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NBME 22 Answers

nbme22/Block 3/Question#39 (41.0 difficulty score)
A 52-year-old man with stable angina pectoris ...

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submitted by nwinkelmann(311),
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I fodun hsit ewhn yigtrn to esddnatnru hyw eidsercna NO audsec sechaeahd: stnNeitat/tsriire era a rvey ocmnom daeahech nad geinmria ofod egrisrtg (MWDe)b adn irsea rincit dixoe e.vlsel gHhi evlsle fo ciitrn oexdi era scodisteaa ihtw igaenmri ty.d()Su decseaaHh nad iegarsimn ear sloa yrve cmnomo in ditemaoisnc ttah obsot itrnic e,dxoi csuh a iavrga (,dsytu) utb it is aneulcr hyw thsi hsnpae.p ehT gaiinolr otiephhssy wsa ttha ircitn xedio isseaencr ldboo velsse zies and sgtriger a n,rmigiae tub het aiavrg sydut and hsoret rpovesidd isht. eerNw isdtues on ciirtn idoex owssh ttha ti ceesranis eht dieppet CPG)(R htat is ercodnsedi rsplseebnio fro gingitregr grieimnsa (S)tyud efrat rineecass ni .aiamomftnlni asecueB nricti dioex is tssciaeoda rnogueince ftanoanimlmi ss,sdieae 'sit eylilk ttah deasceahh nda mginareis rmof ctnrii dxoie era a anrwngi snig of shti ltfanimainmo t.(dSy)u

heT csarrhee is sliycabla titagns atht senratti arsie tnicir oeixd lleevs nad ghih cinitr oixde eselvl rneaesci iotnamlnamif adn esdahache dna emiir.agns oevr,eHw het axcte reasno wyh shit ehappsn si kn.wuonn


taediggity  Goljan and FA mentioned this as Monday Disease for people who worked in industries that heavily used nitrates, where they would build tolerance during the week and then get a headache when they went back to work on Monday +4  
nootnootpenguinn  Just to add to this- one of the side effect of NG when given to patients with MI is "massive headache"! That's how I the question right! +  
mumenrider4ever  This is similar in how triptans induce vasoconstriction which is used to treat migraines +  

submitted by amphotericin(8),
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I tup nitaoosptcin escueba I othhugt eht tmncieodia gnibe cbrsddeie gtihm eb C:CB anc eosemno ipxealn why saritten vreo C?CB

seracen  Wouldn't nitrates be a faster acting drug here? That was my take-away anyway. One is more acute, the other for long term maintenance. +4  
suckitnbme  I also believe it's because CCBs have minimal effect on venous beds and would not cause a significant decrease on preload. +3  
beto  decrease of cardiac preload is another word of Venodilation, so Nitrates primarly venodilators. CCB dilate arteria more than veins +1  
zevvyt  also, verapamil is the one that causes constipation. But Verampamil is non-dyhydropiridine, so it works more on the heart than the vessels +3  

submitted by marbledoc(0),
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hatW si sthi eimntiocda bnegi bddiceser ?eehr Cna ooensem eicmh n.i

thatyummyslice  Nitrates i believe! NO --> increased cGMP in vessel smooth muscle --> myosin light chain dephosphorylate --> vascular smooth muscle RELAX --> Dilate (primarily in venous) AKA more venous capacitance --> LOWER preload and workload for heart. +31  
marbledoc  Thanks! Thought it was nitrates too from the Q stem. But had no clue it was notorious for headaches (only thought of hypotension, dizziness, etc) so doubted it all together. But youโ€™re absolutely right apparently itโ€™s the most common side effect! +  
dr.xx  Previously, Ferid Murad et al. described that organic nitrates, such as nitroglycerine, induce vasodilation by release of nitric oxide, activating soluble guanylyl cyclase and subsequent cyclic guanosine monophosphate formation.7 These discoveries rendered Robert Furchgott, Louis Ignarro, and Ferid Murad the Nobel Prize in Physiology or Medicine in 1998. +  

submitted by yousif7000(3),

I chose bradycardia because I thought he was prescribed beta-blocker, why did we exclude beta-blockers?