APPENDIX F
ESSENTIAL MEDICINE: MEDICINE I
Cardiology Basic Questions
1. Describe how the following signs can be assigned to cardiac causes; i.e., the symptoms and signs of the non-cardiac causes contrasted to cardiac.
a. Shortness of breath
b. Chest pain
c. Nighttime shortness of breath
d. Exercise fatigue and productive cough
e. Syncope
f. Heart rate variability
g. Dependent edema and nocturia
2. Explain how the following can be used to evaluate shortness of breath.
a. Cardiac auscultation (which signs are particularly important)
b. Rales (describe)
c. Chest x-ray, especially blood vessel size and distribution, interstitial lines, pleural effusion and heart size
d. Hepatoyugular reflux and valalva manuever
3. Explain how the following helps in the evaluation of chest pain.
a. Description of the nature, precipitation events, duration and associated symptoms of angina, coronary insufficiency, myocardial infarction and pericarditis.
b. EKG
c. Exercise testing (EKG, MUGA, Setamifi, Thallium, Echocardiogram)
d. Coronary angiography
e. Cardiac enzymes, isoenzymes (appreciate timing)
4. Explain the importance of the following in the new appearance of congestive heart failure.
a. A bratwurst and soup picnic followed by beer and games in a patient with compensated heart failure
b. Appearance of a new loud systolic murmur in a patient with an acutemyocardial infarction
c. Fever and a new murmur
d. CVA
e. Persistence of the "acute" ST changes of an acute MI for months with recurrent episodes of heart failure
f. "Right heart failure" with edema, neck vein distension that increases with inspiration and more than 10 mm of pulses paradoxicus (describe)
g. Variability or intensity of heart sounds, with irregular pulse
5. Describe the methods of distinguishing
a. Ventricular from supraventricular tachycardia
b. Atrial fibrillation from multifocal atrial tachycardia and atrial flutter
6. What illnesses are causes of pericarditis; how can these be evaluated? How can a "rub" be distinguished from a murmur?
7. Describe the role of the following in evaluating hypotension.
a. Standing and lying blood pressure
b. Jugular venous pulse
c. Heart examination and EKG
d. Hematocrit and stool occult blood
e. Mental status, temperature, and CBC
f. Central venous and pulmonary artery monitoring
8. Explain the importance of the following in the evaluation of hypertension.
a. Episodes of sweating, weight loss, great variations of pressure with posture
b. Flank bruit, lack of good pulses on extremities
c. Urine casts, RBCs and protein
d. "I like salt."
e. Current pregnancy, use of contraceptives
f. Generalized edema
g. Constitutional symptoms (weakness, etc.), normal faundoscopic exam
9. What are the important risk factors for coronary artery disease?
10. What are the different types of lipids and their relationship to atherosclerotic cardiovascular disease?
Endocrinology Basic Questions
1. List the endocrinologic causes of the following common syndromes; describe the expected natural history.
a. Fatigue and weight loss
b. Thyroid enlargement, with or without pain
c. Hyponatremia, Hypernatremia
d. Polyuria
e. Delayed puberty, with small testicles
f. Amenorrhea, primary or secondary
g. Hypertension
h. Hypotension
i. Dementia or psychosis
2. Describe the organ pathophysiology, the natural history, and the testing of
a. Simple colloid goiter
b. Grave's disease
c. Thyroid carcinoma (papillary, medullary and anaplastic)
d. Autonomous functioning solitary nodule
e. Thyroiditis (autoimmune and subacute)
3. Describe the clinical picture and the laboratory values in hypo and hyperthyroidism including T3, T4, TSH, TRH stimulation test.
4. Compare and contrast the syndromes of adrenal insufficiency caused by adrenal failure and pituitary failure; include clinical syndromes and testing of cortisol and ACTH levels and the use of ACTH stimulation.
5. List the actions of cortisone-like steroids; include the clinical syndromes associated with short and long-term use on mental status, bone structure, eye structure, glucose metabolism, skin and body habitus and adrenal responsiveness.
6. Discuss the following features of Diabetes Mellitus.
a. Etiology and pathogenesis of Type I and Type II diabetes; include age of onset, genetics, natural history, insulin levels, role of insulin resistance, and role of obesity.
b. List the syndrome of hyperglycemia with and without acidosis, covering symptoms, fluid and electrolyte balance (K+ Na+ and volume), cerebral function and infection.
c. Discuss the following complications of diabetes: "large vessel" damage, microangiopathy, neuropathy, cataracts, renal disease, and retina.
d. Discuss the time course of action of NPH, Regular, Lente and ultralente insulin.
e. Causes of Hypoglycemia.
7. List the causes of and the symptoms and signs of hypercalcemia; how can they be differentiated?
8. Discuss the features associated with deficiency of
a. Calories
b. Thiamine, folic acid, ascorbic acid, or vitamin D
c. Magnesium, potassium, phosphate
9. Discuss pituitary lesions causing both hypofunction and hyperfunction.
Gastrointestinal Questions
1. Describe the nature of pain including location, character, relationship to OTC medications, meals and bowel movement, duration, and radiation of
a. Gastro esophageal reflux
b. Duodenal ulcer
c. Pancreatic pain (pancreatitis and cancer)
d. Irritable bowel syndrome
e. Inflammatory bowel disease
f. Cholecystitis
g. Intestinal obstruction
h. Renal colic
2. Describe the pathophysiology, natural history (include symptoms with eating, and results of testing including esophogram, esophageal motility, and esophagoscopy) of the following:
a. Acid reflux esophagitis and stricture
b. Carcinoma of the esophagus
c. Achalasia
d. Esophageal spasm
e. Systemic sclerosis
3. Discuss the role of the following in the pathogenesis of duodenal and gastric ulcer.
a. Helicobacter pylori
b. Gastrin and acid
c. Aspirin and other nonsteroidal anti-flammatory medications
d. Caffeine, theophyllines, alcohol
e. Stress
4. Describe the natural history, nature of stool and gastric contents, and pathophysiology of bleeding in the following:
a. Peptic ulcer
b. Gastritis
c. Inflammatory bowel disease
d. Ascending colon cancer
e. Rectal cancer
f. A.V. malformation
5. Describe the mechanisms, associated symptoms, and natural history of the following in inflammatory bowel disease.
a. Fever, high sedimentation rate, pain and weight loss
b. Fistulas, intestinal obstruction
c. Carcinoma
d. Biliary disease, arthropathy
6. Differentiate by natural history, liver function tests, isotope scan, ultrasound tests, "ERCP" and CAT scan the following causes of jaundice.
a. Hepatitis
b. Choledocholithiasis
c. Pancreatic carcinoma
d. Drug toxicity
7. Discuss the natural history, serology, and complications of Hepatitis A, Hepatitis B, and Hepatitis C.
8. Describe the natural history, etiology, physical findings, and laboratory findings of the following kinds of cirrhosis.
a. Laennec's
b. Postnecrotic
c. Biliary
d. Cardiac
Include descriptions of hepatic encephalopathy, variceal bleeding, and hypoalbuminemia with ascites.
9. Discuss the natural history of pancreatitis, emphasizing:
a. The role of alcohol, drugs, biliary disease, and hyperlipidemia
b. The development of necrosis, pseudocyst, persisting fever, and malnutrition
c. The presence of respiratory failure, excessive bleeding, low calcium
d. The risk of recurrence
10. Describe the pathophysiology of diarrhea, emphasizing the roles of osmotic causes, secretory causes, abnormal intestinal motility, and bowel inflammation.
a. Infectious colitis
b. Disaccharidase deficiency
c. Bacterial overgrowth
d. Irritable bowel syndrome
e. Inflammatory bowel disease
11. Malabsorption can be defined by what changes in the following:
a. Weight, stool bulk
b. Fat content in the stool
c. Calcium, Vitamin B12, Carotene, Vitamin K
d. Triolein breath test
e. Xylose absorption
Hematology and Oncology Basic Questions
1. Appreciate the features of the common carcinomas with respect to
a. Usual growth rates
b. Common patterns of spread (i.e., direct spread, hematologic spread, etc.)
c. Occurrence of tumor markers or ectopic hormones for lung, breast, colon, cervical, prostatic, and skin carcinoma
2. Describe the tumor-node-metastasis (TNM) classification of cancer.
3. Describe the following oncologic emergencies:
a. Superior Mediastinal Syndrome
b. Pericardial tamponade
c. Spinal cord compression
d. Hypercalcemia, hyponatremia
4. Describe screening techniques for the following cancers; understand the differences between screening and diagnosis in testing (i.e., Beyes Theorem).
a. Breast
b. Colon
c. Lung
5. Describe the natural history of the following breast "lesions:" pre and postmenopausal carcinoma, estrogen receptor neg. and positive cancer, fibrocystic disease, and fibroadenoma.
6. Contrast the differences in biologic behavior between small cell (oat cell) and non-small cell (squamous, adeno, large cell) carcinomas of the lung.
How might those differences lead to differences in "work-up" and therapy?
7. Discuss the differential diagnosis of the following and the relationship to the natural history of colon cancer: iron-deficiency anemia, occult blood positive stools, polyps (sessile or pedunculated), and family history.
8. Discuss the differential diagnosis of the following:
a. Vaginal bleeding
b. Adnexal enlargement
c. Abdominal distension with ascites
9. Discuss the causes of the following:
a. High white count with immature and mature granulocytes
b. High red count
c. High globulins in the blood
Include descriptions of changes in bone marrow, spleen and liver, and ability to fight infections.
10. Describe the following in the natural history or evaluation of anemia:
a. Macrocytosis, hypochromic, cell fragments, nucleated red cells, sickle cells, spherocytes
b. Serum iron, ferritin, iron stores in bone marrow
c. Serum B12, folate, shilling test
d. Reticulocyte count, haptoglobin, Coombs' tests
e. Hemoglobin electrophoresis
11. Discuss the categories of neutropenia and thrombocytopenia together with a common example of each type.
12. Describe the role of the following in characterizing the natural history of Lymphoma.
a. Hodgkin's vs. non-Hodgkin's class
b. Histologic type
c. Fever, weight loss, malaise
d. Types of opportunistic infections
e. Staging
13. Review the abnormalities screened and the diseases suggested by each of the following tests of coagulation:
a. Prothrombin time (PT)
b. Activated partial thromboplastin time (APTT)
c. Thrombin time (TT)
d. Bleeding time (BT)
e. Platelet count
f. Fibrin split products, fibrinogen assay
14. Describe the action of the following with examples of potential use: heparin, Coumadin, streptokinase.
15. Discuss the natural history of chronic lymphocytic leukemia including time course, hepatosplenomegaly, anemia, thrombocytopenia, infection.
Infectious Diseases Basic Questions
1. How do the following findings influence the search for a source of infection?
a. A recent stay in the intensive care unit for major trauma
b. Recent treatment with chemotherapy with a neutrophil count of below 1000
c. An indwelling plastic catheter
d. Diarrhea and a recent trip to Mexico
e. The presence of: petechial skin lesions; enlarging skin papule; erythematous spots with arthralgias; tender skin plaques (erythemia nodosa); diffuse erythema and shock
f. Continuing undiagnosed fever for 3 weeks
g. Health care professional whose tests and appearance are normal
h. Generalized lymph node enlargement
2. Discuss the differential diagnosis and pathophysiology of
a. High fever, stiff neck, confusion, and CSF with WBCs or low glucose and high protein
b. Fever, headache, CSF with neutrophils, glucose of 40 mg and neg. culture after 2 days of antibiotics
c. 3 days of fever, stiff neck, headache, with CSF showing lymphocytes, normal protein, glucose
d. Headache, behavioral abnormality, fever, focal seizures and temporal lobe enhancement on CT with CSF showing a few lymphocytes, normal glucose and protein
e. 2 weeks of deterioration with fever, confusion, and CSF showing 400 lymphocytes, low glucose and high protein
3. What agents are most likely with the following settings?
a. Community acquired, abrupt onset, shaking chills, and yellow sputum with gm pos. diplococcus in the sputum
b. Infiltrate with radiolucent center, fever, purulent and fetid sputum, and history of alcoholism and illness for 4 weeks
c. High fever, patchy infiltrates, tachypnea, and no sputum in a patient on chemotherapy with a neutrophil count below 1000
d. Fever, new infiltrate, purulent sputum in a hospitalized patient with a tracheostomy
e. Fever, dyspnea, acidosis with hypercarbia, and an unchanged chest x-ray in a patient with COPD
f. Pulmonary infiltrate, high fever, clear chest examination, and little sputum with WBCs but no organisms on gm. stain
4. A patient is diagnosed as bacterial endocarditis; what is the pathophysiology of
a. Sudden hemiparesis?
b. Congestive heart failure and changing heart murmurs?
c. Hematuria with proteinuria and red cell casts?
5. What is the meaning of fever, crepitus under mildly inflamed skin in an ill-appearing patient?
6. Discuss the pathophysiology including origin of organisms, types of organisms, and tissue pathology of post-abdominal surgery fevers. How is evaluation different in the setting of pleural effusion? Atelectasis? RUQ tenderness? Presence of an indwelling bladder catheter?
7. What is the role of the following in urinary tract infection?
a. Renal calculus
b. Prostatic enlargement and urinary retention
c. Persistent fever with left pleural effusion
8. Discuss the causes of right upper quadrant tenderness, shaking chills, and jaundice. What, in the history, would suggest malignancy?
9. Discuss the meaning of the following diarrheal illness.
a. Extensive voluminous watery diarrhea
b. Fever, abdominal cramps, WBCs in stool
c. Prior use of antibiotics
d. Diarrhea in travelers
10. Discuss the most common causes of the following genital sores:
a. Painless ulcer with inguinal lymph node
b. Multiple small vesicles or painful small erosions
c. Erythema and cellulitis in a diabetic
11. What are the causes of vaginal discharges described as follows:
a. Abdominal pain, purulent discharge, and uterine and adnexal pain
b. White curdy discharge with vaginal itching
c. Watery grey bubbly discharge with minimal pain
d. Recurrent fever, lower abdominal pain, persisting despite penicillin
12. Discuss the agents that cause acute arthritis, chronic arthritis, septic bursitis.
13. Discuss the special infectious problems of
a. Diabetes mellitus
b. Sickle cell anemia
c. Splenectomy
d. Homosexuality
14. Describe how one gets adequate cultures in the following situations:
a. Suspected SBE
b. Abdominal abscess (including liver)
c. Pneumonia
d. Skin ulcers or cellulitis
e. Osteomyclitis
Nephrology Basic Questions
1. What problems are suggested by the following symptoms?
a. Painful or frequent urination
b. Red urine
c. No urine voided
d. 5-10 minute attacks of pain radiation to the groin
2. What problem(s) in renal pathophysiology is suggested by:
a. Protein in the urine greater than 200 mg/24 hrs.
b. Creatinine clearance less than 15 cc/min.
c. Red cell casts
d. Urine volume less than 12 cc/hr. with osmolality of 300 and sodium of above 80 meq/dl.
e. Small kidneys with creatinine above 4 mg/dl.
3. What is the special value of the following in evaluating renal disease?
a. I.V.P.
b. Sonogram
c. Cystoscopy
d. CAT scan
4. What are the methods of detecting hypovolemia? Hypervolemia?
What are the causes of:
a. Hypovolemic hypernatremia?
b. Hypovolemic hyponatremia?
c. Hypervolemic state?
d. Hyperkalemia?
e. Hypokalemia?
f. Acidosis with and without an anion gap?
5. Discuss the role of the following in the etiology of hypertension. Which play a role in the etiology of renal, essential, or adrenal hypertension?
a. High renin
b. Arterial vasoconstriction from sympathomimetics
c. High vascular volume
d. Low renin, high aldosterone
6. Describe the concepts and the common causes of renal failure in
a. Prerenal azotemia
b. Renal azotemia
c. Post-renal azotemia
Explain the usefulness in each of the following in distinguishing between common causes of Renal failure:
a. U/P ratio of BUN or creatinine
b. Specific gravity or osmolality of the urine
c. Urinalysis
d. Trial of diuretic
7. What are the clinical sequelae of chronic azotemia? Explain and include descriptions of the effect on bones, phosphate, nerves, clotting, and GI tract.
8. Describe the mechanisms of injury to the glomerulus.
a. What are some of the etiologies of glomerular injury?
b. Which slowly progress to permanent damage; which rapidly?
9. How does interstitial kidney disease differ from glomerular disease?
What are some causes of cystic diseases, inflammatory diseases, infiltrative diseases?
10. Describe renal arterial occlusion; renal vein occlusion.
11. What are the common causes of renal or bladder stones?
12. List the causes of ureteral obstruction; urethral obstruction.
13. What usually causes the kidney to malfunction in the following diseases:
a. Diabetes mellitus
b. Lupus erythematosis
c. Hypertension
d. Gout
e. Liver failure
f. Complications of pregnancy
Neurology Basic Questions
1. Define the following terms and identify the associated physical findings.
a. Upper motor neuron/lower motor neuron syndrome
b. Dementia and delirium
c. Higher cortical sensory deficits (agraphesthesia, astereognosis)
d. Apraxia, aphasia
e. Internuclear ophthalmoplegia (INO)
f. Central VII weakness, Bell's palsy
g. L'hermittes phenomena
h. Rigidity, spasticity
i. Myerson's sign (glabellar reflex), snout & grasp reflex
j. Hoffman's sign, Babinski sign
k. Parkinson's tremor, essential tremor
l. Fasciculations
m. Papilledema
n. Myelopathy
2. What are the following conditions and how are they identified?
a. Myelitis
b. Multiple Sclerosis
c. Pseudotumor cerebri (idiopathic intracranial hypertension)
d. Normal pressure hydrocephalus
e. Communicating vs. non-communicating hydrocephalus
f. Conversion disorders
g. Trigeminal neuralgia
h. Myasthenia Gravis
i. Syncope seizure
j. Benign positional vertigo
k. Tourette's syndrome
l. Narcolepsy
m. Spinal stenosis
3. Define epilepsy and the following seizure types.
a. Absence
b. Generalized tonic-clonic
c. Myoclonic
d. Atonic
e. Simple partial
f. Complex partial
g. Secondarily generalized tonic-clonic
4. What are the cardinal features of idiopathic Parkinson's disease?
5. What is Parkinsonism? List 3 different causes.
6. How are migraines and cluster headaches differentiated?
7. How can vitamin B12 deficiency affect the nervous system?
8. What are the neurologic complications of alcoholism?
9. What are the patterns of neurologic dysfunction in HIV infection?
10. What are the possible mechanisms of ischemic cerebral infarction and what studies can be performed to identify them?
11. What are the signs of progressive temporal lobe herniation (uncal herniation)?
12. What are the patterns of visual loss associated with the following?
a. Left occipital lobe tumor
b. Right temporal lobe infarct
c. Optic neuritis/optic neuropathy
d. Amaurosis fugax
e. Migraine with aura
f. Idiopathic intracranial hypertension
Respiratory Tract Basic Questions
1. Describe how each of the following symptoms relates to disease of the lungs; describe the source of the symptom.
a. Cough and sputum production
b. Dry cough
c. Wheeze and reduced forced air flow
d. Snore
e. Chest pain with breathing
f. Shortness of breath with exercise
g. Cyanosis, confusion
2. Describe the common causes of the following:
a. Episodic airway narrowing
b. Chronic lung disease with airway obstruction
c. Pulmonary infiltrates with fever
d. Segmental atelectasis of the lung
e. Small nodules in the lung
f. Large nodules in the lung
g. Interstitial infiltrates (diffuse alveolitis)
3. Contrast and compare "obstructive" and "restrictive" disease with respect to lung volumes, forced expiratory airflow, and chest x-ray.
4. Physiologic causes of hypoxemia include shunting, low V/Q and hypoventilation. Contrast these with respect to
a. Pathologic cause
b. Response to high percentage inspired oxygen
c. Response to slightly increased percentage of inspired oxygen
5. Describe the effect of hypoxemia on the following: pulmonary arterial bed, mental status, and free water clearance.
6. Describe the natural history, etiologies, physical findings, and x-ray findings of the following "obstructive" lung diseases.
a. Emphysema
b. Chronic bronchitis
c. Chronic asthma - be able to make the distinction with chronic bronchitis & emphysema
d. Bronchiectasis
e. Cystic fibrosis
7. Describe the role of the following in asthma:
a. The nature of the Inflammatory Response in asthma and how allergy effects this response
b. Hyperresponsiveness
c. Response to theophylline, sympathomimetics, atropine
d. Role of inflammation in asthma and of drugs that affect inflammation.
8. Discuss the syndromes of pulmonary emboli with respect to symptoms of pain, blood pressure, chest x-ray, and pulmonary angiogram.
a. Multiple non-infarcting emboli
b. Embolus with infarction
c. Embolus obstructing more than 70% of the vascular bed
9. Describe the pathophysiology of the Adult Respiratory Distress Syndrome. List the common causes.
10. Review the questions appropriate for determining the following host factors in pneumonia:
a. Aspiration
b. Immunosuppression (immunoglobulins and lymphocytes)
c. Exposure to tuberculosis and fungi
d. Exposure to epidemic organism
e. Effect of preceding viral respiratory infection
11. Describe the possible x-ray presentations of lung carcinoma
12. Describe obstructive sleep apnea; central apnea. Use a diagram of how Oz sat, airflow and respiratory effort look during each
13. Explain the flow of lymphatic fluid into the pleural space in the following circumstances.
a. Normal lung
b. High pressure in pulmonary veins (congestive heart failure)
c. Low oncotic pressure in plasma (hypoalbuminemia)
d. Abnormal blood vessels in pleural neoplasm
e. Oozing from pneumonia without empyema
f. Empyema
Explain how examination of the fluid for cells, LDH, protein, glucose, and pH helps in this differentiation.
Rheumatic Disease Basic Questions
1. Describe the following:
a. Immunoglobulins, IgG and IgM
b. Rheumatoid factors
c. Antinuclear antibodies
d. Complement
2. Describe the typical pathology, natural history, and symptoms of joints impaired by:
a. Rheumatoid arthritis
b. Osteoarthritis
c. Septic arthritis
d. Crystal induced arthritis (gout, pseudogout)
e. Ankylosing spondylitis
How does this pathology affect the x-ray, the synovial fluid, and the physical exam?
3. Discuss the extra articular manifestations of:
a. Rheumatoid arthritis
b. Lupus erythematosus
c. Gout
d. Gonorrheal arthritis
e. Ankylosing spondylitis and other spondyloarthropathies
f. Psoriatic arthritis
4. Discuss the pathology and presentation of vasculitis in:
a. Rheumatoid arthritis
b. Wegener's granulomatosis
c. Hypersensitivity angiitis
d. Temporal arthritis
5. Describe the principal features of systemic sclerosis and polymositis.
6. Describe the following:
a. Tophi
b. Rheumatoid nodules
c. Raynaud's phenomenon
d. Sjogren's syndrome
e. Morning stiffness in rheumatoid stiffness
f. Polymyalgia rheumatica
g. Fibromyalgia
7. Describe the following common pain syndromes:
a. Traumatic arthritis
b. Tendonitis (bicipital and rotator cuff)
c. Frozen shoulder
d. Herniated lumbar disk, lateral and central
e. Spinal Stenosis
f. Tennis elbow
g. Tears of a knee cartilage
h. Cervical spondylosis
8. Discuss the following drugs' actions, uses, and complications: aspirin, steroids, NSAID's, gold, allopurinol, azathiopirine, and methotrexate.
9. Discuss the role of non-pharmacological treatments including: counseling, heat and cold, rest and physical therapies.