HIGH-YIELD INTERNAL MEDICINE BOARD EXAM PEARLS
This study guide includes:  Chapters covering High-Yield pearls for all major categories seen on the Internal Medicine Board Exam / Shelf Exam  Topics covered include Cardiovascular Disease, Endocrinology & Metabolism, Gastroenterology, General Internal Medicine, Hematology, Infectious Disease, Nephrology / Urology, Oncology, Neurology, Dermatology, Pulmonary Disease & Critical Care, Rheumatology / Orthopedics
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ABIM is a registered trademark of the American Board of Internal Medicine, which neither sponsors nor is affiliated in any way with this product.
KNOWMEDGE
HIGH-YIELD INTERNAL MEDICINE BOARD EXAM PEARLS
Email: support@knowmedge.com Website: www.knowmedge.com Facebook: www.facebook.com/knowmedge Twitter: www.twitter.com/knowmedge YouTube: www.youtube.com/knowmedge The content in this book may be updated periodically. All updates, including known errors or revisions, are available at: www.knowmedge.com/forum Copyright © 2013 Knowmedge ALL RIGHTS RESERVED. No part of this work may be reproduced or used in any form or by any means–graphic, electronic, or mechanical, including photocopying, recording, taping, web distribution–without the prior written permission of Knowmedge Note: ABIM is a registered trademark of the American Board of Internal Medicine, which neither sponsors nor is affiliated in any way with this product.
Dear Reader, Thank you for downloading a copy of this eBook. If you are searching for study materials for the internal medicine board exam, you are on the verge of a significant milestone in your professional journey. Knowmedge is an interactive platform that was launched in April 2013. It features over 900 questions designed to help you understand and reinforce the key concepts covered on the exam. Each of our questions features a highly interactive audio visual explanation, in which our content experts walk you through the principles underlying each question to methodically arrive at the correct answer. This book contains high-yield pearls for the Internal Medicine Boards – ABIM Exam and IM Shelf Exam – written by the team of Knowmedge doctors. There are a total of 12 different pearl articles presented in this book – all from topics that are important to pass the Internal Medicine Boards. We hope you find the pearls in this book to be a valuable asset as you prepare for your upcoming exam. If you are interested in learning more about Knowmedge, please visit us at www.knowmedge.com. If you have any questions about the contents of this eBook, send me a note at sunir@knowmedge.com Best of luck in your preparations! Sincerely,
Sunir Sunir Kumar, MD Co-founder, Chief Editor Knowmedge
Table of Contents 5 Cardiology Pearls .................................................................. 1 By: Dr. Salim Rezaie
5 Endocrinology Pearls ............................................................ 8 By: Dr. Sunir Kumar
5 Gastroenterology Pearls ...................................................... 12 By Dr. Sunir Kumar
Gastroenterology Pearls: Digestive Tract in 7 Major Parts ..... 19 By: Dr. Ruchi Bhatia
General Internal Medicine Pearls: Eye Conditions ................. 25 By: Dr. Sunir Kumar
General Internal Medicine Pearls: Vaccinations ..................... 29 By: Dr. Sunir Kumar
5 Hematology Pearls .............................................................. 32 By Dr. Salim Rezaie
6 Infectious Disease Pearls .................................................... 36 By Dr. Salim Rezaie
11 Nephrology Pearls ............................................................. 40 By Dr. Salim Rezaie
7 Oncology Pearls .................................................................. 45 By: Dr. Sunir Kumar
5 Neurology Pearls ................................................................. 51 By: Dr. Sunir Kumar
Quick and Easy Guide to Selecting the Right Topical Steroid 57 By: Dr. Sheila Krishna
8 Pulmonary Disease & Critical Care Pearls .......................... 61 By: Dr. Sunir Kumar
5 Rheumatology Pearls .......................................................... 68 By: Dr. Sunir Kumar
Bonus: How to study for and pass the ABIM board exam ....... 72 By: Dr. Ravi Bhatia
Bonus: How to study for the Internal Medicine Shelf Exam .... 78 By: Dr. Ravi Bhatia
About our Authors .................................................................. 87
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5 Cardiology Pearls By: Dr. Salim Rezaie Whether studying for emergency medicine, internal medicine, or USMLE board examinations, cardiovascular diseases are by far and away one of the biggest organ systems of which questions get asked. If you pay attention, the first three pearls are all on physical exam findings and the last two pearls are on disease processes with high morbidity and mortality. I have attached a review table for each pearl to help simplify the concepts and buzz phrases. Pearl #1: Know what the maneuvers are that increase and decrease heart murmurs. In general, you should know all the different maneuvers, their effect, and how they would affect valve abnormalities. It is helpful to walk yourself through each valve abnormality, and try and explain why murmurs are increased or decreased, instead of just memorizing a table, which you will forget in 1 – 2 weeks. That being said, common murmurs that seem to get the most questions are: HOCM, AS, MVP, and MR.
Cardiac Maneuvers for the Internal Medicine Board Exam 1|Page
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Pearl #2: Know the abnormal arterial pulsations and the disease state with which they are commonly associated. Arterial pulsations is another physical exam finding that can be very high-yield. Recognizing the buzz phrase (arterial pulse description) and its association to what disorder it is commonly associated can help save you time on questions, which allows you more time on other questions. This is too easy to not know these terms.
Heart Pulses
Pearl #3: Know your normal and abnormal heart sounds. 2|Page
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Heart sounds such as S1 and S2 are also a big part of the cardiovascular physical exam on boards. Know what happens with inspiration/expiration as well as other pathologies. Don’t forget about S3 and S4. Remember, sometimes an S3 can be normal (i.e. pregnancy and children).
Heart Sounds to know for the Internal Medicine Boards
Pearl #4: The number one killer in the world is ischemic heart disease, so know what medications improve morbidity and mortality. 3|Page
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First and foremost, be sure to fix modifiable coronary artery disease risk factors such as diabetes mellitus, hypertension, hyperlipidemia, and smoking. Next, know what medications decrease mortality in ischemic heart disease and acute coronary syndrome. Also be sure to know the contraindications for thrombolytics in STEMI.
CAD ACS Therapy Table for the Internal Medicine Boards – Part I
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CAD ACS Therapy Table for the Internal Medicine Boards – Part II
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Contraindications – Thrombolytics Pearl #5: Congestive Heart Failure (CHF) is common, so know which medications affect mortality CHF is a common disease process seen in hospitalized, elderly patients due to improvements in revascularization techniques. 40% of these patients die from arrhythmias and sudden cardiac death; therefore knowing what medications can improve mortality is essential.
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CHF – Medications
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5 Endocrinology Pearls By: Dr. Sunir Kumar Endocrinology is an essential part of the Internal Medicine Medical Clerkship and ABIM Board exam. According to the ABIM exam blueprint, questions testing endocrinology topics comprise ~8% of the exam. Approximately ~5-10% of the NBME Clerkship exam is composed of endocrinology questions. Pearl #1: Don’t let thyroid nodules intimidate you. This systematic approach will help you workup a thyroid nodule.
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Pearl # 2: Workup of hirsutism is not as difficult as it seems. Follow this approach and you will be able to diagnose the cause of hirsutism.
Hirsutism is caused by either excessive testosterone or excessive 17-OH steroids (DHEA-S) production. Excessive Testosterone production is seen in ovarian cancer or polycystic ovarian syndrome (PCOS) o Ovarian cancer: worked up with trans-vaginal ultrasound to look for adnexal mass. In addition, CA-125 marker is usually elevated in ovarian cancer. PCOS: Amenorrhea, insulin resistance, and LH:FSH ratio of greater than equal to 3:1 Excessive DHEA-S production is seen in congenital adrenal hyperplasia (CAH), Cushing’s disease, or adrenal carcinoma CAH: Usual cause is 21 beta hydroxylase deficiency, which is used to convert 17-OH progesterone to cortisol. Since this enzyme is deficient, 17-OH progesterone levels remain elevated. Decreased cortisol levels will cause an elevated ACTH level through a negative feedback mechanism. With increased ACTH, hyperpigmentation will also occur. Cushing’s disease: Defect in anterior pituitary causes increased ACTH, which o
increases cortisol. MRI of pituitary is ordered to work up Cushing’s. If suspicion is high for Cushing’s disease despite negative MRI of the pituitary, perform inferior petrosal sinus sampling. Adrenal carcinoma: Problem occurs in the adrenal gland, which will lead to elevated cortisol levels. The elevated cortisol level will suppress the ACTH level. Since ACTH is suppressed, hyperpigmentation will not occur.
Pearl # 3: Workup of an adrenal mass and management depends on the size and the functional status of the mass
Many times, adrenal masses are found incidentally on a CT scan. These are known as an “adrenal incidentalomas.” Rules to remember: o If the adrenal mass is either greater than 6 cm in size OR is functional (regardless of size) → surgical intervention is recommended 9|Page
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o
o
o
If an adrenal mass is less than 4 cm AND is non-functional → serial CT scans are recommended every 4-6 months to assess the size of the adrenal mass to make sure it is not growing How to determine functional status of an adrenal mass? Remember the 3 layers of the adrenal cortex and the one layer of the adrenal medulla and know what is produced in each layer to determine if it is functioning or not. Adrenal Cortex layers (remember by mnemonic GFR as in glomerular filtration rate): Zona Glomerulosa → check to see if aldosterone:renin ratio is elevated (usually more than 20:1)
Zona Fasciculata → check 24 hour urine cortisol levels and if greater than 100 mg/dl → Cushing problem should be suspected Zona Reticularis → Check 17 OH steroid (DHEA-S) levels. If elevated, this layer is functioning. Adrenal Medulla: Check urine VMA or urine metanephrine levels. If either of these metabolites are elevated, concern is for pheochromocytoma
Pearl # 4: Systematic approach to workup hypercortisolism
First check 24 hour urine cortisol. If greater than 100 mg/dl, then you either have Cushing syndrome, Cushing’s disease, or ectopic production of ACTH. Next step is to check the ACTH level. If the ACTH level is suppressed, then the problem is Cushing syndrome; CT or MRI of adrenals should be done. If ACTH level is elevated, the patient has either Cushing’s disease (pituitary problem) or ectopic production of ACTH (like lung cancer) To distinguish between Cushing’s disease and ectopic production of ACTH, perform a high dose (8mg) dexamethasone suppression test. o If high dose dexamethasone suppresses cortisol, problem is Cushing’s disease. MRI of the pituitary should be performed. If MRI of the pituitary is negative, o
perform inferior petrosal sinus sampling. If high dose dexamethasone suppression test fails to suppress cortisol, the problem is ectopic production of ACTH. Check CT scan of chest to rule out lung cancer.
Pearl # 5: Must know diabetes mellitus high yield facts 10 | P a g e
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Type 1 DM → lack of insulin because of destruction of pancreatic beta cells → associated with antibodies to glutamic acid decarboxylase Type 2 DM → more common in obese individuals and can occur later in life. Insulin resistance occurs. Diagnose of DM is made when patient has two fasting glucose levels greater than or equal to 126 mg/dl or a random glucose level greater than 200 mg/dl especially in the context of signs and symptoms like polyuria, polydipsia, or unintentional weight loss. Goal Hgba1C is less than 7%. Hgba1C is an average glucose in a 3 month period. Pre-prandial glucose goal in a DM patient is 90-130 mg/dl. 2 hour post-prandial glucose goal is less than 180 mg/dl.
Monofilament foot testing is the best way to prevent diabetic foot ulcers from occurring. A common organism that causes diabetic foot ulcers is Staph aureus or beta hemolytic streptococcus. Eye exams in DM patients are recommended every 1 to 2 years o If eye exam reveals hard exudates or microaneurysms → patient has nonproliferative retinopathy → management is by tighter glucose control o If eye exam reveals neovascularization or cotton-wool spots → patient has proliferative retinopathy → treat with photocoagulation
Once again, the folks who write the Internal Medicine licensing exams don’t expect you to have the depth of knowledge regarding hormone-related conditions, metabolism and diabetes that an endocrinologist possesses. However, topics such as the ones mentioned in the pearls above should assist you with the endocrinology section of the med school clerkship shelf and ABIM board exams.
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5 Gastroenterology Pearls By Dr. Sunir Kumar Gastroenterology and Hepatology comprises about 9% of the ABIM Internal Medicine exam, making it one of the more critical subjects on the boards. Below, we review 5 High Yield Gastroenterology / Hepatology Pearls that may help you score a few extra points on your ABIM or Internal Medicine shelf examination. Pearl # 1: Remembering Hepatitis B markers can be difficult, but is worth it Start with these key points: o
Hepatitis B surface Antigen (HBsAg) → active infection
o
Hepatitis B surface Antibody (HBsAb) → past infection or vaccination against hepatitis B Hepatitis Be Antigen (HBeAg) → active replication of the virus Anti Hepatitis B core IgM Antibody (Anti-HBc IgM) → acute infection Anti Hepatitis B core IgG Antibody (Anti-HBc IgG) → chronic infection
o o o
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As you see above: Along with the Cleared state, both Chronic and Carrier Hepatitis B patients will have positive HBsAg and Anti-HBcIgG. How can these two conditions be differentiated? Easily. Just look at the Liver function tests (LFTs) o o
Chronic → Increased LFTs Carrier → Normal LFTs
What about that Hepatitis D virus? o
Hepatitis D can’t exist on its own. It requires Hepatitis B infection to be present
o
Anti-HBc IgM + Hepatitis D virus → acute co-infection and will not worsen hepatitis Anti-HBc IgG + Hepatitis D virus → acute super-infection and can cause fulminant hepatitis
o
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Pearl # 2: Main causes of dysphagia can be broken down into Mechanical & Motility Problems Mechanical Problems (dysphagia to solids first and liquids later)
Intermittent problem Esophageal ring (a.k.a Steakhouse Syndrome) Clue in history: Patient has difficulty swallowing while chewing foods like bread or steak. Long standing history of GERD Barrett’s esophagus (squamous to columnar metaplasia) or stricture formation. Dysphagia to solids with significant weight loss If long standing smoking history, Squamous cell carcinoma more likely If long standing history of uncontrolled GERD, Adenocarcinoma more likely Eosinophilic esophagitis Dense eosinophilic infiltrate in the squamous epithelium
Mainstay of treatment is viscous budesonide, fluticasone, or proton pump inhibitors (PPIs)
Motility Problems (dysphagia to both solids and liquids concurrently)
Intermittent and associated with chest pain, especially after drinking carbonated drinks Diffuse Esophageal Spasm (DES) Associated with connective tissue disease or heartburn Scleroderma Associated with cough/regurgitation with improvement of dysphagia with raising hand above the head Achalasia (which can in the context of Chagas Disease) Before treating with surgical myotomy or pneumatic dilatation, EGD must be done first to rule out secondary achalasia from lymphoma or cancer. 14 | P a g e
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Achalasia will have increased LES tone on manometry studies. GERD, on the other hand, will have decreased LES tone.
Pearl # 3: Remember the main causes of Pancreatitis by the mnemonic “I GET SMASHED”
Pearl # 4: Alcoholics aren’t the only folks to develop cirrhosis To the lay public, cirrhosis is to alcohol as lung cancer is to smoking. However, we know that it’s not such a simple association. Smokers aren’t the only patients to develop lung cancer and those who don’t drink alcohol can still become cirrhotic. Let’s review some of the non-alcohol related causes of liver failure with two easy-to-digest slides: 15 | P a g e
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First, we review Viral Hepatitis, Fatty Liver/Steatohepatitis, Wilson’s, Alpha 1 AntiTrypsin Deficiency, Hemochromatosis and Budd-Chiari along with helpful clinical clues that may appear in the question vignette:
Of course, we can’t forget Autoimmune Hepatitis, Primary Biliary Cirrhosis, and Primary Sclerosing Cholangitis. Many medical students and residents find it confusing to match up the gender, age, and serologies with the correct condition. While these are not hard-and-fast rules, for exam purposes, in general we can use the following colorful schematic to make it tough to ever forget again.
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Pearl # 5: They may both be considered IBD, but know how to distinguish Ulcerative Colitis and Crohn’s Disease Ulcerative Colitis o
Presents with abdominal pain and bloody diarrhea that is chronic
o
Problem starts in the rectum and spreads proximally (backwash ileitis) Pathology reveals superficial ulcers with crypt abscesses Some common extra-intestinal manifestations include: Aphthous ulcers Pyoderma gangrenosum Primary sclerosing cholangitis
o o
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o o
Ankylosing spondylitis Arthritis (mirrors Ulcerative Colitis) Erythema nodosum (mirrors Ulcerative Colitis) Can show positive p-ANCA on labwork Colonoscopy should be performed 8 years after diagnosis and then every 1-2 years afterwards as patients with UC have an increased risk of colon cancer If dysplasia is seen on colonoscopy, total proctocolectomy should be performed
Crohn’s Disease o
o
o o
o o
o
Rectum is spared with Crohn’s Disease. Crohn’s Disease occurs mainly in the terminal ileum (Skip lesions are common) Common presentation is right lower quadrant mass, weight loss, and diarrhea (can be bloody but can also be watery) Pathology will show deep ulcers with granuloma formation Not as common to see extra-intestinal manifestations with Crohn’s Disease as is seen in patient with UC Colon cancer can occur but is more common in UC patients Can show positive ASCA (anti-Saccharomyces Cerevisiae antibodies) on labwork Colonoscopy should be performed 8 years after diagnosis and then every 1-2 years If dysplasia is seen on colonoscopy, total protocolectomy should be performed
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Gastroenterology Pearls: Digestive Tract in 7 Major Parts By: Dr. Ruchi Bhatia As previously mentioned, the Gastroenterology and Hepatology section of the ABIM Internal Medicine exam comprises of about 9% of the entire exam - that means out of 240 total questions (4 sections of 60 questions each), we can expect about 20 questions to be geared towards our liver and GI tract. For the Internal Medicine Shelf Exam, Gastroenterology comprises 7-13% of the exam. Overall, the digestive system is fascinating (the liver itself is the largest organ in the body and performs over 500 functions!) yet quite simple (think of it this way – food goes in to the mouth, down the esophagus and in to the stomach, through 26 feet of small intestine in to the colon. Then out.) To simplify for the ABIM exam, let’s divide the digestive tract in to 7 major parts and discuss a couple important topics in each – Esophagus, Stomach, Pancreas, Biliary Tract, Small Bowel, Colon, and Liver. 1. Esophagus A favorite topic of boards is GERD and the development of Barrett esophagus. GERD is caused by a decrease in the physiologic antireflux barriers at the GE junction, resulting in gastric contents being released in to the esophagus. Surprisingly, the major cause of GERD is not hypersecretion of gastric contents, but rather an inappropriate relaxation of the lower esophageal sphincter. Remember: o o
o
A 4-week empiric trial of a PPI has a high sensitivity for the diagnosis of GERD Patients presenting with weight loss, dysphagia, odynophagia, or those whose symptoms are refractory to medical therapy should undergo further testing Ambulatory esophageal pH monitoring is the most accurate means to confirm the diagnosis of GERD
The development of Barrett esophagus is a feared complication of GERD due to the increased risk for esophageal adenocarcinoma (remember, squamous cell carcinoma 19 | P a g e
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arises in the upper portion of the esophagus and adenocarcinoma arises distally, closer to the GE junction). Remember: o
o
Histologically, Barrett esophagus has specialized intestinal metaplasia with mucin containing goblet cells Dysplasia found during EGD: none -> surveillance EGD should be repeated in 1 year, then every 5 years if negative
low grade -> surveillance in 6 months for 1 year, then yearly high grade -> surveillance every 3 months for focal dysplasia vs. surgical or endoscopic management for multifocal dysplasia
2. Stomach Given the large number of hospitalizations and deaths from peptic ulcer disease every year, it is not surprising that this remains a major topic tested on the boards. The most common causes are Helicobacter pylori infection and NSAIDs. Remember:
H. pylori is associated with the development of gastric adenocarcinoma
as well as MALT (mucosa-associated lymphoid tissue) lymphoma Treatment for H. pylori consists of triple therapy – PPI, Amoxicillin, and
Clarithromycin (Metronidazole in Clarithromycin resistant areas) Urea breath test and fecal antigen test are both sensitive for the detection of H. pylori
Be able to recognize a patient with a perforated peptic ulcer! Look for a patient who is hypotensive and tachycardic with absent bowel sounds and severe rebound tenderness and guarding. Imaging will show free intraperitoneal air. Stat surgical consultation is required! 3. Pancreas
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The prevalence of pancreatitis continues to rise in the Western world, and thus remains a favorite for the ABIM boards. Although alcohol and gallstones remain the major cause of acute pancreatitis, metabolic (hyperlipidemia, hypercalcemia), infectious (CMV, EBV, parasites), and autoimmune causes should be considered. Remember:
Diagnosis of acute pancreatitis can be made without imaging, but contrast-enhanced CT scan is used if there is concern for necrotizing pancreatitis
If necrotizing pancreatitis is suspected, prophylactic antibiotics should be used – imipenem, cephalosporins, and fluoroquinolones ERCP is used if there is evidence of gallstone pancreatitis and suspected biliary obstruction Consider a deficiency in fat-soluble vitamins (A, D, E, K) in chronic pancreatitis
Look for CA 19-9 as a tumor marker for pancreatic cancer. Better yet, be able to recognize the whole table of important tumor markers discussed in the oncology section of Knowmedge. 4. Biliary Tract The prevalence of gallstones is high in the United States, and thus should be considered as part of a differential for a patient presenting with abdominal pain. Be able to recognize and know how to treat acute cholecystitis, but also know when to expect and how to treat acalculous cholecystitis. Remember:
Consider acalculous cholecystitis in patients with serious comorbidities, including trauma, burns, or prolonged states of fasting Management is similar to that of acute calculous cholecystitis, but patients with severe illness may require percutaneous drainage if unable to tolerate surgery 21 | P a g e
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If choledocholithiasis is suspected, broad-spectrum antibiotics covering enteric gramnegative bacteria should be started. Fluoroquinolones are usually a good initial choice. 5. Small Bowel Another favorite boards topic – diarrhea. Diarrhea can of course be divided multiple ways – acute vs. chronic, secretory vs. osmotic vs. inflammatory, small-bowel vs. largebowel. Be able to easily distinguish the two main types of inflammatory diarrhea, Ulcerative colitis vs. Crohn’s. Since this was already discussed in the last GI blog, I’ll just address some key words for each. Remember:
Ulcerative colitis – Crampy pain. Mucosa and submucosa. Pseudopolyps. HLA-B27. Ankylosing spondylitis. Pyoderma gangrenosum. Primary sclerosing cholangitis. Toxic megacolon. Adenocarcinoma. Crohn’s disease – Colicky pain. Transmural. Lymphocytes. Granulomas. Rectal sparing. Skip lesions. Fistulas. Strictures. B12 deficiency.
Both conditions usually present with diarrhea on the boards, so be able to quickly recognize these key words for some easy points. Don’t forget, both of these conditions have an increased risk of colon cancer estimated to be 1-2% per year after 8 years of disease. Thus surveillance colonoscopy should be started in patients with IBD for 8 years or longer. 6. Colon Colorectal cancer is the second leading cause of cancer death in the United States. According to the CDC, every year about 140,000 Americans are diagnosed with colorectal cancer and over 500,000 die from it. That being said, it should come as no surprise that colon cancer is a major GI topic in the ABIM exam. Remember these Autosomal Dominant conditions and their management:
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annual flex sig beginning at age 10-12, and colectomy should be considered when polyposis is detected Hereditary nonpolyposis colorectal cancer (HNPCC), or Lynch syndrome – caused by a mutations in the MLH1 and MSH2 mismatch repair genes colonoscopy every 1 to 2 years starting at age 20-25 years or 10 years before the age at diagnosis of the youngest family member with colon cancer Peutz-Jeghers syndrome – caused by a germ line mutation in the STK11 gene Juvenile polyposis syndrome – caused by a germ line mutation of the SMAD4 gene
7. Liver Last but definitely not least of the major parts of the digestive tract – the liver. This organ, weighing in at about 3 lbs, is the second largest organ (after the skin) and affects nearly every physiologic process of the human body. For the ABIM board exam, be able to interpret Hepatitis B serologies and have a good understanding of the difference between acute and chronic infection. Remember:
The goal of therapy in chronic Hepatitis B is suppression of viral replication, seroconversion of HBeAg, and decrease in hepatic inflammation (as evidenced by an improvement in liver enzymes) Once a patient is found to have a chronic Hepatitis B infection, surveillance should be undertaken to prevent the development of cirrhosis and HCC by ultrasound and a-fetoprotein level every 6-12 months
In addition to viral hepatitis, several other causes of hepatitis need to be considered. Be able to distinguish between hepatocellular injury and cholestatic injury. Remember:
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Hepatocellular – elevation in ALT and AST released from injured hepatocytes Viral hepatitis, alcoholic hepatitis, drug-induced hepatitis, NASH, ischemic hepatitis, autoimmune hepatitis (look for ASMA!), hemochromatosis, Wilson disease, a1-antitrypsin deficiency Cholestatic – elevation in alkaline phosphatase occurs due to a decrease in the flow of bile Primary biliary cirrhosis (look for antimitochondrial antibodies!), primary sclerosing cholangitis, drug-induced cholestasis
These are just a few key points to help you digest the Gastroenterology and Hepatology section of the ABIM Internal Medicine exam. Good luck!
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General Internal Medicine Pearls: Eye Conditions By: Dr. Sunir Kumar While most of the ABIM Examination topics fall neatly into organ system categories, not all of them fit into this schematic. These include: ophthalmology, primary care screening guidelines, vaccinations, etc. Here at Knowmedge, we’ve incorporated this important group of subject areas into General Internal Medicine, similar to the American College of Physicians’ Internal Medicine In-Training Exam Blueprint. In this first of a series of blog posts, we review the key eye diseases: Conjunctivitis, Macular Degeneration, Glaucoma, Retinal Detachment, and Cataracts. The eyes may see only what the mind knows, but your mind should know these eye conditions for the ABIM exam. 1. Conjunctivitis Conjunctivitis is broken down into viral, bacterial, and allergic conjunctivitis.
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Viral
Usually caused by adenovirus
Having a preceding upper respiratory infection or recent exposure to a person with conjunctivitis are clues to aid in the diagnosis Acute onset Usually unilateral redness Watery discharge is present Highly contagious Frequent hand washing must be performed to prevent spread of infection
Supportive treatment including cold compresses and artificial tears. NO role for antibiotic eye drops with viral conjunctivitis
Bacterial
Common causing agents are Staph aureus, Streptococcus pneumoniae, or
Haemophilus influenzae. People who wear contact lenses can be infected by Pseudomonas aeruginosa Presence of mucopurulent discharge and crusting can occur in the morning when the
discharge is dry Usually leads to redness of unilateral eye but may have bilateral involvement if spread occurs by rubbing both eyes Should be treated with antibiotics (e.g. erythromycin ointment and/or polymyxintrimethoprim drops) for 5-7 days Patients who wear contact lenses should not wear contact lenses for at least 7 days If patient has bacterial conjunctivitis for 4 weeks, this is chronic in nature and should be evaluated by an ophthalmologist
Allergic
Can mimic viral conjunctivitis in terms of having clear (or ropy) discharge but
predominant symptom is eye itching that corresponds to specific seasons Treatment is with oral anti-histamines, topical anti-histamines, and artificial tears
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2. Macular Degeneration
Common in elderly individuals Can lead to visual loss Progression of disease can lead to difficulty reading, driving, or performing activities of daily living Two sub-types of macular degeneration are dry (atrophic) and wet (neo-vascular). Most cases are dry macular degeneration. If, however, patient has wet macular degeneration, it is more serious and can lead to blindness in an acute fashion rather than progressive fashion. Biggest risk factors are age, family history, cardiovascular disease, and smoking Quitting smoking reduces the risk of developing macular degeneration and some studies suggest that diet high in anti-oxidants can be protective. Patients can also benefit by using a magnifying glass.
3. Glaucoma Glaucoma is a condition resulting from increased intra-ocular pressure due to blockage in drainage of aqueous humor. It can be broken down into primary open angle glaucoma (POAG) and acute angle closure glaucoma.
POAG
Most common form of glaucoma and most common cause of irreversible blindness in the world Painless loss of peripheral vision that is gradual in nature. Later on, it can affect central vision Optic cup: disc ratio >0.5 Risk factors include age greater than 40, African-American race, and positive family history Mainstay of treatment is with pharmacological eye agents such as beta blockers, carbonic anhydrase inhibitors, adrenergic agonists, hyperosmotic agents, and prostaglandin analogues
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Acute Angle Closure Glaucoma
More severe than POAG
Red eye, severe pain, headache, nausea and vomiting and visual halos Intra-ocular pressure can be as high as 50 mmHg When suspected, immediate referral to an ophthalmologist is required to prevent permanent optic nerve atrophy
4. Retinal Detachment
Patients may present with floaters, squiggly lines, or flashes of light
This is an ophthalmology emergency and requires immediate attention by an ophthalmologist
5. Cataracts
Opacity of lens will occur Symptoms include painless decreased visual acuity, decreased night vision, glare, and sometimes double vision Physical examination can reveal a decreased or absent red reflex Treatment is surgical removal of the cataract
Once again, the folks who write the Internal Medicine licensing exams don’t expect you to have the depth of knowledge regarding the plethora of eye diagnoses that an ophthalmologist possesses. However, topics such as the ones mentioned in the pearls above should assist you with the General Internal Medicine section of the med school clerkship shelf, ACP intraining and ABIM board exams.
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General Internal Medicine Pearls: Vaccinations By: Dr. Sunir Kumar While most of the ABIM Examination topics fall neatly into organ system categories, not all of them fit into this schematic. These include: primary care screening guidelines, substance abuse, vaccinations, etc. Here at Knowmedge, we’ve incorporated this important group of subject areas into General Internal Medicine, similar to the American College of Physicians’ Internal Medicine In-Training Exam Blueprint. Earlier this week, we reviewed the 5 key eye diseases seen on the ABIM board and NBME shelf exams. Today we explore the high-yield topic of vaccinations.
A comprehensive adult immunization schedule, by Vaccine and Age Group, can be found on the Centers for Disease Control and Prevention website (unlike other preventive health measures, vaccination guidelines are not released by the USPSTF). Fortunately, you don’t need to memorize the entire CDC chart. Instead, for the ACP Internal Medicine in-training exam, ABIM boards and NBME shelf exam, focus on these 7 vaccinations.
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1. Tetanus, diphtheria, pertussis (Tdap)
Administer Tdap to all adults who have not previously received Tdap or whose
vaccination status is unknown. Boost with Td every 10 yrs.
2. Influenza
All individuals age 6 months and older should be vaccinated yearly since the targeted influenza strains changes on a yearly basis.
3. Herpes zoster (Shingles) Adults 60 years of age and older should receive a single dose of the zoster vaccine. This is regardless of whether the patient has had a prior episode of herpes zoster. 2. The vaccine is approved by the Food and Drug Administration (FDA) for patients 50 years of age and older, at this point, the CDC recommends the vaccination beginning at age 60 years so stick with this guideline. 3. Patients with severe immunodeficiency should not receive the zoster vaccine. 1.
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4. Pneumococcus
All adults 65 year of age and older should be recommended to have one-time vaccination against Pneumococcus. Pneumococcal vaccine should also be given to younger individuals who are current smokers, nursing home residents, or have asthma/COPD, diabetes mellitus, chronic renal failure, chronic liver disease, chronic cardiovascular disease, cochlear implants, anatomic asplenia, or alcoholism.
5. Hepatitis A Candidates for immunization against hepatitis A virus include:
Travelers to endemic areas
Illicit drug users Men who have sex with men Patients with chronic liver disease Any patient seeking protection from HAV
6. Meningococcus Only certain populations should be vaccinated against meningococcus:
College students living in dormitories Patients with HIV Asplenia
7. Human Papillomavirus (HPV) Both males and females ages 11-26 are recommended to undergo the full series of the HPV vaccination. The vaccine is not recommended for use in pregnant women. Source: http://annals.org/article.aspx?articleid=1567229
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5 Hematology Pearls By Dr. Salim Rezaie Hematology is a subject that comes up daily in clinical practice, and is a favorite on the ABIM Internal Medicine board exam. Evaluation of anemia, as well as some other hematologic disorders, is paramount for an internist to master. I will try and provide five evidence-based pearls in this post that will help physicians understand some important concepts and avoid common pitfalls in the recognition and treatment of such hematological disorders. Pearl #1: Patients on iron supplementation SHOULD NOT have positive guaiac tests.
Studies in vitro show ferric iron (Fe3+) will give a positive guaiac reaction and ferrous iron (Fe2+) does not
Iron is digested in the ferrous form and carried in the blood in the ferric form
Patients on iron supplementation with positive guaiac require screening for identifying the source of gastrointestinal hemorrhage
Ferrous (Fe2+) iron does not cause positive guaiac tests in vivo
Pearl #2: The pentad of Thrombotic Thrombocytopenic Purpura (TTP) is not always present.
The pentad is: microangiopathic hemolytic anemia (MAHA), thrombocytopenia, renal abnormalities, neurologic abnormalities, and fever
Less than 50% of patients have the complete pentad
Measurement of ADAMTS13 activity is not required to make the diagnosis; the diagnosis is clinical
The gold standard treatment is plasma exchange and if not available you may use fresh frozen plasma as an alternative treatment
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Primary hemostasis Disorders: o A result of platelet function o Immediate clotting o Patients will have petechiae and purpura o All will have elevated bleeding time (platelets don’t work) and normal PT/PTT (no problem with clotting factors)
Secondary hemostasis Disorders: o A result of clotting factors o Delayed clotting (help strengthen clots by fibrin formation) o Patients will have hematomas and hemarthroses o All will have normal bleeding time (platelets work fine) and abnormal PT (extrinsic pathway) and PTT (intrinsic pathway)
Pearl #4: Acute myelogenous leukemia (AML) type M3 has a good prognosis.
AML is the most common type of acute leukemia in adults
Typically M2 – M5 types are myeloperoxidase stain positive (Remember that PTU and micropolyangitis can also be positive)
Auer rods are pathognomonic for AML
Type M3 (promyelocytic) leukemia has t(15,17)
The treatment of choice is all-trans retinoic acid (ATRA)
The single most important prognostic factor in AML is cytogentetics: t(15;17) has a 70% 5 year survival and 33% relapse rate
Pearl #5: Anemia is the most common hematologic abnormality, so know it cold.
Iron deficiency anemia is the world’s most common cause of anemia
Iron deficiency anemia: o Low iron, transferrin saturation, and ferritin o Elevated TIBC
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o Transferrin Receptor Index = transferrin receptor/Log Ferritin is the most sensitive assay for iron deficiency anemia (>2.0 = Iron Deficiency Anemia; <1.0 = Anemia of Chronic Disease) o Treatment is PO iron → if no improvement after 6 weeks consider IV iron o The earliest lab to check after starting iron replacement is the reticulocyte count (Begins to increase at about 5 to 7 days) o Ascorbic acid (vitamin C) supplementation increases absorption of iron o Most iron is absorbed in the duodenum o Celiac sprue can cause iron deficiency anemia: Best test is tissue transglutaminase antibody or antiendomysial antibody; Tx is a gluten free diet; Can see dermatitis herpetiformis associated with this entity As I have stated in my high yield pearls to pass the boards: “Most commons” are emphasized on the ABIM curriculum, so it is good to know these disease processes. Also, diseases that are increasing in incidence or have a high mortality associated with them are also high yield. Anemia (most common hematologic abnormality), AML (most common acute leukemia in adults), and Thrombotic Thrombocytopenic Purpura (high mortality) are 3 of the hematology pearls covered in this post. Best of luck as you are preparing for your ABIM board exam, and hopefully these pearls help you get a few more questions correct. References: 1. George JN. How I Treat Patients With Thrombotic Thrombocytopenic Purpura: 2010. Blood 2010 Nov; 116 (20): 4060 – 9. PMID: 20686117 2. Grimwalde D et al. The Importance of Diagnostic Cytogenetics on Outcome in AML: Analysis of 1,612 patients entered into the MRC AML 10 Trial. The Medical Research Council Adult and Children’s Leukemia Working Parties. Blood 1998 Oct; 92 (7): 2322 – 33. PMID: 9746770 3. Konrad G et al. Are Medication Restrictions Before FOBT Necessary?: Practical Advice Based on a Systematic Review of the Literature. Can Fam Physician 2012 Sep; 58 (9): 939 – 48. PMID: 22972722 4. McDonnell WM et al. Effect of Iron on the Guaiac Reaction. Gastroenterology. 1989 Jan; 96 (1): 74 – 8. PMID: 2909440 34 | P a g e
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5. Rimon E et al. Diagnosis of Iron Deficiency Anemia in the Elderly by Transferrin Receptor-Ferritin Index. Arch Intern Med 2002 Feb; 162 (4): 445 -9. PMID: 11863478
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6 Infectious Disease Pearls By Dr. Salim Rezaie In keeping with the popularity of the high-yield pearls posts from nephrology, I decided to write a post giving you my 5 high-yield infectious disease (ID) pearls, beneficial for your clinical practice and ABIM exam preparation. The purpose of these posts is to give you some concise, practical teaching points that are supported by the medical literature. Pearl # 1: Staphylococcus aureus bacteremia can be more complicated than getting 2 weeks of intravenous antibiotics
Patients treated for at least 2 weeks of antibiotics are more likely to be cured of bacteremia and less likely to have recurrence of bacteremia3 Recurrence of bacteremia may be due to bone, joint, and cardiac involvement due to inadequate initial antimicrobial course3 Patients with cardiac, bone, and joint involvement need at least 4 – 6 weeks of antimicrobial coverage Remove intravascular catheters if patient has Staphylococcus aureus bacteremia (20 – 26% of cases are complicated by infective endocarditis or metastatic infection) 8 Patients with hematuria during Staphylococcus aureus bacteremia should have further evaluation for infective endocarditis8 Oral linezolid can be used to complete a 2-week course in some cases12
Pearl # 2: Candida in the blood is not a contaminant, but could be in the sputum or urine
Candida in the blood is NEVER a contaminant 11 Removal of an intravenous catheter alone is never an absolute treatment; highest mortality rates are seen in patients without antifungal therapy9
All patients with candidemia should undergo ophthalmologic examination 10 Micafungin is the treatment of choice for candidemia, and preferred over azoles8 Asymptomatic candiduria does not require further workups or antifungal therapy in most cases; Symptomatic funguria always requires treatment 6
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Pearl # 3: Clostridium difficile toxin should not be re-checked for cure and has a poor sensitivity
Clostridium difficile associated diarrhea (CDAD) should be suspected after recent antibiotic use and/or if in the hospital for more than 2 days Consider infection with C. difficile in the differential diagnosis when a leukocytosis in hospitalized patients develops Diarrhea does not have to be present to have a diagnosis of C. difficile colitis C. Diff stool assay produces a false negative test 10 – 20% of the time2 C. Diff stool toxin assays remain positive during and after successful treatment, therefore follow up assays for cure are not helpful, follow clinical course 7
Pearl #4: Blood cultures should always be obtained before parenteral antibiotics are given
Both the Infectious Disease Society of America (IDSA) and American Thoracic Society
(ATS) advocate obtaining two sets of blood cultures prior to initiating antibiotic therapy Coagulase-negative staphylococci is a contaminant in blood cultures about 82% of the time11
The difference between blood cultures before the initiation of antibiotics and after the initiation of antibiotics in identifying a pathogen is 40% versus 18.7%4 Appropriate blood cultures, allows for prompt identification of the offending organisms which influences diagnosis, therapy, and prognosis when positive
Pearl #5: Empiric antibiotics for acute uncomplicated cystitis have changed5
Nitrofurantoin monohydrate/macrocrystals 100mg BID for 5 days is the appropriate choice for empiric therapy of urinary tract infection Trimethoprim-sulfamethoxazole 160/800mg BID for 3 days is an appropriate empiric choice if local resistance rates of uropathogens do not exceed 20% (expert opinion) Fosfomycin trometamol 3g in a single dose is an appropriate empiric choice for urinary tract infection, but may be inferior efficacy compared to standard short-course regimens Pivmecillinam 400mg BID for 3 – 7 days is also an appropriate empiric antimicrobial agent where available
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Fluoroquinolones (ofloxacin, ciprofloxacin, and levofloxacin) should be considered alternative antimicrobials for acute uncomplicated cystitis Amoxicillin or ampicillin should not be used for empirical treatment due to resistance to these agents
Pearl #6: The loading dose of vancomycin is 25 – 30mg/kg based on actual body weight in critically ill patients
Best predictor of efficacy of vancomycin is time above the antimicrobial MIC1
There are so many more high-yield pearls for infectious disease, but these in my humble opinion are practice changing, cost saving, and also affect patient outcomes. References: 1. Ackerman BH et al. Necessity of a Loading Dose When Using Vancomycin in Critically Ill Patients. Journal of Antimicrobial Chemotherapy. 1992; 29 (4): 460 – 1. PMID: 1607335 2. Bartlett JG et al. Antibiotic-Associated Diarrhea. NEJM 2002 346: 334 – 339. PMID: 11821511 3. Fowler VG et al. Outcome of Staphylococcus Aureus Bacteremia According to Compliance With Recommendations of Infectious Diseases Specialists: Experience With 244 Patients. Clin Infect Dis 1998 Sep; 27 (3): 478 – 86. PMID: 9770144 4. Grace CJ et al. Usefulness of Blood Culture for Hospitalized Patients who are Receiving Antibiotic Therapy. Clin Infect Dis 2001 Jun; 32 (11): 1651 – 5. PMID: 11340541 5. Gupta et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011 Mar; 52 (5): e103 – 20. PMID: 21292654 6. Hollenbach E. To Treat or Not to Treat – Critically Ill Patients with Candiduria. Mycoses 2008 Sep. 51; (2) 12 – 24. PMID: 18721329 7. Kelly CP et al. Clostridium difficile – More Difficult than Ever. NEJM 2008 Oct; 359 (18): 1932 -40. PMID: 18971494
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8. Kim AI et al. Staphylococcus Aureus Bacteremia: Using Echocardiography to Guide Length of Therapy. Cleve Clin J Med 2003 Jun; 70 (6): 517, 520 -1, 525 -6. PMID: 12828223 9. Nguyen MH et al. Therapeutic Approaches in Patients with Candidemia. Evaluation in a Multicenter, Prospective, Observational Study. Arch Intern Med 1995; 155 (22): 24 – 29. PMID: 7503601 10. Pappas PG et al. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009 Mar; 48 (5) 503 – 35. PMID: 19191635. 11. Pien BC et al. The Clinical and Prognostic Importance of Positive Blood Cultures in Adults. Am J Med 2010 Sep; 123 (9): 819 – 28. PMID: 20800151 12. Sharpe JN et al. Clinical And Economic Outcomes of Oral Linezolid Versus Intravenous Vancomycin in the Treatment of MRSA-complicated, Lower-Extremity Skin and SoftTissue Infections caused by Methicillin-Resistant Staphylococcus Aureus. Am J Surg 2005 Apr; 189 (4): 425 – 8. PMID: 15820454
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11 Nephrology Pearls By Dr. Salim Rezaie 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: Pearl # 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)
Pearl # 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
Pearl # 3: Patients with Decreased GFR or Proteinuria Need to be Evaluated for the Cause
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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
Pearl # 4: Early-Stage CKD Should Have Periodic Evaluation and Intervention to Slow Progression
Try and 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 phosphorous, 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
Pearl # 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 41 | P a g e
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If the same patient has an increase in creatinine from 1.5 to 2.2 (>30% increase) STOP THE ACEI
Pearl # 6: Anemia in Patients with CKD Should be Treated, but not Overtreated
Anemia of Chronic Disease can lead to fatigue, left ventricular hypertrophy, and increased risk of cardiovascular events Hemoglobin target for CKD should be between 11 – 12 g/dL NOT to exceed 13g/dL Overcorrection of hemoglobin can result in higher risk of stroke, thrombosis, and hypertension Correct all other reversible causes of anemia
Pearl # 7: Phosphate-Containing Bowel Preps Should be Used With Caution
Sodium phosphate bowel preparations are more convenient than some other preps (Easier to use) However, some studies have suggested that they can cause phosphate nephropathy leading to AKI or worsening CKD Instead use polyethylene glycol for the bowel prep (only downside is the volume that has to be consumed; Does not cause volume or electrolyte shifts)
Pearl # 8: Patients With Severe CKD Should Avoid Magnesium- or AluminumContaining Preparations
These include over-the-counter agents such as Maalox and Mylanta
Use of these agents can lead to hypermagnesemia, acute aluminum toxicity, worsening renal function, bone disease, and neurotoxicity 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
Pearl # 9: Most Patients With Hypertension Should NOT Be Screened for Secondary Hypertension, But be Aware of Certain Clinical Clues
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In general 95% of patients have primary or essential hypertension, and only 5% have
a secondary cause Clues include: Severe or difficult to control HTN, HTN that suddenly develops, or HTN that is associated with other clinical findings are some clues Hypokalemia: Consider primary hyperaldosteronism Headaches, palpitations, and sweats: Consider Pheochromocytoma Moon facies and/or striae: Consider Cushing Syndrome History of snoring in obese patient: Consider Obstructive Sleep Apnea Bruit on one side of the abdomen: Consider Renal Artery Stenosis
Over-the-counter medications (NSAIDs, Birth Control Pills, or Decongestants) Non-compliance with Diet (High Sodium Intake)
Pearl # 10: Recurrent Nephrolithiasis, Needs a Metabolic Evaluation to Identify and Treat Modifiable Risk Factors
Nephrolithiasis recurrence over a 10 year period for calcium oxalate stones is about 50% without treatment Family History of nephrolithiasis, inflammatory bowel disease, frequent urinary tract infections, or history of nephrocalcinosis should be referred to a nephrologist Initial workup should start with: diet history, medications, serum calcium, phosphorous, electrolytes and uric acid
Pearl # 11: Cyclosporine and Tacrolimus (Calcineurin Inhibitors) Have Many Drug-Drug Interactions
Any new medication or supplement that a post-kidney transplant patient requests
should be reviewed first before prescribing St. John’s Wort, rifampin, phenytoin, and carbamazepine can all lower cyclosporine levels
Diltiazem, verapamil, and erythromycin can increase cyclosporine levels Cyclosporine can interfere with certain statins such as simvastatin, increasing the risk of statin-induced rhabdomyolysis
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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: Improving 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
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7 Oncology Pearls By: Dr. Sunir Kumar Oncology is an essential part of the Internal Medicine Medical Clerkship and ABIM Board exam. According to the ABIM exam blueprint, questions testing Oncology topics comprise ~7% of the exam. Initially, oncology seems like a very difficult subject given how the treatment regimens of the many types of carcinomas are ever-changing. However, realize that Internal Medicine exams are focused on the basics of the different malignancies. These 8 pearls will get you off to a good start for identifying Pearl # 1: Which cancers correspond to lytic bone lesions? Blastic? Lytic or Blastic?
Lytic bone lesions o Melanoma o Multiple Myeloma o Renal cell cancer o Thyroid cancer Blastic bone lesions o Prostate cancer Lytic or blastic lesion o Lung cancer o Breast cancer
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Pearl # 2: Which paraneoplastic syndrome goes with which cancer?
Pearl # 3: Know these high-yield Breast Cancer facts for the ABIM and IM shelf exams
If the lesion is >1cm OR the patient has lymph node involvement → chemotherapy will be part of the treatment protocol. If sentinel node biopsy is negative → no further lymph node biopsy is required If the patient’s breast cancer is ER/PR (+) and patient is pre-menopausal →Tamoxifen is given for 5 years If the patient’s breast cancer is ER/PR (+) and is post-menopausal → Aromatase inhibitors (eg. Anastrozole) is given If the patient’s breast cancer is HER2/neu (+)→ Trastuzumab is given →can cause CHF →check echocardiogram to assess left ventricular function 46 | P a g e
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Triple negative breast cancer (ER negative, PR negative, HER2/neu negative) has the worst prognosis
Pearl # 4: Don’t let chromosomal translocations overwhelm you
t (14,18) → Follicular Lymphoma
t (8,14) → Burkitt’s Lymphoma t (9,22) → Known as Philadelphia Chromosome (BCR-ABL) gene fusion → good
prognosis in CML patients and bad prognosis in ALL patients t (15,17) → Acute promyelogenous Leukemia (M3) → good prognosis → Treatment is with All-Trans Retinoic Acid (ATRA) t (11,14) →Mantle cell Lymphoma → highly aggressive form of Non-Hodgkin’s Lymphoma → cyclin D1 oncogene is overexpressed → treat with R-CHOP
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Pearl # 5: Testicular cancer is broken down into seminomas and non-seminomas
Seminomas are Radiation sensitive and usually have a normal AFP and HCG level
(although HCG can be elevated in 5-10% of cases) Non-Seminomas (e.g., yolk sac tumor, embryonal carcinoma, teratoma, choriocarcinoma) are radiation resistant and usually have elevated AFP and HCG level
Pearl # 6: High-yield facts about Colon Cancer for the ABIM and IM Shelf Exam
If cancer invades mucosa or sub-mucosa → colon resection is required
If cancer invades muscularis propria, serosa, or has LN involvement →colon resection is required +chemotherapy (usually FOLFOX) +/- Irinotecan. FOLFOX is 5 Flurouracil, Oxaliplatin, and Leucovorin Most common area of metastasis for colon cancer is the liver
If solitary liver lesion →resection of liver can be performed If multiple liver lesions → poor prognosis and survival rate is low
Pearl # 7: Must know Oncological Emergencies
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Superior Vena Cava Syndrome → caused by obstruction to the superior vena cava leading to: o Neck and facial swelling o Dyspnea o Cough o Physical examination will show distended jugular veins o Chest x-ray may reveal mediastinal widening or right hilar mas o Most common cause is lung cancer (particularly small cell lung cancer). Malignant lymphoma is also a well-known cause of superior vena cava syndrome o Management obviously requires treatment of the underlying malignancy but symptomatic measures such as diuretics and elevation of the bed usually suffice
Spinal cord compression o Most common cancers that cause spinal cord compression are: lung cancer, breast cancer, prostate cancer, multiple myeloma, and lymphoma o Back pain is the most commonly presenting symptom. Other concerning symptoms include muscle weakness, numbness/tingling, cauda equina syndrome, and loss of bowel or bladder control o Diagnosis is required promptly to prevent further neurological deterioration and an MRI of the entire spine should be ordered o Management for spinal cord compression is with Dexamethasone 10 mg IV X 1 dose, followed by Dexamethasone 4 mg IV every 6 hours o Radiation therapy can help in shrinking the tumor; however, recent studies indicate that surgical decompression is superior to RT. Therefore, an immediate neurosurgical consultation is required when this condition is suspected or diagnosed Tumor Lysis Syndrome o Intracellular contents leak out into the bloodstream o Although this condition can occur with any malignancy, it is more common in aggressive lymphomas and hematological malignancies o Hyperkalemia, Hyperuricemia, Hyperphosphatemia, Acute renal failure, and Hypocalcemia are often seen in patients with tumor lysis syndrome
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o Management of tumor lysis syndrome requires electrolyte abnormality correction, aggressive hydration, and allopurinol Once again, the folks who write the Internal Medicine licensing exams donâ&#x20AC;&#x2122;t expect you to have the depth of knowledge regarding the plethora of cancer diagnoses that an oncologist possesses. However, topics such as the ones mentioned in the pearls above should assist you with the oncology section of the med school clerkship shelf and ABIM board exams.
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5 Neurology Pearls By: Dr. Sunir Kumar 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. Pearl # 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 for the most high-yield conditions associated with hyperreflexia, normal reflexes, hyporeflexia, and delayed reflexes and absent reflexes.
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Pearl # 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 hemianopiacommon 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.
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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. Pearl # 3: Know the indications and contraindications of use of t-PA. Indications: o Ischemic stroke as seen on CT head with CLEARLY defined onset of symptoms o Time of onset of symptoms to administration of t-PA should be no later than 3 hours (180 minutes)
Major Contraindications: o Blood pressure greater than or equal to 185/110mmHg o CT head indicates a hemorrhagic stroke rather than an ischemic stroke o Major trauma to the head within the past 3 months o Major surgery within the past 14 days o Current use of anticoagulants as administering t-PA with anticoagulants increases risk of major bleeds o Platelet count of less than 100,000/uL o PT>15 seconds o Glucose 400 mg/dl
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Pearl # 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 DiseaseBrain atrophy with or without periventricular white matter lesions 54 | P a g e
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Pearl # 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”)
Let’s review it in Knowmedge slide form:
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Once again, the folks who write the Internal Medicine med school clerkship shelf and ABIM board exams donâ&#x20AC;&#x2122;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.
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Quick and Easy Guide to Selecting the Right Topical Steroid By: Dr. Sheila Krishna Several of the most frequently utilized dermatologic treatments—especially for conditions that arise in primary care and thus may be found on the dermatology portion of the Internal Medicine board and medical school shelf exams—belong to the topical corticosteroid category. As there are dozens of options of various strengths, preparation, and container sizes (along with the consideration of whether patients prefer generic vs. brand, over-the-counter vs. prescription), it can be extremely overwhelming to select the “correct” topical corticosteroid. Fortunately, in most instances, there is more than one reasonable treatment option that will provide the patient with the relief they need. Let’s begin by reviewing 5 Dermatologic pearls that will be helpful in your clinical practice and may also help you select a couple more correct answers on the ABIM board exam. Pearl # 1: Know the different strengths of the topical corticosteroids. There are a total of 7 different classes of topical corticosteroids, with class 1 representing the highest potency and class 7 representing the lowest potency. It’s critical to be able to recognize the medication’s potency because we need to find the best match for the patient’s condition—strong enough to treat the disease but gentle enough to avoid unnecessary side effects. In Knowmedge fashion, here’s a slide that gives the most commonly used topical corticosteroids with their class number and relative potency.
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Class 1 and 2 topical corticosteroids should never be prescribed on the face of body folds or groin as these areas have more fragile skin that can be damaged by the skin-thinning potential of these stronger topical agents.
Pearl # 2: When pressed for time, consider these selections.
For treating non-folded trunk and extremities, Triamcinolone 0.1% is a good option. For treating the face and body folds (e.g. axilla, groin, inframammary areas, panniculus), Desonide or Hydrocortisone can be used. For the palms and soles, Fluocinolone or Clobetasol may be tried.
Pearl # 3: Select the correct preparation
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Once you think you have the right medication selected, you may pause when asked by your electronic prescription-ordering system or your local pharmacist which preparation you are ordering: cream, ointment, or lotion. Make sure that the patient has been consulted about their preferred preparation since they may not be adherent with the treatment plan if they find it makes them feel uncomfortable.
From a cosmetic acceptance standpoint, creams tend to be an acceptable option since they absorb well and lack the greasy texture of ointments. However, keep in mind that they may sting if applied to open areas of the skin and they can contain preservatives that can lead to an allergic contact dermatitis.
Ointments usually contain petrolatum, which provides more of an emollient effect to help retain water. They are less likely to sting than creams. The biggest issue is the greasy texture that some patients find uncomfortable. Lotions are more water-based than oil-based. As a result, they are easily absorbed into the skin and spread easily, making them a good choice for covering large areas of the body.
Pearl # 4: Finding the correct amount to prescribe
Unlike the straight-forward exercise of selecting the quantity of oral medicationsâ&#x20AC;&#x201D;90 days of a once daily medication equals 90 pillsâ&#x20AC;&#x201D;providing enough topical agent to last a patient until the next scheduled refill is a bit more challenging. If too little is prescribed, they will be frustrated by frequent trips to the pharmacy, not to mention the high co-pay they may be dishing out each time they visit.
A good rule of thumb to use is that 1 palm is 1% of the body when estimating the % of the skin that is affected by the patientâ&#x20AC;&#x2122;s dermatologic condition. Most topical corticosteroids come in 30 to 60 gram tubes. For a typical 70-kg patient, a 30gram tube provides one application to the entire body.
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Pearl #5: Donâ&#x20AC;&#x2122;t forget the importance of gentle skin care
Atopic dermatitis and xerosis may not resolve despite topical corticosteroids if patients continue to add agents to their skin which can increase drying. Harsh body washes and soap and laundry detergents can do a number on the skin. Tell patients to avoid those and instead apply emollients, which consist of water-supplying moisturizers (e.g. coconut oil, mineral oil) and water loss-reducing occlusives (e.g. petroleum jelly).
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8 Pulmonary Disease & Critical Care Pearls By: Dr. Sunir Kumar 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. Pearl # 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. Pearl # 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-thoracic lung disease. o
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 61 | P a g e
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o
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
Pearl # 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
Pearl # 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 conveniently depicts the criteria for intermittent, mild persistent, moderate persistent, and severe persistent asthma, along with their recommended treatments.
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Pearl # 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:
Dyspnea that is persistent, worsens over time and gets worse with exercise
Chronic cough Chronic sputum production
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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 reveals the cut-off criteria for the different stages.
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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%)
Pearl # 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
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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 Pearl # 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.
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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
Pearl # 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 shelf and ABIM board exams.
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5 Rheumatology Pearls By: Dr. Sunir Kumar 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 blue print, 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! Pearl # 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 are 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: o Progressive synovitis o Vasculitis (ulcers of fingers and toes) o Subcutaneous nodules o HLA-DR4 marker o Elevated ESR o Elevated Rheumatoid Factor o Erosive lesions on X-ray Patients with syncope 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 68 | P a g e
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Certain medications used in the management of RA are: NSAIDs, Hydroxychloroquine, Sulfasalazine, Methotrexate with Folic Acid, Leflunomide, Steroids, and anti-TNF alpha inhibitors o Hydroxychloroquine → frequent eye exams required o Methotrexate → Check CBC and Liver function tests every 6-8 weeks o Leflunomide → Contraindicated in pregnancy. Reverse with cholestyramine X 11 days o 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.
Pearl # 2: Osteoarthritis is a chronic, progressively debilitating disease that is noninflammatory 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 usually.
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.
o Non-pharmacological intervention includes weight reduction and weight resistance training. o Pharmacological intervention includes NSAIDs and narcotics. o Surgical intervention includes steroid injections or knee replacement therapy.
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Pearl # 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 antidsDNA. Anti-dsDNA 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
Pearl # 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.
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In an acute attack, checking a uric acid level has no diagnostic value.
Pearl # 5: Seronegative Spondyloarthropathies (HLA B27+ and Rh factor negative)
HLA B27 is NEVER used in the diagnosis of the seronegative spondyloarthropathies Mnemonic to remember the different seronegative spondyloarthropathies is “PEARR” o P – Psoriatic arthritis o E – Enteropathic arthritis o A – Ankylosing Spondylitis o R – Reactive arthritis o R – Reiter Syndrome → causative agent is Chlamydia. Triad of urethritis, uveitis, and arthritis (Can’t pee, can’t see, can’t climb a tree)
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Bonus: How to study for and pass the ABIM board exam By: Dr. Ravi Bhatia 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 exam It may seem 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 gauge If 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.
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3. Get a study guide to prepare for the ABIM exam It’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 group Study 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 and critical 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. Follow @Knowmedge for twice daily questions and our weekly #ABIMTweetShow hour-long sessions on Sundays. 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. 73 | P a g e
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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 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. 74 | P a g e
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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 you There 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 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 strategies The 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:
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1. For clinical vignettes, read the question (last line) first and then go back and read the 2. 3. 4. 5. 6.
scenario. This way you’ll know what to look for as you are reading the scenario. Try to answer the question even before seeing the answer choices. Pay attention for keywords that can clue you in on an etiology or physical exam. Watch for key demographic information – Geography, ethnicity, gender, age, occupation. 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. 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 76 | P a g e
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for the ABIM Boards, we wish you well – we’re here to help so let us know if you have any questions! Happy studying!
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Bonus: How to study for the Internal Medicine Shelf Exam By: Dr. Ravi Bhatia 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 to study, 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, Diseases 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
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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 “musthave” 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 79 | P a g e
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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 in practice. 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.
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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 problem-based learning (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 middleaged man with chest pain after consuming a fatty meal, an 80-year-old female with a 60-packyear smoking history presenting with her third COPD exacerbation of the year. But they were easy admissions only at the superficial level 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.
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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 82 | P a g e
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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
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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 are also 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 a 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 84 | P a g e
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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 85 | P a g e
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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!
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About our Authors Sunir Kumar, MD Chief Editor Dr. Kumar is a Board Certified Internist at the Cleveland Clinic. Earlier, he practiced at UPMC in Pittsburgh, PA as a hospitalist. Dr. Kumar graduated medical school from St. Matthews University and completed his internal medicine residency at Mercy Hospital and Medical Center in Chicago, IL.
Ravi Bhatia, MD Associate Editor Dr. Bhatia is a Board Certified Internist in Fremont, CA. Dr. Bhatia graduated from the David Geffen School of Medicine at UCLA and completed his internal medicine residency at Allegheny General Hospital in Pittsburgh, PA.
Salim R. Rezaie, MD Dr. Rezaie is currently an attending on the faculty of UTHSCSA in San Antonio, TX. He completed his medical school training at Texas A&M Health Science Center, and followed that up with a combined Emergency Medicine/Internal Medicine residency at East Carolina University in Greenville, NC.
Sheila Krishna, MD Dr. Sheila Krishna is currently Chief Resident of the Department of Dermatology at the Medical College of Virginia/Virginia Commonwealth University Health System. She is interested in complex medical dermatology and general dermatology.
Ruchi Bhatia, MD Dr. Bhatia is currently in her final year of Internal Medicine residency at St. Louis University. She obtained her medical degree from Northeastern Ohio Medical University in Rootstown, Ohio. Dr. Bhatia will be pursuing a fellowship in Gastroenterology and is specifically interested in the area of Liver Disease.
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