NBME Exam

Question 1

At what beta-hcg level would you expect to see an intrauterine pregnancy?

Answer 1

Transvaginal US: 1000-1500 IU/L

Abdominal US: 6000 IU/L

Question 2

Order of appearance of fetal structures in pregnancy

Answer 2

Double ring sign
Double gestational sac
Intrauterine fetal pole
Fetal heart activity

Question 3

Medications to treat angina

Answer 3

Nitro
Calcium channel blocker (2.5 mg amlodipine)
Ranolazine (Ranexa); increases concentration of atorvastatin
Isosorbide mononitrate (Imdur)

Question 4

What is considered a large-bore IV?

Answer 4

14G or 16G

Question 5

How do you calculate cerebral perfusion pressure?

Answer 5

CPP = MAP - ICP

Question 6

What is the Cushing reflex?

Answer 6

Hypertension, bradycardia, and respiratory depression in the setting of increased ICP

Question 7

Treatments for elevated ICP

Answer 7

Elevate the head of the bed to 30 degrees
Hyperventilation to arterial PCO2 of 30-35
Mannitol
Monitoring/lowering blood pressure in consultation with neurosurgery
Providing adequate sedation and analgesia

Question 8

Unstable C-spine injuries

Answer 8

Type III odontoid fracture (involves base and bod of C2)
Hangman’s fracture (spondylolisthesis of C2 over C3)
Flexion teardrop fracture
Bilateral facet dislocation

Question 9

When can you give tPA for ischemic stroke?

Answer 9

3-4.5 hours from symptom onset

Contraindications: NIHSS score < 22, SBP > 180, hx of hemorrhagic stroke, any stroke within the past year, suspected aortic dissection, active bleeding

Question 10

What can you do in the ED to optimize treatment for ischemic stroke?

Answer 10

Supplemental oxygen
MAP > 60, SBP > 90
Serum glucose < 150
Normal temperature
Don't teat HTN until MAP > 130

Question 11

Signs of cardiac tamponade

Answer 11

Beck’s triad = hypotension, JVD, muffled heart sounds

Also electrical alternans on EKG

Question 12

How do you calculate MAP?

Answer 12

MAP = 1/3SBP + 2/3DBP

Question 13

Management of hemorrhagic stroke

Answer 13

ABC’s
Treat BP > 160/105 with nitroprusside, labetalol, nicardipine
Control seizures with lorazepam followed by fosphenytoin

Question 14

Stroke symptoms by vessel affected

Answer 14

ACA: unilateral weakness and/or sensory loss of contralateral lower extremity greater than upper extremity

MCA: unilateral weakness and/or sensory loss of contralateral face and upper extremity greater than lower extremity with either aphasia (if dominant hemisphere) or neglect (if non-dominant hemisphere)

PCA: unilateral visual field deficit in both eyes (homonymous hemianopsia).

Vertebrobasilar syndromes have multiple deficits which typically include contralateral weakness and/or sensory loss in combination with ipsilateral cranial nerve palsies. Suspicion for posterior circulation stroke is heightened if the patient exhibits one of these signs or symptoms beginning with “D”: diplopia, dysarthria, dysphagia, droopy face, dysequilibrium, dysmetria, and decreased level of consciousness. Nausea and vomiting are also frequently associated with brainstem stroke.

Lacunar infarcts are small strokes (measuring less than 1.5 cm) caused by occlusion of one of the deep perforating arteries which supplies the subcortical structures and brainstem. Lacunar infarcts can produce a large variety of clinical deficits depending on their location within the brainstem and have been characterized by more than 70 different clinical syndromes. However, the vast majority of lacunar strokes are described by the 5 most common lacunar syndromes: pure motor hemiparesis, sensorimotor stroke, ataxic hemiparesis, pure sensory stroke, and dysarthria-clumsy hand syndrome.

Question 15

Treatment for bacterial meningitis?

Answer 15

Ceftriaxone or cefotaxime

Add vancomycin if resistance in Strep pneumo
Add ampicillin if Listeria
Add antifungal if HIV+ or immunocompromized

Vancomycin + ceftazidime if post-head trauma or neurosurgical patients

Also add dexamethasone before or at the same time as abx in everyone > 3 months

Question 16

Classic triad of meningitis?

Answer 16

Fever, neck stiffness, AMS

Question 17

How to treat seizure in the acute setting

Answer 17

Benzodiazapine –> if fails, IV fosphenytoin, valproic acid, phenobarbital

Question 18

Definition and treatment of status epilepticus

Answer 18

Definition: continuous seizure > 10 min OR 2+ seizures without full recovery of consciousness between

Tx for convulsive: IV lorazepam or diazepam, fosphenytoin if needed

Tx for non-convulsive: valproic acid, phenobarbital

Further work-up: continuous EEG, head CT, LP, labs

Question 19

Major categorizations of seizures

Answer 19

Generalized: involving both hemispheres of the brain with loss of consciousness

Partial/Focal: only one hemisphere is involved. May spread to become secondary generalization.
Simple partial: cognition is not impaired
Complex partial: cognition is impaired.