Dr. Rahman provides students his own set of notes and questions to practice.
  • iMedicineReview by Dr. Shahid Babar – This three day course (Friday, Saturday, Sunday) course comes with a set of 1,500 review questions.
  • Unique Course by Dr. Satish Dhalla – A six day course (Monday – Friday) taught by one of the Top Internists in the Nation as selected by U.S. News

The cons of a review course are that they are expensive (Often over $1,000 plus hotel stay) and can be inconvenient to travel to and from. Regardless of whether you attend a review course or not, it cannot replace the pre and post-course study time that is needed. It is complementary to study time and does not replace it.


7. Review our suggested ABIM test taking strategiesThe ABIM exam questions are not intended to trick you – they are intended to challenge your knowledge and ability to bring together your understanding of many different concepts and topics. Below are some of the tactics you can use as you are practicing questions and/or taking the actual ABIM exam:

  1. For clinical vignettes, read the question (last line) first and then go back and read the scenario. This way you’ll know what to look for as you are reading the scenario.
  2. Try to answer the question even before seeing the answer choices.
  3. Pay attention for keywords that can clue you in on an etiology or physical exam.
  4. Watch for key demographic information – Geography, ethnicity, gender, age, occupation.
  5. The ABIM test is not intended to be tricky but we are all human so we miss keywords sometimes – such as “least likely” – pay attention to these.
  6. If you are challenged by a longer clinical vignette, note the key items and develop your own scenario – this may trigger an answer.
  7. Most internists we’ve spoken with say time is generally not an issue – but be aware that it is a timed exam and that you have approximately two minutes per question.

We cannot stress enough the mantra “study early and study often.” The exam is challenging but it can be conquered with diligence and proper preparation.


8. Understand and be prepared for ABIM test day

  • Be prepared and confident. No matter how you have chosen to study, on test day – confidence is critical!
  • Get a good night’s rest – last minute cramming and staying up late is only going to stress you out more.
  • Get there early – don’t risk getting caught in traffic. It’s much better to be a little early than be aggravated in traffic.
  • Take an extra layer of clothing. The last thing you want to do is be uncomfortable and cold because someone decided to turn on the air conditioner too high.
  • Test day is long! Be mentally prepared for it. From registration to the optional survey at the end, the day will be 8-10 hours long (depending on whether you are certifying for the first time or taking the maintenance of certification exam).
  • Keep some power snacks with you to take during break time.
  • Review the ABIM exam day schedule so you know exactly what to expect.

That’s a basic overview of how to study for and pass the ABIM board exam. As mentioned, there is no secret sauce or method to this – you simply need to have a broad base of knowledge. There is no substitute for studying early and studying often! If you are preparing for the ABIM Boards, we wish you well – we’re here to help so let us know if you have any questions! Happy studying!

5 Easy Steps to Handle Arterial Blood Gases (ABGs) on the ABIM Board Exam

One of the seemingly challenging concepts to master for the ABIM Board Exam are arterial blood gases (ABGs). However, by following a simple yet systematic approach, we can tackle these questions without difficulty.


Step #1: Identify Acidemia versus Alkalemia

  • Normal pH is 7.35 – 7.45
  • If pH < 7.35 : Acidemia is present
  • If pH > 7.45 : Alkalemia is present


Step #2: Identify the Primary Change

  • If pCO2 is high and pH is low : Primary problem is Respiratory Acidosis
  • If pCO2 is low and pH is high : Primary problem is Respiratory Alkalosis
  • If HCO3 is low and pH is low : Primary problem is Metabolic Acidosis
  • If HCO3 is high and pH is high : Primary problem is Metabolic Alkalosis


Step #3: Check for Compensation

    • If the primary problem is Metabolic Acidosis, determine if the body is appropriately compensating with a Respiratory Alkalosis using Winter’s Formula:
      pCO2 = 1.5 (HCO3) + 8 +/- 2
    • If the primary problem is Metabolic Alkalosis, determine if the body is appropriately compensating with a Respiratory Acidosis using the equation:
      pCO2 = 40 + 0.7 (Δ HCO3)
    • If the primary problem is Respiratory Acidosis, determine if the body is appropriately compensating with a Metabolic Alkalosis using the following rules.
      • Acute: 1 unit increase in HCO3 for every 10 unit increase in pCO2
      • Chronic: 3.5 unit increase in HCO3 for every 10 unit increase in pCO2
    • If the primary problem is Respiratory Alkalosis, determine if the body is appropriately compensating with a Metabolic Acidosis using the following rules.
      • Acute: 2 unit decrease in HCO3 for every 10 unit decrease in pCO2
      • Chronic: 5 unit decrease in HCO3 for every 10 unit decrease in pCO2


    • Step #4: Calculate the Anion Gap
      • Anion Gap = Na – (Cl + HCO3)
      • Normal Anion Gap = 8 – 12 mEq/L
      • If Anion Gap is high and the patient has Metabolic Acidosis, the patient has Widened Anion Gap Metabolic Acidosis (WAGMA).
    • Causes of WAGMA can be remembered by the mnemonic “MUD PILES”
      • Methanol
      • Uremia
      • Diabetic Ketoacidosis
      • Paraldehyde
      • Isoniazid
      • Lactic Acidosis
      • Ethylene Glycol
      • Salicylates
    • NOTE: Salicyclates can also cause Respiratory Alkalosis


    • If the patient has Metabolic Acidosis and Anion Gap is normal, then the patient has a Normal Anion Gap Metabolic Acidosis (NAGMA).Two main causes of NAGMA are:
      • Diarrhea, which will have a negative urine anion gap

(Urine Na + Urine Potassium) – Urine Chloride

      • Renal tubular acidosis, which will have a positive urine anion gap


    • Step #5: Check a Delta Gap, if applicable
      • If the Anion Gap is greater than 20mEq/L, then a Delta Gap needs to be calculated.
      • Delta Gap = Anion Gap – 12
      • If Delta Gap + HCO3 > 30, the patient also has Metabolic Alkalosis present
      • If Delta Gap + HCO3 < 23, the patient also has NAGMA present

This is a general approach for tackling ABGs, as relevant for your preparation of the ABIM Internal Medicine board exam.

5 Easy Steps to Handle Arterial Blood Gases (ABGs) on the ABIM Board Exam

One of the seemingly challenging concepts to master for the ABIM Board Exam are arterial blood gases (ABGs). However, by following a simple yet systematic approach, we can tackle these questions without difficulty.

Step #1: Identify Acidemia versus Alkalemia

  • Normal pH is 7.35 – 7.45
  • If pH < 7.35 : Acidemia is present
  • If pH > 7.45 : Alkalemia is present

Step #2: Identify the Primary Change

  • If pCO2 is high and pH is low : Primary problem is Respiratory Acidosis
  • If pCO2 is low and pH is high : Primary problem is Respiratory Alkalosis
  • If HCO3 is low and pH is low : Primary problem is Metabolic Acidosis
  • If HCO3 is high and pH is high : Primary problem is Metabolic Alkalosis

Step #3: Check for Compensation

    • If the primary problem is Metabolic Acidosis, determine if the body is appropriately compensating with a Respiratory Alkalosis using Winter’s Formula:
      pCO2 = 1.5 (HCO3) + 8 +/- 2
    • If the primary problem is Metabolic Alkalosis, determine if the body is appropriately compensating with a Respiratory Acidosis using the equation:
      pCO2 = 40 + 0.7 (Δ HCO3)
    • If the primary problem is Respiratory Acidosis, determine if the body is appropriately compensating with a Metabolic Alkalosis using the following rules.
      • Acute: 1 unit increase in HCO3 for every 10 unit increase in pCO2
      • Chronic: 3.5 unit increase in HCO3 for every 10 unit increase in pCO2
    • If the primary problem is Respiratory Alkalosis, determine if the body is appropriately compensating with a Metabolic Acidosis using the following rules.
      • Acute: 2 unit decrease in HCO3 for every 10 unit decrease in pCO2
      • Chronic: 5 unit decrease in HCO3 for every 10 unit decrease in pCO2
    • Step #4: Calculate the Anion Gap
      • Anion Gap = Na – (Cl + HCO3)
      • Normal Anion Gap = 8 – 12 mEq/L
      • If Anion Gap is high and the patient has Metabolic Acidosis, the patient has Widened Anion Gap Metabolic Acidosis (WAGMA).
    • Causes of WAGMA can be remembered by the mnemonic “MUD PILES”
      • Methanol
      • Uremia
      • Diabetic Ketoacidosis
      • Paraldehyde
      • Isoniazid
      • Lactic Acidosis
      • Ethylene Glycol
      • Salicylates
    • NOTE: Salicyclates can also cause Respiratory Alkalosis


    • If the patient has Metabolic Acidosis and Anion Gap is normal, then the patient has a Normal Anion Gap Metabolic Acidosis (NAGMA).Two main causes of NAGMA are:
      • Diarrhea, which will have a negative urine anion gap

(Urine Na + Urine Potassium) – Urine Chloride

      • Renal tubular acidosis, which will have a positive urine anion gap


    • Step #5: Check a Delta Gap, if applicable
      • If the Anion Gap is greater than 20mEq/L, then a Delta Gap needs to be calculated.
      • Delta Gap = Anion Gap – 12
      • If Delta Gap + HCO3 > 30, the patient also has Metabolic Alkalosis present
      • If Delta Gap + HCO3 < 23, the patient also has NAGMA present

This is a general approach for tackling ABGs, as relevant for your preparation of the

ABIM Internal Medicine board exam.

ABIM Exam Prep: PVCs and Heart Murmurs

Heart murmurs for the ABIM Internal Medicine exam: Impact of premature ventricular complexes (PVCs)
Heart murmurs for the ABIM Internal Medicine exam: Impact of premature ventricular complexes (PVCs) | Source

5 High Yield Pearls for Success on the ABIM Internal Medicine Boards

It’s crunch time for the ABIM Internal Medicine Boards, and “High Yield” is key. You don’t want to waste your time, and you want to be as efficient as possible. Well, I recently gave a lecture entitled, “Dr. Rezaie’s 5 Pearls to Passing the Boards.” This is a general post, and can be used for any standardized test in your last few weeks of preparation.


Pearl #1: Always read the question first, look over the answers, then go back and read the question stem

  • You waste your time reading the passage and looking at the labs first
  • What do you focus on?
  • How many times do you go back and forth between passage and answers?
  • This process wastes precious time
  • Instead read the question and answers first and then go back and read the passage.
  • Some questions can even be answered without reading the passage


Pearl #2: Know the breakdown of the test

  • Specifically for the ABIM board exam “THE BIG 5” are:
  1. General Internal Medicine
  2. Cardiovascular Disease
  3. Gastroenterology
  4. Infectious Disease
  5. Pulmonary Disease and Critical Care
These 5 sections alone compromise approximately 50 – 60% of the exam If time is short, focus on these five sections Ideally, you have left yourself enough time to go over all sections, but if time is short, reading over things like dermatology are not high yield


Pearl #3: Know the big 4 of medical decision-making

  • If you can answer 4 questions about every disease process, you will be prepared for over 80% of the questions on the test:
    1. What is the BEST initial test?
    2. What is the MOST ACCURATE test?
    3. What is the BEST initial therapy/treatment?
    4. What is the NEXT BEST STEP in management?
  • These four questions are known as “The Fischer Method”


Pearl #4: Pick a single book and question bank and stick with it

  • There are so many options, and all are good.
  • Personally, I think Med Study reads the easiest and is the most high yield followed by MKSAP
  • Ultimately pick one resource and stick with it. Buying five different resources is not realistic to complete and you will not get through all the information
  • Also pick one question bank and stick with it.
  • Whether it be Knowmedge, MKSAP, MedStudy, or Kaplan, you will be able to pass if you learn the material
  • Personally, I have used the Knowmedge and MKSAP question banks and felt like both were very comparable to the ABIM Board Exam


Pearl #5: Focus on most commons

  • I would know the top 3 conditions of each area cold
    • i.e. Top 3 infectious disease killers in the world are HIV/AIDS, Tuberculosis, and Malaria
    • i.e. 3 of the top 5 killers in the world are Cardiovascular diseases, Infectious diseases, and chronic lung disease (No wonder Cardiovascular, pulmonary/critical care, and infectious diseases are 3 of “THE BIG 5”)

In addition to these 5 High Yield Pearls also consider another FREE resource such as twitter (My personal recommendations for daily board review questions and pearls include:@knowmedge, @awesomereview, @IMmemorandum, @uthscsapearls and @srrezaie). Let me wish all of you the best of luck on your studies, ABIM Internal Medicine board exam and future endeavors.

AEIOUG: Indications for Hemodialysis

Indications of hemodialysis can be remembered by the mnemonic AEIOUG. This is an image straight out of the Knowmedge Internal Medicine ABIM Board Exam Questions qVault.
Indications of hemodialysis can be remembered by the mnemonic AEIOUG. This is an image straight out of the Knowmedge Internal Medicine ABIM Board Exam Questions qVault. | Source

10 High Yield Nephrology Pearls for Clinical Practice and the ABIM Board Exam (Part 1 of 2)


Recently, I read an article on some very useful chronic kidney disease (CKD) pearls to help those healthcare providers who are not nephrologists care for their patients and also prepare for the ABIM Internal Medicine Board exam at the same time. The article was titled “The Top 10 Things Nephrologists Wish Every Primary Care Physician Knew” by Paige NM et al and basically stated: early recognition of kidney disease is essential in order to begin measures to prevent progression and complications such as kidney failure, cardiovascular disease, and premature death.I have decided to break the content into two parts; the first half will be discussed in this post:


1. A “Normal” Creatinine Level May Not Be Normal

  • Make sure to take muscle mass, age, sex, height, and limb amputation into account
  • Consider using MDRD or Cockcroft-Gault equations to calculate glomerular filtration rate (GFR)
  • MDRD and Cockcroft-Gault equations are imprecise at high values for GFR (low values for serum creatinine)


2. Know the Medications That Falsely Elevate Serum Creatinine Levels

  • Trimethoprim-sulfamethoxazole and cimetidine decrease secretion of creatinine
  • Both medications can increase creatinine level by as much as 0.4 – 0.5mg/dL
  • An increase in creatinine level is a true decrease in GFR only if there is also a corresponding increase in BUN


3. Patients with Decreased GFR or Proteinuria Need to be Evaluated for the Cause

  • Urine dipstick detects concentration of albumin in urine
  • Urine concentration can affect dipstick results therefore a quantitative estimation of proteinuria is required to evaluate dipstick proteinuria
  • The preferred quantitative test is spot urine protein to creatinine ratio (accurate & more convenient than 24-hr urine collection)
  • A urine protein to creatinine ratio ≥ 1 has a higher risk of progression of CKD


4. Early-Stage CKD Should Have Periodic Evaluation and Intervention to Slow Progression

  • Try to avoid nephrotoxic agents (NSAIDs, aminoglycoside antibiotics, and radiocontrast)
  • Monitor and control blood pressure with a goal of <130/80 mmHg
  • Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) may slow progression of CKD, especially in patients with proteinuria
  • Monitor phosphorus, calcium, and parathyroid hormone levels in all patients with stage 3 to 4 CKD
  • Patients with CKD are at higher risk of cardiovascular events and should be on a baby aspirin, and a lipid lowering agent with goal LDL <100mg/dL (Maybe <70mg/dL for LDL in patients with CAD and CKD)
  • Consider referral and co-management with a nephrologist if a patient has CKD progression, active urine sediment and/or stage 3 CKD
  • ALL patients with Stage 4 – 5 CKD should be referred to a nephrologist


5. DO NOT Discontinue an ACEI or ARB Because of a Small Increase in Serum Creatinine or Potassium

  • Both ACEIs and ARBs are the drugs of choice to prevent progression of proteinuric CKD
  • An increase of 20 to 30% of the creatinine level is acceptable
  • Just make sure to confirm the creatinine stabilizes and does not continue to increase
  • Also a serum potassium of 5.5 mEq/L is acceptable as long as it is stable and as long as the patient is aware of dietary restrictions
  • Serum creatinine and potassium levels should be ordered within one week of increase in dose of ACEI or ARB
  • If a patient has an increase in creatinine from 1.5 to 1.9 (<30% increase) CONTINUE THE ACEI
  • If the same patient has an increase in creatinine from 1.5 to 2.2 (>30% increase) STOP THE ACEI

As chronic kidney disease is increasing world wide, we as primary care practitioners need to make sure we are doing our part to help catch this disease process early, slow down progression, and make referrals when necessary to nephrology. Stay tuned for Part 2 of this series, hopefully this provides some useful clinical pearls for your practice as well as ABIM Internal Medicine exam certification or re-certification preparation.


References:


1. Bakris GL et al. Angiotensin-Converting Enzyme Inhibitor-Associated Elevations in Serum Creatinine: Is this a Cause for Concern? Arch Intern Med. 2000; 160 (5): 685 – 693. PMID: 10724055


2. Douglas K et al. Meta-analysis: The Effect of Statins on Albuminuria. Ann Intern Med. 2006; 145 (2): 117 – 124. PMID: 16847294


3. Levey AS et al. Definition and Classification of Chronic Kidney Disease: A Position Statement from Kidney Disease: Improvemeng Global Outcomes (KDIGO). Kidney Int. 2005; 67 (6): 2089 – 2100. PMID: 15882252

4. Paige NM et al. The Top 10 Things Nephrologists Wish Every Primary Care Physician Knew. May Clin Proc. 2009 Feb; 84 (2): 180 – 186. PMID: 19181652

This post originally appeared on the Knowmedge Blog.

This chart is directly related to a question out of the Knowmedge Internal Medicine ABIM Practice Questions qVault.
This chart is directly related to a question out of the Knowmedge Internal Medicine ABIM Practice Questions qVault. | Source

Internal Medicine ABIM Exam Practice Question

Here’s a practice question directly from Knowmedge’s Internal Medicine Board (ABIM) Exam QVault.

In which of the following scenarios is it appropriate to allow outpatient treatment of community-acquired pneumonia (CAP)?

A. 67-year-old male with CAP, blood pressure of 120/85mmHg, and confusionB. 68-year old male with CAP, blood pressure of 130/80mmHg, and respiratory rate of 18/minC. 69-year old female with CAP, blood pressure of 125/82mmHg, and creatinine of 2.1mg/dL (Baseline is 0.8mg/dL)D. 58-year old female with CAP, blood pressure of 100/50mmHg, and confusionE. 32-year-old female with CAP, blood pressure of 90/50mmHg, altered mental status, and respiratory rate 34/min


Explanation

After diagnosing a patient with community-acquired pneumonia, we must determine whether the patient needs to be hospitalized or not. In order to facilitate this decision, the CURB-65 guidelines can be used. CURB stands for:

● C – Confusion (altered mental status)
● U – Uremia
● R – Respiratory rate greater than 30/minute
● B – Blood pressure that is low (Systolic <90mmHg or Diastolic <60mmHg)
● 65 – Age 65 years or greater

Each category is assigned 1 point
● 0-1 points total means the patient can be treated as an outpatient
● 2 points total requirements treatment in the medical ward
● 3 or more points requires ICU admission

Let’s go over the answer choices:

● Choice A (67-year-old male with CAP, blood pressure of 120/85mmHg, and confusion) has 2 points (age greater than 65 and confusion) and should require admission to the medical ward.

● Choice B (68-year-old male with CAP, blood pressure of 130/80mmHg, and respiratory rate of 18/min) will be the scenario that will require outpatient therapy. This patient only has one point (age greater than 65) so he can be treated for CAP as an outpatient.

● Choice C (69-year old female with CAP, blood pressure of 125/82mmHg, and creatinine of 2.1mg/dL) has 2 points (age greater than 65 and compromised renal function) which means admission to medical ward is most appropriate.

● Choice D (58-year old female with CAP, blood pressure of 100/50mmHg and some confusion) has 2 points (low blood pressure and confusion). Even though this patient has 2 points, this patient may require ICU admission because the patient may be septic. For such scenarios, the CURB score simply serves a guideline but the clinical picture plays a bigger role in deciding where the patient will receive the most appropriate care.

● Choice E (32-year-old female with CAP, blood pressure of 90/50mmHg, altered mental status, and respiratory rate 34/min) has 3 points (altered mental status, respiratory rate greater than 30/min and low blood pressure) that will require the patient to go to the ICU.

Renal Tubular Acidosis

ABIM Exam Review: Bacterial vs. Viral Meningitis

Overview of Bacterial vs. Viral Meningitis. This is an important topic in general and good to understand for the Internal Medicine ABIM Board Exam.
Overview of Bacterial vs. Viral Meningitis. This is an important topic in general and good to understand for the Internal Medicine ABIM Board Exam. | Source

Prepping for the ABIM Exam: an Internist’s Candid Perspective (Part I)

If you are reading this, then congratulations. You have finished, or are about to finish, internal medicine residency.

To get to this point, you have successfully passed the MCAT, USMLE Step 1, USMLE Step 2 CK, USMLE Step 2 CS, and USMLE Step 3. You have poured blood and sweat into years of perpetual q3 or q4 call, surviving page-bombs by nurses, holding life-and-death conferences with overwhelmed family members, boosting the confidence of doe-eyed medical students and interns, and managing the inflated egos of attendings.

We go through all of this for the privilege of taking care of patients, to make a palpable difference in the lives of people who have entrusted their physical and emotional well-being to us. It’s certainly a heady task to take on. But before we can call ourselves truly independent, one last exam looms on the horizon: the American Board of Internal Medicine (ABIM) certification exam.

On the hierarchy of medical exams, the difficulty of the ABIM exam lies somewhere in the middle, below the MCAT and USMLE Step 1, but above USMLE Steps 2 and 3. And importantly, it is strictly pass-fail: either you get enough questions right and become board-certified, or you don’t and must retake the exam the following year. The percentile break-downs are for the egoists among us.

You’d think that a pass-fail test would endow test-takers with a sense of confidence. But if my colleagues from medical school and residency are any indication, then the ABIM test forces the re-emergence of the psychotic college pre-meds dormant in each of us. Sometimes panic ensues.

Yet I’m here to tell you that at the end of the day, the vast majority of you will pass that the test, and become the newest members of a most exclusive guild: board-certified internal medicine physicians.

Based on an anecdotal sample of my peers who took the exam in 2012, there are numerous ways to prepare for the exam. The most fastidious among us began studying in February, carving out an hour each evening to do a handful of questions. On the opposite end, a colleague, going through a series of personal crises involving a love interest, didn’t study at all. I, and most of my friends, fell somewhere in the middle. About 3 or 4 weeks before the exam, we went into “test-mode.” Taking time off from work and personal commitments—and from life in general—we holed up at libraries and coffee shops, passing the days cramming in facts and doing practice questions.

Part II of this series will focus on specific strategies and resources for tackling the ABIM exam in Dr. Feng's question for Internal Medicine Board certificaton.

Hypersensitivity Reactions

ABIM Board Exam Review: This is a slide about the various types of hypersensitivity reactions
ABIM Board Exam Review: This is a slide about the various types of hypersensitivity reactions | Source

Multiple Endocrine Neoplasia

This is a simple way to remember the associated conditions with the various types of Multiple Endocrine Neoplasia (MEN)
This is a simple way to remember the associated conditions with the various types of Multiple Endocrine Neoplasia (MEN) | Source
Understanding Essential Tremor
Understanding Essential Tremor | Source

ABIM Exam Disease of the Week Profile: Benign Prostatic Hyperplasia

This week’s important concept to understand for the Internal Medicine Board (ABIM) exam is Benign Prostatic Hyperplasia.

INTRODUCTION

Benign prostatic hyperplasia (BPH) is a common condition among males as they advance in age. It involves hyperplasia of prostatic stromal and epithelial cells that leads to the formation of a nodule in the region of the periurethral region of the prostate. These nodules can compress the urethral canal, which can lead to partial or complete obstruction of urine flow.

PATHOPHYSIOLOGY/ETIOLOGY

Androgens play a permissive role in the development of BPH. This means that androgens need to be present for BPH to occur but do not necessarily directly cause the condition. Testosterone is converted to dihydrotestosterone (DHT) by the enzyme 5-alpha reductase. DHT is a metabolite of testosterone and is considered a critical mediator of prostatic growth. 5-alpha reductase is primarily concentrated in the prostatic stromal cells; therefore, this is the site for the majority of synthesis of DHT. Understanding the role of 5-alpha reductase and the production of DHT is essential as inhibiting this enzyme plays a major role in the management of BPH (discussed in the Management section).

Anatomically, the posterior urethral glands and transitional zone of the prostate are the sites where hyperplasia most often occurs. Less often, BPH occurs in the peripheral zone of the prostate. The peripheral zone is the location that is most notorious for prostate cancer; therefore, any nodules that are found in the peripheral zone are biopsied to rule out prostate cancer. Individuals who have BPH are NOT at increased risk to develop prostate cancer.

DIAGNOSIS

Two definitive tests must be done to establish that an individual has BPH. A digital rectal examination is performed in males who are 50 years of age or older. In African American males, a digital rectal exam may be performed at 40 years of age as African Americans are at an increased risk of developing BPH or prostate cancer. A digital rectal exam will assess for any enlargement or irregularity of the prostate gland.

The second diagnostic test is a urinalysis. This is done to see if patient has any pyuria (white blood cells in the urine) or hematuria. Checking PSA levels is controversial because as the prostate size increases, so does the PSA level. Using PSA as a screening test for prostate cancer will produce many false positive results in individuals who have BPH and is therefore not established as a universal recommended screening test.

SYMPTOMS

The main symptoms of BPH include:Decreased urinary streamUrinary retentionIncreased frequency of urineIncreased urgencyRecurrent urinary tract infections in malesDysuriaNocturiaPost-urination dribblingAbdominal straining to initiate urinary stream

MANAGEMENT

The management of BPH can be broken down into lifestyle modifications, pharmacological management, and surgical intervention.

Lifestyle modifications include decreasing fluid intake before bedtime, decreasing alcohol consumption and caffeine intake, and follow timed voiding schedules.

Pharmacological management of BPH includes two classes of medications: alpha antagonists (a.k.an alpha blockers) and 5-alpha reductase inhibitors.

Alpha antagonists relax the prostatic smooth muscle in the bladder outflow tract. These medications are considered first line treatment for BPH as they are effective in about 70 percent of men and respond within 48 hours of initiating treatment. Some examples of alpha antagonists include: terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin. Prazosin is an example of an alpha antagonist that is not used in the management of BPH as it requires frequent dosing and has more side effects.

The most common side effect of alpha antagonists is postural hypotension, which can lead to dizziness and headaches. Alpha antagonists should be avoided with agents used for erectile dysfunction (eg. Sildenafil) as concurrent use can exacerbate postural hypotension. Another potential side effect of alpha antagonists is abnormal ejaculation.

The second pharmacological agent class that is used in the management of BPH is 5-alpha reductase inhibitors. These agents take about 6 months to show their full efficacy as they decrease the prostate size and relieve urinary symptoms. They tend to arrest the growth of prostate cells as they inhibit the production of dihydrotestosterone (DHT), which as mentioned above, plays a major role in the development of BPH. 5-alpha reductase inhibitors also decrease serum PSA levels. Examples of 5-alpha reductase inhibitors include finasteride and dutasteride.

The main side effects of these agents are erectile and ejaculatory dysfunction, decreased libido, gynecomastia, and breast tenderness.

When lifestyle modifications and use of pharmacological agents do not relieve symptoms of BPH, surgical intervention is a viable treatment option. The surgical options for BPH include either transurethral resection of the prostate (TURP) or transurethral microwave thermotherapy. Both are similarly efficacious in the treatment of BPH.

Remember that prostate disorders are listed as one of the medical content categories in the ABIM Blueprint for the Internal Medicine board exam.

ABIM Exam Prep Video about Sickle Cell Disease

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ABIM Exam Disease of the Week - Acute Tubular Necrosis

An important concept to understand for the Internal Medicine Board (ABIM) exam is Acute Tubular Necrosis.

Intrinsic renal failure can be divided into three subtypes: allergic interstitial nephritis, acute glomerulonephritis, and acute tubular necrosis. This week’s disease profile of the week covers the most common subtype of intrinsic renal disease: acute tubular necrosis (ATN).

INTRO

ATN can be caused by decreased renal perfusion that leads to transient ischemia. Nephrotoxic agents can also cause ATN. Pre-renal failure can occur from conditions such as extreme vomiting, diarrhea, extensive burns, or sweating, just to name a few. Giving aggressive IV fluids can correct the pre-renal failure. When a patient’s pre-renal failure is not corrected, it can lead to shock or ischemia of vital organs (including the kidney) and, thus, ATN to occur. About half the cases in the hospital of acute kidney injury are from ATN. The hallmark of ATN is tubular dysfunction due to necrosis from debris buildup.

CAUSES

Some of the major causes to remember for the ABIM exam of acute tubular necrosis are certain medications such as aminoglycosides, amphotericin B, chemotherapeutic agent cisplatin, pentamadine, and foscarnet. Other causes of ATN include contrast dye, heavy metals, rhabdomyolysis, and tumor lysis syndrome.

Aminoglycosides are notorious for causing ATN, which can be precipitated by other underlying conditions such as advanced age, volume depletion, diabetes mellitus, or pre-existing renal disease. Some of the most common aminoglycosides that can cause ATN are streptomycin, tobramycin, and gentamycin. These medications are toxic to the proximal convoluted tubule of the nephron of the kidney. ATN caused by aminoglycosides will usually occur 4-5 days after the administration of the antibiotic.

Amphotericin B has a direct nephrotoxic effect, especially when more than 3 grams of the medication is used. It can also lead to type 1 or type 2 renal tubular acidosis (RTA). Type 1 RTA results from a defect of hydrogen excretion in the distal convoluted tubule portion of the nephrons of the kidney. Type 2 RTA, on the other hand, results from a defect of bicarbonate reabsorption in the proximal convoluted tubule portion of the nephrons.

Cisplatin, foscarnet, and pentamadine are also causes of ATN, but the underlying mechanism is not as well understood as aminoglycosides and amphotericin B.

Contrast dye nephropathy occurs in individuals who have underlying renal compromise and are given a load of contrast. Contrast can be administered for coronary angiography or for imaging scans. Individuals who have a creatinine level greater than 1.5 mg/dL are at an increased risk of developing ATN. The clue for contrast nephropathy is characterized by a rise in serum creatinine level 24-48 hours after contrast administration. The best way to prevent contrast induced nephropathy is volume expansion with either isotonic saline or sodium bicarbonate. NSAIDs and metformin should be discontinued before administering contrast.

Rhabdomyolysis is muscle degradation that results in release of muscle enzymes, myoglobin, and intracellular electrolytes into the bloodstream. Breakdown of muscle will lead to elevated CPK levels, increased potassium levels, increased phosphorus, decreased calcium, increased myoglobin levels, and increased uric acid levels. Some of the major causes of rhabdomyolysis are crush injuries (which can lead to compartment syndrome), strenuous exercise, heat stroke, generalized seizures, statin use, cocaine, amphetamines, colchicine, anesthesia (leading to malignant hyperthermia), neuroleptic malignant syndrome, prolonged surgeries, and severe volume contraction. Acute tubular necrosis from rhabdomyolysis occurs because myoglobin can cause direct tubular toxicity and obstruction. Treatment for rhabdomyolysis is aggressive IV fluids and forced diuresis. Alkalinization of the urine should be done to prevent myoglobin induced tubular damage.

Tumor lysis syndrome usually occurs 3 days after chemotherapy use; however, it can also occur before chemotherapy use. Treatment for tumor lysis syndrome is with allopurinol, hydration, and forced diuresis. Allopurinol will decrease the uric acid level that is released from cells after chemotherapy. Uric acid can cause direct tubular damage that will lead to acute tubular necrosis.

DIAGNOSIS


It is also important to understand diagnosis and expected lab values of conditions for the Internal Medicine Board (ABIM) exam .


The diagnosis of acute tubular necrosis is based on history, labs, and analyzing a urinalysis. Taking a careful history from a patient is essential in trying to determine the cause of ATN. Patients can provide important information that can help you determine why the individual developed ATN. Labs will show a BUN: creatinine ratio of around 10:1, fractional excretion of sodium (FeNa) more than 2%, urine sodium greater than 40, and urine osmolality less than 350. The osmolality is low because the tubules lose the ability to concentrate the urine. On a urinalysis, muddy brown casts or dirty “granular” casts are the hallmark of ATN.


TREATMENT


Managing ATN involves addressing the underlying cause. As a result, for certain conditions that cause ATN, treatment options were discussed above. Nephrotoxic agents should be discontinued immediately and aggressive IV fluids should be given to prevent further renal compromise from occurring so that end stage kidney disease does not occur. Hyperkalemia should be treated immediately in patients with ATN as hyperkalemia can cause dangerous cardiac arrhythmias to occur, leading to death. Oliguric ATN usually resolves in 1-4 weeks.


Whether ATN (Acute tubular necrosis) shows up on your Internal Medicine Board (ABIM) exam or not, it is an important topic to understand.

ABIM exam prep - Gallstone Pancreatitis

Knowmedge - ABIM Exam Prep Image of the Week
Knowmedge - ABIM Exam Prep Image of the Week | Source

ABIM Exam Prep Question of the Week

62-year-old Asian male with a history of coronary artery disease, hypertension, and hyperlipidemia presents with a chronic cough. The patient denies fevers, night sweats, or chills. On review of systems, he notes occasional chest pain that only lasts for a few minutes and occurs a couple of times a month. He drinks five shots of whiskey per day and has a 50 pack year history of smoking. Both of his parents died of myocardial infarctions, and his older brother underwent CABG last year. On physical exam, there is a 2/6 holosystolic murmur best heard at the apex. Based on his chest x-ray, what is the most likely cause of his symptoms?

A. Tuberculosis

B. Myocardial infarction

C. Pulmonary neoplasm

D. Sarcoidosis

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    • jabelufiroz profile image

      Firoz 3 years ago from India

      Good exam preparation. Voted up.

    • Knowmedge profile image
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      Knowmedge 3 years ago

      Thanks for the vote!

    • profile image

      Jessica 3 years ago

      Thanks for the excellent summary. I used MKSAP questions and went to the Mayo Clinic board review course and found the boards to be easy. I think doing the MKSAP questions you miss more than once is key. The board review course was really high yield and used some interesting teaching techniques I hadn't seen elsewhere. Highly recommend both!

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