Iraqi Board Internal Medicine common mistakes
Iraqi Board Internal Medicine · Understand the traps and how to avoid them.
In a patient with severe tearing chest pain and a blood-pressure difference between arms, committing to acute coronary syndrome and giving aspirin plus heparin before aortic dissection is excluded.
Chest pain with vascular risk factors strongly cues ACS, and dissection signs such as pulse deficit, back pain, or a widened mediastinum are subtle and easily missed under time pressure.
What to do instead
Before antiplatelet or anticoagulant therapy, deliberately check bilateral arm blood pressures and pulses, ask about tearing or interscapular pain, and review the chest radiograph for mediastinal widening. If dissection is plausible, obtain urgent CT angiography and involve cardiothoracic surgery before giving agents that increase bleeding risk.
In acute severe asthma with a silent chest and a normal or rising PaCO2, documenting improvement and delaying ICU referral because the CO2 is not low.
Candidates learn that early asthma causes hypocapnia and then treat a normal CO2 as reassuring, missing that fatigue and worsening obstruction are producing CO2 retention.
What to do instead
Treat a normal or elevated PaCO2 in acute severe asthma as a pre-arrest warning when accompanied by exhaustion, drowsiness, or a silent chest. Call critical care immediately, prepare for ventilatory support, and do not wait for cyanosis or a falling oxygen saturation.
In a cirrhotic patient with hematemesis, giving large-volume crystalloid and transfusing to a normal hemoglobin while omitting prophylactic antibiotics and a vasoactive drug.
The immediate focus becomes blood pressure and hemoglobin, so variceal-specific therapy and infection prophylaxis are forgotten even though both reduce mortality.
What to do instead
Resuscitate cautiously, transfuse to a restrictive hemoglobin target of about 7-8 g/dL, start a vasoactive agent such as terlipressin or octreotide, give prophylactic ceftriaxone, and arrange endoscopy within 12 hours.
Correcting chronic hyponatremia faster than 8 mmol/L in 24 hours because the first hypertonic saline bolus produces a rapid initial rise.
The seizure risk from low sodium drives urgent correction, while the delayed risk of osmotic demyelination from overcorrection is underestimated.
What to do instead
Use 3% saline only for seizures, coma, or other severe neurologic signs, target a rise of 4-6 mmol/L and never exceed 8 mmol/L in 24 hours, recheck sodium every 4-6 hours, and if overshoot occurs give D5W with desmopressin and seek senior advice.
Starting an intravenous insulin infusion in diabetic ketoacidosis before checking potassium and before beginning isotonic fluid resuscitation.
Management is remembered as a glucose-lowering protocol, so the dependence of insulin therapy on adequate potassium and initial volume replacement is overlooked.
What to do instead
Check potassium first: if below 3.3 mmol/L, hold insulin and replace potassium; if 3.3-5.2 mmol/L, start insulin with potassium in the fluids; if above 5.2 mmol/L, start insulin without added potassium. Give isotonic saline in the first hour and monitor glucose and potassium hourly.
Ordering a platelet transfusion for suspected thrombotic thrombocytopenic purpura because the platelet count is severely low.
Low platelets trigger a reflex transfusion response, but in TTP platelet transfusion can worsen microvascular thrombosis and is not the definitive treatment.
What to do instead
When microangiopathic hemolytic anemia and thrombocytopenia are present, arrange urgent plasma exchange and corticosteroids without waiting for ADAMTS13 results. Avoid platelet transfusion unless there is life-threatening bleeding.
Diagnosing gout and starting NSAIDs or colchicine in a febrile patient with a hot swollen joint without aspirating the joint for crystals and culture.
Gout is common and the joint appearance is familiar, so septic arthritis, which can destroy a joint or cause sepsis within days, is not actively excluded.
What to do instead
Aspirate the joint before treatment whenever it can be done without delay, and send fluid for cell count, crystals, Gram stain, and culture. If septic arthritis is suspected, start empiric intravenous antibiotics immediately after aspiration and do not let a gout diagnosis delay them.
In a febrile returning traveler, ordering broad-spectrum antibiotics through a sepsis pathway without requesting thick and thin malaria films.
Sepsis protocols reward rapid antibiotics, and travel exposure is often buried in the history, so malaria is not considered before treatment is started.
What to do instead
Make travel history a routine part of the febrile admission note. For any patient returning from an endemic area, order thick and thin blood films and a rapid malaria antigen test within hours, and treat suspected severe malaria urgently alongside other sepsis care.
Activating the stroke thrombolysis pathway for acute hemiparesis without first checking a capillary blood glucose.
Time-critical stroke protocols focus on door-to-needle time, and hypoglycemia is a treatable stroke mimic that can be missed when the team moves directly to imaging and thrombolysis.
What to do instead
Make glucose measurement a mandatory first step in every acute focal neurologic deficit: treat hypoglycemia, reassess the deficit, and document the glucose result before any thrombolytic is given.
Giving repeated fixed fluid boluses in septic shock without reassessing fluid responsiveness, perfusion, or signs of pulmonary edema.
Early septic shock care is taught as a protocol with large-volume crystalloid, and candidates continue the sequence even when the patient is not responding or has cardiac or renal comorbidity.
What to do instead
After the initial bolus, reassess blood pressure, capillary refill, lactate, urine output, lung auscultation, and oxygen requirement. Use dynamic measures where available, stop fluids if there is no response or overload, and start vasopressors early rather than giving blind repeat boluses.