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Internal Medicine Residency Interview Questions and Answers

Medical Residency Application & Interview Preparation Specialists

Interviews for a Medical Residency in Internal Medicine can require a breadth of knowledge and attributes. Here, we present 10 specific questions and answer suitable for candidates to an Internal Medicine Medical Residency in the US. These focus in on specialty knowledge. Further questions can be found in our Medical Residency Interview Question Bank

Knowledge of the Career

What is the structure of Internal Medicine residencies and fellowships?

A standard general internal medicine residency will take three years. After this, one can undertake subspecialty training, also known as a fellowship. This can take between one to three years, depending on the subspecialty chosen. It’s also possible to take on a combined training program, which combines basic internal medicine with other specialties – for example internal medicine and paediatrics, which is the most common. Note that these are residencies rather than fellowships. 

What subspecialties are you interested in? What is the training pathway for them?

I’m interested in Cardiovascular Medicine – in particular, Interventional Cardiology or Heart Failure and Transplant Cardiology. Being able to conduct procedures to tackle heart disease interests me, as does the chance to become a true specialist in the end, whilst being able to build up a truly broad understanding of Medicine beforehand. I understand that the pathway for Interventional Cardiology is the internal medicine residency, then a three year fellowship in cardiovascular disease, and finally an additional year of training in interventional cardiology. Heart Failure and Transplant Cardiology equally allows one to conduct procedures in a highly-specialised field, having first undergone broader training; I need to truly dedicate myself to the field to differentiate between these areas. Equally, there may well be other subspecialties which become more appealing during my training. The path for this subspeciality is the same as for interventional cardiology – the residency, then fellowship of three years, then an additional year of training. 

How has Internal Medicine changed since the 1990s?

The most important change in the 1990s was the expansion and adoption of hospitalist Medicine. This in turn led to inpatient and outpatient care becoming two different specialised areas; an internal medicine specialist might now be a hospitalist, or could work in primary care. Currently, there’s a huge shift towards preventive care, with internal medicine beginning to move towards lifestyle changes, patient education, and the understanding that we must work with patients to prevent common conditions, rather than be reactive and use expensive, time-consuming procedures or medications. Equally, there’s greater focus on community care (even amongst hospitalists), with efforts to shift care into the community and create links with community leaders and carers. 

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Knowledge of Disease

What are the causes of a pulseless electrical activity cardiac arrest?

The causes of PEA may be classified as primary (cardiac) or secondary (non cardiac) causes. Primary pulseless electrical activity, which is often related to cardiac arrest, is due to the depletion of myocardial energy reserves, and will typically not respond to therapy. In general, the causes of secondary pulseless electrical activity are categorised according to the 5Hs and 5Ts. These are:
Hypovolaemia, hypoxia, hydrogen ions (acidosis), hypokalemia or hyperkalemia, and hypothermia; tension pneumothorax, trauma, tamponade, thrombosis (pulmonary) and thrombosis (coronary). PEA accounts for around 20% of sudden cardiac deaths outside of hospital, and 68% of recorded in-hospital deaths. PEA is the first documented rhythm in around 30% of adults who have a cardiac arrest in hospital. 

What is the difference between cholangitis, cholecystitis and cholelithiasis?

Acute cholangitis is an infection of the biliary tree, caused by biliary outflow obstruction and biliary infection. It is uncommon, but life threatening. Median age at presentation is 50-60 years old. The typical symptoms include fever, RUQ pain, and jaundice – Charcot’s triad. Cholecystitis presents with constant RUQ pain, fever, and raised inflammatory markers. However, there is typically no jaundice as there is no associated biliary obstruction. Choleliathisis is the formation of gallstones, and if symptomatic it is known as biliary colic. Here we would see RUQ pain, but no fever or jaundice. It is caused by an impacted stone at the neck of the gallbladder, and patients typically present with abdominal pain without infective features. It is triggered by the consumption of fatty foods.

What is Dressler’s Syndrome?

Dressler’s syndrome is a form of pericarditis. It occurs some weeks or months after a myocardial infarction. An autoimmune response triggers systemic inflammation, which in turn affects the pleura and other serous membranes. There may be pericardial effusion. It is relatively uncommon, although it should be considered in all patients with persistent malaise or fatigue following an MI or cardiac surgery. 

 

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Patient Management

What are the two major approaches to tachycardia?

The two approaches are rate control or rhythm control. Rate control uses beta-blockers, calcium channel blockers or digoxin. Rhythm control may either involve chemical cardioversion, through amiodarone or flecainide, or electrical cardioversion through DC shock. Typically, a symptomatic patient with well rate controlled AF will have the same outcome as someone in sinus rhythm, so cardioversion is not necessary. However, for patients with new-onset AF, LV dysfunction secondary to AF, a reversible cause of AF, or those with a reasonable chance of maintaining sinus rhythm, will be considered for cardioversion. If we take AVRT as an example, electrical cardioversion will be the best initial option, although flecainide may be used for a chemical cardioversion. Pathway ablation is curative. Note that tachycardia is not a diagnosis, rather an umbrella term for various diagnoses, which will have different treatment pathways. 

How would you treat a UTI in a pregnant patient?

A UTI should be managed more aggressively in pregnant women. Urine samples should be sent for culture and empiric treatment initiated whilst awaiting results. Oral nitrofurantoin is a suitable choice of antibiotic, with cephalexin also a common choice. Norfloxacin should not be used in pregnancy. Parenteral antibiotics are required in pyelonephritis. 

How would you assess a patient with suspected malnutrition?

First, I’d cover their weight history, their meal history, protein intake and fluid intake. I’d ensure that I covered their current weight, changes to weight, changes to how their clothes fit, and whether any changes to weight were the result of conscious changes. Then moving onto the clinical examination, I would assess their weight, their BMI, review their muscle mass stores, and their subcutaneous fat stores. I would also consider grip strength, mid-arm muscle circumference, and triceps skin fold thickness. A variety of other factors would be involved depending on the direction a more general history or systems examination took; for example, a patient with suspect anorexia nervosa would require a different assessment to a patient with suspected malignancy. 

You have a patient with hyperkalemia. What findings would prompt urgent treatment? How would you manage them?

A potassium level of 7.0mmol/L or greater and/or changes on the ECG would require urgent treatment. Treatment would focus on preventing further accumulation of potassium – which will involve stopping IV fluids with potassium, medications which could increase potassium, and supplements with potassium; stabilising the cardiac membrane, which will involve administer 10mls of 10% solution of calcium gluconate (if ECG changes are present); shifting potassium into cells, which can be performed using insulin-glucose infusion or salbutamol; removing potassium from the body if needed using calcium resonium. Of course, one should seek to correct the underlying cause.

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