internal medicine oral examination practice

IM ORAL EXAM

1. COMMUNITY ACQUIRED PNEUMONIA
Possible chief
complaints
Dyspnea, painful breathing upon deep inspiration, cough
Summary of
important
findings (just put
the signs and
symptoms for
HPI and those
that are pertinent
positives in the
PE)
● Dry cough, fever → productive cough, sputum brownish red and mucoid + fever + loss of appetite → dyspnea, pain upon deep
inhalation
● Increased HR (100 bpm), RR (34 cpm), Temp (39.5)
● Neck: Suprasternal retractions
● Chest: Intercostal retrah
● Mctions, increased tactile fremitus on the base of the right lung upon palpation, dullness on the base of the right side upon
percussion, decreased lung sound on the base of the right lung upon auscultation
● Cardiovascular: Tachycardic
Differential
diagnosis
Rule in Rule out
Tuberculosis(+) hemoptysis
(+) pain on chest
(+) cough

(-) cough at least 2 weeks
(-) known exposure to patient with TB
(-) significant and unintentional weight loss
(-) night sweats
COPD (+) cough
(+) smoking history
(+) dyspnea
(+) occupational
exposure
(+) sputum production
(+) >40

(-) recurrent wheezing
(-) decreased tactile fremitus
(-) hyperresonance on percussion
(-) progressive exercise intolerance
(-) chronic cough
(-) recurrent lower respiratory tract infections
(-) barrel chest
Asthma (+) coughing
(+) dyspnea
(+) occupational
exposure

(-) no early onset/ history/ heredofamilial disease
(-) wheezing
(-) hyperresonance on percussion
(-) no known environment trigger
(-) symptoms worse at night or early morning
(-) variable expiratory airflow
COVID 19 (+) coughing
(+) dyspnea
(+) fever
(-) chills
(-) fatigue
(-) muscle or body aches
(-) loss of taste or smell
(-) sore throat
(-) congestion or runny nose
(-) nausea and vomiting
(-) diarrhea
Acute
Bronchitis
(+) cough
(+) sputum production
(+) dyspnea
(+) fever

(-) wheezing
(-) rhonchi
(-) prolonged expiration
(+) consolidation
(+) high grade fever
Influenza (+) rhinorrhea
(+) cough
(+) malaise
(+) chills
(+) fever
≥50 yrs old
(+) crackles
(+) dyspnea
(+) percussion dullness
(+) increased tactile fremitus
(-) conjunctivitis
Hypersensitivit
y Pneumonitis
(+) fever
(+) chiills
(+) malaise
(+) dyspnea
(+) cough
(-) history of exposure to an offending antigen
Diagnostic
management
Gold standard -
rationale
● Sputum gram stain, culture, and sensitivity - To know the causative agent as basis for its treatment, to know if the
patient is drug-resistant
● Chest xray - To check for presence of infiltrate on right lower lung base; to rule out TB (presence of
lymphadenopathy)

2. ● CBC - To check for leukocytosis (bacterial infection) or leukopenia (sepsis)
Supportive -
rationale
● Urinary antigen test - Supplement sputum gram strain and culture, to test for presence of Legionella and
pneumococcal antibodies
● Polymerase chain reaction - Supplement sputum gram strain and culture, increase bacterial load is associated
with increased risk for septic shock, need for mechanical ventilation, death
● Biomarkers (C reactive protein and procalcitonin) - Supplements history, PE, and other lab tests, To see if there is
treatment failure or when to stop treatment
● Blood Urea Nitrogen - To assess kidney function and measure urea for severity
● Creatinine - to assess kidney function
● Direct sputum smear microscopy - To rule out tuberculosis
● TB culture - to rule out COPD
● Spirometry with and without glucocorticoids - to rule
● out COPD and asthma (its asthma if patient feels relief after glucocorticoids)
● Reverse Transcription-Polymerase Chain Reaction - to rule out COVID 19
● Ferritin and LDH levels - to assess for sepsis
Therapeutic
management


Gold standard -
rationale
● Antibiotics
● Continue remaining dosage for antibiotics (if patient was given prior to admission and has not finished yet)
● Moderate-risk: Cefuroxime 1.5 g q8h IV or Ceftriaxone 2g OD +
○ Azithromycin 500 mg OD PO
○ Clarithromycin 500 mg BID PO
○ Levofloxacin 500mg OD PO
○ Moxifloxacin 400 mg OD PO
(Azithromycin, Clarithromycin, Levofloxacin, & Moxifloxacin -> added in moderate CAP to provide coverage for atypical
pathogens such as M. pneumoniae, C. pneumoniae, Legionella)
● High-risk: Antipseudomonal beta-lactam + IV extended macrolides + aminoglycosides
● Monitor sugar levels and BP (if diabetic and hypertensive)
Supportive -
rationale
● Supplemental oxygen with nasal cannula (maximum of 5L/min)
● 24-72H after initiation of therapy:
○ Assess vitals
○ Repeat chest radiograph if no improvement
○ Test sputum gram stain and culture if not responding to treatment
● De-escalate antibiotic therapy if patient is clinically improving
● Discharge patient if:
○ Temperature is 36-37.5
o
C
○ Pulse <100 bpm
■ RR: 16-24 cpm
○ Systolic BP >90 mmHg
○ Blood oxygen saturation >90%
○ Functioning GI tract
● Educate patient
○ Regarding effects of smoking on current diagnosis
○ Regarding the rate of improvement of symptoms
○ Benefits of pneumococcal and influenza vaccines and encourage to receive them
○ Hydrate to facilitate secretion clearance
● Repeat chest radiograph after 4-6 weeks of discharge to exclude possibility to malignancy associated with CAP
(since patient is a smoker)
● Even if patient has good compliance to maintenance medication, still remind him about taking them

PEPTIC ULCER DISEASE
Possible chief
complaints
epigastric pain
Summary of
important
findings (just put
the signs and
symptoms for
HPI and those
that are pertinent
positives in the
PE)
● long term use of NSAIDs
● Type 1 Obese patient, Male patient
● persistent dull epigastric pain temporarily relieved by antacids and food consumption
● Localized burning epigastric pain
● nausea and vomiting
● Black tarry stools or melena
Differential
diagnosis
Rule in Rule out
GERD (+) nausea and
vomiting
(-) epigastric pain did not radiate to chest, throat and back
(-) no heartburn

3. (+) epigastric pain
(+) pain slightly
relieved by antacids
(-) epi pain relieved by food consumption
Acute
cholecystitis
(+) N/V after a fatty
meal
(+) upper abdomen
tenderness upon
palpation
(+) Type 1 Obese
(-) Neg Murphy’s sign
(-) epi pain did not radiate to right shoulder nor to the back
(-) normal stool color & unaltered bowel movements
(-) no fever & chills
Cholelithiasis(+) epigastric pain &
tenderness
(+) nausea
(+) bloating after eating
fatty food
(+) pain aggravated by
fatty food
(-) pain is a severe steady ache
(-) pain radiates to the interscapular area, shoulder, & right scapula
ST-segment
elevation
myocardial
infarction
(STEMI)
(+) epigastric pain &
tenderness
(-) pain radiates to arms, abdomen, back, lower jaw, & neck
(-) pain is usually described as heavy, squeezing, & crushing
Diagnostic
management
Gold standard -
rationale
● Upper Gastrointestinal Endoscopy- to visualize esophagus, stomach and duodenum, and biopsy possible ulceration
● Biopsy Urease Test - to identify H. pylori
● C- or C-urea breath test - to identify H. pylori
● Fecal H. pylori Antigen Test - to identify H. pylori
Supportive -
rationale
● CBC - to determine if there is significant blood loss and/or infection; leukocytosis (bacterial infection);
thrombocytopenia (NSAIDs)
● LFT- to check if there is elevated liver transaminase, which may be caused by taking NSAIDs, also to rule out STEMI
● Ultrasonography- to check for stones to rule out cholelithiasis
Therapeutic
management
Gold standard -
rationale
● If due to H. pylori, triple therapy (e.g. Clarithromycin Triple: Proton pump inhibitors, Clarithromycin, & Amoxicillin) is
recommended for 14 days followed by continued acid-suppressing drugs for a total of 4-6 weeks. Then, H. pylori
eradication should be documented 4 weeks after therapy either by Fecal H. pylori antigen test or urea breath test.
● For NSAID-related mucosal injury, the injurious agent should be stopped as the first step, then treatment with Acid-
Neutralizing Agents is indicated
● Acid-Neutralizing/Inhibitory Drugs: Antacids (Mylanta, Gaviscon), H2 Receptor Antagonists (Cimetidine, Ranitidine),
PPI (Omeprazole, Lansoprazole)
Supportive -
rationale
● Blood transfusion in cases of severe blood loss
● Discontinue smoking, drinking alcohol, & taking NSAIDs (if not avoidable, use the lowest dose possible for the
shortest time)



ACUTE UNCOMPLICATED PYELONEPHRITIS
Possible chief
complaints
Fever, chills and dysuria

Summary of
important
findings (just put
the signs and
symptoms for
HPI and those
that are pertinent
positives in the
PE)

● (+)High grade fever and chills
● (+) Nausea
● (+)Vomiting
● (+) Hypotension
● (+) Tachycardia
● (+)Costovertebral angle tenderness
● (+) Urinary frequency
● (+) Urinary urgency
● (+)Flank pain
● (+)KPS sign
● age
● female
● Sexually active
● History of UTI
● Patient may have or not have symptoms of Acute cystitis(dysuria,urinary urgency and frequency)
Differential
diagnosis
Rule in Rule out
Acute pelvicFever and chills, -History of sexually transmitted disease

4. inflammatory
disease
dysuria, sexually
active, lower
abdominal pain

(+) episodes of
vomiting
-Common in less than 25 years of age female
-Abnormal foul vaginal discharge
-dyspareunia
(+) Kidney Punch Sign
(-) Murphy’s Sign
(-) Rebound tenderness
Acute
Appendicitis
Fever, lower
abdominal pain, body
malaise, nausea and
vomiting
-common in males
-common in less than 30 years old
-Rovsing’s sign
-Psoas sign
-diarrhea
-anorexia
Cystitis (+) Dysuria
(+) flank pain
aggravated by lifting
heavy
objects

(+) high grade fever
(+) chills
Ectopic
Pregnancy
(if Female)
(+) High Grade Fever
(+) episodes of
vomiting
(+) flank pain
(+) chills
LMP: 1 month ago
(-) Vaginal bleeding
Nephrolithiasis(+) flank pain
aggravated by lifting
heavy
objects
(+) episodes of
vomiting
(-) Painless gross hematuria
(-) Radiating pain
(+) High Grade Fever
Diagnostic
management
Gold standard
- rationale
a. History and Physical Exam
b. Pregnancy Test – to further rule out pregnancy
c. Urinalysis and Urine Dipstick Test
• Check for Pyuria and presence of hematuria
• Nitrite test is performed to detect Enterobacteriaceae
d. Urine Culture and Sensitivity
• Diagnostic gold standard
e. DMSA (dimercaptosuccinic acid) scan - current gold standard but this nuclear medicince is not easilt obtainable in most
centers
Supportive -
rationale
●
Therapeutic
management
Gold standard
- rationale
Pharmacologic
a. Fluoroquinolones – first line of therapy
b. Ceftriaxone- 1g IV is given if susceptibility is not known

c. Extended-spectrum cephalosporin with or without an aminoglycoside, or a carbapenem
d. Combinations of a β-lactam and a β-lactamase inhibitor (e.g., ampicillin-sulbactam,
ticarcillin- clavulanate, piperacillin-tazobactam) or a carbapenem (imipenem- cilastatin,
ertapenem, meropenem) can be used in patients with more complicated histories.



Supportive -
rationale
a. Increase fluid intake
b. Instruct patient to urinate frequently and urinate post-coitus
c. Instruct proper hygiene

5. ACUTE UNCOMPLICATED CYSTITIS
Possible chief
complaints
Hypogastric Pain
Summary of
important
findings (just put
the signs and
symptoms for
HPI and those
that are pertinent
positives in the
PE)
● Hypogastric pain and low grade fever; gross hematuria, dysuria, urinary frequency and urgency; sexually active patient
● Habit of holding in urine, female, (+) KPS, acute onset of chills, flank pain, nausea
Differential
diagnosis
Rule in Rule out
Acute
Pyelonephritis
(+) Fever
(+) dysuria
(+) Frequent Urination
(+) Hematuria
(+) chilly sensation
(-) KPS
(-) Flank Pain
Ectopic
Pregnancy
(+) Hypogastric Pain
(+) Urinary Frequency
and urgency
(+) Dysuria
No Pregnancy Test Result; No Ultrasound Result; Cannot be ruled out completely
Acute
Appendicitis
(+) Fever
(+) Hypogastric Pain
(-) Good appetite
(+) hematuria
(+) dysuria
(+) urinary frequency and urgency
Diagnostic
management
Gold standard -
rationale
● Urine Culture & sensitivity - gold standard for UTI, to detect causative agent
● Urinalysis - cost effective, to check for hematuria, pyuria, WBCs
● Blood Culture - not routinely recommended unless with signs of sepsis
Supportive -
rationale
● Vital Signs Monitoring
● Laboratory Examinations
○ CBC
○ Pregnancy Test
○ Electrolytes
○ Creatinine monitoring
● Ultrasonography (KUB) - to rule out nephrolithiasis, obstruction, or abscess
● Test for STDs
○ RPR/FTABS for Syphilis
○ HIV Rapid test
Therapeutic
management
Gold standard -
rationale
● Oral Ciprofloxacin for 7 days

Supportive -
rationale
● Oral TMP-SMX
● Px is pregnant: IV Ampicillin and Gentamicin; if refractory: IV Ceftriaxone w/ or w/o aminoglycoside
COMPLICATED URINARY TRACT INFECTION
Tips: Know the classification of UTI - general is the UNCOMPLICATED/ACUTE(?), COMPLICATED,
ASYMPTOMATIC BACTERIURIA. If doesn’t fit with most cases, it’s complicated, especially with
comorbidities or risk factors (mine was post-menopausal age and diabetes)

Possible chief
complaints
Hypogastric pain, dysuria

6. Summary of
important
findings (just put
the signs and
symptoms for
HPI and those
that are pertinent
positives in the
PE)
- hypogastric pain and dysuria
- had fever but temperature was not taken; temporarily relieved by Paracetamol
● Patient also noted polyuria
● Hypogastric pain and dysuria persisted and were aggravated.
● Past hx of diabetes and hypertension are risk factors
● PE of genitourinary (FEMALE) was typical for menopausal - dry, vulva artophic
● No radiation of pain, no flank pain (which could have been signs of pyelonephritis)
● Px’s first time UTI, so not recurrent
● No hx of sex so sti very unlikely
Differential
diagnosis
Rule in Rule out
Acute
uncomplicated
cystitis

● (+) dysuria
● (+) polyuria
● (+) hypogastric
pain
● (-) vaginal
discharge

● (-) hematuria
● (-) hesitancy

Urolithiasis
● (+) dysuria
● (+) polyuria
● (+) hypogastric
pain
● (+) nausea

● (+) fever
● (-) flank pain
● (-) family history
● (-) palpated masses
● pain relieved by medications

Pelvic
inflammatory
disease

● (+) hypogastric
pain
● (+) dysuria
● (+) fever
● (+) polyuria

● (-) vaginal discharge
● (-) urinary incontinence
● (-) multiple sexual partners
● Older women have lower risk

Diagnostic
management
Gold standard -
rationale ● Urine culture (gold standard) - to confirm presence of microorganisms
Supportive -
rationale ● Urinalysis & urine dipstick - to check for pyuria, hematuria, nitrite or leukocyte esterase positivity
● Complete blood count - to check for leukocytosis or neutrophilia
● Fasting blood glucose - to monitor sugar level (if diabetic)
● HBA1c - to monitor glycemic control (for diabetic)
● Lower abdominal ultrasound (cost-effective) - to rule out masses or malignancy
● CT scan (ideal) - to rule our masses
Therapeutic
management
Gold standard -
rationale ● Definitive: *determine if patient has risk factors for drug-resistance
○ Ciprofloxacin 500-750 mg BID or 1000 mg extended release tablet OD x 7-14 days
○ Norfloxacin 400 mg BID x 7-14 days
○ Amoxicillin/clavulanate 500 mg/125 mg TID or 875 mg/125 mg BID x 7-14 days
Supportive -
rationale Supportive
○ continue Metformin 500 mg 1 tablet daily for diabetes (but doc advised me to change to insulin instead)
○ continue Lozartan 50 mg 1 tablet daily for hypertension
○ encourage fluids for fever
​ACUTE CORONARY SYNDROME/ UNSTABLE ANGINA
Tips: 1. 3 subgroups:
● Unstable Angina - (-) Necrosis, (-) ECG changes, (-) Cardiac biomarkers (elevated)
● NSTEMI - (+) Necrosis, (-) ST segment elevation (Possible T wave inversion)
​ (+) cardiac biomarkers
● STEMI - (+) Necrosis, (+) ST segment elevation, (+) cardiac biomarkers

7. 2. CPG for ACS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4833805/

Possible chief
complaints
Chest Pain, dyspnea
Summary of
important
findings (just put
the signs and
symptoms for
HPI and those
that are pertinent
positives in the
PE)
● Pain is sudden in onset, Crushing/Pressure Pain
● Angina at rest
● Crescendo pattern of pain
● Pain radiating to the left arm and neck
● S4 Gallop, Elevated PMI, Systolic murmur
● Dyspnea, Tachycardia
● Diaphoresis
● >65 years old, Male, Smoking, DM, Hypertension, Sedentary lifestyle

Differential
diagnosis
Rule in Rule out
Pulmonary
Embolism
● Chest pain
● Sudden in onset
● Dyspnea,
Tachycardia,
Tachypnea
● Rales
● Hx of Smoking
(-) Pleuritic Pain
(-) Hypotension
(-) Cyanosis
(-) Syncope
GERD ● Chest Pain
● Alcohol Use
● Smoker
(-) Regurgitation
(-) Burning Pain
(-) Dysphagia
(-) N & V
Aortic
dissection
(+)Chest pain
(+) diaphoresis
Sudden, excruciating pain radiating to scapula or back

(-) rapid weak pulse
(-) Fainting or dizziness
(-) Pale skin

Acute
pericarditis
(+) Chest pain
(+) Dsypnea
(+) diaphoresis
(-) Pericardial pain especially during inspiration
(-) Pericardial friction rub
CHF
Diagnostic
management
Gold standard -
rationale
● 12-lead ECG- Done within 10 mins of arrival. To assess cardiac injury or ischemia
● Cardiac Biomarkers (cardiac troponin I) - Highly sensitive in the detection of necrosis in the heart
● Chest Radiograph - To rule out pulmonary causes of chest pain
● 2D Echo - minimally invasive, to rule out pulmonary embolism and valvular disease
Supportive -
rationale
● HbA1C - Monitor risk factors (DM)
● CBC - Rule out hematologic causes if there is ischemia (Anemia)
● ABG - Monitor O2 Sat
● Liver Function Test - Monitor patient undergoing statin therapy
Therapeutic
management
Gold standard -
rationale
● Antiplatelet Agents - Reduce Plaque progression and Prevent thrombus plaque rupture
● Statins - Lowers LDL, anti-inflam and anti-thrombotic effect, lowers risk of CV death
● Beta Blockers - Controls Heart rate and symptoms
● Nitrates - Added or substituted if BB is unsuccessful
● ACEI & Dihydropyridine CCB - If patient has hypertension, reduces risk of CV death, MI and stroke
● Anticoagulants:
○ UFH (unfractionated heparin)
○ LMWH, enoxaparin
○ Bivalirudin, direct thrombin inhibitor
○ Indirect factor Xa inhibitor, fondaparinux
● If asked surgery: PCI or CABG

Supportive -
rationale
● Healthy Diet - Lower total caloric intake
● Regular Physical activity
● Weight Control
● Cessation of smoking
● BP control (<140/90 or <130/90 for CKD or DM)

ACUTE ISCHEMIC STROKE

8. Possible chief
complaints
● Left-side weakness (weakness in one part of the of the body)
● Left/ Right Ipsilateral Weakness
Summary of
important
findings (just put
the signs and
symptoms for
HPI and those
that are pertinent
positives in the
PE)
● Risk factors: Px is smoker, diabetic, old, overweight
● left-sided weakness; numbness and tingling; “pin and needles”; slurring of speech, facial asymmetry
● Incomplete lid closure
● CN V: motor (weak); sensory (weak)
● CN VII: (+) facial asymmetry
● CN IX, X: uvula deviated to left; weak GAG reflex
● CN XI: weak on left side
● (-) graphestesia and stereognosis on left
● Weak reflex on left (1+)
Differential
diagnosis
Rule in Rule out
Acute
Hemorrhagic
Stroke

Headache, nausea,
vomiting, dizziness,
numbness, weakness
of extremities, slurred
speech,difficulty
swallowing
Cannot be ruled out completely; non contrast CT Scan needed to be differentiated with AIS
Diabetic
Neuropathy

Px is diabetic;
numbness and
weakness in upper and
lower extremities,
nausea and vomiting,
dizziness
No EMG (Electromyography) to be ruled out completely
Diagnostic
management
Gold standard -
rationale
● CT Scan
Supportive -
rationale
● P.E.: vital sign monitoring, neurologic examination
● Lab Exams:
○ CBC
○ ESR
○ Serum Electrolytes
○ BUN
○ Creatinine
○ Capillary Blood Glucose
○ Serum Lipid Profile
○ PT and PTT
Therapeutic
management
Gold standard -
rationale
● Check ABC’s first
● Check blood glucose before administering IV-rTPA
● IV thrombolysis (intravenous recombinant tissue plasminogen activator; IV-rTPA)

Supportive -
rationale
● Thrombectomy
● Antiplatelet therapy: Aspirin
● Rehabilitation
● Patient Education
○ Healthy lifestyle
○ Increase intake of fruits and veggies
○ Exercise 30 mins/day
○ Weight loss
○ Ensure compliance to maintenance medications
LEPTOSPIROSIS
Possible chief
complaints
Intermittent high grade fever
Summary of
important
findings (just put
the signs and
symptoms for
HPI and those
that are pertinent
positives in the
PE)
● 2-3cm abrasion on foot
● Intermittent High grade fever
● Myalgia
● Arthralgia
● Headache
● Fatigue
● Abdominal pain on epigastric region
● Jaundice
● Hepatomegaly on PE
Differential
diagnosis
Rule in Rule out

9. Leptospirosis2-3cm abrasion on
foot, Intermittent High
grade fever, Myalgia,
Arthralgia, Headache,
Fatigue, Abdominal
pain on epigastric
region, Jaundice
Hepatomegaly on PE

dengue Rainy season,
intermittent high grade
fever, abdominal pain
Consider but Ruled out by dengue rapid test
influenza Fever, rainy season,Normal chest exam
malaria Fever, jaundice, rainy
season
Ruled out by blood smear

Diagnostic
management
Gold standard -
rationale
● Latex agglutination test- confirm leptospirosis
● Dengue rapid test- rule out dengue
● Peripheral blood smear- rule out malaria
● Chest xray- rule out influenza
Supportive -
rationale
● Creatinine-assess leptospirosis dissemination
● Urinalysis-assess kidneys
● CBC-check for thrombocytopenia, leukocytosis
● Bilirubin- check for liver damage
● Liver function test- check for liver damage
● CRP and ESR-check for inflammation
Therapeutic
management
Gold standard -
rationale
● Doxycycline- for leptospirosis
● Antimalarial drugs- for malaria


Supportive -
rationale
● Fluid resuscitation- for hydration
● Paracetamol-for fever
● Blood transfusion- if needed