Top Categories to Study on the Internal Medicine Boards

The Internal Medicine boards are getting tougher, with a pass rate of 87% in 2022. With all the new breakthroughs in internal medicine, there is a growing body of knowledge for potential inclusion in the exam.

There is no single method for studying for the boards which can guarantee that the examinee will pass. There are tips, however, which can help you prepare by suggesting the subject matter known to be frequently included in the exam.

According to the ABIM Internal Medicine Certification Blueprint, the exam covers the following topics:

• Allergy and Immunology 2%
• Cardiovascular Disease 14%
• Dermatology 3%
• Endocrinology, Diabetes, and Metabolism 9%
• Gastroenterology 9%
• Geriatric Syndromes 3%
• Hematology 6%
• Infectious Disease 9%
• Nephrology and Urology 6%
• Neurology 4%
• Obstetrics and Gynecology 3%
• Medical Oncology 6%
• Ophthalmology 1%
• Otolaryngology and Dental Medicine 1%
• Psychiatry 4%
• Pulmonary Disease 9%
• Rheumatology and Orthopedics 9%
• Miscellaneous 2%

It’s important to note that the questions on the boards are not evenly distributed among the topics. Emphasis is on cardiovascular disease, pulmonary disease, and gastroenterology.

Cardiology Tips

1. Know the heart sounds, both normal and abnormal. Know the characteristics of S1 and S2, including the differences and how they change with respiration. Know how S3 and S4 sound – recall that S3 can be normal in pregnancy and children.
2. Coronary artery disease (CAD) is the number one case of death in the United States. It’s important to know what medications reduce morbidity and mortality. Know what factors contribute to CAD that can be altered to reduce morbidity, such as: smoking, hypertension, diabetes, and hyperlipidemia. Know the medications that decrease mortality and their mechanisms of action: aspirin, morphine, heparin, nitroglycerin, and clopidogrel.
3. Congestive heart failure is common, especially in the elderly, so it’s usually on the exam. Know what medications reduce morbidity and mortality. They include: ACE inhibitors, angiotensin II blockers, spironolactone, hydralazine, and beta blockers. Drugs which do not reduce morbidity and mortality include: digoxin, calcium channel blockers, diuretics, and nesiritide.
4. Know the contraindications for thrombolysis.

Gastroenterology Tips

1. Ulcerative colitis and Crohn’s disease are both inflammatory bowel disease, but are very different. Know the differences. Characteristics of ulcerative colitis include: abdominal pain and bloody diarrhea, superficial ulcers on the GI mucosa, starts at the rectum and advances deeper into the colon. Signs outside of the bowel include: aphthous ulcers, pyoderma gangrenosome, sclerosing cholangitis, ankylosing spondylitis, arthritis, erythema nodosum. Characteristics of Crohn’s disease include: rectum is spared, often starts with a painful mass in the right lower quadrant, deep ulcers with granuloma formation, not associated with signs outside the bowel.
2. All cirrhosis is not alcohol-related. Other causes include hepatitis B and C, nonalcoholic fatty liver, steatohepatitis, Wilson’s disease, alpha-1 antitrypsin deficiency, hemochromatosis, Budd-Chiari syndrome, autoimmune hepatitis, primary sclerosing cholangitis.
3. Know peptic ulcer disease: the most common causes are H. pylori and NSAIDS. Know what a patient with a perforated peptic ulcer looks like: hypotensive, tachycardic, absent bowel sounds, severe rebound tenderness, and guarding. X-ray shows free intraperitoneal air.
4. Colorectal cancer is the second leading cause of cancer deaths in the United States. Every year about 140,000 Americans are diagnosed with it, and more than 500,000 die with it. Know the disease.
5. Know hepatitis B markers:
   Hepatitis B surface antigen (HBsAg) Active infection
   Hepatitis B surface antibody (HBsAb) Past infection or vaccinated
   Hepatitis Be antigen (HbeAg) Active replication of virus
   Anti Hepatitis B core IgM antibody (Anti-HBc IgM) Acute infection
   Anti Hepatitis B core IgG antibody (Anti-HBc IgG) Chronic infection

Pulmonary Tips

1. Know the difference between obstructive and restrictive lung disease. With obstructive lung disease, total lung capacity (TLC) is increased, (asthma and COPD). With restrictive lung disease, TLC is decreased, (sarcoidosis, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, pneumoconiosis, asbestosis, silicosis, berylliosis).
2. Asthma – frequency of symptoms determines classification: intermittent, mild persistent, moderate persistent, severe persistent. Know treatments for each class.
3. Know COPD classification (using GOLD criteria) and treatment for the classifications. Criteria include dyspnea that is persistent, chronic cough, chronic sputum production, history of exposure to risk factors (tobacco smoke, smoke from cooking, occupational dust, chemicals), family history of COPD. Stage I – mild, stage II – moderate, stage III – severe, stage IV – very severe.
4. Know the difference between exudative and transudative pleural effusions. Transudative effusions include: CHF, nephrotic syndrome, cirrhosis and hypothyroidism. Exudative effusions include: neoplasm, infection, RA, SLE, esopageal perforation, pancreatitis and Dressler syndrome.

These tips are not all-inclusive, but are some of the topics you’ll surely see on the boards.

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