NBME Practice Shelf

Question 1

Post-operative pt has sudden onset dyspnea while receiving blood transfusion. Reports back pain & painful IV site. On exam, pt is diaphoretic, has a low grade fever, tachypneic, normo-tensive, saturates well on room air. Skin exam is negative, breath sounds are CTAB, & the incision site looks good. Diagnosis?

Answer 1

Acute hemolytic transfusion reaction

2/2 preformed Abs to transfused blood &
ABO incompatibility (clerical error)

Question 2

Etiology & Management of
Acute Hemolytic Transfusion Reaction

Answer 2

ABO incompatibility / Pre-formed Abs

Stop transfusion immediately and provide supportive care

Question 3

Acute hemolytic transfusion reaction results in profound hemolysis and presents with:

≥ 99ºF
back/flank pain
hemoglobinuria (dark pee),

A positive ___ test.

Rapidly progresses to→ ____

Answer 3

Coombs

DIC

Question 4

Immune response to transfused ___ may be s/t:
1. Anaphylactic reaction to donor’s Ig
2. IgA deficient pts
3. Host Inflammatory response s/t excess cytokines in the donor’s plasma
(aka febrile nonhemolytic transfusion reaction)

Answer 4

plasma proteins

Question 5

Donor plasma proteins
can illicit a host immune response in what 3 scenarios?

1. Anaphylaxis
2. _____ deficient pts
3. _____ transfusion reaction

Answer 5

2. IgA deficient
3. Febrile non-hemolytic transfusion reaction

Question 6

Acute hemolytic transfusion reactions

s/t transfused ___ incompatible RBCs

(Host/recipient) ___ attack

(Donor) ___ on the surface of RBCs

resulting in hemolysis & fever

Answer 6

ABO incompatible RBCs

Preformed antibodies (host)
ABO antigens (donor)

Question 7

Pt presents with acute onset respiratory distress, crackles fever, and ± Hypotension within minutes to 6 hours after starting a transfusion

Dx & Tx?

Answer 7

Transfusion related acute lung injury (TRALI)

Treatment is supportive (ventilation, vasopressors, antipyretics)

*Donor WBCs (Anti-Leukocytes) Abs attack recipient

Question 8

New infiltrates/pulm edema on CXR that develop within 6 hours of transfusion of any blood product

Answer 8

Transfusion related acute lung injury (TRALI)
or TACO

Question 9

Patients who develops respiratory failure secondary to transfusion associated cardiac overload

Answer 9

TACO
Transfusion associated cardiac overload

Question 10

Patients who recover from TRALI can receive blood products but these products should not be from the

Answer 10

same prior blood donor

Question 11

Pt has shortness of breath immediately after beginning transfusion of blood products. T 100°F, Tachycardic, Tachypneic, normotensive, SO2 82%, crackles in bilateral lungs, cyanosis of extremities, & clear urine. Diagnosis?

Answer 11

Transfusion related acute lung injury (TRALI)

Question 12

May present with tachycardia, hypoxia, and chest pain, but diffuse crackles on pulmonary examination would be unusual for a

Answer 12

PE

Question 13

Pt presents with hypotension, tachycardia, AMS, and organ dysfunction in the setting of a presumed infection. General Dx?

Answer 13

Sepsis

(if unsure of dx consider temporal relationship of sxs as hinting at the more likely dx)

Question 14

[Organ] is most commonly injured organ in the setting of blunt abdominal trauma injury. It can present with abdominal tenderness and (if severe) hemodynamic instability from large-volume hemo-peritoneum.

Answer 14

spleen

*exploratory laparotomy is the next best step in
HD–unstable pts

Question 15

Pts with splenic injuries may have left upper quadrant tenderness, peritonitis or referred pain to the ___

Answer 15

Left shoulder
(s/t diaphragmatic irritation)

Question 16

Hemodynamically stable patients with minor splenic injuries may be treated with ___

Answer 16

observation and reassessment
(Repeat CT scan in 24hrs)

Question 17

Trauma patient is alert with neck pain, numbness and paresis below mid-chest. Pt has low grade fever, normal pulses, unlabored respiration, and BP 80/50. C-spine XR shows fractured C7/T1. BP does not improve after infusion of 2L IVFs, why?

Answer 17

Neurogenic shock s/t
Spinal Cord Injury.

*injury to autonomic (SNS) fibers from motor medulla center. Cannot get input from baroreceptors in the aortic and carotid sinus to regulate BP due to injured sympathetic fibers which cant signal vessels to vasoconstrict (lose vascular tone & dilate)

Question 18

Neurogenic Shock occurs when a spinal cord injury causes injury to ____ fibers from motor medulla center. These fibers are no longer able to get input from ____ baroreceptors to regulate BP. Hence vessels can’t ___.

Additionally, injury to sympathetic fibers from the Cardiovascular Center in the medulla may also lead to ___.

Answer 18

autonomic (SNS)

aortic & carotid sinus

vasoconstrict (lose vascular tone & dilate)

bradycardia

Question 19

Neurogenic Shock s/t spinal cord injury results in:

Hypotension (refractory to IVFs)
& Bradycardia (in SOME cases)

Management of this may include (3)

Answer 19

1. Fluid resuscitation
   (for maintaining perfusion)
2. Atropine– antimuscarinic block PSNS
   (for bradycardia)
3. Vasoactive pressor– Nor-Epi/ADH
   (to maintain MAP)

Question 20

____ can lead to neurogenic shock through disruption of autonomic centers however patients present with altered mental status, not just neurologic deficits like in spinal cord injury

Answer 20

Closed head injury/ traumatic brain injury

Question 21

Female presents with a 3 weeks history of headache; today headache has worsened with new blurred vision. Pt is obese afebrile with mild hypertension. Fundoscopy shows bilateral papilledema. Negative head CT.
Dx & next best step in management?

Answer 21

Idiopathic intracranial hypertension
Lumbar Puncture

*caused by inadequate resorption of cerebrospinal fluid and is characterized by signs of increased intracranial pressure like headache papilledema and elevated opening pressure on LP without gross abnormalities on Imaging

Question 22

In Idiopathic intracranial hypertension, headaches may worsen when __ and relieved by ___.

Answer 22

lying down

standing

Medication’s associated with IIH include tetracyclines, growth hormones and danazol (for endometriosis/ fibrocystic breast)

Question 23

If Idiopathic intracranial hypertension is suspected (Female, Fat, Migraines, Papilledema) what is the initial and second step in evaluation?

Answer 23

CT Head

if CT is normal, LP

Question 24

Management of Idiopathic intracranial hypertension includes:
1. weight loss
2. [Med]
3. therapeutic [Procedure]
in rare cases
4. [surgical intervention]

Answer 24

2. Carbonic anhydrase Inhibitors
3. lumbar puncture
4. CSF shunt

(or optic n. sheath fenestration)

Question 25

IV administration of ___ is useful for the acute management of optic neuritis was generally presents with acute onset vision loss, ocular pain worsened by ocular movements, decrease visual acuity/color, and
pupillary defects.
(Most commonly associated with multiple sclerosis)

Answer 25

Methylprednisolone

Question 26

Elderly male presents with lesion on his nose gradually increasing in size over the years. Lesion is a 1cm pinkish red dimple with rolled borders and central shiny, raw ulceration on the tip of nose. Diagnosis and next best step in management?

Answer 26

BCC

excision bx (5mm- 1cm) or Mohs procedure (if on face)

Question 27

Complete surgical excision with a margin of between __ to __ is recommended as first-line treatment for BCC located in non-critical areas amenable to complete resection

Answer 27

5 mm – 10 mm
(0.5 cm – 1.0 cm)

*In critical areas of the face or other delicate regions pick:
Mohs micrographic surgery → visible lesion layer excised, viewed under microscope, another thin layer is excised and examined until no more cancer is seen

Question 28

Management of mild frostbite include rewarming the affected area in warm water, analgesia, and admission to the hospital for ___

Answer 28

observation &
wound care

Question 29

Immediate ___ in the affected extremities is indicated in pts with acute limb ischemia with LOSS of pulses

Answer 29

Arteriography

*If limb is threatened but has some doppler A/V flow or sensorimotor fxn → Arteriography → Heparin & Revascularization via:
Percutaneous balloon angioplasty
Stent
Thrombectomy or Bypass

*Irreversibly damaged necrotic limb w/o doppler flow & sensorimotor fxn → amputation

Question 30

___ and stent placement are options for
revascularization in patients with PAD but the presence of gangrene is an indication for amputation

Answer 30

Percutaneous balloon angioplasty

Question 31

POD #3 pt with cardiac hx presents with abdominal pain, anxiety, diaphoresis, and tachycardia. Next best step in management (2)

Answer 31

ECG and Troponin

Question 32

If PE is considered, is a D-dimer or CTA better?

Answer 32

CTA

Question 33

Patients with severe or symptomatic aortic stenosis (Syncope, Angina, Dyspnea)
decrease ___
or a LVEF less than __% benefit from aortic valve replacement which may be performed surgically or through a transcatheter approach

Answer 33

exercise tolerance

Less than 50%

Question 34

Etiology of TACO

Answer 34

Transfusion causing fluid overload in patient with a h/o CHF or other cardiac hx

Question 35

Etiology of TRALI

Answer 35

Donor’s blood contains antibodies to recipient’s leukocytes/WBCs

Question 36

Name that Transfusion Reaction:

Wheezing, Angioedema, Dyspnea, (+Hypotension), s/t recipient IgA Abs → within minutes

Answer 36

Anaphylactic

Question 37

Name that Transfusion Reaction:

Red wheels s/t Host IgE Abs → within 2 hrs
Febrile Non-Hemolytic: Fever, chills, Dyspnea, Clear lungs, Clear urine → within 6 hrs

Answer 37

Urticarial

Question 38

Transfusion Reaction that presents with:

Fever,
± hypotension,
Dyspnea,
Clear lungs,
Flank (or back) pain,
Dark urine

→ within 1 hr

Answer 38

Acute Hemolytic

Question 39

Transfusion Reaction that Presents with:

Respiratory distress
(pulmonary infiltrates/Crackles/edema)
± hypotension
within 6 hours after transfusion initiation

TX: immediate transfusion cessation and respiratory supportive care

Answer 39

TRALI

(Supportive = vent/pressors/antipyretic)

Question 40

Name that Transfusion Reaction:

Afebrile, Dyspnea, Crackles in lungs, HTN → within 6 hrs of transfusion

Resolves with Diuresis

Answer 40

TACO