BMS Licensure Preparatory Course Internal Medicine By Dr Nooraldaem Ahmed

1. BMS Licensure Preparatory Course Internal Medicine By DrNooraldaem Ahmed Senior Medical Resident SMC September 2012

2. Must Know Medical Topics

3. Acute Coronary Syndrome 1: STEMI – NSTEMI – UA - Late Presentation MI - SA – Prinzmetal’s Angina 2: Cardiac Biomarkers (troponin/CK-MB/Myoglobin) 3: Right Ventricular Infarction (V4) 4: Reperfusion Strategy (Primary PCI Vs Thrombolysis) 5: Contraindications Of Thrombolysis 6: Signs Of Successful Thrombolysis

4. HEART FAILURE 1: Ejection Fraction 2:Digoxin 3: B.blockers 4: ACEI (Angioedema/RAS/Cough/Renal function/pregnancy) 5/: Diuretics

5. Cardiac Arrhythmias • SVT: Adenosin – Isoptin - Cardioversion • Atrial Fibrillation: Rhythm & Rate Control - Anticougulation (CHADS2). Wide Complex Tachycardia: Amiodarone- MgSO4 - Defibrillation. WPW: Amiodarone – Cardioversion - Radiofrequency catheter ablation

6. CHRONIC OBSTRUCTIVE AIRWAY DISEASE

7. Bronchial Asthma • Diagnosis: ≥20% improvement of peak flow following treatment. • ≥20% decrease in peak flow following a trigger.

8. Pulmonary Embolism • Breathing difficulty + ECG (Sinus Tachy/ RBBBlock/ S1Q3T3) + Normal CXR + Rv. Strain by ECHO. • Alterations in blood flow: immobilization (after surgery, injury, pregnancy , obesity (also procoagulant). • Factors affecting the properties of the blood (procoagulant state): • Estrogen-containing hormonal contraception • Thrombophilia (Genetic/Acquired) • Cancer Thrombolysis: Massive PE causing hemodynamic instability. CTPA of choice except in renal impairment pregnancy/ Allergy to iodinated contrast Target INR= 2-3 +

9. Inflammatory Bowel Diseases

10. Upper Gastrointestinal Bleeding

11. Diabetic Ketoacidosis

12. Management Of Adrenal Crisis • Administration of Glucocorticoidsin supraphysiologic or stress doses is the only definitive therapy (Any delay is dangerous & in appropriate) • Dexamethasone does not interfere with serum cortisol assay and, thus, may be the initial drug of choice. • However, because dexamethasone has little mineralocorticoid activity, fluid and electrolyte replacement are essential. • A short ACTH stimulation test may be performed during resuscitation. Once complete, hydrocortisone 100 mg IV every 6 hours is the preferred treatment to provide mineralocorticoid support.. • Fludrocortisone, a mineralocorticoid, may also be given • Search for a precipitating cause, give empiric antibiotics.. Pressors(eg, dopamine, norepinephrine) & Aggressive Hydration may be necessary to combat hypotension

13. Cushing’s Syndrome (Work Up)

14. Acute Kidney Injury

15. Electrolyte Imbalance

16. CSF Analysis

17. Pleural Fluid Analysis • Light’s Criteria: • The ratio of pleural fluid protein to serum protein is greater than 0.5 • The ratio of pleural fluid LDH and serum LDH is greater than 0.6 • Pleural fluid LDH is greater than 0.6 or ⅔times the normal upper limit for serum. CHECK ALSO:difference between the albumin level in the blood and the pleural fluid is greater than 1.2 g/dL (12 g/L), this suggests that the patient has a transudative pleural effusion

18. Ascitic Fluid Analysis The Serum-ascites albumin gradient (SAAG). A high gradient (> 1.1 g/dL) = ascites is due to portal hypertension. A low gradient (< 1.1 g/dL) = ascites of non-portal hypertensive etiology. Causes of high SAAG ("transudate") are: Cirrhosis - 81% (alcoholic in 65%, viral in 10%, cryptogenic in 6%) Heart failure Hepatic Venous occlusion: Budd-Chiari syndrome Constrictive pericarditis / Heart failure Causes of low SAAG ("exudate") are: Nephroticsyndrome Cancer (primary peritoneal carcinomatosis and metastasis) - 10% Infection: Tuberculosis - 2% or Spontaneous bacterial peritonitis Pancreatitis - 1% Serositis

21. (1): Which finding is consistent with the diagnosis of prinzmetal’s Angina? A): pain reproduced by palpation of chest B): Non specific ST-T wave abnormalities C):Relief of pain with drinking cold water D: ST Segment elevation in inferior leads E):ST Segment depression in lateral leads

22. (2): The most common cause of a pleural effusion is: A): Cirrhosis B): Left Ventricular Failure. C): Malignancy D): Pneumonia E): Pulmonary Embolism

23. (3): When evaluating a patient with Ascites a high (more than 1.1 g/dL) SAAG is consistent with all of the following diagnoses except: A): Cirrhosis B): Congestive heart failure C): Constrictive pericarditis D): Hepatic vein thrombosis

24. (4): Complications of peritoneal dialysis include which of the following: A): Hypotension after drainage of dialysate B): Hypoalbuminemia C): Hypercholestrolemia D): Hypoglycemia E): Left pleural Effusion

25. (5): A 74 years old female sees her physician for a following up visit for hypertension. serum chemistries reveal a Sodium of 126 meq/L. Which of the following medications most likely she was taking? A): Enalopril B): Frusemide C): Hydrochlorothiazide D): Metoprolol E): Spironolactone

26. (6): An 84 years old man; k/C/O myelodysplasia, CHF, Hyperlipidemia & CKD Stage 4; diagnosed as Acute gouty arthritis. His Cr = 240mmol/l & CBC= pancytopenia. Which of the following is most appropriate? A): Allopurinol B): Colchicine C): Indomethacin D): Prednisolone E): Probenecid

27. (7): All of the following are effects of Hypercalcemia; except: A): Diarrhea B): Confusion C): polyurea D): Shortened QT interval E): Nephrolithiasis

28. (8): Which nerve functions are spared in a patient with ventral cord syndrome due to Anterior spinal cord infarct? A): Bladder sphincter control B): Motor strength C): Pain sensation D): Proprioception E): Tendon reflexes

29. (9): which of the following Hemolytic anemias can be classified as extracorpuscular? A): Elliptocytosis B):paroxysmal nocturnal hemoglobinuria C): Pyruvate kinase deficiency D): sickel cell anemia E): Thrombotic thrombocytopenic purpura

30. (10): Helicobacter pylori colonization is implicated in all of the following conditions; except: A): Dudenal ulcer disease B): Gastric adenocarcinoma C): Gastric Mucosa-associated lumphoid tissue (MALT Lymphoma) D): Gastroesophageal reflux disease E): Peptic ulcer disease

31. (11): When deciding whether to initiate anticoagulation for a patient with Atrial fibrillation; which of the following factors is least important? (A): Age (B): History of diabetes (C): Mitral stenosis (D): Use of antiarrhythmic medications (E): Hypertension

32. (12): A patient evaluated in the emergency department for peripheral Cyanosis. Which of the following is not a potential etiology? A): Cold exposure B): Deep venous thrombosis C): Methemoglobinemia D): Peripheral vascular disease E): Raynaud’s phenomenon

33. (13): Which of the following extraintestinal manifestations of inflammatory bowel disease typically worsens with exacerbations of disease activity? A): Ankylosing spondylitis B): Arthritis C): Nephrolithiasis D): Primary sclersingcholengitis E): Uveitis

34. (14): In patient with Chronic Renal Failure, which of the following is the most important contributer to renal Osteodystrophy? A): Impaired renal production of 1,25 (OH)2D3 B): Hypocalcemia C): Hypophosphatemia D): Loss of vitamin D & Calcium via dialysis E): The use of Calcitrol

35. (15): Which of the following joints are typically spared in Osteoarthritis? A): Ankle B): Cervical spine C): Distal interphalangeal joint D): Hip E): Knee

36. (16): Which of the following is the most common sign of Cushing’s syndrome? A): Amenorrhea B): Hirsutism C): Obesity D): Purple skin striae E): Skin hyperpigmentation

37. (17): A 78 Years old female with a long history of vascular disease presents after an embolic Cerebrovascular Accident with sever & unrelenting pain on the right side. She describes the pain as burning as if she had been bathed in acid. Where is the most likely site of the recent embolic CVA? A): Frontal lobe B): Hypothalamus C): pons D): Temporal lobe E): Thalamus

38. (18): All of the following are suggestive of Iron Deficiency Anemia except? A): Koilonychia B): Pica C): Decreased serum ferritin D): Decreased total iron binding capacity E): Low reticulocyte response

39. (19): The Standard starting regimen for Acid –fast bacilli smear-positive active pulmonary tuberculosis is: A): Isoniazid B): Isoniazide, Rifampicine C):Isoniazid, Moxifloxacin, Pyrazinamide, Ethambutol D):Isoniazid, Rifampicin, Pyrazinamide, Ethambutol E):Rifampicin, Moxifloacin, Pyrazinamide, Ethambutol

40. (20): All of the following conditions are associated with an increase incidence of Cancer, except? A): Down’s syndrome B): Fanconi’s syndrome C): Von Hippel-Linduau syndrome D): Neurofibromatosis E): Fragile X Syndrome

42. (1): Which finding is consistent with the diagnosis of prinzmetal’s Angina? A): pain reproduced by palpation of chest B): Non specific ST-T wave abnormalities C): Relief of pain with drinking cold water D: ST Segment elevation in inferior leads E): ST Segment depression in lateral leads The Answer Is(D)

43. (2): The most common cause of a pleural effusion is: A): Cirrhosis B): Left Ventricular Failure. C): Malignancy D): Pneumonia E): Pulmonary Embolism The Answer is (B)

44. (3): When evaluating a patient with Ascites a high (more than 1.1 g/dL) SAAG is consistent with all of the following diagnoses except: A): Cirrhosis B): Congestive heart failure C): Constrictive pericarditis D): Hepatic vein thrombosis E): Nephrosis The Answer Is (E)

45. (4): Complications of peritoneal dialysis include which of the following: A): Hypotension after drainage of dialysate B): Hypoalbuminemia C): Hypercholestrolemia D): Hypoglycemia E): Left pleural Effusion The Answer Is (B)

46. (5): A 74 years old female sees her physician for a following up visit for hypertension. serum chemistries reveal a Sodium of 126 meq/L. Which of the following medications most likely she was taking? A): Enalopril B): Frusemide C): Hydrochlorothiazide D): Metoprolol E): Spironolactone The Answer Is (C)

47. (6): An 84 years old man; k/C/O myelodysplasia, CHF, Hyperlipidemia & CKD Stage 4; diagnosed as Acute gouty arthritis. His Cr = 240mmol/l & CBC= pancytopenia. Which of the following is most appropriate? A): Allopurinol B): Colchicine C): Indomethacin D): Prednisolone E): Probenecid The Answer is(D)

48. (7): All of the following are effects of Hypercalcemia; except: A): Diarrhea B): Confusion C): polyurea D): Shortened QT interval E): Nephrolithiasis The Answer Is (A)

49. (8): Which nerve functions are spared in a patient with ventral cord syndrome due to Anterior spinal cord infarct? A): Bladder sphincter control B): Motor strength C): Pain sensation D): Proprioception E): Tendon reflexes The Answer Is (D)

50. (9): which of the following Hemolytic anemias can be classified as extracorpuscular? A): Elliptocytosis B): paroxysmal nocturnal hemoglobinuria C): Pyruvate kinase deficiency D): sickel cell anemia E): Thrombotic thrombocytopenic purpura The answer is (E)