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KNOWMEDGE AchalasiawillhaveincreasedLEStoneonmanometrystudies.GERD,ontheotherhand,will
havedecr...

KNOWMEDGEFirst,wereviewViralHepatitis,FattyLiver/Steatohepatitis,Wilsons,Alpha1AntiTrypsin
Deficiency...

KNOWMEDGEPearl#5:TheymaybothbeconsideredIBD,butknowhowtodistinguishUlcerativeColitisand
Crohns...

KNOWMEDGE ooAnkylosingspondylitis Arthritis(mirrorsUlcerativeColitis) Erythemanodosum(mirrors

Ulc...

KNOWMEDGEGastroenterologyPearls:DigestiveTractin7MajorPartsBy:Dr.RuchiBhatiaAspreviously
mentioned,...

KNOWMEDGEarisesintheupperportionoftheesophagusandadenocarcinomaarisesdistally,closertotheGE
junct...

KNOWMEDGETheprevalenceofpancreatitiscontinuestoriseintheWesternworld,andthusremainsafavoritefor
...

KNOWMEDGEIfcholedocholithiasisissuspected,broadspectrumantibioticscoveringentericgramnegativebacteria
...

KNOWMEDGE annualflexsigbeginningatage1012,andcolectomyshouldbeconsideredwhen
polyposisi...

KNOWMEDGE HepatocellularelevationinALTandASTreleasedfrominjuredhepatocytes Viralhepatitis,

al...

KNOWMEDGEGeneralInternalMedicinePearls:EyeConditionsBy:Dr.SunirKumarWhilemostoftheABIM
Examination...

KNOWMEDGEViral Usuallycausedbyadenovirus Havingaprecedingupperrespiratoryinfectionorrecent

expo...

KNOWMEDGE2.MacularDegeneration CommoninelderlyindividualsCanleadtovisualloss
Progression...

KNOWMEDGEAcuteAngleClosureGlaucoma MoreseverethanPOAG Redeye,severepain,headache,

nauseaandvo...

KNOWMEDGEGeneralInternalMedicinePearls:VaccinationsBy:Dr.SunirKumarWhilemostoftheABIM
Examinationt...

KNOWMEDGE:1.Tetanus,diphtheria,pertussis(Tdap) AdministerTdaptoalladultswhohavenotpreviously
re...

KNOWMEDGE4.Pneumococcus Alladults65yearofageandoldershouldberecommendedtohaveonetime
vaccina...

KNOWMEDGE5HematologyPearlsByDr.SalimRezaieHematologyisasubjectthatcomesupdailyinclinical
practic...

KNOWMEDGE PrimaryhemostasisDisorders:oAresultofplateletfunctionoImmediateclottingoPatientswill
h...

KNOWMEDGEoTransferrinReceptorIndex=transferrinreceptor/LogFerritinisthemostsensitiveassayforiron
d...

KNOWMEDGE5.RimonEetal.DiagnosisofIronDeficiencyAnemiaintheElderlybyTransferrinReceptor
FerritinI...

KNOWMEDGE6InfectiousDiseasePearlsByDr.SalimRezaieInkeepingwiththepopularityofthehighyield
pearls...

KNOWMEDGEPearl#3:Clostridiumdifficiletoxinshouldnotberecheckedforcureandhasapoorsensitivity
...

KNOWMEDGE Fluoroquinolones(ofloxacin,ciprofloxacin,andlevofloxacin)shouldbeconsideredalternative
ant...

KNOWMEDGE8.KimAIetal.StaphylococcusAureusBacteremia:UsingEchocardiographytoGuideLengthof
Therapy.C...

KNOWMEDGE11NephrologyPearlsByDr.SalimRezaieRecently,Ireadanarticleonsomeveryusefulchronic
kidney...

KNOWMEDGE Thepreferredquantitativetestisspoturineproteintocreatinineratio(accurate&more
conveni...

KNOWMEDGE Ifthesamepatienthasanincreaseincreatininefrom1.5to2.2(>30%increase)STOPTHEACEI
Pea...

KNOWMEDGE Ingeneral95%ofpatientshaveprimaryoressentialhypertension,andonly5%have a
se...

KNOWMEDGEReferences:1.BakrisGLetal.AngiotensinConvertingEnzymeInhibitorAssociatedElevationsin
Serum...

KNOWMEDGE7OncologyPearlsBy:Dr.SunirKumarOncologyisanessentialpartoftheInternalMedicine
MedicalCl...

KNOWMEDGEPearl#2:Whichparaneoplasticsyndromegoeswithwhichcancer?Pearl#3:Knowthesehighyield
Brea...

KNOWMEDGE Triplenegativebreastcancer(ERnegative,PRnegative,HER2/neunegative)hastheworst
prognosis...

KNOWMEDGEPearl#5:Testicularcancerisbrokendownintoseminomasandnonseminomas Seminomasare
Radiation...

KNOWMEDGE SuperiorVenaCavaSyndromecausedbyobstructiontothesuperiorvenacavaleadingto:o
Neckand...

KNOWMEDGEoManagementoftumorlysissyndromerequireselectrolyteabnormalitycorrection,aggressive
hydration,...

KNOWMEDGE5NeurologyPearlsBy:Dr.SunirKumarNeurologyisanextremelyimportantpartoftheInternal
Medicin...

KNOWMEDGEPearl#2:Werenottrainedophthalmologistsbutrememberingtheseeyeconditionscanaddpointsto
yo...

KNOWMEDGEWithMarcusGunnpupil,letssupposethelefteyeisaffected.Iflightisshinedintotherighteye,...

KNOWMEDGEPearl#4:Identifyingbuzzwordsiskeyforselectingthecorrectneurologicaldiagnosiswhen
CT/MRIfi...

KNOWMEDGEPearl#5:DifferentiatingMyastheniaGravisandEatonLambertSyndromecanseemchallengingat
first....

KNOWMEDGEOnceagain,thefolkswhowritetheInternalMedicinemedschoolclerkshipshelfandABIMboard
examsd...

KNOWMEDGEQuickandEasyGuidetoSelectingtheRightTopicalSteroidBy:Dr.SheilaKrishnaSeveralofthe
most...

KNOWMEDGEClass1and2topicalcorticosteroidsshouldneverbeprescribedonthefaceofbodyfoldsorgroinas
...

KNOWMEDGEOnceyouthinkyouhavetherightmedicationselected,youmaypausewhenaskedbyyour
electronicpres...

KNOWMEDGEPearl#5:DontforgettheimportanceofgentleskincareAtopicdermatitisandxerosismaynot
resolv...

KNOWMEDGE8PulmonaryDisease&CriticalCarePearlsBy:Dr.SunirKumarPulmonarydiseaseandcriticalcare
are...

KNOWMEDGE oSilicosis BerylliosisExtrathoracicLungDisease(FEV1/FVCnormalorincreasedabove80%,

DLCO...

KNOWMEDGEPearl#5:Similarly,masteringCOPDclassification(usingtheGOLDcriteria)andtreatmentis
essentia...

KNOWMEDGE Historyofexposuretoriskfactors(Tobaccosmoke,smokefromhomecooking,occupational
dust,ch...

KNOWMEDGEOtherindicationsforOxygentherapyinCOPDpatientsare: PaO2lessthan55mmHgor
Oxygensatur...

KNOWMEDGEHYPERSENSITIVITYPNEUMONITISIgElevelsandperipheraleosinophilsarenormal
Removeoffendingagen...

KNOWMEDGE Transudateeffusionsincludeconditionssuchas:CHF,Nephroticsyndrome,Cirrhosis,
Hypothyroid...

KNOWMEDGE5RheumatologyPearlsBy:Dr.SunirKumarRheumatologyisasubjectthatcomesupdailyin
clinicalpra...

KNOWMEDGE CertainmedicationsusedinthemanagementofRAare:NSAIDs,Hydroxychloroquine,
Sulfasalazine,Met...

KNOWMEDGEPearl#3:KnowingantibodiesandtheirassociatedconditionsareveryhighyieldfortheABIMboard
ex...

KNOWMEDGE Inanacuteattack,checkingauricacidlevelhasnodiagnosticvalue.Pearl#5:SeronegativeSpo...

KNOWMEDGEBonus:HowtostudyforandpasstheABIMboardexamBy:Dr.RaviBhatiaAstheABIMinternal
medicine...

KNOWMEDGE3.GetastudyguidetopreparefortheABIMexamItsimportanttohaveagoodstudyguidethatis
tai...

KNOWMEDGE5.GetaquestionbankthatfitsyourpersonalneedsWhatisthevalueofanInternalMedicine
question...

KNOWMEDGE HighqualityABIMexamreviewquestionscanbefoundinmanyplacesquestionbanksarenot
theonl...

KNOWMEDGE1.Forclinicalvignettes,readthequestion(lastline)firstandthengobackandreadthe2.3.4.5...

KNOWMEDGEfortheABIMBoards,wewishyouwellwereheretohelpsoletusknowifyouhaveany
questions!Ha...

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

HighYieldInternalMedicineBoardReviewPearls

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HighYieldInternalMedicineBoardReviewPearls
1.1.HIGHYIELDINTERNALMEDICINEBOARDEXAMPEARLSThisstudyguideincludes: Chapters
coveringHighYieldpearlsforallmajorcategoriesseenontheInternalMedicineBoardExam/ShelfExam Topics
coveredincludeCardiovascularDisease,Endocrinology&Metabolism,Gastroenterology,GeneralInternalMedicine,
Hematology,InfectiousDisease,Nephrology/Urology,Oncology,Neurology,Dermatology,PulmonaryDisease&
CriticalCare,Rheumatology/Orthopedicswww.knowmedge.comABIMisaregisteredtrademarkoftheAmerican
BoardofInternalMedicine,whichneithersponsorsnorisaffiliatedinanywaywiththisproduct.
2.2.KNOWMEDGEHIGHYIELDINTERNALMEDICINEBOARDEXAMPEARLSEmail:
support@knowmedge.comWebsite:www.knowmedge.comFacebook:www.facebook.com/knowmedgeTwitter:
www.twitter.com/knowmedgeYouTube:www.youtube.com/knowmedgeThecontentinthisbookmaybeupdated
periodically.Allupdates,includingknownerrorsorrevisions,areavailableat:www.knowmedge.com/forum
Copyright2013KnowmedgeALLRIGHTSRESERVED.Nopartofthisworkmaybereproducedorusedinany
formorbyanymeansgraphic,electronic,ormechanical,includingphotocopying,recording,taping,web
distributionwithoutthepriorwrittenpermissionofKnowmedgeNote:ABIMisaregisteredtrademarkofthe
AmericanBoardofInternalMedicine,whichneithersponsorsnorisaffiliatedinanywaywiththisproduct.
3.3.DearReader,ThankyoufordownloadingacopyofthiseBook.Ifyouaresearchingforstudymaterialsforthe
internalmedicineboardexam,youareonthevergeofasignificantmilestoneinyourprofessionaljourney.
KnowmedgeisaninteractiveplatformthatwaslaunchedinApril2013.Itfeaturesover900questionsdesignedto
helpyouunderstandandreinforcethekeyconceptscoveredontheexam.Eachofourquestionsfeaturesahighly
interactiveaudiovisualexplanation,inwhichourcontentexpertswalkyouthroughtheprinciplesunderlyingeach

questiontomethodicallyarriveatthecorrectanswer.ThisbookcontainshighyieldpearlsfortheInternalMedicine
BoardsABIMExamandIMShelfExamwrittenbytheteamofKnowmedgedoctors.Thereareatotalof12
differentpearlarticlespresentedinthisbookallfromtopicsthatareimportanttopasstheInternalMedicineBoards.
Wehopeyoufindthepearlsinthisbooktobeavaluableassetasyouprepareforyourupcomingexam.Ifyouare
interestedinlearningmoreaboutKnowmedge,pleasevisitusatwww.knowmedge.com.Ifyouhaveanyquestions
aboutthecontentsofthiseBook,sendmeanoteatsunir@knowmedge.comBestofluckinyourpreparations!
Sincerely,SunirSunirKumar,MDCofounder,ChiefEditorKnowmedge
4.4.TableofContents5CardiologyPearls..................................................................1By:Dr.SalimRezaie5
EndocrinologyPearls............................................................8By:Dr.SunirKumar5GastroenterologyPearls
......................................................12ByDr.SunirKumarGastroenterologyPearls:DigestiveTractin7MajorParts
.....19By:Dr.RuchiBhatiaGeneralInternalMedicinePearls:EyeConditions.................25By:Dr.SunirKumar
GeneralInternalMedicinePearls:Vaccinations.....................29By:Dr.SunirKumar5HematologyPearls
..............................................................32ByDr.SalimRezaie6InfectiousDiseasePearls
....................................................36ByDr.SalimRezaie11NephrologyPearls.............................................................
40ByDr.SalimRezaie7OncologyPearls..................................................................45By:Dr.SunirKumar
5.5.5NeurologyPearls.................................................................51By:Dr.SunirKumarQuickandEasyGuideto
SelectingtheRightTopicalSteroid57By:Dr.SheilaKrishna8PulmonaryDisease&CriticalCarePearls
..........................61By:Dr.SunirKumar5RheumatologyPearls..........................................................68By:Dr.
SunirKumarBonus:HowtostudyforandpasstheABIMboardexam.......72By:Dr.RaviBhatiaBonus:Howto
studyfortheInternalMedicineShelfExam....78By:Dr.RaviBhatiaAboutourAuthors
..................................................................87
6.6.KNOWMEDGE5CardiologyPearlsBy:Dr.SalimRezaieWhetherstudyingforemergencymedicine,
internalmedicine,orUSMLEboardexaminations,cardiovasculardiseasesarebyfarandawayoneofthebiggest
organsystemsofwhichquestionsgetasked.Ifyoupayattention,thefirstthreepearlsareallonphysicalexam
findingsandthelasttwopearlsareondiseaseprocesseswithhighmorbidityandmortality.Ihaveattachedareview
tableforeachpearltohelpsimplifytheconceptsandbuzzphrases.Pearl#1:Knowwhatthemaneuversarethat
increaseanddecreaseheartmurmurs.Ingeneral,youshouldknowallthedifferentmaneuvers,theireffect,andhow
theywouldaffectvalveabnormalities.Itishelpfultowalkyourselfthrougheachvalveabnormality,andtryand
explainwhymurmursareincreasedordecreased,insteadofjustmemorizingatable,whichyouwillforgetin12
weeks.Thatbeingsaid,commonmurmursthatseemtogetthemostquestionsare:HOCM,AS,MVP,andMR.
CardiacManeuversfortheInternalMedicineBoardExam1|Page
7.7.KNOWMEDGEPearl#2:Knowtheabnormalarterialpulsationsandthediseasestatewithwhichtheyare
commonlyassociated.Arterialpulsationsisanotherphysicalexamfindingthatcanbeveryhighyield.Recognizing
thebuzzphrase(arterialpulsedescription)anditsassociationtowhatdisorderitiscommonlyassociatedcanhelp
saveyoutimeonquestions,whichallowsyoumoretimeonotherquestions.Thisistooeasytonotknowtheseterms.
HeartPulsesPearl#3:Knowyournormalandabnormalheartsounds.2|Page
8.8.KNOWMEDGEHeartsoundssuchasS1andS2arealsoabigpartofthecardiovascularphysicalexamon
boards.Knowwhathappenswithinspiration/expirationaswellasotherpathologies.DontforgetaboutS3andS4.
Remember,sometimesanS3canbenormal(i.e.pregnancyandchildren).HeartSoundstoknowfortheInternal
MedicineBoardsPearl#4:Thenumberonekillerintheworldisischemicheartdisease,soknowwhatmedications
improvemorbidityandmortality.3|Page
9.9.KNOWMEDGEFirstandforemost,besuretofixmodifiablecoronaryarterydiseaseriskfactorssuchas
diabetesmellitus,hypertension,hyperlipidemia,andsmoking.Next,knowwhatmedicationsdecreasemortalityin
ischemicheartdiseaseandacutecoronarysyndrome.Alsobesuretoknowthecontraindicationsforthrombolyticsin
STEMI.CADACSTherapyTablefortheInternalMedicineBoardsPartI4|Page
10.10.KNOWMEDGECADACSTherapyTablefortheInternalMedicineBoardsPartII5|Page
11.11.KNOWMEDGEContraindicationsThrombolyticsPearl#5:CongestiveHeartFailure(CHF)iscommon,so
knowwhichmedicationsaffectmortalityCHFisacommondiseaseprocessseeninhospitalized,elderlypatientsdue
toimprovementsinrevascularizationtechniques.40%ofthesepatientsdiefromarrhythmiasandsuddencardiac
deaththereforeknowingwhatmedicationscanimprovemortalityisessential.6|Page
12.12.KNOWMEDGECHFMedications7|Page
13.13.KNOWMEDGE5EndocrinologyPearlsBy:Dr.SunirKumarEndocrinologyisanessentialpartofthe
InternalMedicineMedicalClerkshipandABIMBoardexam.AccordingtotheABIMexamblueprint,questions
testingendocrinologytopicscomprise~8%oftheexam.Approximately~510%oftheNBMEClerkshipexamis
composedofendocrinologyquestions.Pearl#1:Dontletthyroidnodulesintimidateyou.Thissystematicapproach
willhelpyouworkupathyroidnodule.8|Page
14.14.KNOWMEDGEPearl#2:Workupofhirsutismisnotasdifficultasitseems.Followthisapproachandyou
willbeabletodiagnosethecauseofhirsutism. Hirsutismiscausedbyeitherexcessivetestosteroneorexcessive

17OHsteroids(DHEAS)production.ExcessiveTestosteroneproductionisseeninovariancancerorpolycystic
ovariansyndrome(PCOS)oOvariancancer:workedupwithtransvaginalultrasoundtolookforadnexalmass.In
addition,CA125markerisusuallyelevatedinovariancancer.PCOS:Amenorrhea,insulinresistance,andLH:FSH
ratioofgreaterthanequalto3:1ExcessiveDHEASproductionisseenincongenitaladrenalhyperplasia(CAH),
Cushingsdisease,oradrenalcarcinomaCAH:Usualcauseis21betahydroxylasedeficiency,whichisusedto
convert17OHprogesteronetocortisol.Sincethisenzymeisdeficient,17OHprogesteronelevelsremainelevated.
DecreasedcortisollevelswillcauseanelevatedACTHlevelthroughanegativefeedbackmechanism.Withincreased
ACTH,hyperpigmentationwillalsooccur.Cushingsdisease:DefectinanteriorpituitarycausesincreasedACTH,
whicho increasescortisol.MRIofpituitaryisorderedtoworkupCushings.Ifsuspicionishighfor
CushingsdiseasedespitenegativeMRIofthepituitary,performinferiorpetrosalsinussampling.Adrenalcarcinoma:
Problemoccursintheadrenalgland,whichwillleadtoelevatedcortisollevels.Theelevatedcortisollevelwill
suppresstheACTHlevel.SinceACTHissuppressed,hyperpigmentationwillnotoccur.Pearl#3:Workupofan
adrenalmassandmanagementdependsonthesizeandthefunctionalstatusofthemass Manytimes,adrenal
massesarefoundincidentallyonaCTscan.Theseareknownasanadrenalincidentalomas.Rulestoremember:oIf
theadrenalmassiseithergreaterthan6cminsizeORisfunctional(regardlessofsize)surgicalinterventionis
recommended9|Page
15.15.KNOWMEDGEoooIfanadrenalmassislessthan4cmANDisnonfunctionalserialCTscansare
recommendedevery46monthstoassessthesizeoftheadrenalmasstomakesureitisnotgrowingHowto
determinefunctionalstatusofanadrenalmass?Rememberthe3layersoftheadrenalcortexandtheonelayerofthe
adrenalmedullaandknowwhatisproducedineachlayertodetermineifitisfunctioningornot.AdrenalCortex
layers(rememberbymnemonicGFRasinglomerularfiltrationrate): ZonaGlomerulosachecktoseeif
aldosterone:reninratioiselevated(usuallymorethan20:1) ZonaFasciculatacheck24hoururinecortisol
levelsandifgreaterthan100mg/dlCushingproblemshouldbesuspectedZonaReticularisCheck17OH
steroid(DHEAS)levels.Ifelevated,thislayerisfunctioning.AdrenalMedulla:CheckurineVMAorurine
metanephrinelevels.Ifeitherofthesemetabolitesareelevated,concernisforpheochromocytomaPearl#4:
Systematicapproachtoworkuphypercortisolism Firstcheck24hoururinecortisol.Ifgreaterthan100mg/dl,
thenyoueitherhaveCushingsyndrome,Cushingsdisease,orectopicproductionofACTH.Nextstepistocheckthe
ACTHlevel.IftheACTHlevelissuppressed,thentheproblemisCushingsyndromeCTorMRIofadrenalsshould
bedone.IfACTHleveliselevated,thepatienthaseitherCushingsdisease(pituitaryproblem)orectopicproduction
ofACTH(likelungcancer)TodistinguishbetweenCushingsdiseaseandectopicproductionofACTH,performa
highdose(8mg)dexamethasonesuppressiontest.oIfhighdosedexamethasonesuppressescortisol,problemis
Cushingsdisease.MRIofthepituitaryshouldbeperformed.IfMRIofthepituitaryisnegative,operforminferior
petrosalsinussampling.Ifhighdosedexamethasonesuppressiontestfailstosuppresscortisol,theproblemisectopic
productionofACTH.CheckCTscanofchesttoruleoutlungcancer.Pearl#5:Mustknowdiabetesmellitushigh
yieldfacts10|Page
16.16.KNOWMEDGE Type1DMlackofinsulinbecauseofdestructionofpancreaticbetacells
associatedwithantibodiestoglutamicaciddecarboxylaseType2DMmorecommoninobeseindividualsandcan
occurlaterinlife.Insulinresistanceoccurs.DiagnoseofDMismadewhenpatienthastwofastingglucoselevels
greaterthanorequalto126mg/dlorarandomglucoselevelgreaterthan200mg/dlespeciallyinthecontextofsigns
andsymptomslikepolyuria,polydipsia,orunintentionalweightloss.GoalHgba1Cislessthan7%.Hgba1Cisan
averageglucoseina3monthperiod.PreprandialglucosegoalinaDMpatientis90130mg/dl.2hourpostprandial
glucosegoalislessthan180mg/dl. Monofilamentfoottestingisthebestwaytopreventdiabeticfootulcers
fromoccurring.AcommonorganismthatcausesdiabeticfootulcersisStaphaureusorbetahemolyticstreptococcus.
EyeexamsinDMpatientsarerecommendedevery1to2yearsoIfeyeexamrevealshardexudatesor
microaneurysmspatienthasnonproliferativeretinopathymanagementisbytighterglucosecontroloIfeye
examrevealsneovascularizationorcottonwoolspotspatienthasproliferativeretinopathytreatwith
photocoagulationOnceagain,thefolkswhowritetheInternalMedicinelicensingexamsdontexpectyoutohavethe
depthofknowledgeregardinghormonerelatedconditions,metabolismanddiabetesthatanendocrinologistpossesses.
However,topicssuchastheonesmentionedinthepearlsaboveshouldassistyouwiththeendocrinologysectionof
themedschoolclerkshipshelfandABIMboardexams.11|Page
17.17.KNOWMEDGE5GastroenterologyPearlsByDr.SunirKumarGastroenterologyandHepatologycomprises
about9%oftheABIMInternalMedicineexam,makingitoneofthemorecriticalsubjectsontheboards.Below,we
review5HighYieldGastroenterology/HepatologyPearlsthatmayhelpyouscoreafewextrapointsonyourABIM
orInternalMedicineshelfexamination.Pearl#1:RememberingHepatitisBmarkerscanbedifficult,butisworthit
Startwiththesekeypoints:oHepatitisBsurfaceAntigen(HBsAg)activeinfectionoHepatitisBsurfaceAntibody
(HBsAb)pastinfectionorvaccinationagainsthepatitisBHepatitisBeAntigen(HBeAg)activereplicationof
thevirusAntiHepatitisBcoreIgMAntibody(AntiHBcIgM)acuteinfectionAntiHepatitisBcoreIgGAntibody
(AntiHBcIgG)chronicinfectionooo12|Page

18.18.KNOWMEDGEAsyouseeabove:AlongwiththeClearedstate,bothChronicandCarrierHepatitisB
patientswillhavepositiveHBsAgandAntiHBcIgG.Howcanthesetwoconditionsbedifferentiated?Easily.Just
lookattheLiverfunctiontests(LFTs)ooChronicIncreasedLFTsCarrierNormalLFTsWhataboutthat
HepatitisDvirus?oHepatitisDcantexistonitsown.ItrequiresHepatitisBinfectiontobepresentoAntiHBcIgM
+HepatitisDvirusacutecoinfectionandwillnotworsenhepatitisAntiHBcIgG+HepatitisDvirusacute
superinfectionandcancausefulminanthepatitiso13|Page
19.19.KNOWMEDGEPearl#2:MaincausesofdysphagiacanbebrokendownintoMechanical&Motility
ProblemsMechanicalProblems(dysphagiatosolidsfirstandliquidslater) Intermittentproblem Esophageal
ring(a.k.aSteakhouseSyndrome) Clueinhistory:Patienthasdifficultyswallowingwhilechewingfoodslikebread
orsteak.LongstandinghistoryofGERDBarrettsesophagus(squamoustocolumnarmetaplasia)orstricture
formation. Dysphagiatosolidswithsignificantweightloss Iflongstandingsmokinghistory,Squamouscell
carcinomamorelikely IflongstandinghistoryofuncontrolledGERD,AdenocarcinomamorelikelyEosinophilic
esophagitis Denseeosinophilicinfiltrateinthesquamousepithelium Mainstayoftreatmentisviscous
budesonide,fluticasone,orprotonpumpinhibitors(PPIs)MotilityProblems(dysphagiatobothsolidsandliquids
concurrently) Intermittentandassociatedwithchestpain,especiallyafterdrinkingcarbonateddrinks
DiffuseEsophagealSpasm(DES)Associatedwithconnectivetissuediseaseorheartburn SclerodermaAssociated
withcough/regurgitationwithimprovementofdysphagiawithraisinghandabovethehead Achalasia(whichcanin
thecontextofChagasDisease) Beforetreatingwithsurgicalmyotomyorpneumaticdilatation,EGDmustbedone
firsttoruleoutsecondaryachalasiafromlymphomaorcancer.14|Page
20.20.KNOWMEDGE AchalasiawillhaveincreasedLEStoneonmanometrystudies.GERD,ontheotherhand,
willhavedecreasedLEStone.Pearl#3:RememberthemaincausesofPancreatitisbythemnemonicIGET
SMASHEDPearl#4:AlcoholicsarenttheonlyfolkstodevelopcirrhosisTothelaypublic,cirrhosisistoalcohol
aslungcanceristosmoking.However,weknowthatitsnotsuchasimpleassociation.Smokersarenttheonly
patientstodeveloplungcancerandthosewhodontdrinkalcoholcanstillbecomecirrhotic.Letsreviewsomeofthe
nonalcoholrelatedcausesofliverfailurewithtwoeasytodigestslides:15|Page
21.21.KNOWMEDGEFirst,wereviewViralHepatitis,FattyLiver/Steatohepatitis,Wilsons,Alpha1AntiTrypsin
Deficiency,HemochromatosisandBuddChiarialongwithhelpfulclinicalcluesthatmayappearinthequestion
vignette:Ofcourse,wecantforgetAutoimmuneHepatitis,PrimaryBiliaryCirrhosis,andPrimarySclerosing
Cholangitis.Manymedicalstudentsandresidentsfinditconfusingtomatchupthegender,age,andserologieswith
thecorrectcondition.Whilethesearenothardandfastrules,forexampurposes,ingeneralwecanusethefollowing
colorfulschematictomakeittoughtoeverforgetagain.16|Page
22.22.KNOWMEDGEPearl#5:TheymaybothbeconsideredIBD,butknowhowtodistinguishUlcerative
ColitisandCrohnsDiseaseUlcerativeColitisoPresentswithabdominalpainandbloodydiarrheathatischronico
Problemstartsintherectumandspreadsproximally(backwashileitis)Pathologyrevealssuperficialulcerswithcrypt
abscessesSomecommonextraintestinalmanifestationsinclude: Aphthousulcers Pyodermagangrenosum
Primarysclerosingcholangitisoo17|Page
23.23.KNOWMEDGE ooAnkylosingspondylitis Arthritis(mirrorsUlcerativeColitis) Erythemanodosum
(mirrorsUlcerativeColitis)CanshowpositivepANCAonlabworkColonoscopyshouldbeperformed8yearsafter
diagnosisandthenevery12yearsafterwardsaspatientswithUChaveanincreasedriskofcoloncancer If
dysplasiaisseenoncolonoscopy,totalproctocolectomyshouldbeperformedCrohnsDiseaseoooooooRectumis
sparedwithCrohnsDisease.CrohnsDiseaseoccursmainlyintheterminalileum(Skiplesionsarecommon)
Commonpresentationisrightlowerquadrantmass,weightloss,anddiarrhea(canbebloodybutcanalsobewatery)
PathologywillshowdeepulcerswithgranulomaformationNotascommontoseeextraintestinalmanifestationswith
CrohnsDiseaseasisseeninpatientwithUCColoncancercanoccurbutismorecommoninUCpatientsCanshow
positiveASCA(antiSaccharomycesCerevisiaeantibodies)onlabworkColonoscopyshouldbeperformed8years
afterdiagnosisandthenevery12years Ifdysplasiaisseenoncolonoscopy,totalprotocolectomyshouldbe
performed18|Page
24.24.KNOWMEDGEGastroenterologyPearls:DigestiveTractin7MajorPartsBy:Dr.RuchiBhatiaAs
previouslymentioned,theGastroenterologyandHepatologysectionoftheABIMInternalMedicineexamcomprises
ofabout9%oftheentireexamthatmeansoutof240totalquestions(4sectionsof60questionseach),wecanexpect
about20questionstobegearedtowardsourliverandGItract.FortheInternalMedicineShelfExam,
Gastroenterologycomprises713%oftheexam.Overall,thedigestivesystemisfascinating(theliveritselfisthe
largestorganinthebodyandperformsover500functions!)yetquitesimple(thinkofitthiswayfoodgoesintothe
mouth,downtheesophagusandintothestomach,through26feetofsmallintestineintothecolon.Thenout.)To
simplifyfortheABIMexam,letsdividethedigestivetractinto7majorpartsanddiscussacoupleimportanttopics
ineachEsophagus,Stomach,Pancreas,BiliaryTract,SmallBowel,Colon,andLiver.1.EsophagusAfavoritetopic
ofboardsisGERDandthedevelopmentofBarrettesophagus.GERDiscausedbyadecreaseinthephysiologic
antirefluxbarriersattheGEjunction,resultingingastriccontentsbeingreleasedintotheesophagus.Surprisingly,the

majorcauseofGERDisnothypersecretionofgastriccontents,butratheraninappropriaterelaxationofthelower
esophagealsphincter.Remember:oooA4weekempirictrialofaPPIhasahighsensitivityforthediagnosisof
GERDPatientspresentingwithweightloss,dysphagia,odynophagia,orthosewhosesymptomsarerefractoryto
medicaltherapyshouldundergofurthertestingAmbulatoryesophagealpHmonitoringisthemostaccuratemeansto
confirmthediagnosisofGERDThedevelopmentofBarrettesophagusisafearedcomplicationofGERDduetothe
increasedriskforesophagealadenocarcinoma(remember,squamouscellcarcinoma19|Page
25.25.KNOWMEDGEarisesintheupperportionoftheesophagusandadenocarcinomaarisesdistally,closertothe
GEjunction).Remember:ooHistologically,Barrettesophagushasspecializedintestinalmetaplasiawithmucin
containinggobletcellsDysplasiafoundduringEGD: none>surveillanceEGDshouldberepeatedin1year,then
every5yearsifnegative lowgrade>surveillancein6monthsfor1year,thenyearlyhighgrade>surveillance
every3monthsforfocaldysplasiavs.surgicalorendoscopicmanagementformultifocaldysplasia2.StomachGiven
thelargenumberofhospitalizationsanddeathsfrompepticulcerdiseaseeveryyear,itisnotsurprisingthatthis
remainsamajortopictestedontheboards.ThemostcommoncausesareHelicobacterpyloriinfectionandNSAIDs.
Remember: H.pyloriisassociatedwiththedevelopmentofgastricadenocarcinoma aswellasMALT(mucosa
associatedlymphoidtissue)lymphomaTreatmentforH.pyloriconsistsoftripletherapyPPI,Amoxicillin,and
Clarithromycin(MetronidazoleinClarithromycinresistantareas)Ureabreathtestandfecalantigentestareboth
sensitiveforthedetectionofH.pyloriBeabletorecognizeapatientwithaperforatedpepticulcer!Lookforapatient
whoishypotensiveandtachycardicwithabsentbowelsoundsandseverereboundtendernessandguarding.Imaging
willshowfreeintraperitonealair.Statsurgicalconsultationisrequired!3.Pancreas20|Page
26.26.KNOWMEDGETheprevalenceofpancreatitiscontinuestoriseintheWesternworld,andthusremainsa
favoritefortheABIMboards.Althoughalcoholandgallstonesremainthemajorcauseofacutepancreatitis,
metabolic(hyperlipidemia,hypercalcemia),infectious(CMV,EBV,parasites),andautoimmunecausesshouldbe
considered.Remember: Diagnosisofacutepancreatitiscanbemadewithoutimaging,butcontrastenhancedCT
scanisusedifthereisconcernfornecrotizingpancreatitis Ifnecrotizingpancreatitisissuspected,prophylactic
antibioticsshouldbeusedimipenem,cephalosporins,andfluoroquinolonesERCPisusedifthereisevidenceof
gallstonepancreatitisandsuspectedbiliaryobstructionConsideradeficiencyinfatsolublevitamins(A,D,E,K)in
chronicpancreatitis LookforCA199asatumormarkerforpancreaticcancer.Betteryet,beabletorecognize
thewholetableofimportanttumormarkersdiscussedintheoncologysectionofKnowmedge.4.BiliaryTractThe
prevalenceofgallstonesishighintheUnitedStates,andthusshouldbeconsideredaspartofadifferentialfora
patientpresentingwithabdominalpain.Beabletorecognizeandknowhowtotreatacutecholecystitis,butalsoknow
whentoexpectandhowtotreatacalculouscholecystitis.Remember: Consideracalculouscholecystitisin
patientswithseriouscomorbidities,includingtrauma,burns,orprolongedstatesoffastingManagementissimilarto
thatofacutecalculouscholecystitis,butpatientswithsevereillnessmayrequirepercutaneousdrainageifunableto
toleratesurgery21|Page
27.27.KNOWMEDGEIfcholedocholithiasisissuspected,broadspectrumantibioticscoveringenteric
gramnegativebacteriashouldbestarted.Fluoroquinolonesareusuallyagoodinitialchoice.5.SmallBowelAnother
favoriteboardstopicdiarrhea.Diarrheacanofcoursebedividedmultiplewaysacutevs.chronic,secretoryvs.
osmoticvs.inflammatory,smallbowelvs.largebowel.Beabletoeasilydistinguishthetwomaintypesof
inflammatorydiarrhea,Ulcerativecolitisvs.Crohns.SincethiswasalreadydiscussedinthelastGIblog,Illjust
addresssomekeywordsforeach.Remember: UlcerativecolitisCrampypain.Mucosaandsubmucosa.
Pseudopolyps.HLAB27.Ankylosingspondylitis.Pyodermagangrenosum.Primarysclerosingcholangitis.Toxic
megacolon.Adenocarcinoma.CrohnsdiseaseColickypain.Transmural.Lymphocytes.Granulomas.Rectal
sparing.Skiplesions.Fistulas.Strictures.B12deficiency.Bothconditionsusuallypresentwithdiarrheaontheboards,
sobeabletoquicklyrecognizethesekeywordsforsomeeasypoints.Dontforget,bothoftheseconditionshavean
increasedriskofcoloncancerestimatedtobe12%peryearafter8yearsofdisease.Thussurveillancecolonoscopy
shouldbestartedinpatientswithIBDfor8yearsorlonger.6.ColonColorectalcanceristhesecondleadingcauseof
cancerdeathintheUnitedStates.AccordingtotheCDC,everyyearabout140,000Americansarediagnosedwith
colorectalcancerandover500,000diefromit.Thatbeingsaid,itshouldcomeasnosurprisethatcoloncancerisa
majorGItopicintheABIMexam.RemembertheseAutosomalDominantconditionsandtheirmanagement:
Familialadenomatouspolyposis(FAP)causedbyamutationintheAPCgene22|Page
28.28.KNOWMEDGE annualflexsigbeginningatage1012,andcolectomyshouldbeconsideredwhen
polyposisisdetectedHereditarynonpolyposiscolorectalcancer(HNPCC),orLynchsyndromecausedbya
mutationsintheMLH1andMSH2mismatchrepairgenes colonoscopyevery1to2yearsstartingatage2025
yearsor10yearsbeforetheageatdiagnosisoftheyoungestfamilymemberwithcoloncancerPeutzJeghers
syndromecausedbyagermlinemutationintheSTK11geneJuvenilepolyposissyndromecausedbyagermline
mutationoftheSMAD4gene7.LiverLastbutdefinitelynotleastofthemajorpartsofthedigestivetracttheliver.
Thisorgan,weighinginatabout3lbs,isthesecondlargestorgan(aftertheskin)andaffectsnearlyeveryphysiologic
processofthehumanbody.FortheABIMboardexam,beabletointerpretHepatitisBserologiesandhaveagood

understandingofthedifferencebetweenacuteandchronicinfection.Remember: Thegoaloftherapyinchronic
HepatitisBissuppressionofviralreplication,seroconversionofHBeAg,anddecreaseinhepaticinflammation(as
evidencedbyanimprovementinliverenzymes)OnceapatientisfoundtohaveachronicHepatitisBinfection,
surveillanceshouldbeundertakentopreventthedevelopmentofcirrhosisandHCCbyultrasoundandafetoprotein
levelevery612monthsInadditiontoviralhepatitis,severalothercausesofhepatitisneedtobeconsidered.Beable
todistinguishbetweenhepatocellularinjuryandcholestaticinjury.Remember:23|Page
29.29.KNOWMEDGE HepatocellularelevationinALTandASTreleasedfrominjuredhepatocytes Viral
hepatitis,alcoholichepatitis,druginducedhepatitis,NASH,ischemichepatitis,autoimmunehepatitis(lookfor
ASMA!),hemochromatosis,Wilsondisease,a1antitrypsindeficiencyCholestaticelevationinalkalinephosphatase
occursduetoadecreaseintheflowofbile Primarybiliarycirrhosis(lookforantimitochondrialantibodies!),
primarysclerosingcholangitis,druginducedcholestasisThesearejustafewkeypointstohelpyoudigestthe
GastroenterologyandHepatologysectionoftheABIMInternalMedicineexam.Goodluck!24|Page
30.30.KNOWMEDGEGeneralInternalMedicinePearls:EyeConditionsBy:Dr.SunirKumarWhilemostofthe
ABIMExaminationtopicsfallneatlyintoorgansystemcategories,notallofthemfitintothisschematic.These
include:ophthalmology,primarycarescreeningguidelines,vaccinations,etc.HereatKnowmedge,weve
incorporatedthisimportantgroupofsubjectareasintoGeneralInternalMedicine,similartotheAmericanCollegeof
PhysiciansInternalMedicineInTrainingExamBlueprint.Inthisfirstofaseriesofblogposts,wereviewthekey
eyediseases:Conjunctivitis,MacularDegeneration,Glaucoma,RetinalDetachment,andCataracts.Theeyesmaysee
onlywhatthemindknows,butyourmindshouldknowtheseeyeconditionsfortheABIMexam.1.Conjunctivitis
Conjunctivitisisbrokendownintoviral,bacterial,andallergicconjunctivitis.25|Page
31.31.KNOWMEDGEViral Usuallycausedbyadenovirus Havingaprecedingupperrespiratoryinfectionor
recentexposuretoapersonwithconjunctivitisarecluestoaidinthediagnosisAcuteonsetUsuallyunilateralredness
WaterydischargeispresentHighlycontagiousFrequenthandwashingmustbeperformedtopreventspreadof
infection Supportivetreatmentincludingcoldcompressesandartificialtears.NOroleforantibioticeye
dropswithviralconjunctivitisBacterial CommoncausingagentsareStaphaureus,Streptococcuspneumoniae,or
Haemophilusinfluenzae.PeoplewhowearcontactlensescanbeinfectedbyPseudomonasaeruginosaPresenceof
mucopurulentdischargeandcrustingcanoccurinthemorningwhenthe dischargeisdryUsuallyleadsto
rednessofunilateraleyebutmayhavebilateralinvolvementifspreadoccursbyrubbingbotheyesShouldbetreated
withantibiotics(e.g.erythromycinointmentand/orpolymyxintrimethoprimdrops)for57daysPatientswhowear
contactlensesshouldnotwearcontactlensesforatleast7daysIfpatienthasbacterialconjunctivitisfor4weeks,this
ischronicinnatureandshouldbeevaluatedbyanophthalmologistAllergic Canmimicviralconjunctivitisinterms
ofhavingclear(orropy)dischargebut predominantsymptomiseyeitchingthatcorrespondstospecificseasons
Treatmentiswithoralantihistamines,topicalantihistamines,andartificialtears26|Page
32.32.KNOWMEDGE2.MacularDegeneration CommoninelderlyindividualsCanleadtovisual
lossProgressionofdiseasecanleadtodifficultyreading,driving,orperformingactivitiesofdailylivingTwosub
typesofmaculardegenerationaredry(atrophic)andwet(neovascular).Mostcasesaredrymaculardegeneration.If,
however,patienthaswetmaculardegeneration,itismoreseriousandcanleadtoblindnessinanacutefashionrather
thanprogressivefashion.Biggestriskfactorsareage,familyhistory,cardiovasculardisease,andsmokingQuitting
smokingreducestheriskofdevelopingmaculardegenerationandsomestudiessuggestthatdiethighinantioxidants
canbeprotective.Patientscanalsobenefitbyusingamagnifyingglass.3.GlaucomaGlaucomaisacondition
resultingfromincreasedintraocularpressureduetoblockageindrainageofaqueoushumor.Itcanbebrokendown
intoprimaryopenangleglaucoma(POAG)andacuteangleclosureglaucoma.POAG Mostcommon
formofglaucomaandmostcommoncauseofirreversibleblindnessintheworldPainlesslossofperipheralvisionthat
isgradualinnature.Lateron,itcanaffectcentralvisionOpticcup:discratio>0.5Riskfactorsincludeagegreater
than40,AfricanAmericanrace,andpositivefamilyhistoryMainstayoftreatmentiswithpharmacologicaleyeagents
suchasbetablockers,carbonicanhydraseinhibitors,adrenergicagonists,hyperosmoticagents,andprostaglandin
analogues27|Page
33.33.KNOWMEDGEAcuteAngleClosureGlaucoma MoreseverethanPOAG Redeye,severepain,
headache,nauseaandvomitingandvisualhalosIntraocularpressurecanbeashighas50mmHgWhensuspected,
immediatereferraltoanophthalmologistisrequiredtopreventpermanentopticnerveatrophy 4.Retinal
Detachment Patientsmaypresentwithfloaters,squigglylines,orflashesoflight Thisisanophthalmology
emergencyandrequiresimmediateattentionbyanophthalmologist5.Cataracts Opacityoflenswilloccur
Symptomsincludepainlessdecreasedvisualacuity,decreasednightvision,glare,andsometimesdoublevision
PhysicalexaminationcanrevealadecreasedorabsentredreflexTreatmentissurgicalremovalofthecataractOnce
again,thefolkswhowritetheInternalMedicinelicensingexamsdontexpectyoutohavethedepthofknowledge
regardingtheplethoraofeyediagnosesthatanophthalmologistpossesses.However,topicssuchastheones
mentionedinthepearlsaboveshouldassistyouwiththeGeneralInternalMedicinesectionofthemedschool
clerkshipshelf,ACPintrainingandABIMboardexams.28|Page

34.34.KNOWMEDGEGeneralInternalMedicinePearls:VaccinationsBy:Dr.SunirKumarWhilemostofthe
ABIMExaminationtopicsfallneatlyintoorgansystemcategories,notallofthemfitintothisschematic.These
include:primarycarescreeningguidelines,substanceabuse,vaccinations,etc.HereatKnowmedge,weve
incorporatedthisimportantgroupofsubjectareasintoGeneralInternalMedicine,similartotheAmericanCollegeof
PhysiciansInternalMedicineInTrainingExamBlueprint.Earlierthisweek,wereviewedthe5keyeyediseasesseen
ontheABIMboardandNBMEshelfexams.Todayweexplorethehighyieldtopicofvaccinations.Acomprehensive
adultimmunizationschedule,byVaccineandAgeGroup,canbefoundontheCentersforDiseaseControland
Preventionwebsite(unlikeotherpreventivehealthmeasures,vaccinationguidelinesarenotreleasedbytheUSPSTF).
Fortunately,youdontneedtomemorizetheentireCDCchart.Instead,fortheACPInternalMedicineintraining
exam,ABIMboardsandNBMEshelfexam,focusonthese7vaccinations.29|Page
35.35.KNOWMEDGE:1.Tetanus,diphtheria,pertussis(Tdap) AdministerTdaptoalladultswhohavenot
previouslyreceivedTdaporwhose vaccinationstatusisunknown.BoostwithTdevery10yrs.2.Influenza All
individualsage6monthsandoldershouldbevaccinatedyearlysincethetargetedinfluenzastrainschangesona
yearlybasis.3.Herpeszoster(Shingles)Adults60yearsofageandoldershouldreceiveasingledoseofthezoster
vaccine.Thisisregardlessofwhetherthepatienthashadapriorepisodeofherpeszoster.2.Thevaccineisapproved
bytheFoodandDrugAdministration(FDA)forpatients50yearsofageandolder,atthispoint,theCDC
recommendsthevaccinationbeginningatage60yearssostickwiththisguideline.3.Patientswithsevere
immunodeficiencyshouldnotreceivethezostervaccine.1.30|Page
36.36.KNOWMEDGE4.Pneumococcus Alladults65yearofageandoldershouldberecommendedtohave
onetimevaccinationagainstPneumococcus.Pneumococcalvaccineshouldalsobegiventoyoungerindividualswho
arecurrentsmokers,nursinghomeresidents,orhaveasthma/COPD,diabetesmellitus,chronicrenalfailure,chronic
liverdisease,chroniccardiovasculardisease,cochlearimplants,anatomicasplenia,oralcoholism.5.HepatitisA
CandidatesforimmunizationagainsthepatitisAvirusinclude: Travelerstoendemicareas IllicitdrugusersMen
whohavesexwithmenPatientswithchronicliverdiseaseAnypatientseekingprotectionfromHAV 6.
MeningococcusOnlycertainpopulationsshouldbevaccinatedagainstmeningococcus: Collegestudentsliving
indormitoriesPatientswithHIVAsplenia7.HumanPapillomavirus(HPV)Bothmalesandfemalesages1126are
recommendedtoundergothefullseriesoftheHPVvaccination.Thevaccineisnotrecommendedforuseinpregnant
women.Source:http://annals.org/article.aspx?articleid=156722931|Page
37.37.KNOWMEDGE5HematologyPearlsByDr.SalimRezaieHematologyisasubjectthatcomesupdailyin
clinicalpractice,andisafavoriteontheABIMInternalMedicineboardexam.Evaluationofanemia,aswellassome
otherhematologicdisorders,isparamountforaninternisttomaster.Iwilltryandprovidefiveevidencebasedpearls
inthispostthatwillhelpphysiciansunderstandsomeimportantconceptsandavoidcommonpitfallsinthe
recognitionandtreatmentofsuchhematologicaldisorders.Pearl#1:PatientsonironsupplementationSHOULDNOT
havepositiveguaiactests. Studiesinvitroshowferriciron(Fe3+)willgiveapositiveguaiacreactionandferrous
iron(Fe2+)doesnot Ironisdigestedintheferrousformandcarriedinthebloodintheferricform Patientson
ironsupplementationwithpositiveguaiacrequirescreeningforidentifyingthesourceofgastrointestinalhemorrhage
Ferrous(Fe2+)irondoesnotcausepositiveguaiactestsinvivoPearl#2:ThepentadofThrombotic
ThrombocytopenicPurpura(TTP)isnotalwayspresent. Thepentadis:microangiopathichemolyticanemia
(MAHA),thrombocytopenia,renalabnormalities,neurologicabnormalities,andfever Lessthan50%ofpatients
havethecompletepentad MeasurementofADAMTS13activityisnotrequiredtomakethediagnosisthediagnosis
isclinical Thegoldstandardtreatmentisplasmaexchangeandifnotavailableyoumayusefreshfrozenplasmaas
analternativetreatmentPearl#3:Primaryhemostasisdisordersareaplateletdysfunctionandsecondaryhemostasis
disordersareaclottingfactordisorder.32|Page
38.38.KNOWMEDGE PrimaryhemostasisDisorders:oAresultofplateletfunctionoImmediateclottingo
PatientswillhavepetechiaeandpurpuraoAllwillhaveelevatedbleedingtime(plateletsdontwork)andnormal
PT/PTT(noproblemwithclottingfactors) SecondaryhemostasisDisorders:oAresultofclottingfactorsoDelayed
clotting(helpstrengthenclotsbyfibrinformation)oPatientswillhavehematomasandhemarthrosesoAllwillhave
normalbleedingtime(plateletsworkfine)andabnormalPT(extrinsicpathway)andPTT(intrinsicpathway)Pearl#4:
Acutemyelogenousleukemia(AML)typeM3hasagoodprognosis. AMListhemostcommontypeofacute
leukemiainadults TypicallyM2M5typesaremyeloperoxidasestainpositive(RememberthatPTUand
micropolyangitiscanalsobepositive) AuerrodsarepathognomonicforAML TypeM3(promyelocytic)
leukemiahast(15,17) Thetreatmentofchoiceisalltransretinoicacid(ATRA) Thesinglemostimportant
prognosticfactorinAMLiscytogentetics:t(1517)hasa70%5yearsurvivaland33%relapseratePearl#5:Anemia
isthemostcommonhematologicabnormality,soknowitcold. Irondeficiencyanemiaistheworldsmostcommon
causeofanemia Irondeficiencyanemia:oLowiron,transferrinsaturation,andferritinoElevatedTIBC33|Page
39.39.KNOWMEDGEoTransferrinReceptorIndex=transferrinreceptor/LogFerritinisthemostsensitiveassay
forirondeficiencyanemia(>2.0=IronDeficiencyAnemia<1.0=AnemiaofChronicDisease)oTreatmentisPO
ironifnoimprovementafter6weeksconsiderIVironoTheearliestlabtocheckafterstartingironreplacementis

thereticulocytecount(Beginstoincreaseatabout5to7days)oAscorbicacid(vitaminC)supplementationincreases
absorptionofironoMostironisabsorbedintheduodenumoCeliacspruecancauseirondeficiencyanemia:Besttest
istissuetransglutaminaseantibodyorantiendomysialantibodyTxisaglutenfreedietCanseedermatitis
herpetiformisassociatedwiththisentityAsIhavestatedinmyhighyieldpearlstopasstheboards:Mostcommons
areemphasizedontheABIMcurriculum,soitisgoodtoknowthesediseaseprocesses.Also,diseasesthatare
increasinginincidenceorhaveahighmortalityassociatedwiththemarealsohighyield.Anemia(mostcommon
hematologicabnormality),AML(mostcommonacuteleukemiainadults),andThromboticThrombocytopenic
Purpura(highmortality)are3ofthehematologypearlscoveredinthispost.Bestofluckasyouarepreparingforyour
ABIMboardexam,andhopefullythesepearlshelpyougetafewmorequestionscorrect.References:1.GeorgeJN.
HowITreatPatientsWithThromboticThrombocytopenicPurpura:2010.Blood2010Nov116(20):40609.
PMID:206861172.GrimwaldeDetal.TheImportanceofDiagnosticCytogeneticsonOutcomeinAML:Analysisof
1,612patientsenteredintotheMRCAML10Trial.TheMedicalResearchCouncilAdultandChildrensLeukemia
WorkingParties.Blood1998Oct92(7):232233.PMID:97467703.KonradGetal.AreMedicationRestrictions
BeforeFOBTNecessary?:PracticalAdviceBasedonaSystematicReviewoftheLiterature.CanFamPhysician2012
Sep58(9):93948.PMID:229727224.McDonnellWMetal.EffectofIronontheGuaiacReaction.
Gastroenterology.1989Jan96(1):748.PMID:290944034|Page
40.40.KNOWMEDGE5.RimonEetal.DiagnosisofIronDeficiencyAnemiaintheElderlybyTransferrin
ReceptorFerritinIndex.ArchInternMed2002Feb162(4):4459.PMID:1186347835|Page
41.41.KNOWMEDGE6InfectiousDiseasePearlsByDr.SalimRezaieInkeepingwiththepopularityofthehigh
yieldpearlspostsfromnephrology,Idecidedtowriteapostgivingyoumy5highyieldinfectiousdisease(ID)pearls,
beneficialforyourclinicalpracticeandABIMexampreparation.Thepurposeofthesepostsistogiveyousome
concise,practicalteachingpointsthataresupportedbythemedicalliterature.Pearl#1:Staphylococcusaureus
bacteremiacanbemorecomplicatedthangetting2weeksofintravenousantibiotics Patientstreatedfor
atleast2weeksofantibioticsaremorelikelytobecuredofbacteremiaandlesslikelytohaverecurrenceof
bacteremia3Recurrenceofbacteremiamaybeduetobone,joint,andcardiacinvolvementduetoinadequateinitial
antimicrobialcourse3Patientswithcardiac,bone,andjointinvolvementneedatleast46weeksofantimicrobial
coverageRemoveintravascularcathetersifpatienthasStaphylococcusaureusbacteremia(2026%ofcasesare
complicatedbyinfectiveendocarditisormetastaticinfection)8PatientswithhematuriaduringStaphylococcusaureus
bacteremiashouldhavefurtherevaluationforinfectiveendocarditis8Orallinezolidcanbeusedtocompletea2week
courseinsomecases12Pearl#2:Candidainthebloodisnotacontaminant,butcouldbeinthesputumorurine
CandidainthebloodisNEVERacontaminant11Removalofanintravenouscatheteraloneisneveranabsolute
treatmenthighestmortalityratesareseeninpatientswithoutantifungaltherapy9 Allpatientswithcandidemia
shouldundergoophthalmologicexamination10Micafunginisthetreatmentofchoiceforcandidemia,andpreferred
overazoles8Asymptomaticcandiduriadoesnotrequirefurtherworkupsorantifungaltherapyinmostcases
Symptomaticfunguriaalwaysrequirestreatment636|Page
42.42.KNOWMEDGEPearl#3:Clostridiumdifficiletoxinshouldnotberecheckedforcureandhasapoor
sensitivity Clostridiumdifficileassociateddiarrhea(CDAD)shouldbesuspectedafterrecentantibiotic
useand/orifinthehospitalformorethan2daysConsiderinfectionwithC.difficileinthedifferentialdiagnosiswhen
aleukocytosisinhospitalizedpatientsdevelopsDiarrheadoesnothavetobepresenttohaveadiagnosisofC.difficile
colitisC.Diffstoolassayproducesafalsenegativetest1020%ofthetime2C.Diffstooltoxinassaysremain
positiveduringandaftersuccessfultreatment,thereforefollowupassaysforcurearenothelpful,followclinical
course7Pearl#4:Bloodculturesshouldalwaysbeobtainedbeforeparenteralantibioticsaregiven Boththe
InfectiousDiseaseSocietyofAmerica(IDSA)andAmericanThoracicSociety (ATS)advocateobtainingtwosets
ofbloodculturespriortoinitiatingantibiotictherapyCoagulasenegativestaphylococciisacontaminantinblood
culturesabout82%ofthetime11 Thedifferencebetweenbloodculturesbeforetheinitiationofantibioticsand
aftertheinitiationofantibioticsinidentifyingapathogenis40%versus18.7%4Appropriatebloodcultures,allows
forpromptidentificationoftheoffendingorganismswhichinfluencesdiagnosis,therapy,andprognosiswhenpositive
Pearl#5:Empiricantibioticsforacuteuncomplicatedcystitishavechanged5 Nitrofurantoin
monohydrate/macrocrystals100mgBIDfor5daysistheappropriatechoiceforempirictherapyofurinarytract
infectionTrimethoprimsulfamethoxazole160/800mgBIDfor3daysisanappropriateempiricchoiceiflocal
resistanceratesofuropathogensdonotexceed20%(expertopinion)Fosfomycintrometamol3ginasingledoseisan
appropriateempiricchoiceforurinarytractinfection,butmaybeinferiorefficacycomparedtostandardshortcourse
regimensPivmecillinam400mgBIDfor37daysisalsoanappropriateempiricantimicrobialagentwhereavailable
37|Page
43.43.KNOWMEDGE Fluoroquinolones(ofloxacin,ciprofloxacin,andlevofloxacin)shouldbeconsidered
alternativeantimicrobialsforacuteuncomplicatedcystitisAmoxicillinorampicillinshouldnotbeusedforempirical
treatmentduetoresistancetotheseagentsPearl#6:Theloadingdoseofvancomycinis2530mg/kgbasedonactual
bodyweightincriticallyillpatients BestpredictorofefficacyofvancomycinistimeabovetheantimicrobialMIC1

Therearesomanymorehighyieldpearlsforinfectiousdisease,buttheseinmyhumbleopinionarepractice
changing,costsaving,andalsoaffectpatientoutcomes.References:1.AckermanBHetal.NecessityofaLoading
DoseWhenUsingVancomycininCriticallyIllPatients.JournalofAntimicrobialChemotherapy.199229(4):460
1.PMID:16073352.BartlettJGetal.AntibioticAssociatedDiarrhea.NEJM2002346:334339.PMID:11821511
3.FowlerVGetal.OutcomeofStaphylococcusAureusBacteremiaAccordingtoComplianceWith
RecommendationsofInfectiousDiseasesSpecialists:ExperienceWith244Patients.ClinInfectDis1998Sep27(3):
47886.PMID:97701444.GraceCJetal.UsefulnessofBloodCultureforHospitalizedPatientswhoareReceiving
AntibioticTherapy.ClinInfectDis2001Jun32(11):16515.PMID:113405415.Guptaetal.International
ClinicalPracticeGuidelinesfortheTreatmentofAcuteUncomplicatedCystitisandPyelonephritisinWomen:A2010
UpdatebytheInfectiousDiseasesSocietyofAmericaandtheEuropeanSocietyforMicrobiologyandInfectious
Diseases.ClinInfectDis2011Mar52(5):e10320.PMID:212926546.HollenbachE.ToTreatorNottoTreat
CriticallyIllPatientswithCandiduria.Mycoses2008Sep.51(2)1224.PMID:187213297.KellyCPetal.
ClostridiumdifficileMoreDifficultthanEver.NEJM2008Oct359(18):193240.PMID:1897149438|Page
44.44.KNOWMEDGE8.KimAIetal.StaphylococcusAureusBacteremia:UsingEchocardiographytoGuide
LengthofTherapy.CleveClinJMed2003Jun70(6):517,5201,5256.PMID:128282239.NguyenMHetal.
TherapeuticApproachesinPatientswithCandidemia.EvaluationinaMulticenter,Prospective,ObservationalStudy.
ArchInternMed1995155(22):2429.PMID:750360110.PappasPGetal.ClinicalPracticeGuidelinesforthe
ManagementofCandidiasis:2009UpdatebytheInfectiousDiseasesSocietyofAmerica.ClinInfectDis2009Mar
48(5)50335.PMID:19191635.11.PienBCetal.TheClinicalandPrognosticImportanceofPositiveBlood
CulturesinAdults.AmJMed2010Sep123(9):81928.PMID:2080015112.SharpeJNetal.ClinicalAnd
EconomicOutcomesofOralLinezolidVersusIntravenousVancomycinintheTreatmentofMRSAcomplicated,
LowerExtremitySkinandSoftTissueInfectionscausedbyMethicillinResistantStaphylococcusAureus.AmJSurg
2005Apr189(4):4258.PMID:1582045439|Page
45.45.KNOWMEDGE11NephrologyPearlsByDr.SalimRezaieRecently,Ireadanarticleonsomeveryuseful
chronickidneydisease(CKD)pearlstohelpthosehealthcareproviderswhoarenotnephrologistscarefortheir
patientsandalsopreparefortheABIMInternalMedicineBoardexamatthesametime.ThearticlewastitledThe
Top10ThingsNephrologistsWishEveryPrimaryCarePhysicianKnewbyPaigeNMetalandbasicallystated:
earlyrecognitionofkidneydiseaseisessentialinordertobeginmeasurestopreventprogressionandcomplications
suchaskidneyfailure,cardiovasculardisease,andprematuredeath.Ihavedecidedtobreakthecontentintotwoparts
thefirsthalfwillbediscussedinthispost:Pearl#1:ANormalCreatinineLevelMayNotBeNormal Makesure
totakemusclemass,age,sex,height,andlimbamputationintoaccount ConsiderusingMDRDorCockcroftGault
equationstocalculateglomerularfiltrationrate(GFR)MDRDandCockcroftGaultequationsareimpreciseathigh
valuesforGFR(lowvaluesforserumcreatinine) Pearl#2:KnowtheMedicationsThatFalselyElevateSerum
CreatinineLevels Trimethoprimsulfamethoxazoleandcimetidinedecreasesecretionofcreatinine Both
medicationscanincreasecreatininelevelbyasmuchas0.40.5mg/dLAnincreaseincreatininelevelisatrue
decreaseinGFRonlyifthereisalsoacorrespondingincreaseinBUNPearl#3:PatientswithDecreasedGFRor
ProteinuriaNeedtobeEvaluatedfortheCause UrinedipstickdetectsconcentrationofalbumininurineUrine
concentrationcanaffectdipstickresultsthereforeaquantitativeestimationofproteinuriaisrequiredtoevaluate
dipstickproteinuria40|Page
46.46.KNOWMEDGE Thepreferredquantitativetestisspoturineproteintocreatinineratio(accurate&more
convenientthan24hrurinecollection)Aurineproteintocreatinineratio1hasahigherriskofprogressionofCKD
Pearl#4:EarlyStageCKDShouldHavePeriodicEvaluationandInterventiontoSlowProgression Tryandavoid
nephrotoxicagents(NSAIDs,aminoglycosideantibiotics,andradiocontrast) Monitorandcontrolbloodpressure
withagoalof<130/80mmHgAngiotensinconvertingenzymeinhibitors(ACEIs)andangiotensinIIreceptor
blockers(ARBs)mayslowprogressionofCKD,especiallyinpatientswithproteinuriaMonitorphosphorous,
calcium,andparathyroidhormonelevelsinallpatientswithstage3to4CKDPatientswithCKDareathigherriskof
cardiovasculareventsandshouldbeonababyaspirin,andalipidloweringagentwithgoalLDL<100mg/dL(Maybe
<70mg/dLforLDLinpatientswithCADandCKD)Considerreferralandcomanagementwithanephrologistifa
patienthasCKDprogression,activeurinesedimentand/orstage3CKDALLpatientswithStage45CKDshould
bereferredtoanephrologist Pearl#5:DONOTDiscontinueanACEIorARBBecauseofaSmallIncrease
inSerumCreatinineorPotassium BothACEIsandARBsarethedrugsofchoicetopreventprogressionof
proteinuric CKDAnincreaseof20to30%ofthecreatininelevelisacceptableJustmakesuretoconfirmthe
creatininestabilizesanddoesnotcontinuetoincrease Alsoaserumpotassiumof5.5mEq/Lisacceptableas
longasitisstableandaslongasthepatientisawareofdietaryrestrictionsSerumcreatinineandpotassiumlevels
shouldbeorderedwithinoneweekofincreaseindoseofACEIorARBIfapatienthasanincreaseincreatininefrom
1.5to1.9(<30%increase)CONTINUETHEACEI41|Page
47.47.KNOWMEDGE Ifthesamepatienthasanincreaseincreatininefrom1.5to2.2(>30%increase)STOP
THEACEIPearl#6:AnemiainPatientswithCKDShouldbeTreated,butnotOvertreated Anemiaof

ChronicDiseasecanleadtofatigue,leftventricularhypertrophy,andincreasedriskofcardiovascularevents
HemoglobintargetforCKDshouldbebetween1112g/dLNOTtoexceed13g/dLOvercorrectionofhemoglobin
canresultinhigherriskofstroke,thrombosis,andhypertensionCorrectallotherreversiblecausesofanemiaPearl#
7:PhosphateContainingBowelPrepsShouldbeUsedWithCaution Sodiumphosphatebowelpreparations
aremoreconvenientthansomeotherpreps(Easiertouse)However,somestudieshavesuggestedthattheycancause
phosphatenephropathyleadingtoAKIorworseningCKDInsteadusepolyethyleneglycolforthebowelprep(only
downsideisthevolumethathastobeconsumedDoesnotcausevolumeorelectrolyteshifts)Pearl#8:PatientsWith
SevereCKDShouldAvoidMagnesiumorAluminumContainingPreparations Theseincludeoverthecounter
agentssuchasMaaloxandMylanta Useoftheseagentscanleadtohypermagnesemia,acutealuminumtoxicity,
worseningrenalfunction,bonedisease,andneurotoxicityThepreferredquantitativetestisspoturineproteinto
creatinineratio(accurate&moreconvenientthan24hrurinecollection)Aurineproteintocreatinineratio1hasa
higherriskofprogressionofCKD Pearl#9:MostPatientsWithHypertensionShouldNOTBeScreenedfor
SecondaryHypertension,ButbeAwareofCertainClinicalClues42|Page
48.48.KNOWMEDGE Ingeneral95%ofpatientshaveprimaryoressentialhypertension,andonly5%have
asecondarycauseCluesinclude:SevereordifficulttocontrolHTN,HTNthatsuddenlydevelops,orHTN
thatisassociatedwithotherclinicalfindingsaresomecluesHypokalemia:Considerprimaryhyperaldosteronism
Headaches,palpitations,andsweats:ConsiderPheochromocytomaMoonfaciesand/orstriae:ConsiderCushing
SyndromeHistoryofsnoringinobesepatient:ConsiderObstructiveSleepApneaBruitononesideoftheabdomen:
ConsiderRenalArteryStenosis Overthecountermedications(NSAIDs,BirthControlPills,orDecongestants)
NoncompliancewithDiet(HighSodiumIntake) Pearl#10:RecurrentNephrolithiasis,NeedsaMetabolic
EvaluationtoIdentifyandTreatModifiableRiskFactors Nephrolithiasisrecurrenceovera10yearperiodfor
calciumoxalatestonesisabout50%withouttreatmentFamilyHistoryofnephrolithiasis,inflammatoryboweldisease,
frequenturinarytractinfections,orhistoryofnephrocalcinosisshouldbereferredtoanephrologistInitialworkup
shouldstartwith:diethistory,medications,serumcalcium,phosphorous,electrolytesanduricacidPearl#11:
CyclosporineandTacrolimus(CalcineurinInhibitors)HaveManyDrugDrugInteractions Anynewmedicationor
supplementthatapostkidneytransplantpatientrequests shouldbereviewedfirstbeforeprescribingSt.Johns
Wort,rifampin,phenytoin,andcarbamazepinecanalllowercyclosporinelevels Diltiazem,verapamil,and
erythromycincanincreasecyclosporinelevelsCyclosporinecaninterferewithcertainstatinssuchassimvastatin,
increasingtheriskofstatininducedrhabdomyolysis43|Page
49.49.KNOWMEDGEReferences:1.BakrisGLetal.AngiotensinConvertingEnzymeInhibitorAssociated
ElevationsinSerumCreatinine:IsthisaCauseforConcern?ArchInternMed.2000160(5):685693.PMID:
107240552.DouglasKetal.Metaanalysis:TheEffectofStatinsonAlbuminuria.AnnInternMed.2006145(2):
117124.PMID:168472943.LeveyASetal.DefinitionandClassificationofChronicKidneyDisease:APosition
StatementfromKidneyDisease:ImprovingGlobalOutcomes(KDIGO).KidneyInt.200567(6):20892100.
PMID:158822524.PaigeNMetal.TheTop10ThingsNephrologistsWishEveryPrimaryCarePhysicianKnew.
MayClinProc.2009Feb84(2):180186.PMID:1918165244|Page
50.50.KNOWMEDGE7OncologyPearlsBy:Dr.SunirKumarOncologyisanessentialpartoftheInternal
MedicineMedicalClerkshipandABIMBoardexam.AccordingtotheABIMexamblueprint,questionstesting
Oncologytopicscomprise~7%oftheexam.Initially,oncologyseemslikeaverydifficultsubjectgivenhowthe
treatmentregimensofthemanytypesofcarcinomasareeverchanging.However,realizethatInternalMedicine
examsarefocusedonthebasicsofthedifferentmalignancies.These8pearlswillgetyouofftoagoodstartfor
identifyingPearl#1:Whichcancerscorrespondtolyticbonelesions?Blastic?LyticorBlastic? Lyticbone
lesionsoMelanomaoMultipleMyelomaoRenalcellcanceroThyroidcancerBlasticbonelesionsoProstatecancer
LyticorblasticlesionoLungcanceroBreastcancer45|Page
51.51.KNOWMEDGEPearl#2:Whichparaneoplasticsyndromegoeswithwhichcancer?Pearl#3:Knowthese
highyieldBreastCancerfactsfortheABIMandIMshelfexams Ifthelesionis>1cmORthepatienthas
lymphnodeinvolvementchemotherapywillbepartofthetreatmentprotocol.Ifsentinelnodebiopsyisnegative
nofurtherlymphnodebiopsyisrequiredIfthepatientsbreastcancerisER/PR(+)andpatientispremenopausal
Tamoxifenisgivenfor5yearsIfthepatientsbreastcancerisER/PR(+)andispostmenopausalAromatase
inhibitors(eg.Anastrozole)isgivenIfthepatientsbreastcancerisHER2/neu(+)Trastuzumabisgivencan
causeCHFcheckechocardiogramtoassessleftventricularfunction46|Page
52.52.KNOWMEDGE Triplenegativebreastcancer(ERnegative,PRnegative,HER2/neunegative)hasthe
worstprognosisPearl#4:Dontletchromosomaltranslocationsoverwhelmyou t(14,18)FollicularLymphoma
t(8,14)BurkittsLymphomat(9,22)KnownasPhiladelphiaChromosome(BCRABL)genefusion
good prognosisinCMLpatientsandbadprognosisinALLpatientst(15,17)Acutepromyelogenous
Leukemia(M3)goodprognosisTreatmentiswithAllTransRetinoicAcid(ATRA)t(11,14)Mantlecell
LymphomahighlyaggressiveformofNonHodgkinsLymphomacyclinD1oncogeneisoverexpressedtreat
withRCHOP47|Page

53.53.KNOWMEDGEPearl#5:Testicularcancerisbrokendownintoseminomasandnonseminomas
SeminomasareRadiationsensitiveandusuallyhaveanormalAFPandHCGlevel (althoughHCGcanbeelevated
in510%ofcases)NonSeminomas(e.g.,yolksactumor,embryonalcarcinoma,teratoma,choriocarcinoma)are
radiationresistantandusuallyhaveelevatedAFPandHCGlevelPearl#6:HighyieldfactsaboutColonCancerfor
theABIMandIMShelfExam Ifcancerinvadesmucosaorsubmucosacolonresectionisrequired If
cancerinvadesmuscularispropria,serosa,orhasLNinvolvementcolonresectionisrequired+chemotherapy
(usuallyFOLFOX)+/Irinotecan.FOLFOXis5Flurouracil,Oxaliplatin,andLeucovorinMostcommonareaof
metastasisforcoloncanceristheliver IfsolitaryliverlesionresectionoflivercanbeperformedIfmultiple
liverlesionspoorprognosisandsurvivalrateislowPearl#7:MustknowOncologicalEmergencies48|Page
54.54.KNOWMEDGE SuperiorVenaCavaSyndromecausedbyobstructiontothesuperiorvenacavaleading
to:oNeckandfacialswellingoDyspneaoCoughoPhysicalexaminationwillshowdistendedjugularveinsoChest
xraymayrevealmediastinalwideningorrighthilarmasoMostcommoncauseislungcancer(particularlysmallcell
lungcancer).MalignantlymphomaisalsoawellknowncauseofsuperiorvenacavasyndromeoManagement
obviouslyrequirestreatmentoftheunderlyingmalignancybutsymptomaticmeasuressuchasdiureticsandelevation
ofthebedusuallysuffice SpinalcordcompressionoMostcommoncancersthatcausespinalcordcompression
are:lungcancer,breastcancer,prostatecancer,multiplemyeloma,andlymphomaoBackpainisthemostcommonly
presentingsymptom.Otherconcerningsymptomsincludemuscleweakness,numbness/tingling,caudaequina
syndrome,andlossofbowelorbladdercontroloDiagnosisisrequiredpromptlytopreventfurtherneurological
deteriorationandanMRIoftheentirespineshouldbeorderedoManagementforspinalcordcompressioniswith
Dexamethasone10mgIVX1dose,followedbyDexamethasone4mgIVevery6hoursoRadiationtherapycanhelp
inshrinkingthetumorhowever,recentstudiesindicatethatsurgicaldecompressionissuperiortoRT.Therefore,an
immediateneurosurgicalconsultationisrequiredwhenthisconditionissuspectedordiagnosedTumorLysis
SyndromeoIntracellularcontentsleakoutintothebloodstreamoAlthoughthisconditioncanoccurwithany
malignancy,itismorecommoninaggressivelymphomasandhematologicalmalignanciesoHyperkalemia,
Hyperuricemia,Hyperphosphatemia,Acuterenalfailure,andHypocalcemiaareoftenseeninpatientswithtumor
lysissyndrome49|Page
55.55.KNOWMEDGEoManagementoftumorlysissyndromerequireselectrolyteabnormalitycorrection,
aggressivehydration,andallopurinolOnceagain,thefolkswhowritetheInternalMedicinelicensingexamsdont
expectyoutohavethedepthofknowledgeregardingtheplethoraofcancerdiagnosesthatanoncologistpossesses.
However,topicssuchastheonesmentionedinthepearlsaboveshouldassistyouwiththeoncologysectionofthe
medschoolclerkshipshelfandABIMboardexams.50|Page
56.56.KNOWMEDGE5NeurologyPearlsBy:Dr.SunirKumarNeurologyisanextremelyimportantpartofthe
InternalMedicineMedicalClerkshipandABIMBoardexam.AccordingtotheABIMexamblueprint,Neurology
comprises~4%oftheexam.Pearl#1:InNeurologyquestionsonthemedicalschoolclerkshipandABIMboard
exam,nothinghelpsnarrowthediagnosisthanthereflexesmentionedinthevignetteReviewtheslidebelowforthe
mosthighyieldconditionsassociatedwithhyperreflexia,normalreflexes,hyporeflexia,anddelayedreflexesand
absentreflexes.51|Page
57.57.KNOWMEDGEPearl#2:Werenottrainedophthalmologistsbutrememberingtheseeyeconditionscanadd
pointstoyourABIMscore Opticnervelesioncanleadtocompleteblindnessintheipsilateraleye
(monocularblindnessoftheipsilateraleye)OpticchiasmlesionBitemporalhemianopia commoninpituitary
tumorsthatcompresstheopticchiasmOptictractlesioncontralateralhomonymoushemianopiaOpticradiation
lesioncontralateralhomonymousquadrantanopiaLackofanipsilateraladductiontoacontralateralgazeisa
MedialLongitudinalFasciculus(MLF)lesion.Thiscondition,whichisalsoknownasintranuclearophthalmoplegia,
isseeninpatientswhohaveMultipleSclerosis.Innormalindividuals,ifaskedtolooktheright,therighteyeshould
abductandthelefteyeshouldadduct.IfapatientwithMSisaskedtolooktotheright(forexample),he/shewillbe
abletoabducttherighteyebutfailstoadductthelefteyeLesionisLeftMLF.Sameconceptapplieswhenaskedto
looktotheleft.Normally,thelefteyewillabductandtherighteyeshouldadduct.InpatientswithMS,patientslose
theabilitytoadducttherighteyeLesionisRightMLF.ArgyllRobertsonPupileyeswillbeabletoconstrict
whenthepatientfocusesonanearobject(eg.bringingfingerstothenose).Thisisknownasaccommodation.
However,patientswithanArgyllRobertsonpupillosetheabilitytoconstricttheeyeswhenbrightlightisshinedinto
theireyes.Inanutshell,theeyescantreacttolightbutcanaccommodate.Thisconditionisoftenseeninpatients
withsyphilis.MarcusGunnPupilThisconditionisalsoknownasRelativeAfferentPupillaryDefect(RAPD).In
normalindividuals,whenaswingingflashlighttestisperformed,boththedirectandconsensualeyeshouldconstrict
tolight.52|Page
58.58.KNOWMEDGEWithMarcusGunnpupil,letssupposethelefteyeisaffected.Iflightisshinedintothe
righteye,boththedirectandconsensualwillconstrict.Whenlightisshinedintothelefteye,boththedirectand
consensualeyewillseemdilated(lackofconstriction)Showsdamagetotheipsilateralopticnerve.Pearl#3:
KnowtheindicationsandcontraindicationsofuseoftPA. Indications:oIschemicstrokeasseenonCTheadwith

CLEARLYdefinedonsetofsymptomsoTimeofonsetofsymptomstoadministrationoftPAshouldbenolaterthan
3hours(180minutes) MajorContraindications:oBloodpressuregreaterthanorequalto185/110mmHgoCThead
indicatesahemorrhagicstrokeratherthananischemicstrokeoMajortraumatotheheadwithinthepast3monthso
Majorsurgerywithinthepast14daysoCurrentuseofanticoagulantsasadministeringtPAwithanticoagulants
increasesriskofmajorbleedsoPlateletcountoflessthan100,000/uLoPT>15secondsoGlucose400mg/dl53|Pa
ge
59.59.KNOWMEDGEPearl#4:Identifyingbuzzwordsiskeyforselectingthecorrectneurologicaldiagnosis
whenCT/MRIfindingsareincludedinthevignette. MultipleSclerosisincreasedT2signalanddecreasedT1
signal.Therewillbe increasedenhancementofactivelesionswithgadolinium.Multiinfarctdementia
multiplehypodenseareaswithoutenhancement.Toxoplasmosis,brainabscess,andlymphomaRingenhancing
lesionsseenonCT scanCerebralatrophydilatedventricleswithdilatedsulciNormalpressure
hydrocephalusdilatedventricleswithoutdilatedsulci.Patientiswet,wobbly,andweird.(urinaryincontinence,
ataxia,anddementiatriadisoftenseeninthesepatients)AlzheimersDisease Brainatrophywithorwithout
periventricularwhitematterlesions54|Page
60.60.KNOWMEDGEPearl#5:DifferentiatingMyastheniaGravisandEatonLambertSyndromecanseem
challengingatfirst.ThatswhytheyreontheABIM.EverfindyourselfsecondguessingwhetheritsEatonLambert
orMyastheniaGravisthatimproveswithrepetitivemovements?And,whichoneisassociatedwiththymoma?Before
lettingyourheadspinordocartwheels,takeafewminutestolearnthedifferencebetweenthesetwoneuromuscular
disorders.Theconciseyetusefulcategorizationwillmakeitdifficulttogetthetwomixedup.Myastheniagravis
Antibodiestopostsynapticacetylcholinereceptors PtosisanddiplopiacanbepresentingsymptomsCanbe
associatedwiththymomaReflexesarenormalPowerdecreaseswithrepetition EatonLambertSyndrome
Antibodiestopresynapticacetylcholinereceptors PtosisanddiplopiaareusuallyabsentUsuallyassociatedwith
oatcellcarcinoma(smallcellcarcinoma)ofthelungReflexesaredecreased(hyporeflexia)Powerimproveswith
repetition(AsyouEAT,yougetstronger) LetsreviewitinKnowmedgeslideform:55|Page
61.61.KNOWMEDGEOnceagain,thefolkswhowritetheInternalMedicinemedschoolclerkshipshelfand
ABIMboardexamsdontexpectyoutohavethedepthofknowledgeregardingneurologicalconditionsthata
neurologistpossesses.However,topicssuchastheonesmentionedintheslidesandpearlsaboveshouldassistyou
withtheneurologysectionoftheseexams.56|Page
62.62.KNOWMEDGEQuickandEasyGuidetoSelectingtheRightTopicalSteroidBy:Dr.SheilaKrishnaSeveral
ofthemostfrequentlyutilizeddermatologictreatmentsespeciallyforconditionsthatariseinprimarycareandthus
maybefoundonthedermatologyportionoftheInternalMedicineboardandmedicalschoolshelfexamsbelongto
thetopicalcorticosteroidcategory.Astherearedozensofoptionsofvariousstrengths,preparation,andcontainer
sizes(alongwiththeconsiderationofwhetherpatientsprefergenericvs.brand,overthecountervs.prescription),it
canbeextremelyoverwhelmingtoselectthecorrecttopicalcorticosteroid.Fortunately,inmostinstances,thereis
morethanonereasonabletreatmentoptionthatwillprovidethepatientwiththerelieftheyneed.Letsbeginby
reviewing5Dermatologicpearlsthatwillbehelpfulinyourclinicalpracticeandmayalsohelpyouselectacouple
morecorrectanswersontheABIMboardexam.Pearl#1:Knowthedifferentstrengthsofthetopicalcorticosteroids.
Thereareatotalof7differentclassesoftopicalcorticosteroids,withclass1representingthehighestpotencyand
class7representingthelowestpotency.Itscriticaltobeabletorecognizethemedicationspotencybecauseweneed
tofindthebestmatchforthepatientsconditionstrongenoughtotreatthediseasebutgentleenoughtoavoid
unnecessarysideeffects.InKnowmedgefashion,heresaslidethatgivesthemostcommonlyusedtopical
corticosteroidswiththeirclassnumberandrelativepotency.57|Page
63.63.KNOWMEDGEClass1and2topicalcorticosteroidsshouldneverbeprescribedonthefaceofbodyfoldsor
groinastheseareashavemorefragileskinthatcanbedamagedbytheskinthinningpotentialofthesestrongertopical
agents.Pearl#2:Whenpressedfortime,considertheseselections.Fortreatingnonfoldedtrunkandextremities,
Triamcinolone0.1%isagoodoption.Fortreatingthefaceandbodyfolds(e.g.axilla,groin,inframammaryareas,
panniculus),DesonideorHydrocortisonecanbeused.Forthepalmsandsoles,FluocinoloneorClobetasolmaybe
tried.Pearl#3:Selectthecorrectpreparation58|Page
64.64.KNOWMEDGEOnceyouthinkyouhavetherightmedicationselected,youmaypausewhenaskedbyyour
electronicprescriptionorderingsystemoryourlocalpharmacistwhichpreparationyouareordering:cream,ointment,
orlotion.Makesurethatthepatienthasbeenconsultedabouttheirpreferredpreparationsincetheymaynotbe
adherentwiththetreatmentplaniftheyfinditmakesthemfeeluncomfortable.Fromacosmeticacceptance
standpoint,creamstendtobeanacceptableoptionsincetheyabsorbwellandlackthegreasytextureofointments.
However,keepinmindthattheymaystingifappliedtoopenareasoftheskinandtheycancontainpreservativesthat
canleadtoanallergiccontactdermatitis.Ointmentsusuallycontainpetrolatum,whichprovidesmoreofanemollient
effecttohelpretainwater.Theyarelesslikelytostingthancreams.Thebiggestissueisthegreasytexturethatsome
patientsfinduncomfortable.Lotionsaremorewaterbasedthanoilbased.Asaresult,theyareeasilyabsorbedinto
theskinandspreadeasily,makingthemagoodchoiceforcoveringlargeareasofthebody.Pearl#4:Findingthe

correctamounttoprescribeUnlikethestraightforwardexerciseofselectingthequantityoforalmedications90
daysofaoncedailymedicationequals90pillsprovidingenoughtopicalagenttolastapatientuntilthenext
scheduledrefillisabitmorechallenging.Iftoolittleisprescribed,theywillbefrustratedbyfrequenttripstothe
pharmacy,nottomentionthehighcopaytheymaybedishingouteachtimetheyvisit.Agoodruleofthumbtouseis
that1palmis1%ofthebodywhenestimatingthe%oftheskinthatisaffectedbythepatientsdermatologic
condition.Mosttopicalcorticosteroidscomein30to60gramtubes.Foratypical70kgpatient,a30gramtube
providesoneapplicationtotheentirebody.59|Page
65.65.KNOWMEDGEPearl#5:DontforgettheimportanceofgentleskincareAtopicdermatitisandxerosismay
notresolvedespitetopicalcorticosteroidsifpatientscontinuetoaddagentstotheirskinwhichcanincreasedrying.
Harshbodywashesandsoapandlaundrydetergentscandoanumberontheskin.Tellpatientstoavoidthoseand
insteadapplyemollients,whichconsistofwatersupplyingmoisturizers(e.g.coconutoil,mineraloil)andwaterloss
reducingocclusives(e.g.petroleumjelly).60|Page
66.66.KNOWMEDGE8PulmonaryDisease&CriticalCarePearlsBy:Dr.SunirKumarPulmonarydiseaseand
criticalcareareanextremelyimportantpartoftheInternalMedicineMedicalClerkshipandABIMBoardexam.
AccordingtotheABIMexamblueprint,questionstestingpulmonarydiseasetopicscomprises~10%oftheexam.
Thatplacesitsecondonlytocardiologys14%intermsofrelativepercentage.Pearl#1:ABGsdonotneedtostand
forAnyBodysGuessThenexttimeyouseeanarterialbloodgas(ABG)onapracticeoractualexamquestion,dont
startsearchingforthePanic(orSkip)button.DeterminingdiagnosesbasedonABGscanseemdauntingatfirst
butbyfollowingasimpleyetsystematicapproach,wecantacklethesequestionswithoutdifficulty.Clickonthelink
toourpreviousHowtoHandleABGsontheABIMBoardExamandafterreviewingthe5easysteps,itwontbe
longbeforeyoulookforwardtoABGquestionsontheexam.Pearl#2:ObstructiveorRestrictive?Thatisthe
questionsurroundingLungDiseaseTodistinguishbetweenobstructiveandrestrictivelungdisease,thefirstvalueto
lookatonthepulmonaryfunctiontest(PFT)reportistheTotalLungCapacity(TLC),whichisdefinedasthevolume
ofaircontainedinthelungsattheendofamaximalinspiration. ObstructiveLungDisease:TLCwillbeincreased
(example:asthmaandCOPD) RestrictiveLungDisease:TLCwillbedecreased.RestrictiveLungDiseaseisfurther
subdividedintointrathoracicandextrathoraciclungdisease.oIntrathoraciclungDisease(FEV1/FVCnormalor
increasedabove80%,DLCOdecreased,ResidualVolumedecreased) Sarcoidosis Idiopathic
PulmonaryFibrosisHypersensitivityPneumonitisPneumoconiosisABPAChurgStraussSyndromeAsbestosis61|P
age
67.67.KNOWMEDGE oSilicosis BerylliosisExtrathoracicLungDisease(FEV1/FVCnormalorincreased
above80%,DLCOnormal,ResidualVolumeincreased) Obesity Kyphosis MyastheniaGravis Guillain
BarreSyndrome MusculardystrophyPearl#3:TheMnemonicCHADPARShelpsrecallthemajorcausesof
bronchiectasis. CCYSTICFIBROSISHHYPOGAMMAGLOBULINEMIAAALPHA1
ANTITRYPSINDEFICIENCYDDYSKINETICCILIARYSYNDROMEPPNEUMONIAAALLERGIC
BRONCHOPULMONARYASPERGILLOSIS(ABPA)RRHEUMATOIDARTHRITISSSJOGRENS
SYNDROMEPearl#4:NotallthatwheezesisasthmabutitsureisimportantfortheABIMboardsandmedicine
shelfexamFrequencyofasthmasymptomsprovidesthenecessaryinformationforproperclassificationofthis
reversibleobstructivelungdisease(definedbygreaterthanorequalto12%increaseintheFEV1afteruseofan
albuterolinhaler).Onlythencanwedeterminethebesttreatmentfortheaffectedpatientinanexamvignette.This
slideconvenientlydepictsthecriteriaforintermittent,mildpersistent,moderatepersistent,andseverepersistent
asthma,alongwiththeirrecommendedtreatments.62|Page
68.68.KNOWMEDGEPearl#5:Similarly,masteringCOPDclassification(usingtheGOLDcriteria)andtreatment
isessentialUnlikeasthma,COPDisanirreversiblecondition.Administeringthebronchodilatoralbuterolwillnot
increaseFEV1.GOLD(GlobalInitiativeforChronicObstructiveLungDisease)criteriaistheprimarymethodused
todiagnoseandidentifytheseverityofCOPD.AdiagnosisofCOPDshouldbeconsideredforanypatientoverthe
ageof40whohasanyofthefollowingconditions: Dyspneathatispersistent,worsensovertimeandgetsworse
withexercise ChroniccoughChronicsputumproduction 63|Page
69.69.KNOWMEDGE Historyofexposuretoriskfactors(Tobaccosmoke,smokefromhomecooking,
occupationaldust,chemicals)FamilyhistoryofCOPDFEV1/FVCratiolessthan70%isanindicationthatthereisan
airflowlimitationand,thus,COPD.ThespirometriccriteriaforadiagnosisofCOPDisapostbronchodilator
FEV1/FVCratiolessthan70%.FEV1willtellustheintensityoftheCOPDwhichcanbecharacterizedintofour
stages: StageI(Mild):FEV1>80%ofpredictedvalueRx:ShortactingBronchodilatorasneededwithor
withoutIpratropiumStageII(Moderate):50%FEV1<80%ofpredictedvalueRx:ShortactingBronchodilatoras
neededwithlongactingbronchodilatoraroundtheclockwithorwithoutpulmonaryrehabStageIII(Severe):30%
FEV1<50%ofpredictedvalueRx:AsaboveformoderateCOPDplusInhaledsteroidsStageIV(Verysevere):
FEV1<30%ofpredictedvalue(orFEV1<50%ofpredictedvaluepluschronicrespiratoryfailure)Rx:Asabove
forsevereCOPDplusLongtermoxygentherapyforatleast15hoursdaily.Surgicalinterventionshouldbe
considered.Theslidebelowrevealsthecutoffcriteriaforthedifferentstages.64|Page

70.70.KNOWMEDGEOtherindicationsforOxygentherapyinCOPDpatientsare: PaO2lessthan55mmHg
orOxygensaturationlessthan88%ORPaO2lessthan59mmHgorOxygensaturationgreaterthan88%with
evidenceofCorpulmonale(Rightventriculardysfunction)orsecondaryerythrocytosis(hematocritgreaterthan55%)
Pearl#6:IgEandEosinophillevelshelpusdistinguishABPA,Hypersensitivitypneumonitis,andChurgStrauss
syndromeABPAIncreasedIgElevelsandincreasedperipheraleosinophils>10%Rxwithsteroids65|Page
71.71.KNOWMEDGEHYPERSENSITIVITYPNEUMONITISIgElevelsandperipheraleosinophilsare
normalRemoveoffendingagentCHURGSTRAUSSSYNDROMEIgElevelsarenormal,peripheral
eosinophils>10%(Clue:asthmaticpatientwithincreaseperipheraleosinophilsandafootdrop)Management
withsteroidsPearl#7:LightscriteriawillguideyoutocorrectlyidentifyingPleuralEffusionsaseitherExudativeor
TransudativeBrokendownintoTransudativeandExudativeeffusion.RememberthatforTransudate,allofthe
followingneedtobemet.Ifallarenotmet,thenthepatienthasanexudativeeffusion.66|Page
72.72.KNOWMEDGE Transudateeffusionsincludeconditionssuchas:CHF,Nephroticsyndrome,Cirrhosis,
HypothyroidismExudativeeffusionsincludeconditionssuchas:Neoplasm,Infection,RA,SLE,Esophageal
perforation,Pancreatitis,andDresslerSyndromePearl#8:Bronchoalveolarlavage(BAL)findingscanhelpnarrow
down,ifnotnail,thediagnosis. IncreasedNeutrophilsthinkIdiopathicPulmonaryFibrosis
IncreasedCD8>CD4thinkHypersensitivityPneumonitisIncreasedCD4>CD8thinkSarcoidosisIncreased
EosinophilsthinkEosinophilicpneumoniaPositiveSilverMethanamineStainthinkPneumocystisJiroveciin
patientswithHIVInclusionbodiesthinkCMVpneumoniaOnceagain,thefolkswhowritetheInternalMedicine
licensingexamsdontexpectyoutohavethedepthofknowledgeregardinglungconditionsthatapulmonologist
possesses.However,topicssuchastheonesmentionedintheslidesandpearlsaboveshouldassistyouwiththe
pulmonarysectionofthemedschoolclerkshipshelfandABIMboardexams.67|Page
73.73.KNOWMEDGE5RheumatologyPearlsBy:Dr.SunirKumarRheumatologyisasubjectthatcomesupdaily
inclinicalpractice,andisafavoriteontheABIMInternalMedicineboardexam.AccordingtotheABIMInternal
Medicineexamblueprint,Rheumatology/Orthopedicsrepresents8%oftheexam.Herewecoverfiveevidence
basedhighyieldpearlsthatwillhelpyoubebetterpreparedfortheInternalMedicineABIMcertificationexam!Pearl
#1:RheumatoidArthritisisasystemic,inflammatoryandsymmetricalcondition Systemicmeans
thatitnotonlyinvolvesjointsbutalsowillaffectdifferentpartsofthebodylikethelungs,heart,bloodvessels,skin,
kidneys,andthehematologicalsystem.Inflammatorymeansthatthejointsthatareaffectedwillbeerythematous,
warm,swollen,andtendertotouch.Sinceitisaninflammatorycondition,ESRandCRP(inflammatorymarkers)will
alsobeelevated.Symmetricalconditionmeansthatbothsidesofthebodywillbeaffected.Themainjointsthatare
affectedarethewrist,MCP,andPIPjoints.DIPjointandlowerbackareusuallynotaffected.Mostspecificantibody
forRAisantiCCP.ThemostcommonextraarticularmanifestationofRAissubcutaneousnodules.Poorprognostic
factorsforRAinclude:oProgressivesynovitisoVasculitis(ulcersoffingersandtoes)oSubcutaneousnoduleso
HLADR4markeroElevatedESRoElevatedRheumatoidFactoroErosivelesionsonXrayPatientswithsyncopeor
numbness/tinglingintheupperextremitiesorweaknessmayhaveatlantoodontoidsubluxation.MRIofthecervical
spineisthediagnostictestofchoice.Surgicalcompressioniswarrantedifpatienthassymptomsorthesizeisgreater
than8mmindiameter68|Page
74.74.KNOWMEDGE CertainmedicationsusedinthemanagementofRAare:NSAIDs,Hydroxychloroquine,
Sulfasalazine,MethotrexatewithFolicAcid,Leflunomide,Steroids,andantiTNFalphainhibitorso
HydroxychloroquinefrequenteyeexamsrequiredoMethotrexateCheckCBCandLiverfunctiontestsevery6
8weeksoLeflunomideContraindicatedinpregnancy.ReversewithcholestyramineX11daysoAntiTNFalpha
inhibitorsPPDtestingneedstobecheckedbeforestartingmedication.NEVERgivetwoantiTNFalphainhibitors
concurrentlyasthisincreasestheriskofinfections.Usuallyifoneisnotworking,anotherantiTNFalphainhibitor
willwork.Pearl#2:Osteoarthritisisachronic,progressivelydebilitatingdiseasethatisnoninflammatoryandnon
systemic Noninflammatorymeansthatthisconditiondoesnotpresentwitherythemaorwarmthtoajointbutcan
haveswelling.Sinceitisanoninflammatorycondition,theinflammatorymarkers(ESRandCRP)arealsonormal
usually. Nonsystemicmeansthatonlyjointsgetaffectedwithoutcompromisingtheintegrityoftheentirebody.
Pathophysiologyisbasedonprogressivedestructionofcartilagethatsurroundsbonethatleadstoboneonbone
phenomenon.SomeofthemajorriskfactorsforOsteoarthritisincludeobesity,repetitiveuse,olderage,andtraumato
ajoint.Jointinvolvementcanbemonoarticularorasymmetrical,chronicpolyarticular.Majorjointsthatare
involvedarethehipjoint,kneejoint,lowerback,PIP(Bouchardsnodes),andDIPjoints(Heberdennodes).Usually
MCPjointisspared.Mainstayoftreatmentisnonpharmacological,pharmacological,orsurgical. oNon
pharmacologicalinterventionincludesweightreductionandweightresistancetraining.oPharmacological
interventionincludesNSAIDsandnarcotics.oSurgicalinterventionincludessteroidinjectionsorkneereplacement
therapy.69|Page
75.75.KNOWMEDGEPearl#3:Knowingantibodiesandtheirassociatedconditionsareveryhighyieldforthe
ABIMboardexamination ANAscreeningtestforSLE.MostspecificforSLEisantiSmith,followedby
antidsDNA.AntidsDNAisoftenseeninpatientswithlupusnephritis.AntihistoneDruginducedlupus(most

commondrugsareProcainamide,Hydralazine,INH,PTU,Minocycline,andMethylDopa)AntiCCPmost
specificantibodyforRheumatoidArthritis AntiSSA(Ro)andAntiSSB(La)commonlyseeninSjogrens
Syndrome.NOTE:AntiSSA(Ro)canleadtoanewbornhavingcompleteheartblock Diffusesystemic
sclerosis(Scleroderma)antiSCL70(antitopoisomerase1)CRESTsyndromeanticentromere
Polymyositis/DermatomyositisantiJo1MixedConnectiveTissueDiseaseantiRNPPearl#4:Interpretationof
jointeffusionplaysacriticalroleinestablishingdiagnosis WBCof2002000injointeffusionnoninflammatory
conditionslikeOsteoarthritis WBCof500050,000injointeffusionsinflammatoryconditionslikeRA,gout,
pseudogout,ortraumaWBC>50,000likelysepticarthritisWithgout,inflammatoryjointeffusionwillbeseen.
Additionally,monosodiumuratecrystalswillbepresentandnegativebirefringenceispresentWithpseudogout,
inflammatoryjointeffusionwillbesuspected.Calciumpyrophosphatecrystalswillbeseenandpositivebirefringence
willbepresentWithsepticarthritis,ifpatientislessthan40yearsofage,thelikelycausativeagentisNeisseria
gonorrheaandtreatmentiswithCeftriaxone.Inpatientsmorethan40years ofage,likelycausativeagent
isStaphaureusandtreatmentiswithNafcillinforMSSAorVancomycinforMRSA.NOTE:Neverstarturicacid
loweringagentinanacutegoutyattackANDneverdiscontinueuricacidloweringagentifpatientalreadyonauric
acidloweringagentinanacuteattack. Goaluricacidleveltopreventfurtherattacksofgoutshouldbelessthan6
mg/dl.70|Page
76.76.KNOWMEDGE Inanacuteattack,checkingauricacidlevelhasnodiagnosticvalue.Pearl#5:
SeronegativeSpondyloarthropathies(HLAB27+andRhfactornegative) HLAB27isNEVERusedinthe
diagnosisoftheseronegativespondyloarthropathiesMnemonictorememberthedifferentseronegative
spondyloarthropathiesisPEARRoPPsoriaticarthritisoEEnteropathicarthritisoAAnkylosingSpondylitis
oRReactivearthritisoRReiterSyndromecausativeagentisChlamydia.Triadofurethritis,uveitis,and
arthritis(Cantpee,cantsee,cantclimbatree)71|Page
77.77.KNOWMEDGEBonus:HowtostudyforandpasstheABIMboardexamBy:Dr.RaviBhatiaAstheABIM
internalmedicinecertificationexamapproached,wereceivedalargenumberofemailsfromoursubscribersasking
forsuggestionsonthebestwaytostudyfortheboards.Thetruthisthereisnoonepathtosuccessthoughthereare
certainlywaystoincreaseyourlikelihoodofpassing.Regardlessofwhetheryouarepreparingforboardcertification
ortryingtoachievemaintenanceofcertification(MOC),thebesttriedandtrueoverallmethodistostudyearlyand
studyoften.Belowwelayoutpossiblestrategiesandtactics(innoparticularorder)forpassingtheABIMboard
exam:1.KnowthebasicsoftheInternalMedicineboardexamItmayseemobviousbutalotofpeoplesimplydont
reviewthispriortostartingtheirexampreparationandinsteadrelyontheirABIMstudysourceofchoicetoprovide
theinformation. ReviewtheABIMexamblueprintandunderstandthetopicscoveredontheexam Alarge
percentage(33%)oftheexamiscomprisedofCardiovascularDisease,Gastroenterology,andPulmonaryDisease
Over75percentarebasedonpatientpresentationsmosttakeplaceinanoutpatientoremergencydepartmentothers
areprimarilyininpatientsettingssuchastheintensivecareunitoranursinghome.Whileitsnotabigpartofthe
exam,bepreparedandexpecttointerpretsomepictorialinformationsuchaselectrocardiograms,radiographs,and
photomicrographs(e.g.,bloodfilms,Gramstains,urinesediments). 2.Usetheintrainingexamasastartinggauge
Ifyouarearesident,theInternalMedicineintrainingexamisagoodstartingpointtoseewhereyoustand.Its
simplythatabarometerofwhereyoustand.Itwillgiveyouanideawhereyoumaybeweakandwhereyoumaybe
prettystrong.Itwillalsogiveyouanideaofhowyoucomparewithyourpeers.DontalteryourABIMstudyplan
simplybasedonitbutitdoesgiveyouanearlymetricoftheareasyouneedtofocuson.72|Page
78.78.KNOWMEDGE3.GetastudyguidetopreparefortheABIMexamItsimportanttohaveagoodstudy
guidethatistailoredfortheexam.Someofthemorepopularandeffectiveguideswevecomeacrossarethe
MedStudyInternalMedicineBoardReviewbooksandHarrisonsPrinciplesofInternalMedicineBoardReview.4.
JoinastudygroupStudygroups,ifutilizedproperly,areparticularlyeffectivebecausetheyallowyoutolearnfrom
yourcolleaguesandotherexamtakers.Oftentimes,peoplewillformstudygroupswiththeircolleagues(ideally
limitedto34people)attheirresidencyprogram.TacticstouseinABIMstudygroupsmayinclude: Focusona
newInternalMedicinecategorybyweek.Forexample,focusoneweekoncardiologyandthenextonpulmonaryand
criticalcare.Theexamcanbebrokenintoadozenorsocategories(seetheABIMexamblueprint).Themajorityof
thesubspecialtyquestionsontheInternalMedicineboardexamwillfocusoncardiology,gastroenterology,and
pulmonarycare.However,donotneglecttheotherareasastheABIMwantstoensurethatinternistshaveabroad
baseofmedicalknowledge. TesteachotherwithInternalMedicinequestionsyouhavewrittenyourself.Weare
firmbelieversinthephilosophythatthebestwaytolearnistoteach.Ifyouhelpotherslearn,yourknowledgeof
medicalconceptswillbegreatlystrengthened.Werecognizethatjoiningastudygroupisoftennotfeasible
especiallyforthosenolongerinresidencyprogramswhereeveryoneispreparingtheboards.Fortunately,weliveina
digitalagewherebeingpartofastudygroupismucheasier.YoucanconnectwithcolleaguesthroughSkype,Google
Hangoutoranumberofotherchannels.Oneofourfavoriteapproachesistoremaininformedandlearnthroughthe
powerofsocialmediainparticularTwitter.Inapreviouspost,wehighlightedexcellentTwitterhandlestofollow
forABIMexamreviewasyouprepareforcertification.Follow@Knowmedgefortwicedailyquestionsandour

weekly#ABIMTweetShowhourlongsessionsonSundays.IfTwitterisnotyourcupoftea,youcanalsoconnect
withcolleaguesthroughtheKnowmedgeABIMcommunityonGoogle+.Regardlessofwhatapproachyoudecide,
studyingalongsideotherspreparingforthesameexamisagreatmotivationaltoolforsuccess.73|Page
79.79.KNOWMEDGE5.GetaquestionbankthatfitsyourpersonalneedsWhatisthevalueofanInternal
Medicinequestionbank?Thisisadiscussionnearanddeartoourheart,ofcourse.Questionbankshavebecomea
populartoolbecausetheybringtogetheralotofmaterialinaquestionformatandhelpcreateatesttaking
environment.TherearealotofquestionbankstochoosefromsowhatshouldyoulookforinanABIMqbank?
HighqualityABIMstylequestionsinaformatsimilartotheexam:Theexamismostlyfilledwithclinicalvignettes
andhasstraightforwardquestionsaswell.Ata minimum,yourABIMexamquestionbankshouldhaveboth
ofthesetypesofquestions.Quantityisimportantbutthequalityofthequestionsandexplanationsismuchmore
important.Detailedexplanationsthatreviewwhytheincorrectchoiceswerewrong:Aquestionbankthatdoesnot
provideyoudetailedexplanationsisprobablynotworththemoneyandtimespent.Asyoureviewquestions,youwill
inevitablygetsomewrongyourchoiceofABIMquestionbankshoulddetailwhyyourchoiceisincorrectandthe
reasoningbehindthecorrectchoice.Abilitytotrackyourpersonalperformance:YourchoiceofABIMqbankshould
beabletotellyouyourperformanceoverallandbycategory.Mostnotallquestionbanksprovideyouadashboard
brokendownbycategory.TheKnowmedgequestionbankhasgoneanadditionalsteptobreakthecategoriesinto
subcategoriesasseenontheABIMexamblueprint.Thisallowsyoutoreviewyourstrengthsandweaknessesata
granularlevel.Knowingyouareweakatcardiovasculardiseaseisgreatknowingyouareweakatarrhythmia
questionsismorevaluable.AddonsNotes,Labvalues,Highlighting:Dependingonhowyoustudy,thesemaybe
valuablefeatures.ABIMexamquestionsstraighttalk: NoquestionbanknotMKSAP,notKnowmedge,notany
knowswhatwillbeontheactualABIMexam.BasedontheABIMBlueprint,youcanmakeassumptionsonwhatare
themosthighyieldareastostudy.Thepointofaquestionbankisnottogiveyoutheexactquestionsthatwillbeon
theexamitistohopefullyteachyouconceptsyoumayseeontheexamandhowtoreasonthroughwhatyoudont
knowimmediately.74|Page
80.80.KNOWMEDGE HighqualityABIMexamreviewquestionscanbefoundinmanyplacesquestionbanks
arenottheonlyplace.Therearestudyguides,books,andevenfreesources.Sodontsimplybaseyourdecisionon
questionbankonthequestions.Inadditiontothequalityofthequestions,whattrulydifferentiatesoneABIMexam
questionbankfromanotheriswhetheritwilltrulyhelpyoubuildabroadbaseofknowledgeandhelpyouretain
informationfortheexam.Ifyouarenotcomfortablereadingabunchoftextitwontmatterhowgreatthequestions
are.Ifyouarenotanaudiovisuallearner,theMedStudyorKnowmedgevideoswontdoanythingforyou(Asclarity,
theKnowmedgeqbankcontainstextandaudiovisualexplanationsforthisexactreason).Ifyouareanold
fashionedlearnerthatprefersprintoutsUSMLEWorldisdefinitelynotforyouthosewhohaveusedthemare
wellawaretheirsoftwarewillblockyoufromtakingprintscreensorcopyingoftheircontent.Inshortdontfollow
theherdeachoneofuslearnsdifferentlyandyouneedtopickthebestmethodforyou.6.Considerwhethera
reviewcourseisrightforyouThereareprosandconstotakingareviewcourseforyourABIMexamprep.Thepros
arethatitgivesyouaseriousdoseofreviewinashortperiodoftime.Itgetsyoufocusedifyouwerentfocusedand
somecoursesareabsolutelyexcellentweknowsomeinternistsareardentsupportersofsomeoftheprofessorsthat
teachthesecourses.Theconsofareviewcoursearethattheyareexpensive(Oftenover$1,000plushotelstay)and
canbeinconvenienttotraveltoandfrom.Regardlessofwhetheryouattendareviewcourseornot,itcannotreplace
thepreandpostcoursestudytimethatisneeded.Itiscomplementarytostudytimeanddoesnotreplaceit.7.Review
oursuggestedABIMtesttakingstrategiesTheABIMexamquestionsarenotintendedtotrickyoutheyareintended
tochallengeyourknowledgeandabilitytobringtogetheryourunderstandingofmanydifferentconceptsandtopics.
Belowaresomeofthetacticsyoucanuseasyouarepracticingquestionsand/ortakingtheactualABIMexam:75|P
age
81.81.KNOWMEDGE1.Forclinicalvignettes,readthequestion(lastline)firstandthengobackandreadthe2.3.
4.5.6.scenario.Thiswayyoullknowwhattolookforasyouarereadingthescenario.Trytoanswerthequestion
evenbeforeseeingtheanswerchoices.Payattentionforkeywordsthatcanclueyouinonanetiologyorphysical
exam.WatchforkeydemographicinformationGeography,ethnicity,gender,age,occupation.TheABIMtestisnot
intendedtobetrickybutweareallhumansowemisskeywordssometimessuchasleastlikelypayattentionto
these.Ifyouarechallengedbyalongerclinicalvignette,notethekeyitemsanddevelopyourownscenariothismay
triggerananswer.7.Mostinternistswevespokenwithsaytimeisgenerallynotanissuebutbeawarethatitisa
timedexamandthatyouhaveapproximatelytwominutesperquestion.Wecannotstressenoughthemantrastudy
earlyandstudyoften.Theexamischallengingbutitcanbeconqueredwithdiligenceandproperpreparation.8.
UnderstandandbepreparedforABIMtestday Bepreparedandconfident.Nomatterhowyouhave
chosentostudy,ontestdayconfidenceiscritical!Getagoodnightsrestlastminutecrammingandstayingup
lateisonlygoingtostressyououtmore.Getthereearlydontriskgettingcaughtintraffic.Itsmuchbettertobea
littleearlythanbeaggravatedintraffic.Takeanextralayerofclothing.Thelastthingyouwanttodoisbe
uncomfortableandcoldbecausesomeonedecidedtoturnontheairconditionertoohigh.Testdayislong!Be

mentallypreparedforit.Fromregistrationtotheoptionalsurveyattheend,thedaywillbe810hourslong
(dependingonwhetheryouarecertifyingforthefirsttimeortakingthemaintenanceofcertificationexam).Keep
somepowersnackswithyoutotakeduringbreaktime.ReviewtheABIMexamdayschedulesoyouknowexactly
whattoexpect.ThatsabasicoverviewofhowtostudyforandpasstheABIMboardexam.Asmentioned,thereisno
secretsauceormethodtothisyousimplyneedtohaveabroadbaseofknowledge.Thereisnosubstitutefor
studyingearlyandstudyingoften!Ifyouarepreparing76|Page
82.82.KNOWMEDGEfortheABIMBoards,wewishyouwellwereheretohelpsoletusknowifyouhaveany
questions!Happystudying!77|Page
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