DNB Medicine Final Internal — Last Night Revision Guide

Strategy First

• DNB internals typically test clinical reasoning, long cases (1-2 patients), and short cases + viva. Focus on mechanisms, diagnostics, and management protocols — not trivia.
• Prioritize common diseases with complex management over rare ones.
• For each topic: know the definition, key pathophysiology, diagnostic criteria, and first-line management.

🔴 Tier 1 — Must Cover Tonight

1. Heart Failure

• HFrEF vs HFpEF distinction (EF cut-off: <40% vs ≥50%)
• ACCF/AHA stages A–D vs NYHA functional class
• Cardinal features: dyspnea, fatigue, elevated JVP, pulmonary crackles, peripheral edema
• Management of HFrEF: ACE inhibitor/ARB/ARNI (sacubitril-valsartan) + beta-blocker + MRA + SGLT2 inhibitor (the "fantastic four")
• Acute decompensated HF: diuretics, vasodilators, inotropes
• BNP/NT-proBNP cutoffs for diagnosis

2. Diabetes Mellitus

• Type 1 vs Type 2 pathophysiology
• Diagnostic criteria: FPG ≥126, 2hr OGTT ≥200, HbA1c ≥6.5%, random ≥200 with symptoms
• DKA vs HHS — key differences in osmolarity, pH, ketones, treatment
• Microvascular (nephropathy, retinopathy, neuropathy) and macrovascular complications
• Diabetic nephropathy: leading cause of CKD/ESRD; microalbuminuria → proteinuria → declining GFR; RAAS blockade + SGLT2i as nephroprotection
• Drug selection: metformin first-line → SGLT2i/GLP-1 RA with CV/renal benefit

3. Hypertension

• JNC 8 / ACC/AHA 2017 staging
• Target BP: <130/80 mmHg in most; <140/90 in older patients
• Compelling indications (e.g., ACE-i in CKD/DM, beta-blocker post-MI, CCB in isolated systolic HTN in elderly)
• Hypertensive emergency vs urgency — end-organ damage distinguishes them; IV labetalol/nicardipine/nitroprusside

4. Chronic Kidney Disease (CKD)

• GFR-based staging (G1–G5) + albuminuria staging
• Complications: anemia (EPO deficiency), hyperkalemia, metabolic acidosis, secondary hyperparathyroidism, uremia
• Management: RAAS blockade, SGLT2i (finerenone in DKD), phosphate binders, EPO stimulating agents
• Indications for dialysis (AEIOU: Acidosis, Electrolytes, Intoxication, Overload, Uremia)

🟠 Tier 2 — High Yield, Cover If Time Permits

5. Acute Coronary Syndrome (ACS)

• STEMI vs NSTEMI vs Unstable Angina — ECG changes, troponin kinetics
• STEMI management: primary PCI within 90 min (door-to-balloon); fibrinolysis if PCI unavailable within 120 min
• Dual antiplatelet (aspirin + P2Y12 inhibitor), anticoagulation, statins, RAAS blockade post-MI
• Killip classification

6. Community-Acquired Pneumonia (CAP)

• Common organisms: S. pneumoniae, atypicals (Mycoplasma, Legionella, Chlamydophila)
• CURB-65 score → guides inpatient vs ICU admission
• Treatment: amoxicillin ± macrolide (outpatient); beta-lactam + macrolide or respiratory fluoroquinolone (inpatient); add anti-pseudomonal coverage in severe/ICU
• Complications: parapneumonic effusion, empyema, abscess

7. Liver Disease / Cirrhosis

• Child-Pugh and MELD scores
• Complications: ascites (Na restriction, spironolactone ± furosemide), SBP (cefotaxime), variceal bleeding (terlipressin + banding + prophylactic propranolol), hepatic encephalopathy (lactulose, rifaximin), HRS
• NAFLD/NASH progression

8. Thyroid Disorders

• Hypothyroidism: TSH ↑, free T4 ↓; treatment levothyroxine; myxedema coma (IV T4 + steroids)
• Hyperthyroidism: Graves' disease (TSH-R antibodies), toxic nodule; treatment carbimazole/PTU, radioiodine, surgery
• Thyroid storm: Burch-Wartofsky score; management — PTU, beta-blocker, iodine (after PTU), steroids

9. Respiratory Failure / ARDS / COPD

• Type 1 (hypoxemic) vs Type 2 (hypercapnic) respiratory failure
• COPD exacerbation: SABA/SAMA nebulization, steroids, antibiotics (if purulent sputum), controlled O2 (target SpO2 88–92%), NIV
• ARDS: Berlin criteria (PaO2/FiO2 < 300), lung-protective ventilation (low tidal volume 6 mL/kg), prone positioning in severe ARDS

10. Anemia

• Microcytic (IDA — low ferritin, low MCV), normocytic (ACD, hemolysis), macrocytic (B12/folate deficiency)
• Iron deficiency: cause must always be found; treat with oral iron (IV if malabsorption/intolerance)
• B12 deficiency: subacute combined degeneration of cord — posterior + lateral column signs; treat with IM hydroxocobalamin

🟡 Tier 3 — Quick Review (30 min each)

📋 How to Spend Tonight's Time

💡 Viva Tips

• Always lead with pathophysiology before jumping to treatment
• Know first-line vs second-line drugs cold
• Mention scoring systems by name (CURB-65, MELD, Ranson, NIHSS, Wells, DAS-28)
• For any organ failure: know indications for specialist referral, ICU admission, and renal replacement therapy
• DNB examiners love asking: "What would you do next?" — always have a step-by-step plan