Internal Medicine
What Internal Medicine tests
The internal medicine section of the Palestinian Board Part I is weighted toward diagnosis and first-line management of conditions seen on any inpatient ward: acute coronary syndrome, heart failure, diabetes and its emergencies, COPD and asthma, cirrhosis, acute kidney injury and electrolyte disorders. Questions usually give a short vignette and ask for the next best step, the most likely diagnosis, or the immediate danger to correct.
Core rules
- ACS: ECG within 10 minutes; aspirin 300 mg chewed; a P2Y12 inhibitor; reperfusion by primary PCI if achievable within 120 minutes of first medical contact, otherwise fibrinolysis within 12 hours of symptom onset in STEMI.
- Heart failure with reduced ejection fraction: start the four pillars - ARNI or ACE inhibitor, beta-blocker, MRA, SGLT2 inhibitor - unless contraindicated.
- Hyperkalaemia with ECG changes: IV calcium first for membrane stabilisation, then insulin with glucose, salbutamol, and dialysis for refractory cases.
- Hyponatraemia: correct no faster than 8–10 mmol/L in 24 hours to avoid osmotic demyelination.
Worked example
A 24-year-old with type 1 diabetes presents with vomiting, Kussmaul breathing, glucose 480 mg/dL, pH 7.10, bicarbonate 8 mmol/L, ketones 4+, and potassium 3.1 mmol/L. Reason: this is diabetic ketoacidosis. Give 0.9% saline first, but do not start the insulin infusion until potassium is above 3.3 mmol/L, because insulin drives potassium into cells and can precipitate arrhythmia. Replace potassium at 20–40 mmol/L, then run insulin at 0.1 U/kg/h, add 5% dextrose once glucose falls below 200–250 mg/dL, and continue insulin until ketones clear. Bicarbonate is reserved for pH below 6.9.
Traps
Giving insulin before checking potassium; stopping insulin when glucose normalises while ketones persist; treating hyperkalaemia with calcium as though it lowered potassium rather than protecting the myocardium; correcting sodium too quickly.