Iran Specialty Board - Internal Medicine cheat sheet

Acute STEMI: activate reperfusion within 90 minutes of first medical contact for primary PCI; fibrinolysis is reserved when PCI cannot be achieved within 120 minutes and symptom onset is under 12 hours.

Dual antiplatelet therapy after ACS: aspirin 81 mg plus a P2Y12 inhibitor for 12 months is standard; shorten to 6 months or less when bleeding risk dominates, and continue aspirin indefinitely.

Heart failure with reduced ejection fraction (LVEF ≤40%): the four pillars are ARNI/ACEi/ARB, evidence-based beta-blocker, MRA, and SGLT2 inhibitor; each reduces mortality and should be started early.

Atrial fibrillation stroke risk: CHA2DS2-VASc score ≥2 in men or ≥3 in women warrants oral anticoagulation; DOACs are preferred over warfarin except in moderate-severe mitral stenosis or mechanical valves.

Acute pericarditis: diagnosis requires 2 of 4 criteria (chest pain, pericardial rub, diffuse ST elevation/PR depression, new effusion); treat with NSAID plus colchicine.

Aortic stenosis severity: severe when peak velocity ≥4 m/s, mean gradient ≥40 mmHg, or valve area ≤1.0 cm²; symptomatic severe AS or LVEF <50% is a class I indication for valve replacement.

Hypertrophic cardiomyopathy: avoid dehydration and vasodilators; septal reduction is indicated for drug-refractory symptoms with resting or provoked gradient ≥50 mmHg.

Infective endocarditis: obtain 3 sets of blood cultures before antibiotics; surgery is indicated for heart failure from valve dysfunction, uncontrolled infection, or high embolic risk with large vegetations.

COPD is confirmed by post-bronchodilator FEV1/FVC <0.70; GOLD ABE grouping guides inhaled therapy, and triple therapy is reserved for group E with eosinophils ≥300 or frequent exacerbations.

Asthma control is assessed by symptom frequency, reliever use, and activity limitation; step-up adds ICS-formoterol as reliever and maintenance rather than short-acting beta-agonist alone.

Community-acquired pneumonia severity: CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30, low blood pressure, age ≥65) with score ≥2 supports admission.

Pleural effusion: Light's criteria classify exudate when pleural protein/serum protein >0.5, pleural LDH/serum LDH >0.6, or pleural LDH >2/3 upper normal serum LDH.

Pulmonary embolism: use age-adjusted D-dimer in patients >50 years; high-risk PE with hypotension requires systemic thrombolysis or embolectomy.

Obstructive sleep apnea: diagnosis requires apnea-hypopnea index ≥5 with symptoms or ≥15 regardless of symptoms; CPAP is first-line for symptomatic moderate-severe disease.

Pulmonary function interpretation: obstruction when FEV1/FVC is below LLN; restriction when FVC is low with normal or high ratio, confirmed by reduced total lung capacity.

Tuberculosis: sputum AFB smear and culture plus nucleic acid amplification; standard drug-susceptible regimen is 2 months HRZE followed by 4 months HR.

Upper GI bleeding: pre-endoscopic proton pump inhibitor infusion plus endoscopy within 24 hours; variceal bleeding adds vasoactive drug and prophylactic antibiotics.

Helicobacter pylori eradication: bismuth quadruple therapy for 14 days is preferred where clarithromycin resistance exceeds 15%; confirm eradication at least 4 weeks after therapy.

Acute pancreatitis: diagnosis needs 2 of 3 (typical pain, lipase >3× upper limit, imaging); early management is aggressive lactated Ringer's and enteral nutrition, not prophylactic antibiotics.

Ascites from cirrhosis: diagnostic paracentesis with SAAG ≥1.1 g/dL indicates portal hypertension; spontaneous bacterial peritonitis when ascitic PMN ≥250/mm³, treat with third-generation cephalosporin.

Hepatorenal syndrome: functional renal failure in cirrhosis unresponsive to volume; terlipressin plus albumin is first-line, and liver transplantation is definitive.

Inflammatory bowel disease: ulcerative colitis is continuous and mucosal; Crohn disease is transmural, skip lesions, and fistula-prone; treat with 5-ASA for mild UC and biologics for moderate-severe disease.

Celiac disease: screen with tissue transglutaminase IgA plus total IgA; duodenal biopsy showing villous atrophy confirms diagnosis while on a gluten-containing diet.

Colorectal cancer screening: start at age 45 in average risk; colonoscopy every 10 years or annual fecal immunochemical test are acceptable strategies.

Acute kidney injury: KDIGO stages by creatinine rise (1.5–1.9×, 2.0–2.9×, ≥3× or ≥4 mg/dL) or urine output (<0.5 mL/kg/h for 6, 12, 24 hours).

Fractional excretion of urea <35% suggests prerenal azotemia when diuretics confound fractional excretion of sodium.

Hyperkalemia with ECG changes: give intravenous calcium first, then insulin with glucose and beta-agonist to shift potassium, then remove with diuretics or dialysis.

Hyponatremia: correct chronic hyponatremia by ≤8 mmol/L in 24 hours to avoid osmotic demyelination; hypertonic saline is reserved for symptomatic or severe cases.

Metabolic acidosis: calculate anion gap (Na − [Cl + HCO3]); high-gap causes include ketoacidosis, lactate, uremia, and toxins; normal-gap suggests diarrhea or renal tubular acidosis.

Chronic kidney disease staging uses GFR categories G1–G5 and albuminuria A1–A3; SGLT2 inhibitors slow progression in albuminuric CKD regardless of diabetes.

Nephrotic syndrome: proteinuria >3.5 g/day, hypoalbuminemia, edema, hyperlipidemia; biopsy is generally indicated in adults to define histology.

Hypokalemia: each 1 mmol/L fall in serum potassium reflects roughly 200–400 mmol total body deficit; replace with potassium chloride and correct magnesium concurrently.

Diabetes diagnosis: fasting glucose ≥126 mg/dL, 2-hour glucose ≥200 mg/dL, HbA1c ≥6.5%, or random ≥200 with symptoms; confirm with a second test unless unequivocal.

Type 1 diabetes: check GAD65 and islet antigen-2 antibodies when phenotype is atypical; insulin is required from diagnosis.

Diabetic ketoacidosis: manage with isotonic fluid, insulin infusion at 0.1 U/kg/h, and potassium replacement; add dextrose when glucose falls below 200–250 mg/dL.

Thyroid function: TSH plus free T4; subclinical hypothyroidism is elevated TSH with normal free T4, and treatment is considered when TSH >10 mIU/L.

Thyroid storm: clinical diagnosis with Burch-Wartofsky score; treat with beta-blocker, thionamide, iodine after thionamide, and glucocorticoid.

Adrenal crisis: draw cortisol and ACTH then give dexamethasone or hydrocortisone immediately with saline; do not delay steroids for results.

Primary hyperaldosteronism: aldosterone-to-renin ratio is the screening test; confirm with saline suppression or captopril challenge before adrenal vein sampling.

Pheochromocytoma: screen with plasma free metanephrines; alpha-blockade precedes beta-blockade to avoid unopposed vasoconstriction.

Iron deficiency anemia: low ferritin is diagnostic; ferritin can be falsely normal in inflammation, so check transferrin saturation and soluble transferrin receptor.

Anemia of chronic disease: normocytic with low serum iron, low TIBC, normal or high ferritin, and low transferrin saturation.

B12 deficiency: macrocytic anemia with elevated methylmalonic acid and homocysteine; treat with intramuscular or high-dose oral cyanocobalamin.

Microangiopathic hemolytic anemia: schistocytes with thrombocytopenia and elevated LDH suggests TTP; urgent plasma exchange is indicated when ADAMTS13 is <10%.

Neutropenic fever: absolute neutrophil count <500/µL with fever ≥38.3°C once or ≥38.0°C sustained; give empiric antipseudomonal beta-lactam within 60 minutes.

Tumor lysis syndrome: Cairo-Bishop criteria use uric acid, potassium, phosphate, and calcium; prevent with hydration and allopurinol or rasburicase in high-risk disease.

Venous thromboembolism in cancer: low-molecular-weight heparin or direct oral anticoagulants are preferred over warfarin; continue while active malignancy persists.

Febrile transfusion reaction: stop the transfusion, maintain intravenous access, and evaluate for hemolysis; acute hemolytic reactions require immediate cessation and fluid support.

Sepsis: use qSOFA (respiratory rate ≥22, altered mentation, systolic blood pressure ≤100) for risk stratification; give broad-spectrum antibiotics within 1 hour of septic shock recognition.

Meningitis: perform blood cultures and lumbar puncture without delay; empiric therapy for adults is ceftriaxone plus vancomycin plus ampicillin when Listeria risk is present.

Infective endocarditis: three sets of blood cultures from separate sites before antibiotics; add gentamicin only for specific organisms such as enterococcus.

HIV: initiate antiretroviral therapy regardless of CD4 count; screen for tuberculosis, hepatitis B and C, and sexually transmitted infections at baseline.

Hepatitis B: treatment threshold includes HBV DNA >2000 IU/mL with elevated ALT or fibrosis; tenofovir or entecavir are first-line agents.

Clostridioides difficile: oral vancomycin or fidaxomicin for initial episodes; fecal microbiota transplantation is reserved for recurrent disease after appropriate antibiotics.

Malaria: thick and thin smears plus rapid antigen test; severe falciparum malaria requires intravenous artesunate.

Antimicrobial stewardship: de-escalate based on culture and susceptibility; procalcitonin can support stopping antibiotics in lower respiratory tract infection when used with clinical judgment.

Rheumatoid arthritis: anti-cyclic citrullinated peptide is highly specific; methotrexate is first-line disease-modifying therapy, with biologic or targeted synthetic agents added for inadequate response.

Systemic lupus erythematosus: antinuclear antibody is sensitive but not specific; anti-double-stranded DNA and anti-Smith are specific, and complement consumption tracks activity.

Gout: joint aspiration showing negatively birefringent needle-shaped crystals is diagnostic; treat acute flares with NSAIDs, colchicine, or glucocorticoids, not urate-lowering therapy alone.

Ankylosing spondylitis: sacroiliitis on imaging plus inflammatory back pain; HLA-B27 supports but does not confirm the diagnosis.

Giant cell arteritis: new headache, jaw claudication, or visual symptoms in a patient >50 years warrants immediate high-dose glucocorticoid and temporal artery biopsy, without waiting for biopsy.

Antiphospholipid syndrome: persistent lupus anticoagulant, anticardiolipin, or anti-beta-2 glycoprotein I antibodies with thrombosis or pregnancy loss; long-term anticoagulation for thrombotic disease.

Scleroderma renal crisis: new hypertension and rising creatinine in diffuse systemic sclerosis; treat with an ACE inhibitor immediately.

Anaphylaxis: intramuscular epinephrine 0.3–0.5 mg of 1:1000 solution into the lateral thigh is first-line, followed by airway support and antihistamines as adjuncts.

Acute ischemic stroke: noncontrast CT excludes hemorrhage; intravenous alteplase is indicated within 4.5 hours of onset, and mechanical thrombectomy for large vessel occlusion up to 24 hours in selected patients.

Stroke thrombectomy: do not delay for response to thrombolysis; large vessel occlusion with small core and salvageable penumbra benefits from endovascular therapy.

Status epilepticus: benzodiazepine first, then second-line levetiracetam, valproate, or fosphenytoin; refractory cases need anesthetic infusion and continuous EEG.

Headache red flags: thunderclap onset, fever with neck stiffness, focal deficit, papilledema, age >50 with new headache, or pregnancy warrant urgent imaging or lumbar puncture.

Multiple sclerosis: diagnosis requires dissemination in space and time by McDonald criteria; acute relapse is treated with high-dose corticosteroids, and disease-modifying therapy reduces relapse rate.

Myasthenia gravis: fatigable weakness with ptosis and diplopia; anti-acetylcholine receptor antibodies are most specific, and respiratory failure requires urgent plasma exchange or IVIG.

Guillain-Barré syndrome: ascending symmetric weakness with areflexia and albuminocytologic dissociation; monitor vital capacity and treat with IVIG or plasma exchange.

Delirium: acute fluctuating inattention with altered cognition; identify and treat precipitating causes such as infection, medications, and metabolic derangement before using antipsychotics.

Stevens-Johnson syndrome and toxic epidermal necrolysis: mucosal involvement with epidermal detachment; stop the culprit drug, provide supportive burn-like care, and avoid prophylactic antibiotics.

Atopic dermatitis: emollients plus topical corticosteroids are first-line; dupilumab is an option for moderate-severe disease refractory to topical therapy.

Psoriasis: topical corticosteroids for limited plaque disease; methotrexate, biologics, or phototherapy for moderate-severe disease, and screen for tuberculosis before biologics.

Cellulitis: nonpurulent and usually streptococcal; treat with cephalexin or clindamycin, and consider MRSA coverage when purulence or abscess is present.

Urticaria: second-generation H1 antihistamines are first-line; if uncontrolled, increase dose or add omalizumab rather than chronic oral corticosteroids.

Contact dermatitis: patch testing identifies allergens; avoid the allergen and use topical corticosteroids for localized flares.

Pemphigus vulgaris: flaccid bullae with mucosal erosions; anti-desmoglein 3 antibodies and intraepidermal clefting on biopsy confirm, treated with corticosteroids plus rituximab.

Drug reaction with eosinophilia and systemic symptoms: fever, rash, eosinophilia, and organ involvement; withdraw the drug and monitor for viral reactivation and autoimmune sequelae.

Frailty and falls: assess gait, vision, medications, and orthostatic blood pressure; deprescribe sedatives and antihypertensives when orthostasis is present.

Polypharmacy: use Beers criteria or STOPP/START to identify potentially inappropriate medications; anticholinergics and benzodiazepines increase delirium and fall risk.

Delirium prevention: orientation, sleep hygiene, early mobilization, hydration, and minimizing restraints reduce incidence in hospitalized older adults.

Palliative care: assess pain, dyspnea, and total suffering; opioids are first-line for cancer pain, and bowel prophylaxis is added with chronic opioid use.

Prognosis communication: use the SPIKES framework (setting, perception, invitation, knowledge, empathy, strategy) for breaking bad news.

Advance care planning: document goals of care and code status; a healthcare proxy should be identified before acute deterioration when possible.

Deprescribing at end of life: stop statins, bisphosphonates, and tight glycemic control when life expectancy is limited and burdens outweigh benefit.

Adult immunization: influenza annually, COVID-19 per schedule, pneumococcal vaccination for adults ≥65, and shingles vaccine for adults ≥50.

Septic shock: 30 mL/kg crystalloid within the first 3 hours for hypotension or lactate ≥4 mmol/L, then norepinephrine to target mean arterial pressure ≥65 mmHg.

Acute respiratory distress syndrome: Berlin criteria require onset within 1 week, bilateral opacities, and PaO2/FiO2 ≤300 on PEEP ≥5; use low tidal volume 6 mL/kg predicted body weight.

Mechanical ventilation: lung-protective ventilation targets plateau pressure ≤30 cmH2O and driving pressure ≤15 cmH2O; permissive hypercapnia is acceptable.

Diabetic ketoacidosis and hyperosmolar hyperglycemic state: correct volume first, then insulin; monitor potassium and add dextrose when glucose is 200–250 mg/dL.

Anaphylaxis and airway: epinephrine intramuscularly, high-flow oxygen, and early intubation when stridor or angioedema progresses; antihistamines do not reverse airway edema.

Poisoning: activated charcoal within 1 hour for life-threatening ingestion if airway is protected; naloxone for opioid toxicity and N-acetylcysteine for acetaminophen overdose.

Cardiac arrest: high-quality chest compressions at 100–120/min with depth 5–6 cm; defibrillate shockable rhythms and use epinephrine 1 mg every 3–5 minutes.

Hypertensive emergency: reduce mean arterial pressure by no more than 25% in the first hour, then to 160/100 mmHg over 2–6 hours, except in aortic dissection or eclampsia.