Internal Medicine - NBME Shelf Exam
Questions and Answers
Acute iiMigraine iiHeadache iiTherapy ii- iiAnswers ii-Subcu iitriptans iiand iiIv iiantiemetics
ii(prochlorperazine, iimetoclopramide iithat iiblock iiD2 iireceptors iiand iiserotonin iireceptors
iiat iihigher iidoses), iishown iito iibe iiefficacious iiin iitreating iiacute iimigraine, iiespecially
iiwhen iiassociated iiwith iinausea/vomiting.
*contraind*: iiergotamine iiand iitriptans iiin iipersons iiwith iiheart iiconditions--ergotamine
ii(vasoconstriction iiof iicoronary iiartery); iisumatriptan ii(trigger iicoronary iivasospasm)
Hemodynamic iimeasurements iiin iishock: iiHypovolemic, iiCardiogenic, iiSeptic iishock. ii-
iiAnswers ii-PCWP iipressure ii= iipre-load. iiIt's iionly iiINCREASED iiin ii*cardiogenic iishock*
iiwhen iifailure iiof iiforward iiblood iiflow iioccurs iiand iicauses iian iiincrease iiin iiLEFT iiatrial
iiPresure ii-PRELOAD. iicardio iishock ii= iilow iicardiac iiindex, iipump iiis iifailing
*Tension iipnemo:* iiobstruction iiof iivena iicava iiand ii*decreased iivenous iireturn iito iiRA*. ii
*Volume iidepletion* ii(hemorrhagic iishock) iialso iileads iito ii*decreased iivenous iireturn iito
iiRA*. iiIf iidecreased iiRV iipre-load iithen iiboth ii= iiPCWP iiand iiCI iiare iilow. ii
CI ii= iicardiac iiindex ii(pump iifunction/cardiac iicontractility).
Obstructive iishock iicauses ii- iiAnswers ii-cardiac iitamponade, iiPE, iitension
iipneumothorax
Obstructive iishock iitreatment ii- iiAnswers ii-1.Increasing iicardiac iioutput iishould iibe iithe
iipriority iiin iitreating iicardiac iitamponade.
2.Apply iihigh-flow iioxygen.
3.The iionly iidefinitive iitreatment iifor iicardiac iitamponade iiis iisurgery.
obstructive iishock ii(pathophys iiof iimassive/submassive iiPE) ii= iiRV iidysfuction ii-
iiAnswers ii-right iiventricular iioutflow iiobstruction--> iiincrease iiin iiRV iipressure=
RV iihypokinesis ii& iidilation ii& iiRV iiwall iitension ii+ iiincreased iiRV iimycoardial iiO2
iidemand
=decrease iiRV iicardiac iioutput iiand iiseptal iideviation iitoward iiLV ii& iiRV iiischemia iiand
iiinfarction ii
= iidecrease iiLV iipreload iiand iicardiac iioutput ii--> iidecrease iicoronary iiperfusion iiand
iidecrease iiRV iimyocardial iisupply
Dementia iisubtypes ii- iiAnswers ii-1. iivascular iidementia: iistep-wise iidecline; iiearly
iiexecutive iidysfunction; iicerebral iiinfarction ii&/or iideep iiwhite iimatter iichanges iion
iineuroimaging ii(present iiwith iiischemic iistroke iiand iisubsequent iivascular iidementia-
patient iihas iiobjective iineuro iideficits). iirisk iifactors: iiHTN, iiage, iiDM, iiSmoking, iihx iiof
iistroke.
,2. iidementia iiwith iilewy iibodies: iivisual iihallucinations; iispontaneous iiParkinsonism;
iifluctuation iicognition; ii
3. iiAlzheimer: ii*temporal iilobe iiatrophy, iiaroun iidhippocampus* iiearly, iiinsidious iishort
iiterm iimemory iiloss; ii*language iideficits iiand iispacial iidisorientation*, ii*later iipersonality
iichanges*
4. iifrontotemporal iidementia: iiearly iipersonality iichanges, iiapathy, iidis-inhibition iiand
iicompulsive iibehavior; ii*frontotemporal iiatrophy iion iineuroimaging*
5. iiprion iidisease: iibehavioral iichanges, iirapid iiprogression, iimyoclonus iiand/or iiseizures
6. iiNormal iipressure iihydrocephalus: iiataxia iiearly iiin iidisease, iiurinary iiincontinence,
iidilated iiventricles iion iineuroimaging ii(Wet, iiwacky, iiwobbly).
folic iiacid iideficiency ii- iiAnswers ii-assoc iiw/ iineural iitube iidefects; iigingival iihyperplasia,
iiand iimegaloblastic iianemia
s/e iiof iiphenytoin iitherapy
Mixed iicryoglobulinemia iisyndrome ii- iiAnswers ii-a iivasculitis iicharacterized iiby iiimmune
iicomplex iideposition iiin iismall iiand iimedium iisized iivessels. iiPresents iiw/ iipalpable
iipurpura, iilow iic4, iiassoc iiw/ iichronic iihep iic, iiperipheral iineuropathy ii(hyporeflexia),
iiALT, iiAST iiinvolvement, iiarthalgias, iiand iisystemic iisymptoms ii- iifatigue, iiweakness.
Diagnose: iiassay iifor iicryoglobulins iithat iiclassically iicontains iiRheumatoid iiFactor ii(IgM
iiand iiIgG) iiand iipolyclonal iiIgG. iitissue iibiopsy iidemonstrates iismall iivessel iileukoclastic
iivasculitis. iihas ii*livido iireticularis*
Hypertrophic iiCardiomyopathy ii(HCM) ii- iimanagement ii- iiAnswers ii-CCBs iior iibeta
iiblockers, iiavoid iivolume iidepletion; iisurgery iiif iipersistent iisymptoms.
CPPD-calcium iipyrophosphate iideposition ii- iiAnswers ii--pseudo iigout: iirhomboid iishape
iicrystals, iipositive iibirefringence
-result iiof iicalcium iipyrophosphate iicrystals iiforming iiin iijoints ii
-knee iimc iiaffected
-*chondro-calcinosis* iiis iithe iiprimary iiradiographic iifinding: iimeniscal iicalcification
ii(example)
Imaging iiin iilow iiback iipain ii- iiAnswers ii-MRI: ii1. iisensory/motor iideficits
2. iicauda iiequina iisyndrome ii(saddle iianesthesia)
3. iisuspected iiepidural iiabscess/infection ii(fever, iiIVDU, iiconcurrent iiinfection,
iihemodyalisis)
Frostbite iitreatment ii- iiAnswers ii-Rapid iirewarming iiwith iiwarm iiwater ii(do iiNOT iiwait, iior
iiuse iitoo iihot iior iidry iiheat)
Multifocal iiAtrial iiTachycardia ii(MAT) ii- iiAnswers ii->100
irregular ii
P iiwaves iihave iiat iileast ii3 iidifferent iishapes
-MAT ii*does iinot iicreate iiincreased iirisk iiof iiatrial iithrombus iiformation iiand
iithromobembolism, iianticoag iiis iinot iirecommended.*
, -Treatment: ii*monitor iiwhile iitreating iiCOPD iiexacerbation.* ii
[vs iiAtrial iifibrillation: iiirregular iiRRi; iiabsent iip iiwaves; iiuse iiantiarrhymthmic iidrugs
ii(amiodarone) iiif iistable iior iidirect iicurrent iicardioconversion iiif iiunstable. ii]
ankylosing iispondylitis: iiLBP iiworse iiat iinight iiimproves iiwith iiphysical iiactivity ii-
iiAnswers ii-a iiform iiof iirheumatoid iiarthritis iithat iiprimarily iicauses iiinflammation iiof iithe
iijoints iibetween iithe iivertebrae. ii
-affects iisits iiof iiligamentous iiinsertion ii(enthesitis), iileading iito iigradual iionset iiof iiLow
iiBack iiPain iiand iiprogressive iistiffness. ii
-AS iieventually iileads iito iidestruction iiof iithe iiarticular iicartilage, iiespecially iiat iithe
iisacroiliac iijoints iiand iiapophyseal iijoints iiin iispine. ii
(immune-mediate iidisorder/inflammatory iispondylarthritis iidisorders, iiothers iiinclude:
iipsoriatic iiarthritis, iireactive iiarthritis, iiarthritis iiassoc iiw/ iiinflammatory iibowel iidisease).
Pituitary iiadenoma: iitx iiw/ iidompamine iiagonist iitherapy ii- iiAnswers ii-1. iicarbergoline
2. iibromocriptine
Light's iiCriteria ii- iiAnswers ii-
delayed iisleep-wake iiphase iidisorder ii- iiAnswers ii-a iicircadian iirhythm iisleep-wake
iidisorder iicharacterized iiby iisleep-onset iiinsomnia iiand iiexcessive iimorning iisleepiness.
iithis iisleep iicycle iiis ii*congruent* iiwith iithe iipatient's iinormal iicircadian iiclock
vs. iishift-work iidisorder: iidue iito iiwork iischedule iithat iiis ii*incongruent* iiwith iia iinormal
iicircadian iiclock.
lichen iiplanus ii- iiAnswers ii-flexural iisurfaces iiwrist iiand iiankles- ii5 iip's iipruritic,
iipurple/pink, iipolygonal iipapules iiand iiplaques
febrile iineutropenia, iitreat iifor iipseudomonas ii- iiAnswers ii-chemo iileads iito iidisruption iiof
iiskin iiand iimucosal iibarrier iiof iithe iimouth iiand iigi iitract, iiresulting iiin iimucositis iiand
iisubsequent iitranslocation iiof iibacteria iito iibloodstreatm. ii*gram iinegative, iiespecially
iipseudomonas* iiis iimost iifrequently iiidentified
Antipseudomonals ii- iiAnswers ii-beta iilactams:
cefepine,
meropenem
pieracillin-tazo
Ticarcillin-Piperacillin
proteus iimirabilis ii- iiAnswers ii-Urine iipH iiis iiincreased ii(alaklization) iidt iiurease-
producing iibacteria. iisometimes iialso iiklebsiella iipneumonia. ii
proteus iialso iicauses iistruvite iistones ii(magnesium iiammonium iiphosphate)
Digoxin iitoxicity iicommon iiin ii- iiAnswers ii-patients iichronically iitaking iidigoxin. iiPresent
iiwith: iidiarrhea, iinausea, iifatigue, iidecreased iiappetite, iiconfusion, iiweakness. iivisual
iiscotomata, iiblurry iivision iiwith iichanges iiin iicolor iior iiblindness. ii*inciting iievent:* iiviral
Questions and Answers
Acute iiMigraine iiHeadache iiTherapy ii- iiAnswers ii-Subcu iitriptans iiand iiIv iiantiemetics
ii(prochlorperazine, iimetoclopramide iithat iiblock iiD2 iireceptors iiand iiserotonin iireceptors
iiat iihigher iidoses), iishown iito iibe iiefficacious iiin iitreating iiacute iimigraine, iiespecially
iiwhen iiassociated iiwith iinausea/vomiting.
*contraind*: iiergotamine iiand iitriptans iiin iipersons iiwith iiheart iiconditions--ergotamine
ii(vasoconstriction iiof iicoronary iiartery); iisumatriptan ii(trigger iicoronary iivasospasm)
Hemodynamic iimeasurements iiin iishock: iiHypovolemic, iiCardiogenic, iiSeptic iishock. ii-
iiAnswers ii-PCWP iipressure ii= iipre-load. iiIt's iionly iiINCREASED iiin ii*cardiogenic iishock*
iiwhen iifailure iiof iiforward iiblood iiflow iioccurs iiand iicauses iian iiincrease iiin iiLEFT iiatrial
iiPresure ii-PRELOAD. iicardio iishock ii= iilow iicardiac iiindex, iipump iiis iifailing
*Tension iipnemo:* iiobstruction iiof iivena iicava iiand ii*decreased iivenous iireturn iito iiRA*. ii
*Volume iidepletion* ii(hemorrhagic iishock) iialso iileads iito ii*decreased iivenous iireturn iito
iiRA*. iiIf iidecreased iiRV iipre-load iithen iiboth ii= iiPCWP iiand iiCI iiare iilow. ii
CI ii= iicardiac iiindex ii(pump iifunction/cardiac iicontractility).
Obstructive iishock iicauses ii- iiAnswers ii-cardiac iitamponade, iiPE, iitension
iipneumothorax
Obstructive iishock iitreatment ii- iiAnswers ii-1.Increasing iicardiac iioutput iishould iibe iithe
iipriority iiin iitreating iicardiac iitamponade.
2.Apply iihigh-flow iioxygen.
3.The iionly iidefinitive iitreatment iifor iicardiac iitamponade iiis iisurgery.
obstructive iishock ii(pathophys iiof iimassive/submassive iiPE) ii= iiRV iidysfuction ii-
iiAnswers ii-right iiventricular iioutflow iiobstruction--> iiincrease iiin iiRV iipressure=
RV iihypokinesis ii& iidilation ii& iiRV iiwall iitension ii+ iiincreased iiRV iimycoardial iiO2
iidemand
=decrease iiRV iicardiac iioutput iiand iiseptal iideviation iitoward iiLV ii& iiRV iiischemia iiand
iiinfarction ii
= iidecrease iiLV iipreload iiand iicardiac iioutput ii--> iidecrease iicoronary iiperfusion iiand
iidecrease iiRV iimyocardial iisupply
Dementia iisubtypes ii- iiAnswers ii-1. iivascular iidementia: iistep-wise iidecline; iiearly
iiexecutive iidysfunction; iicerebral iiinfarction ii&/or iideep iiwhite iimatter iichanges iion
iineuroimaging ii(present iiwith iiischemic iistroke iiand iisubsequent iivascular iidementia-
patient iihas iiobjective iineuro iideficits). iirisk iifactors: iiHTN, iiage, iiDM, iiSmoking, iihx iiof
iistroke.
,2. iidementia iiwith iilewy iibodies: iivisual iihallucinations; iispontaneous iiParkinsonism;
iifluctuation iicognition; ii
3. iiAlzheimer: ii*temporal iilobe iiatrophy, iiaroun iidhippocampus* iiearly, iiinsidious iishort
iiterm iimemory iiloss; ii*language iideficits iiand iispacial iidisorientation*, ii*later iipersonality
iichanges*
4. iifrontotemporal iidementia: iiearly iipersonality iichanges, iiapathy, iidis-inhibition iiand
iicompulsive iibehavior; ii*frontotemporal iiatrophy iion iineuroimaging*
5. iiprion iidisease: iibehavioral iichanges, iirapid iiprogression, iimyoclonus iiand/or iiseizures
6. iiNormal iipressure iihydrocephalus: iiataxia iiearly iiin iidisease, iiurinary iiincontinence,
iidilated iiventricles iion iineuroimaging ii(Wet, iiwacky, iiwobbly).
folic iiacid iideficiency ii- iiAnswers ii-assoc iiw/ iineural iitube iidefects; iigingival iihyperplasia,
iiand iimegaloblastic iianemia
s/e iiof iiphenytoin iitherapy
Mixed iicryoglobulinemia iisyndrome ii- iiAnswers ii-a iivasculitis iicharacterized iiby iiimmune
iicomplex iideposition iiin iismall iiand iimedium iisized iivessels. iiPresents iiw/ iipalpable
iipurpura, iilow iic4, iiassoc iiw/ iichronic iihep iic, iiperipheral iineuropathy ii(hyporeflexia),
iiALT, iiAST iiinvolvement, iiarthalgias, iiand iisystemic iisymptoms ii- iifatigue, iiweakness.
Diagnose: iiassay iifor iicryoglobulins iithat iiclassically iicontains iiRheumatoid iiFactor ii(IgM
iiand iiIgG) iiand iipolyclonal iiIgG. iitissue iibiopsy iidemonstrates iismall iivessel iileukoclastic
iivasculitis. iihas ii*livido iireticularis*
Hypertrophic iiCardiomyopathy ii(HCM) ii- iimanagement ii- iiAnswers ii-CCBs iior iibeta
iiblockers, iiavoid iivolume iidepletion; iisurgery iiif iipersistent iisymptoms.
CPPD-calcium iipyrophosphate iideposition ii- iiAnswers ii--pseudo iigout: iirhomboid iishape
iicrystals, iipositive iibirefringence
-result iiof iicalcium iipyrophosphate iicrystals iiforming iiin iijoints ii
-knee iimc iiaffected
-*chondro-calcinosis* iiis iithe iiprimary iiradiographic iifinding: iimeniscal iicalcification
ii(example)
Imaging iiin iilow iiback iipain ii- iiAnswers ii-MRI: ii1. iisensory/motor iideficits
2. iicauda iiequina iisyndrome ii(saddle iianesthesia)
3. iisuspected iiepidural iiabscess/infection ii(fever, iiIVDU, iiconcurrent iiinfection,
iihemodyalisis)
Frostbite iitreatment ii- iiAnswers ii-Rapid iirewarming iiwith iiwarm iiwater ii(do iiNOT iiwait, iior
iiuse iitoo iihot iior iidry iiheat)
Multifocal iiAtrial iiTachycardia ii(MAT) ii- iiAnswers ii->100
irregular ii
P iiwaves iihave iiat iileast ii3 iidifferent iishapes
-MAT ii*does iinot iicreate iiincreased iirisk iiof iiatrial iithrombus iiformation iiand
iithromobembolism, iianticoag iiis iinot iirecommended.*
, -Treatment: ii*monitor iiwhile iitreating iiCOPD iiexacerbation.* ii
[vs iiAtrial iifibrillation: iiirregular iiRRi; iiabsent iip iiwaves; iiuse iiantiarrhymthmic iidrugs
ii(amiodarone) iiif iistable iior iidirect iicurrent iicardioconversion iiif iiunstable. ii]
ankylosing iispondylitis: iiLBP iiworse iiat iinight iiimproves iiwith iiphysical iiactivity ii-
iiAnswers ii-a iiform iiof iirheumatoid iiarthritis iithat iiprimarily iicauses iiinflammation iiof iithe
iijoints iibetween iithe iivertebrae. ii
-affects iisits iiof iiligamentous iiinsertion ii(enthesitis), iileading iito iigradual iionset iiof iiLow
iiBack iiPain iiand iiprogressive iistiffness. ii
-AS iieventually iileads iito iidestruction iiof iithe iiarticular iicartilage, iiespecially iiat iithe
iisacroiliac iijoints iiand iiapophyseal iijoints iiin iispine. ii
(immune-mediate iidisorder/inflammatory iispondylarthritis iidisorders, iiothers iiinclude:
iipsoriatic iiarthritis, iireactive iiarthritis, iiarthritis iiassoc iiw/ iiinflammatory iibowel iidisease).
Pituitary iiadenoma: iitx iiw/ iidompamine iiagonist iitherapy ii- iiAnswers ii-1. iicarbergoline
2. iibromocriptine
Light's iiCriteria ii- iiAnswers ii-
delayed iisleep-wake iiphase iidisorder ii- iiAnswers ii-a iicircadian iirhythm iisleep-wake
iidisorder iicharacterized iiby iisleep-onset iiinsomnia iiand iiexcessive iimorning iisleepiness.
iithis iisleep iicycle iiis ii*congruent* iiwith iithe iipatient's iinormal iicircadian iiclock
vs. iishift-work iidisorder: iidue iito iiwork iischedule iithat iiis ii*incongruent* iiwith iia iinormal
iicircadian iiclock.
lichen iiplanus ii- iiAnswers ii-flexural iisurfaces iiwrist iiand iiankles- ii5 iip's iipruritic,
iipurple/pink, iipolygonal iipapules iiand iiplaques
febrile iineutropenia, iitreat iifor iipseudomonas ii- iiAnswers ii-chemo iileads iito iidisruption iiof
iiskin iiand iimucosal iibarrier iiof iithe iimouth iiand iigi iitract, iiresulting iiin iimucositis iiand
iisubsequent iitranslocation iiof iibacteria iito iibloodstreatm. ii*gram iinegative, iiespecially
iipseudomonas* iiis iimost iifrequently iiidentified
Antipseudomonals ii- iiAnswers ii-beta iilactams:
cefepine,
meropenem
pieracillin-tazo
Ticarcillin-Piperacillin
proteus iimirabilis ii- iiAnswers ii-Urine iipH iiis iiincreased ii(alaklization) iidt iiurease-
producing iibacteria. iisometimes iialso iiklebsiella iipneumonia. ii
proteus iialso iicauses iistruvite iistones ii(magnesium iiammonium iiphosphate)
Digoxin iitoxicity iicommon iiin ii- iiAnswers ii-patients iichronically iitaking iidigoxin. iiPresent
iiwith: iidiarrhea, iinausea, iifatigue, iidecreased iiappetite, iiconfusion, iiweakness. iivisual
iiscotomata, iiblurry iivision iiwith iichanges iiin iicolor iior iiblindness. ii*inciting iievent:* iiviral
