How to Succeed on Your Internal Medicine Shelf Exam: The Hardest Shelf Exam

Hi friends! Welcome to a post covering tips on how to succeed on your internal medicine self exam! I’m sharing things that are very important in doing well on the exam, but are not explicitly taught in studying resources like Uworld. If you keep these things in mind while studying, I’m confident you’ll do well!

Learn to recognize patterns of patient presentations for common diseases.

For example, when a patient presents with shortness of breath, depending on their past medical history, two of your top differential diagnoses may include a CHF exacerbation and a COPD exacerbation. When reading the question stem, you should be actively looking for clues to help you differentiate between these two such as signs of fluid overload seen in CHF (i.e. peripheral edema). Other common disease presentations you should develop a methodological approach for identifying are pre-renal vs. intrinsic renal injury, osteoarthritis vs. rheumatoid arthritis, TTP vs. other bleeding disorders, chron’s vs. ulcerative colitis, etc. It’s a skill that takes time to develop, but doing many, many practice problems will help!

Know the necessary steps to work up a common complaint or disease.

Example: What are the steps to work up a patient with suspected Cushing’s syndrome? Start with a 24-hr urine free cortisol and a low dose dexamethasone test —> if this test doesn’t suppress the elevated cortisol —> order an ACTH level —> if ACTH is low then it’s likely an adrenal tumor (get a CT). If ACTH is high then consider lung cancer vs. Cushing’s disease (pituitary tumor) —> order a high dose dexamethasone test —> if this test doesn’t suppress cortisol —> you likely have ACTH being produced from small cell lung cancer (get a CT of the chest, abdomen and pelvis) vs. a pituitary tumor.

Write out algorithms like these each time you do a question on it. Questions on the exam may start at any point within the algorithm, and you’ll need to know what to do next!

Most importantly, know the ‘next best step’ in management.

This can be really tricky because there are multiple correct ways to treat a disease. However, you have to be able to rank the importance of various treatment options.

Example: What do you do if someone presents with hypercalcemia? Appropriate treatment options include IV fluids, calcitonin, and bisphosphonates. However, 0.9% IV Saline would be your FIRST choice. You then add calcitonin for acute management and bisphosphates for long term management.

Know which medications reduce mortality or recurrence of diseases such as CHF, strokes, etc.

Even though you can treat diseases with multiple drugs, it’s important to know which ones actually have a mortality benefit vs. are for symptom control.

For example, for CHF, ACE-I, beta-blockers, and spironolactone decrease mortality whereas furosemide, nitrates, digoxin improve symptoms. For COPD, smoking cessation and O2 supplementation improve mortality whereas albuterol/ipratropium improves symptoms. 

Know which medications are first vs. second line in the treatment of diseases.

Just like you need to know what the ‘next best step’ in management is, you need to know which drugs are considered “first line.” This distinction was asked on many NBME questions.

Example: Patients with CHF exacerbations can be treated with furosemide, ACE-I, BB, hydrazine. However, the first-line agents are ACE-I and furosemide. Beta-blockers are given if the patient is still symptomatic after initial treatment. Hydralazine can be added if symptoms still don’t resolve or if ACE-I/ARBs are contraindicated.

Biostats is low yield.

Of the 110 questions, I had 2 questions on biostats. It’s the exact same content for Step 1 so I recommend just reviewing your Step 1 biostats notes a few days before your exam.

Neurology is low yield.

I had basic questions on coma vs. persistent vegetative state, stroke management, tremors, headaches, dementia, but no questions requiring identification location of stroke symptoms.

Lastly, use Emma Holliday!

Emma Holliday, MD has a 2-hour long Internal Medicine Shelf review video on YouTube. It hits all the high yield points. I would recommend watching it and reviewing the powerpoint slide that goes along with it a few days before your exam.

As always, let me know if you have any questions! Good luck!!


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