Preparing for Higher Level Exams

8/6/2019 Preparing for Higher Level Exams

1/36

Preparing for HigherPreparing for HigherLevel ExamsLevel Exams

Nowreen Haq, MD, MPHNowreen Haq, MD, MPH

Attending PhysicianAttending Physician

Department of Internal MedicineDepartment of Internal Medicine

Johns Hopkins School of MedicineJohns Hopkins School of Medicine

Maryland, USAMaryland, USA


2/36

The planningThe planning

Where do you see yourself 2 years fromWhere do you see yourself 2 years fromnow, 5 years from now and 10 years fromnow, 5 years from now and 10 years fromnow?now?

How did I plan my career?How did I plan my career?

International exams have a commonInternational exams have a commonstandard and curriculumstandard and curriculum--USMLE, MRCP,USMLE, MRCP,CMCEE, AUMC and so forthCMCEE, AUMC and so forth


3/36

USMLEUSMLE--what you should knowwhat you should know

www.usmle.orgwww.usmle.org

www.nbme.orgwww.nbme.org

Anyone with foreign medical graduationAnyone with foreign medical graduationwill have to take USMLE step 1, step 2will have to take USMLE step 1, step 2Clinical Knowledge and step 2 clinicalClinical Knowledge and step 2 clinicalskillsskills

step 1 and 2 CK can be taken instep 1 and 2 CK can be taken inBangladeshBangladesh

CS and srtep 3 conducted in USACS and srtep 3 conducted in USA


4/36

USMLEUSMLE--what you should knowwhat you should know

You can take step 3 after you match forYou can take step 3 after you match forresidency or even during residency, butresidency or even during residency, but

better to take it after step 2, so that youbetter to take it after step 2, so that youcan get H1 visacan get H1 visa

For you, 90(220) should be the PASSINGFor you, 90(220) should be the PASSINGScoreScore

A recent graduate with no longer than 5A recent graduate with no longer than 5years after graduation is highly preferredyears after graduation is highly preferred


5/36

Applying for ResidencyApplying for Residency

You can apply after even step 1, but IYou can apply after even step 1, but Idont encourage!dont encourage!

Better to apply with step 1 and 2 completeBetter to apply with step 1 and 2 complete

scores by September 2011 to match for ascores by September 2011 to match for aposition from July 2012position from July 2012

You can get visit visa for Step 2 CS andYou can get visit visa for Step 2 CS andinterviews and observershipsinterviews and observerships

Observership or external rotation isObservership or external rotation isimportant for LORimportant for LOR


6/36

ExpensesExpenses

The process is very expensive with noThe process is very expensive with noguarantee of securing a spotguarantee of securing a spot

$750 to $1200 for each of the USMLE$750 to $1200 for each of the USMLE

examsexams Individual match application costs $50Individual match application costs $50--

$100 and you need to apply to at least 100$100 and you need to apply to at least 100hospitals to get 1hospitals to get 1--2 interviews2 interviews

Observership is also a paid program mostObservership is also a paid program mostof the timeof the time


7/36

What are the Benefits?What are the Benefits?

Job securityJob security

Better paycheckBetter paycheck--one of the highest paidone of the highest paid

salaries in USsalaries in USMultiple options in building your careerMultiple options in building your career

You can chose your lifestyleYou can chose your lifestyle

Career satisfactionCareer satisfaction


8/36

USMLE contents and our planUSMLE contents and our plan

We will go per subject and divide our studyWe will go per subject and divide our studycontent into each organ system, e.g.content into each organ system, e.g.cardiology, pulmonary, hematology andcardiology, pulmonary, hematology and

oncology, infectious disease, nephrology,oncology, infectious disease, nephrology,GI, endocrinology, rheumatology, allergyGI, endocrinology, rheumatology, allergyand immunology, epidemiology andand immunology, epidemiology andbiostatistics, Critical care medicine andbiostatistics, Critical care medicine andneurologyneurology

It is timeIt is time--consumingconsuming


9/36

PulmonologyPulmonology--in a nutshellin a nutshell

Signs and symptomsSigns and symptoms--

Pulmonary Function TestsPulmonary Function Tests

CXRCXR

Obstructive and restricitve dzObstructive and restricitve dz

PEPE

Lung cancerLung cancer


10/36


11/36

Pulmonary Function Tests (PFTs)Pulmonary Function Tests (PFTs)

Identify presence or absence ofIdentify presence or absence ofobstructionobstruction

Assess vital capacityAssess vital capacityConfirm restriction with lung volumeConfirm restriction with lung volume

Assess severity of obstruction orAssess severity of obstruction or

restricitonrestriciton


12/36

Pulmonary Function TestPulmonary Function Test

Flow volume curveFlow volume curve

Airflow measured by expiratory flowAirflow measured by expiratory flowrate(ratio of forced expiratory volume in 1rate(ratio of forced expiratory volume in 1s to forced vital capacity [FEV1/FVC] ors to forced vital capacity [FEV1/FVC] orforced expiratory flow between 25forced expiratory flow between 25--75% of75% ofexpirationexpiration--MMFRMMFR

Alveolar membrane permeabilityAlveolar membrane permeabilitymeasured by DLCO (diffusing capacity ofmeasured by DLCO (diffusing capacity ofa gas)a gas)


13/36

Pulmonary volumesPulmonary volumes

TLCTLC VCVC ICIC

IRVIRV

VTVT

RVRV FRCFRC ERVERV


14/36

Interpret Forced Expiratory CurveInterpret Forced Expiratory Curve

FEV1/FVC=4/5 (volume per sec)FEV1/FVC=4/5 (volume per sec)

FEV1/FVC=1.3/3.1

FEV1/FVC=2.8/3.1


15/36

Clinical interpretationClinical interpretation

PFT indicesPFT indices Patient 1Patient 1 Patient 2Patient 2TLCTLC 87%87% 55%55%

RVRV 120%120% 50%50%

VCVC 90%90% 50%50%

FEF (25FEF (25--75%)75%) 50%50% 90%90%

Diagnosis?Diagnosis?


16/36

Disturbance in Gas ExchangeDisturbance in Gas Exchange

PaO2 or arterial O2 does not assess O2PaO2 or arterial O2 does not assess O2transport to tissuestransport to tissues

Oxygen tissueOxygen tissue

content=CO(1.34*hgb*saturation)+0.031*Pcontent=CO(1.34*hgb*saturation)+0.031*PO2O2

AlveolarAlveolar--arterial O2 Gradient (PAO2arterial O2 Gradient (PAO2--PaO2)=150PaO2)=150--1.25*PCO21.25*PCO2--PaO2PaO2

55--15 normal, patient with hypoxemia will15 normal, patient with hypoxemia willhave higher valueshave higher values


17/36


18/36

QuestionQuestion

76 yr old man with dyspnea and pleuritic76 yr old man with dyspnea and pleuriticchest pain worsened over last month. Alsochest pain worsened over last month. Alsonoticed wt. loss of 20 lbs and lownoticed wt. loss of 20 lbs and low--gradegrade

fever. His respiratory rate is 24, there isfever. His respiratory rate is 24, there isreduced air entry in right lower lobe withreduced air entry in right lower lobe withdullness to percussion. CXR showsdullness to percussion. CXR showsopacified shadow in oneopacified shadow in one--third of right lungthird of right lungfield.field.

What is your diagnosis?What is your diagnosis?


19/36

How to differentiate transudate andHow to differentiate transudate and

exudate?exudate? Two important thingsTwo important things--

LDH, Protein, getLDH, Protein, getboth plural fluid andboth plural fluid and

serum levelsserum levels Causes of exudativeCauses of exudative

and transudativeand transudativeplerual effusionsplerual effusions

TransudateTransudate ExudateExudate

LDH200

LDH E/SLDH E/S0.6

ProteinProteinE/S


20/36


21/36

Obstructive DiseaseObstructive Disease

Asthma=Reversible obsttuctionAsthma=Reversible obsttuction Know intrinsic and extrinsic asthmaKnow intrinsic and extrinsic asthma

What is the 1What is the 1stst line of therapyline of therapy

When do you start inhaled corticostaroids?When do you start inhaled corticostaroids?

Common regimen in moderate to severeCommon regimen in moderate to severeasthmaasthma--albuterol and beclomethasonealbuterol and beclomethasone

RememberRemember--increased PaCO2 in statusincreased PaCO2 in statusasthmaticus is an ominous signasthmaticus is an ominous sign


22/36

COPDCOPD

Both Emphysema and chronic bronchitis.Both Emphysema and chronic bronchitis.

Chronic bronchitis with productive cough of atChronic bronchitis with productive cough of atleast 3 months for at least 2 years.least 3 months for at least 2 years.

Emphysema creates abnormal permanentEmphysema creates abnormal permanentdilation of air spaces distal to the terminaldilation of air spaces distal to the terminalbronchioles with destruction of cartilagebronchioles with destruction of cartilage

Patients can have bothPatients can have both

Chronic smokers, rarely alphaChronic smokers, rarely alpha--1 antitrypsin1 antitrypsindeficiency can cause emphysemadeficiency can cause emphysema


23/36

COPDCOPD--what you must knowwhat you must know

Anticholinergic inhalers like Ipratropium isAnticholinergic inhalers like Ipratropium isthe 1the 1stst line agent in treatment than betaline agent in treatment than beta--agonistsagonists

Main stay of treatment if Home 02 ifMain stay of treatment if Home 02 ifsaturation is


24/36


25/36

Restrictive Lung DiseaseRestrictive Lung Disease

Idiopathic Pulmonary Fibrosis(IPF)Idiopathic Pulmonary Fibrosis(IPF)

AA 5555 year old man comes for evaluation ofyear old man comes for evaluation ofexercise tolerance over past 6 months. Noexercise tolerance over past 6 months. Nopast medical history, but now cannot walkpast medical history, but now cannot walkeven a short distance. Nonsmoker, noeven a short distance. Nonsmoker, nomedications used. RR is 24, JVD is 8 cm,medications used. RR is 24, JVD is 8 cm,coarse cracklescoarse crackles on auscualtation,on auscualtation,clubbing and trace pedal edema.clubbing and trace pedal edema. DiffuseDiffusereticular pattern on CXRay.reticular pattern on CXRay.


26/36

IPFIPF

CT scan shows groundCT scan shows ground--glass appearanceglass appearance

Treatment with steroids with or withoutTreatment with steroids with or withoutazathioprine only benefits 20% of patients.azathioprine only benefits 20% of patients.


27/36


28/36

SarciodosisSarciodosis

Histologically confirmed by havingHistologically confirmed by havingnoncaseating granulomas, mainly in lungsnoncaseating granulomas, mainly in lungs

Lofgren syndromeLofgren syndrome--E.nodoum, hilarE.nodoum, hilar

adenopathy, arthritisadenopathy, arthritisMacrophages produce vitamin D andMacrophages produce vitamin D and

hypercacemia is evident in lab testshypercacemia is evident in lab tests

Also sometimes associated with parotidAlso sometimes associated with parotidenlargement and Bells palsy.enlargement and Bells palsy.


29/36

PneumoconiosisPneumoconiosis

Occupational lung disease, occurs 20Occupational lung disease, occurs 20--3030yrs after getting exposed to gold, silver ,yrs after getting exposed to gold, silver ,lead or copper dustslead or copper dusts

Honeycombing in Lung images is the clueHoneycombing in Lung images is the clue

Restricive pattern with decreased DLCoRestricive pattern with decreased DLCo


30/36

AsbestosisAsbestosis

Mine, shipyard, Pipeline and boilerMine, shipyard, Pipeline and boilerworkersworkers

Pleural thickening, pleural calcificationPleural thickening, pleural calcification

Associated with bronchogenic ca likeAssociated with bronchogenic ca likeAdenocarcinoma and Squamous cellAdenocarcinoma and Squamous cellcarcinomacarcinoma

Lung biopsy shows classic barbellLung biopsy shows classic barbell--shapedshapedasbestos fiberasbestos fiber


31/36

SilicosisSilicosis

Exposure to silica dusts such as glassExposure to silica dusts such as glassfactory workers, sandblasting, mining,factory workers, sandblasting, mining,pottery makerspottery makers

Nodules in upper lobe in CXR withNodules in upper lobe in CXR withcommonly found eggshell calcificationscommonly found eggshell calcifications

Should get PPD and if >10 mm, should getShould get PPD and if >10 mm, should getINH therapyINH therapy


32/36

Lung CancerLung Cancer

Overall 5 yr survival for SCC is 5% and NSCC isOverall 5 yr survival for SCC is 5% and NSCC is8%8%

Sqamous Cell Ca: Centrally located, a/w cavitarySqamous Cell Ca: Centrally located, a/w cavitarylesions,lesions, hypercalcemia because these callshypercalcemia because these callssecret parathyroid hormone like substancesecret parathyroid hormone like substance

Adenocarcinoma/brochoalveolar ca: PerpherallyAdenocarcinoma/brochoalveolar ca: Perpherallylocated, a/w pleural effusions with highlocated, a/w pleural effusions with highhyaluronidase levels. Needs thoracotomy withhyaluronidase levels. Needs thoracotomy withpleural biopsypleural biopsy

SCC:A/W EatonSCC:A/W Eaton--Lambert syndrome, SIADH,Lambert syndrome, SIADH,and other paraneoplastic syndromes. It alsoand other paraneoplastic syndromes. It alsocauses venocaval obstructioncauses venocaval obstruction


33/36

QuestionQuestion

65 yr old man admitted because of blurry65 yr old man admitted because of blurryvision and headache. He also hasvision and headache. He also hasprominent neck vein distension and darkerprominent neck vein distension and darkercoloration over his face and neck. He iscoloration over his face and neck. He isconfused.Chest Xray reveals right upperconfused.Chest Xray reveals right upperlobe lung mass and blood tests showlobe lung mass and blood tests show

hypercalcemia.hypercalcemia.What is your diagnosis?What is your diagnosis?


34/36

PEPE

32 yr old woman comes with acute onset of32 yr old woman comes with acute onset ofSOB, while she was shopping. SheSOB, while she was shopping. Sherecently started oral contraceptives, herrecently started oral contraceptives, herHR is 114 and RR is 26.CXR normal andHR is 114 and RR is 26.CXR normal andABG shows pH pf 7.52, PCO2 of 25 andABG shows pH pf 7.52, PCO2 of 25 andPO2 of 75.PO2 of 75.

What are the causes of her diagnosis?What are the causes of her diagnosis?


35/36

Signs and Treatment of PESigns and Treatment of PE

EKG: Right axis deviation, S1Q3T3EKG: Right axis deviation, S1Q3T3 Elevated dElevated d--dimer level is sensitive testdimer level is sensitive test

Doppler USG of the legs should show DVTDoppler USG of the legs should show DVT

Special image like V/Q scan mismatch orSpecial image like V/Q scan mismatch orspiral CT scan with IV contrastspiral CT scan with IV contrast

Continuous IV heparin therapy or LovenoxContinuous IV heparin therapy or Lovenoxweight based dose with Coumadinweight based dose with Coumadin(warfarin) minimun 3 months, if recurs,(warfarin) minimun 3 months, if recurs,lifelong therapylifelong therapy


36/36

More to comeMore to come

Thank You!Thank You!

Documents

Preparing for Higher Level Exams