I was tasked with writing "board style questions" after giving a series of lectures. A lot of people have asked that I publish these on my blog and give answers and explanations. The questions are written in USMLE/Comlex Step 2 and 3 format, and may also be found on Internal Medicine In-Service exams. Here are the first few questions in a "Board Review Series".

1. A 56 year old male was mowing the lawn and began having chest pain. The pain radiated down his left arm and he became nauseous and lightheaded. He sat down to take a break and then pain slightly improved but was still there. It was a dull achy, squeezing pain that was a 6-8 out of 10. His wife activated EMS and an ambulance brought him to the hospital. Upon arrival his vitals were pulse of 150, respirations of 20, blood pressure of 155/88, and SpO2 of 100% on room air. On exam he was alert and oriented X3, in mild to moderate distress, No JVD, Lungs were clear, Heart was regular, No murmurs, No S3 or S4, Abdomen was soft and obese, extremities were not edematous. An EKG was performed by the ED staff and demonstrated Sinus Tachycardia and ST elevations of 3-4mm in leads V2-V4. The ED staff has placed him on O2, given him 325mg of chewable Asprin, and placed an inch of nitro paste on him. In addition to activating the cardiac catheterization team, what would be the next best step?

A. Start a IIb/IIIa inhibitor
B. Give him clopidigrel
C. Start an ACE Inhibitor
D. Start a Beta Blocker
E. Start Insulin

2. In the cath lab, which vessel was the most likely stenosed vessel in the above patient?
A. Left Circumflex
B. Posterior Descending
C. Right Coronary
D. Left Anterior Descending
E. Right Posterior Lateral

3. Upon discharge, all AMI patients (not just the previous patient) should be on which combination of medications?
A. Statin, Asprin, ACE Inhibitor, Beta Blocker
B. Statin, Asprin, Clopidigrel, Beta Blocker
C. Statin, Asprin, ACE Inhibitor, Calcium Channel Blocker
D. Asprin, Beta Blocker, Spironolactone, ACE Inhibitor
E. Asprin, Nitroglycerin, Beta Blocker, Statin

I just got done taking the American Board of Osteopathic Internal Medicine exam and here are my thoughts.

Can we discuss the test?

Yes, you are allowed to discuss it and tell people about it. I signed an agreement at the beginning of the exam stating that I will not try to memorize the questions and reproduce them. I won't do that. Just a general discussion of strategies on how to take this test, which topics I felt were covered, and what is the best preparation.

Basics

You have two 3.5 hours sections of 160 questions each. In between, you get an hour off, if you want to use it. I finished the first section in 2.5 hours and the second section in 3 hours. It's not a mentally draining test. Some tests just drain you and see if you have the stamina. This does not do that. It simply wants to know if you know.

What was it like?

The questions were very similar to the In-Service exam that we take every year. That was the level of questioning. The MKSAP questions that I used to prepare for the exam as my primary source of questions were way to difficult compared to the real exam. The exam seemed more like a Step 3 level exam or a family practice type of exam. By that, I mean that the questions seemed to have a more outpatient slant than an inpatient slant. We are used to treating pretty sick patients in the hospital, but the majority seemed to be focused on outpatient management in clinic. This is their way of eliminating dangerous drivers, which is the goal of all of these exams we take.

The question stems were really short. The MKSAP questions were pretty long and had a ton of laboratory data. These were much shorter. Most questions were probably just one or two lines or three at the most. A lot of questions were just recall, like "Which of the following medications will interact with coumadin?" About 20-30% were probably cases that needed some thinking and had lab values to analyze. Those are the ones I enjoyed and thought were really "internal medicine" type questions. Those were the kind of inpatients I was used to treating (the really sick ones).

They also seemed to want to eliminate the dangerous drivers. They asked a lot of questions about the worst possible complication of something, to see if you remember and to make sure you know how to head that off. So that you aren't a dangerous driver.

There was a lot of "buzzword" type questions. Reed-Sternberg cells, worst headache of my life, gram positive cocci in clusters, opening click, widened medistinum, etc. They discuss a case and throw in a buzzword at the end that is supposed to tip you off about the diagnosis. This seemed kinda silly, but they aren't trying to trick you. They want to hand you the diagnosis and see if you know what to do with it.

Although we are supposed to be trying to get away from eponyms, they keep using them. I can't tell you how many times I saw the word "Babinski" instead of "up going toes". That is really sad. It sucks when they use one that no one has ever heard of like "Jergadz-Litter-Shy-Fanconitis-Creutzfeld Syndrome".

Any pictures?

A lot of peripheral blood smears. Don't worry it's usually very obvious. They will describe a case, then show you a smear. It will usually be something obvious to figure out, like spherocytes, teardrop cells, schistocytes, inclusions inside RBCs, hypersegmented nuetrophils... nothing that is too hard.

A lot of EKGs. The EKGs were fun for me and pretty easy. A lot of times you didn't really need to look at it to figure it out, so don't worry. They may describe someone with palpitations tell you that the EKG was obtained and is pictured, what are your anticoagulation options? So you know it's A-Fib.... the question just wants to see if you know what to do with the patient. The EKG just helps a little. None of the EKGs were anything bizarre. Know your two kinds of second degree AV blocks, be able to see A-fib, know what 2:1 AV block looks like, the usual basic EKG stuff.

Also know how to pick up on a STEMI on an EKG. They like the "Inferior MI" question, just like MKSAP. What do you do with an Inf STEMI? How do they present? What physical exam findings to look for? They love the RV infarct question too. Physical exam signs? What drugs should you not give? (morphine, beta-blockers, nitro)

They had a lot of chest xrays too. They seem to like the benign asbestos plaques in the lower lobes. Just real basic CXR stuff. Hilar LAD, infiltrates, effusions, etc, The case usually gives you more than enough info to solve it without the CXR. The pictures of CXRs in Medstudy were plenty.

They had some hand and spine xrays. The Rheum department stuff. Degenerative hand joints, some spinal fusion pictures, nothing too bad.

Another group of pictures was one or too pulmonary function testing curves. Know the very basics of these. Restrictive versus obstructive. Is it reversible with albuterol?

Cardio?

The cardiology section was pretty straight forward. You should know which drugs are indicated for various stages of heart failure, because they like to ask "what drug should be added to this patients regimen?" Also which drugs for MI, what drug not to give a possible dissection patient, syncope workup, know the buzzwords for various murmurs, the abx prophylaxis for mvp that's currently recommend (none), etc. Tamponade, when do they need pericardial window, or do they just need dialysis, etc. Some basic cardio emergencies. Nothing too hard.

GI?

It seemed like we were in diarrhea heaven! Every question was about diarrhea! Know your diarrhea work up. Osmotic gap? Stool water electrolyte analysis, etc. They had the rare GI infections that cause diarrhea. They had the usual liver enzyme analysis questions. A few Hepatits questions, when to start treatment, what to use. Analyzing the dreaded Hep B antibodies and antigens.

Pulm?

I love pulm. They had very simple ventilator management questions. Know what to do with COPD/Asthma patients on a vent to allow longer expiration. They had some weaning questions. Best test to know if a patient can be weaned?  They had some real basic ABG analysis. Know a little bit about ARDS and shunting. I was disappointed that the Pulm section wasn't harder. We get awesome pulm training and I was hoping to put my knowledge to good use. Oh well. A lot of pnuemonia questions, outpatient and inpatient. Tried a few abx, now what to give?

Renal?

Know those damn glomerulonephropathies! This section upset me. I studied renal so long ago. Which Glomerulonephropathy gives you what findings on histology? Which one goes with Goodpastures/Wegners/Post-infectious/vasculitis/etc. Just read the glomerulonephropathy section intently and memorize it. Also know a little bit about which RTA causes low K and slightly acidic urine. Know what FENa gives you ATN, what you see on random urine or urine sediment, etc. Nothing too complicated in that regard. Some SIADH and central DI versus nephro DI.

Endo?

Not a huge section on the test. Know your pituitary hormones. The MKSAP questions for this really helped. It helped you figure out what affects what, and which tests to order. Some basic diabetes questions. They still ask about 70/30 insulin, although the ADA now recommends basal/bolus with long acting and mealtime boluses. Not sure why they aren't caught up with the times. They liked the dexamethasone suppression test. Know what happens when you have too much ACTH/Cortisol/Prolactin/Growth Hormone/etc. Pheocromocytoma, primary hyperaldosteronism, adrenal insufficiency, thyroiditis, graves, etc. Know what to do with thyroid nodules, goiters, etc. Know what happens to thyroid tests during acute severe illnesses. A few vitamin D and calcium questions. What goes up what goes down in various disease states?

Heme/Onc?

A lot more peripheral smears than I thought. Know your breast cancer stuff. Which drugs, which options, for what stages. Know the common stuff. Know your multiple myeloma stuff. Know your leukemias and lymphomas (the adult stuff, not kids).

OMM?

There isn't any OMM. At least not on my test. I heard there were OMM questions though. I think if they ask OMM questions it'd be in the context of "a patient pulls a muscle in his back, in addition to OMM what would you prescribe?" or something like that.

Derm?

Maybe one question. Drug reaction? Skin necrosis? Steven-Johnson sydrome. Just keep the dangerous drivers off the road type stuff. Just know the one or two derm emergencies.

What to Study?

I highly recommend MEDSTUDY! It seems like the people writing and editing the test copied from Medstudy verbatim. If you want to learn Medicine, read Harrisons. If you want to pass this test, memorize Medstudy.

All I did was do MKSAP questions (all of them) and read the explanations as well as read the MKSAP curriculum material that comes with the questions. If I could go back, I would not do any MKSAP questions and just read Medstudy and do those easy questions in Medstudy.