Internal Medicine - NBME Shelf Questions and
Complete solutions Updated
Acute Migraine Headache Therapy
Subcu triptans and Iv antiemetics (prochlorperazine, metoclopramide that block D2
receptors and serotonin receptors at higher doses), shown to be efficacious in treating
acute migraine, especially when associated with nausea/vomiting.
contraind: ergotamine and triptans in persons with heart conditions--ergotamine
(vasoconstriction of coronary artery); sumatriptan (trigger coronary vasospasm)
Hemodynamic measurements in shock: Hypovolemic, Cardiogenic, Septic shock.
PCWP pressure = pre-load. It's only INCREASED in cardiogenic shock when failure of
forward blood flow occurs and causes an increase in LEFT atrial Presure -PRELOAD.
cardio shock = low cardiac index, pump is failing
Tension pnemo: obstruction of vena cava and decreased venous return to RA.
Volume depletion (hemorrhagic shock) also leads to decreased venous return to
RA. If decreased RV pre-load then both = PCWP and CI are low.
CI = cardiac index (pump function/cardiac contractility).
Obstructive shock causes
cardiac tamponade, PE, tension pneumothorax
Obstructive shock treatment
1.Increasing cardiac output should be the priority in treating cardiac tamponade.
2.Apply high-flow oxygen.
3.The only definitive treatment for cardiac tamponade is surgery.
obstructive shock (pathophys of massive/submassive PE) = RV dysfuction
right ventricular outflow obstruction--> increase in RV pressure=
RV hypokinesis & dilation & RV wall tension + increased RV mycoardial O2 demand
=decrease RV cardiac output and septal deviation toward LV & RV ischemia and
infarction
,= decrease LV preload and cardiac output --> decrease coronary perfusion and
decrease RV myocardial supply
Dementia subtypes
1. vascular dementia: step-wise decline; early executive dysfunction; cerebral infarction
&/or deep white matter changes on neuroimaging (present with ischemic stroke and
subsequent vascular dementia-patient has objective neuro deficits). risk factors: HTN,
age, DM, Smoking, hx of stroke.
2. dementia with lewy bodies: visual hallucinations; spontaneous Parkinsonism;
fluctuation cognition;
3. Alzheimer: temporal lobe atrophy, aroun dhippocampus early, insidious short
term memory loss; language deficits and spacial disorientation, later personality
changes
4. frontotemporal dementia: early personality changes, apathy, dis-inhibition and
compulsive behavior; frontotemporal atrophy on neuroimaging
5. prion disease: behavioral changes, rapid progression, myoclonus and/or seizures
6. Normal pressure hydrocephalus: ataxia early in disease, urinary incontinence, dilated
ventricles on neuroimaging (Wet, wacky, wobbly).
folic acid deficiency
assoc w/ neural tube defects; gingival hyperplasia, and megaloblastic anemia
s/e of phenytoin therapy
Mixed cryoglobulinemia syndrome
a vasculitis characterized by immune complex deposition in small and medium sized
vessels. Presents w/ palpable purpura, low c4, assoc w/ chronic hep c, peripheral
neuropathy (hyporeflexia), ALT, AST involvement, arthalgias, and systemic symptoms -
fatigue, weakness.
Diagnose: assay for cryoglobulins that classically contains Rheumatoid Factor (IgM and
IgG) and polyclonal IgG. tissue biopsy demonstrates small vessel leukoclastic vasculitis.
has livido reticularis
Hypertrophic Cardiomyopathy (HCM) - management
CCBs or beta blockers, avoid volume depletion; surgery if persistent symptoms.
CPPD-calcium pyrophosphate deposition
, -pseudo gout: rhomboid shape crystals, positive birefringence
-result of calcium pyrophosphate crystals forming in joints
-knee mc affected
-chondro-calcinosis is the primary radiographic finding: meniscal calcification
(example)
Imaging in low back pain
MRI: 1. sensory/motor deficits
2. cauda equina syndrome (saddle anesthesia)
3. suspected epidural abscess/infection (fever, IVDU, concurrent infection,
hemodyalisis)
Frostbite treatment
Rapid rewarming with warm water (do NOT wait, or use too hot or dry heat)
Multifocal Atrial Tachycardia (MAT)
>100
irregular
P waves have at least 3 different shapes
-MAT does not create increased risk of atrial thrombus formation and
thromobembolism, anticoag is not recommended.
-Treatment: monitor while treating COPD exacerbation.
[vs Atrial fibrillation: irregular RRi; absent p waves; use antiarrhymthmic drugs
(amiodarone) if stable or direct current cardioconversion if unstable. ]
ankylosing spondylitis: LBP worse at night improves with physical activity
a form of rheumatoid arthritis that primarily causes inflammation of the joints between
the vertebrae.
-affects sits of ligamentous insertion (enthesitis), leading to gradual onset of Low Back
Pain and progressive stiffness.
-AS eventually leads to destruction of the articular cartilage, especially at the sacroiliac
joints and apophyseal joints in spine.
(immune-mediate disorder/inflammatory spondylarthritis disorders, others include:
psoriatic arthritis, reactive arthritis, arthritis assoc w/ inflammatory bowel disease).
Pituitary adenoma: tx w/ dompamine agonist therapy
Complete solutions Updated
Acute Migraine Headache Therapy
Subcu triptans and Iv antiemetics (prochlorperazine, metoclopramide that block D2
receptors and serotonin receptors at higher doses), shown to be efficacious in treating
acute migraine, especially when associated with nausea/vomiting.
contraind: ergotamine and triptans in persons with heart conditions--ergotamine
(vasoconstriction of coronary artery); sumatriptan (trigger coronary vasospasm)
Hemodynamic measurements in shock: Hypovolemic, Cardiogenic, Septic shock.
PCWP pressure = pre-load. It's only INCREASED in cardiogenic shock when failure of
forward blood flow occurs and causes an increase in LEFT atrial Presure -PRELOAD.
cardio shock = low cardiac index, pump is failing
Tension pnemo: obstruction of vena cava and decreased venous return to RA.
Volume depletion (hemorrhagic shock) also leads to decreased venous return to
RA. If decreased RV pre-load then both = PCWP and CI are low.
CI = cardiac index (pump function/cardiac contractility).
Obstructive shock causes
cardiac tamponade, PE, tension pneumothorax
Obstructive shock treatment
1.Increasing cardiac output should be the priority in treating cardiac tamponade.
2.Apply high-flow oxygen.
3.The only definitive treatment for cardiac tamponade is surgery.
obstructive shock (pathophys of massive/submassive PE) = RV dysfuction
right ventricular outflow obstruction--> increase in RV pressure=
RV hypokinesis & dilation & RV wall tension + increased RV mycoardial O2 demand
=decrease RV cardiac output and septal deviation toward LV & RV ischemia and
infarction
,= decrease LV preload and cardiac output --> decrease coronary perfusion and
decrease RV myocardial supply
Dementia subtypes
1. vascular dementia: step-wise decline; early executive dysfunction; cerebral infarction
&/or deep white matter changes on neuroimaging (present with ischemic stroke and
subsequent vascular dementia-patient has objective neuro deficits). risk factors: HTN,
age, DM, Smoking, hx of stroke.
2. dementia with lewy bodies: visual hallucinations; spontaneous Parkinsonism;
fluctuation cognition;
3. Alzheimer: temporal lobe atrophy, aroun dhippocampus early, insidious short
term memory loss; language deficits and spacial disorientation, later personality
changes
4. frontotemporal dementia: early personality changes, apathy, dis-inhibition and
compulsive behavior; frontotemporal atrophy on neuroimaging
5. prion disease: behavioral changes, rapid progression, myoclonus and/or seizures
6. Normal pressure hydrocephalus: ataxia early in disease, urinary incontinence, dilated
ventricles on neuroimaging (Wet, wacky, wobbly).
folic acid deficiency
assoc w/ neural tube defects; gingival hyperplasia, and megaloblastic anemia
s/e of phenytoin therapy
Mixed cryoglobulinemia syndrome
a vasculitis characterized by immune complex deposition in small and medium sized
vessels. Presents w/ palpable purpura, low c4, assoc w/ chronic hep c, peripheral
neuropathy (hyporeflexia), ALT, AST involvement, arthalgias, and systemic symptoms -
fatigue, weakness.
Diagnose: assay for cryoglobulins that classically contains Rheumatoid Factor (IgM and
IgG) and polyclonal IgG. tissue biopsy demonstrates small vessel leukoclastic vasculitis.
has livido reticularis
Hypertrophic Cardiomyopathy (HCM) - management
CCBs or beta blockers, avoid volume depletion; surgery if persistent symptoms.
CPPD-calcium pyrophosphate deposition
, -pseudo gout: rhomboid shape crystals, positive birefringence
-result of calcium pyrophosphate crystals forming in joints
-knee mc affected
-chondro-calcinosis is the primary radiographic finding: meniscal calcification
(example)
Imaging in low back pain
MRI: 1. sensory/motor deficits
2. cauda equina syndrome (saddle anesthesia)
3. suspected epidural abscess/infection (fever, IVDU, concurrent infection,
hemodyalisis)
Frostbite treatment
Rapid rewarming with warm water (do NOT wait, or use too hot or dry heat)
Multifocal Atrial Tachycardia (MAT)
>100
irregular
P waves have at least 3 different shapes
-MAT does not create increased risk of atrial thrombus formation and
thromobembolism, anticoag is not recommended.
-Treatment: monitor while treating COPD exacerbation.
[vs Atrial fibrillation: irregular RRi; absent p waves; use antiarrhymthmic drugs
(amiodarone) if stable or direct current cardioconversion if unstable. ]
ankylosing spondylitis: LBP worse at night improves with physical activity
a form of rheumatoid arthritis that primarily causes inflammation of the joints between
the vertebrae.
-affects sits of ligamentous insertion (enthesitis), leading to gradual onset of Low Back
Pain and progressive stiffness.
-AS eventually leads to destruction of the articular cartilage, especially at the sacroiliac
joints and apophyseal joints in spine.
(immune-mediate disorder/inflammatory spondylarthritis disorders, others include:
psoriatic arthritis, reactive arthritis, arthritis assoc w/ inflammatory bowel disease).
Pituitary adenoma: tx w/ dompamine agonist therapy
