PAEA INTERNAL MEDICINE EOR PRACTICE TEST UPDATED
EXAM QUESTIONS AND ANSWERS GRADED A+
✔✔Treatment for PSVT - ✔✔Stable patient: vagal maneuvers (carotid massage, sink
patient's head in water)
Unstable patient: if non-responsive to vagal maneuvers; start IV adenosine or IV CCB
(verapamil, diltiazem)
✔✔Tx: Multifocal Atrial Tachycardia (MAT) - ✔✔Stabilize pt, 100% O2 by face
✔✔Tachycardia, wide complex QRS with sloping "delta wave" - ✔✔Wolff-Parkinson-
White Syndrome
✔✔Tx: WPW syndrome - ✔✔Tx: acute vagal maneuvers, IV adenosine; IV
procainamide in refractive cases
Long-term: radiofrequency ablation can be curative
✔✔Tachycardia with very wide and bizarre QRS complexes w/no distinctly discernable
P or T waves - ✔✔Ventricular tachycardia; likely will require cardioversion - stable pt
gets IV amiodarone (lidocaine and procainamide if refractory)
✔✔Cause of Torsade de Pointes - ✔✔Anything that prolongs the QT interval; MC
cause: hypomagnesemia
✔✔Tx of atrial fibrillation in emergency settings: - ✔✔A fib w hemodynamic instability:
cardioversion
A fib w rapid ventricular response: CCB
Stroke/TIA - stroke protocol
✔✔Outpatient atrial fibrillation management: - ✔✔- CCBs (diltiazem, verapamil) are
used as anti-arrhythmic of choice (they slow AV conduction)
- Anticoagulants to reduce the formation of mural thrombus (Warfarin) or if CI - plavix
✔✔Tx for Atrial Flutter: - ✔✔Rate control: CCB; Warfarin for anticoagulation (same as a
fib)
✔✔Fibrates - ✔✔Primarily used to tx high triglycerides; increases lipoprotein lipase
which breaks down TGs [do not combine w statins (rhabdomyolysis)]
✔✔Difference between synchronized cardioversion and non-synchronized -
✔✔Synchronized is used for pts w/ an arrhythmia w a pulse; non-synchronized is for pts
with an arrhythmia (vtach, vfib) w/o a pulse
,✔✔Treatment for acute pericarditis: - ✔✔Aspirin or NSAIDs; can add corticosteroids if
refractory
If Dressler's: only ASA or colchicine*
✔✔Pericarditis - ✔✔Inflammation of pericardium
Cause: Idiopathic, viral, malignant, Dressler's
S/Sx: Sharp, *Restrosternal, Improved with sitting up and leaning forward, Friction Rub*
Common presentations: young, chest pain, no risk factors, after viral infection
Dressler's common after procedure for MI
✔✔Pericarditis EKG - ✔✔Diffuse ST segment elevation-upward curves (smile)
p-r depression
✔✔Pericarditis work-up and Treatment - ✔✔IV, monitor, pain control
EKG
CXR
CBC, BMP, ESR, Trop(4-6 hours after onset of chest pain), +/- blood cultures
Tx: Anti-inflammatory agent,Cardiology consult
✔✔PE EKG - ✔✔S in lead 1, Q in lead 3, and inverted T in lead 3 are characteristic
findings
✔✔PE Diagnosis and Treatment - ✔✔Dx: Well's Criteria (risk factors), Ddimer, Doppler
US, PERC Rule, CTA, VQ Scan
Tx: Heparin (quick on/off) vs. LMWH (easier to give)
Thrombolytics (Saddle PE, admit to ICU)
Embolectomy
✔✔Aortic Dissection - ✔✔Intimal tear with leaking blood into media and longitudinal
cleavage from the adventitia
Risk factors: *HTN*, connective tissue disease (Marfan's), pregnancy, smoking, aortic
valve abnormalities
M>F, 50-70 years old, 33% mortality if untreated
✔✔Aortic Dissection Signs and Symptoms - ✔✔Symptoms: Abrupt onset, Chest or back
pain, *Tearing or Ripping* which propagates, *Neuroo deficits*
Signs: Asymmetric BP, shock vs HTN, New murmur, Tamponade, may mimic AMI and
CVA
✔✔Aortic Dissection workup and Treatment - ✔✔Work up: CXR, CTA (stable pt), TEE
(unstable), Pain control, Control shear forces if hypertensive (esmolol, labetolol, 60 bpm
goal HR)-beta blocker plus nitroprusside, Fluids for hypotension, Prepare PRBC,
Consult surgeon.
Need to Type and Cross 10 units of PRBC
, ✔✔Aortic Aneurysm - ✔✔Weakened and bulging area in the aorta, true aneurysm (all 3
layers), Genetic, structural, metabolic milieu
Age >60, atherosclerosis, HTN, smoking, lipids, other vascular disease
*97% Infrarenal*
✔✔Aortic Aneurysm Signs and Symptoms - ✔✔Symptoms: *Syncope and chest pain*,
Sudden onset of abdominal, back, or flank pain, hematuria, scrotal mass, femoral
neuropathy
Signs: *Pulsatile mass*, ecchymosis, abdominal bruits, tenderness, distal extremity
ischemia
✔✔Aortic aneurysm workup and treatment - ✔✔High suspicion(non-urgent, urgent,
emergent)
US vs CT, 2 large bore IV's, Type and Cross 6-10 units PRBC, BP control, don't over
resuscitate
Surgical Consult- 3.5-4 cm needs consult and further work up
✔✔Shock Definition and Types - ✔✔Failure to adequately deliver blood, oxygen, or
nutrients to tissue to meet metabolic demands
1. Hypovolemic (not enough blood)
2. Cardiogenic (heart is not working well enough)
3. Distributive (Sepsis, anaphylaxis, cord injury)
4. Obstructive (PE, Tamponade)
✔✔Hypertension Urgency & Emergency - ✔✔Urgency: Diastolic BP >120, Systolic
>140, No end organ damage
Emergency: *End organ Damage*, CNS, CV, Renal, AMI
*Increased ICP, HTN, Wide PP, bradycardia,irregular respirations*
Pulmonary Edema, Aortic dissection, Eclampsia
✔✔HTN Work up and Treatment - ✔✔Work-up: CBC, CMP (creatinine), UA, EKG, Trop,
CXR, head CT (based on complaint)
Exotica
Tx: Arrange F/U in majority of pts
Lower SBP 25% in 24 hours
Labetolol (IV form is fast onset, oral is spontaneous)
Nitrates, Hydralazine, ?benzos
✔✔CVA Treatment - ✔✔Ischemic: Activate stroke team, TPA vs Intervention, Modest
BP control (no more than 25% decrease) <185/110
Hemorrhagic: Activate Stroke Team, Contact neurosurgeon, Modest BP control
(variable practice, Nimodipine), Consider FFP, rVIIA, platelets, Reverse anti-coagulation
EXAM QUESTIONS AND ANSWERS GRADED A+
✔✔Treatment for PSVT - ✔✔Stable patient: vagal maneuvers (carotid massage, sink
patient's head in water)
Unstable patient: if non-responsive to vagal maneuvers; start IV adenosine or IV CCB
(verapamil, diltiazem)
✔✔Tx: Multifocal Atrial Tachycardia (MAT) - ✔✔Stabilize pt, 100% O2 by face
✔✔Tachycardia, wide complex QRS with sloping "delta wave" - ✔✔Wolff-Parkinson-
White Syndrome
✔✔Tx: WPW syndrome - ✔✔Tx: acute vagal maneuvers, IV adenosine; IV
procainamide in refractive cases
Long-term: radiofrequency ablation can be curative
✔✔Tachycardia with very wide and bizarre QRS complexes w/no distinctly discernable
P or T waves - ✔✔Ventricular tachycardia; likely will require cardioversion - stable pt
gets IV amiodarone (lidocaine and procainamide if refractory)
✔✔Cause of Torsade de Pointes - ✔✔Anything that prolongs the QT interval; MC
cause: hypomagnesemia
✔✔Tx of atrial fibrillation in emergency settings: - ✔✔A fib w hemodynamic instability:
cardioversion
A fib w rapid ventricular response: CCB
Stroke/TIA - stroke protocol
✔✔Outpatient atrial fibrillation management: - ✔✔- CCBs (diltiazem, verapamil) are
used as anti-arrhythmic of choice (they slow AV conduction)
- Anticoagulants to reduce the formation of mural thrombus (Warfarin) or if CI - plavix
✔✔Tx for Atrial Flutter: - ✔✔Rate control: CCB; Warfarin for anticoagulation (same as a
fib)
✔✔Fibrates - ✔✔Primarily used to tx high triglycerides; increases lipoprotein lipase
which breaks down TGs [do not combine w statins (rhabdomyolysis)]
✔✔Difference between synchronized cardioversion and non-synchronized -
✔✔Synchronized is used for pts w/ an arrhythmia w a pulse; non-synchronized is for pts
with an arrhythmia (vtach, vfib) w/o a pulse
,✔✔Treatment for acute pericarditis: - ✔✔Aspirin or NSAIDs; can add corticosteroids if
refractory
If Dressler's: only ASA or colchicine*
✔✔Pericarditis - ✔✔Inflammation of pericardium
Cause: Idiopathic, viral, malignant, Dressler's
S/Sx: Sharp, *Restrosternal, Improved with sitting up and leaning forward, Friction Rub*
Common presentations: young, chest pain, no risk factors, after viral infection
Dressler's common after procedure for MI
✔✔Pericarditis EKG - ✔✔Diffuse ST segment elevation-upward curves (smile)
p-r depression
✔✔Pericarditis work-up and Treatment - ✔✔IV, monitor, pain control
EKG
CXR
CBC, BMP, ESR, Trop(4-6 hours after onset of chest pain), +/- blood cultures
Tx: Anti-inflammatory agent,Cardiology consult
✔✔PE EKG - ✔✔S in lead 1, Q in lead 3, and inverted T in lead 3 are characteristic
findings
✔✔PE Diagnosis and Treatment - ✔✔Dx: Well's Criteria (risk factors), Ddimer, Doppler
US, PERC Rule, CTA, VQ Scan
Tx: Heparin (quick on/off) vs. LMWH (easier to give)
Thrombolytics (Saddle PE, admit to ICU)
Embolectomy
✔✔Aortic Dissection - ✔✔Intimal tear with leaking blood into media and longitudinal
cleavage from the adventitia
Risk factors: *HTN*, connective tissue disease (Marfan's), pregnancy, smoking, aortic
valve abnormalities
M>F, 50-70 years old, 33% mortality if untreated
✔✔Aortic Dissection Signs and Symptoms - ✔✔Symptoms: Abrupt onset, Chest or back
pain, *Tearing or Ripping* which propagates, *Neuroo deficits*
Signs: Asymmetric BP, shock vs HTN, New murmur, Tamponade, may mimic AMI and
CVA
✔✔Aortic Dissection workup and Treatment - ✔✔Work up: CXR, CTA (stable pt), TEE
(unstable), Pain control, Control shear forces if hypertensive (esmolol, labetolol, 60 bpm
goal HR)-beta blocker plus nitroprusside, Fluids for hypotension, Prepare PRBC,
Consult surgeon.
Need to Type and Cross 10 units of PRBC
, ✔✔Aortic Aneurysm - ✔✔Weakened and bulging area in the aorta, true aneurysm (all 3
layers), Genetic, structural, metabolic milieu
Age >60, atherosclerosis, HTN, smoking, lipids, other vascular disease
*97% Infrarenal*
✔✔Aortic Aneurysm Signs and Symptoms - ✔✔Symptoms: *Syncope and chest pain*,
Sudden onset of abdominal, back, or flank pain, hematuria, scrotal mass, femoral
neuropathy
Signs: *Pulsatile mass*, ecchymosis, abdominal bruits, tenderness, distal extremity
ischemia
✔✔Aortic aneurysm workup and treatment - ✔✔High suspicion(non-urgent, urgent,
emergent)
US vs CT, 2 large bore IV's, Type and Cross 6-10 units PRBC, BP control, don't over
resuscitate
Surgical Consult- 3.5-4 cm needs consult and further work up
✔✔Shock Definition and Types - ✔✔Failure to adequately deliver blood, oxygen, or
nutrients to tissue to meet metabolic demands
1. Hypovolemic (not enough blood)
2. Cardiogenic (heart is not working well enough)
3. Distributive (Sepsis, anaphylaxis, cord injury)
4. Obstructive (PE, Tamponade)
✔✔Hypertension Urgency & Emergency - ✔✔Urgency: Diastolic BP >120, Systolic
>140, No end organ damage
Emergency: *End organ Damage*, CNS, CV, Renal, AMI
*Increased ICP, HTN, Wide PP, bradycardia,irregular respirations*
Pulmonary Edema, Aortic dissection, Eclampsia
✔✔HTN Work up and Treatment - ✔✔Work-up: CBC, CMP (creatinine), UA, EKG, Trop,
CXR, head CT (based on complaint)
Exotica
Tx: Arrange F/U in majority of pts
Lower SBP 25% in 24 hours
Labetolol (IV form is fast onset, oral is spontaneous)
Nitrates, Hydralazine, ?benzos
✔✔CVA Treatment - ✔✔Ischemic: Activate stroke team, TPA vs Intervention, Modest
BP control (no more than 25% decrease) <185/110
Hemorrhagic: Activate Stroke Team, Contact neurosurgeon, Modest BP control
(variable practice, Nimodipine), Consider FFP, rVIIA, platelets, Reverse anti-coagulation
