Question of the Week # 425

425) A 80 day old african american woman with advanced dementia is admitted to the intensive care unit for overwhelming sepsis secondary to a urinary tract infection. At presentation she was hypoxemic and was subsequently, intubated and placed on a ventilator. Blood and urine cultures are obtained and she is started on antibiotics A chest x-ray post-intubation shows endotracheal tube in place and bilateral diffuse alveolar infiltrates. On examination, his pulse is 110/min, Blood pressure is 110/80 mm Hg and respiratory rate is 18/min with the patient on Assist-Control mode on the ventilator. Pulse oximetry reveals 88% on Fio2 90%. Chest examination reveals diffuse crackles. Cardiac examination reveals tachycardia, there is no S3 gallop. Brain natriuretic peptide level is 50 pg/ml . A 2D echocardiogram shows normal left ventricular function with an ejection fraction of 60%. His ventilator settings are as follows : Assist-Control mode; Fio2 ( Fraction of inspired oxygen) : 90%, Respiratory rate : 18/minute, Tidal Volume : 500 ml, PEEP ( Positive End expiatory Pressure) : 5 cm H20 . Arterial blood gas analysis reveals ( on Fio2 70%): pH : 7.36, pCo2 : 45 mmHg, pO2 : 55 mm Hg, Bicarbonate : 23 Meq/L

Which of the following is indicated at this time?

A) Intravenous Furosemide

B) Swan-Ganz Catheter Placement

C) Increase PEEP by 3 cm H20

D) Increase Tidal Volume to 650 ml

E) Increase Fio2 to 100%

Question of the Week # 257

257)  A 72 year old man with history of Diabetes Mellitus is rushed to the emergency room by the EMS 30 minutes after he collapsed at his home with severe left sided chest pain. Upon arrival, the patient was found to have very low blood pressure at 70/40 mm Hg.  Chest examination revealed diffuse coarse crepitations. An electrocardiogram showed ST elevations in the anterior leads with reciprocal depressions. The patient was immediately started on Aspirin, GP IIb/IIIA inhibitors, Clopidogrel and Heparin. He is placed on 50% 02 by Venturi mask and his oxygen saturation on this supplemental oxygen is 92%. A diagnosis of cardiogenic shock and pulmonary edema is made and the patient is admitted to intensive care unit. The patient is placed on Intra-Aortic Balloon Counterpulsation Pump (IABP) and is rushed to cardiac catheterization lab. In which of the following situations, IABP confers more harm than benefit?

A) Acute Mycocardial Infarction (MI) with Cardiogenic Shock

B) Aortic dissection with aortic regurgitation

C) Severe left ventricular failure with pulmonary edema

D)  Post-MI Ventricular Septal Perforation

E) Post-MI Acute Mitral Regurgitation

Question of the Week # 256

256)  A 72 year old man with history of Diabetes Mellitus is rushed to the emergency room by the EMS 30 minutes after he collapsed at his home with severe left sided chest pain. Upon arrival, the patient was found to have very low blood pressure at 70/40 mm Hg.  Chest examination revealed diffuse coarse crepitations. An electrocardiogram showed ST elevations in the anterior leads with reciprocal depressions. The patient was immediately started on Aspirin, GP IIb/IIIA inhibitors, Clopidogrel and Heparin. He is placed on 50% 02 by Venturi mask and his oxygen saturation on this supplemental oxygen is 92%. A diagnosis of cardiogenic shock and pulmonary edema is made and the patient is admitted to intensive care unit. If performed immediately, which of the following interventions would most likely reduce his risk of death?

A)     Thrombolytic therapy

B)     Dopamine infusion

C)      Intra-Aortic Balloon Pump (IABP)

D)     Percutaneous Coronary Intervention

E)     Left Ventricular Assist Device (LVAD)

Note : SHOCK TRIAL

Question of the Week # 254

254 )  A 72 year old man with history of metastatic prostate cancer is admitted with severe weakness and lethargy. He has been having vomiting and abdominal pain for the past two weeks.  He also reports intermittent diarrhea alternating with constipation over the past 2 months. Three months ago, he was noted to have progressive prostate cancer despite therapy with bicalutamide and leuprolide. His PSA at that time was 300ng/ml. He was started on Ketoconozole at that time and he is compliant with it. His most recent visit to the outpatient clinic was 4 weeks ago at which time his PSA was 60ng/ml. On examination, his temperature is 98F, Heart rate is 130/min, Respiratory rate 20/min and Blood pressure 70/40 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A CT scan of the adbomen reveals enlarged prostate and osteoblastic bone metastases in pelvis but no evidence of bowel obstruction. Urinalysis and Chest x-ray are benign. The patient is started on intravenous isotonic saline. Which of the following is the most appropriate next step in managing this patient?

A) Start Chemotherapy

B) Refer to Hospice

C) Intravenous Hydrocortisone

D) Start Norepinephrine drip

E) Intravenous Biphosphonates

 

Question of the Week # 253

253 )  A 75 year old african-american woman with history of Alzheimer’s dementia and recent cerebro-vascular accident is transferred from the Nursing home for deterioration in mental status and fever. As per the nursing home staff, she has stopped feeding and has been having fever for the past three days. On examination, her temperature is 102F, Heart rate is 130/min, Respiratory rate 28/min and Blood pressure 80/45 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A foley catheter is in place draining very cloudy urine. Dipstick urinalysis revealed 2+ protein, positive leucoesterase and nitrite. Blood cultures are obtained and the intravenous normal saline is started via. two large bore needles. In managing her Septic Shock, which of the following is the most appropriate goal that must be met in the first 6 hours of adequate resuscitation?

A) Mean Arterial Blood pressure > 50mm Hg

B) Serum Creatinine < 1.5 mg%

C) Urine output > 0.25ml/kg/hr

D) Mixed Venous Saturation > 65%

E) Hematocrit > 30%

Note: Surviving Sepsis guidelines

Question of the Week # 252

252 )  A 75 year old african-american woman with history of Alzheimer’s dementia and recent cerebro-vascular accident is transferred from the Nursing home for deterioration in mental status and fever. As per the nursing home staff, she has stopped feeding and has been having fever for the past three days. On examination, her temperature is 102F, Heart rate is 130/min, Respiratory rate 28/min and Blood pressure 80/45 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A foley catheter is in place draining very cloudy urine. Dipstick urinalysis revealed 2+ protein, positive leucoesterase and nitrite. Blood cultures are obtained and the intravenous normal saline is started via. two large bore needles. Which of the following is the most important next step in managing this patient?

A) Put in reverse trendelenberg position

B) Place a central venos catheter

C) Start Dopamie infusion via. peripheral access

D) Intravenous Hydrocortisone

E) Obtain Arterial Blood Gas analysis

note: Surviving Sepsis guidelines

Question of the Week # 243

243) A 65 year old man with a long history of COPD and history of metastatic colon cancer presents with complaints of increasingly severe shortness of breath that occurred at rest today. He reports that his symptoms are much more severe than his usual baseline. On examination , he is afebrile and tachypneic. Blood pressure is normal. Chest exam reveals occassional rhonchii. EKG shows sinus tachycardia. Arterial blood gases are obtained on the room air and show Ph : 7.45 Po2 40 PCo2 50 and Bicarbonate of 36. Chest X-ray shows changes of emphysema. His home medications include ipratropium and albuterol inhalers. He is placed on 4 liters oxygen by nasal cannula.

Which of the following is the most appropriate next step?

A) Intravenos corticosteroids

B) Intubation

C) Spiral CT scan and empiric Low molecular weight heparin

D) Non invasive positive pressure ventilation

E) Bed-side Spirometry

Question of the Week # 230

230) A 72-year-old white man with history of type 2 diabetes mellitus and hypertension is evaluated in your office during a follow up visit. He was discharged 3 days ago from the hospital after undergoing diagnostic cardiac catheterization for an abnormal exercise stress test. Femoral sheath was removed three days ago. He denies any chest pain or shortness of breath.  On physical examination, he is afebrile, HR 120/min and blood pressure is 120/70 mm hg.  There is a new palpable mass in the right groin and systolic bruit is heard at the catheter insertion site. Dorsalis pedis and posterior tibial pulses are intact. Which of the following is the most likely diagnosis?

A)     Arterio-venos fistula

B)     Local Hematoma

C)      Femoral artery true aneurysm

D)     Hematoma in continuity with arterial lumen

E)     Femoral artery thrombosis

Question of the Week # 229

229 )  A 70-year-old white man with history of poorly controlled type 2 diabetes mellitus and hypertension is evaluated in the emergency room for severe pain in the right thigh. The patient has a coronary artery disease for which he underwent cardiac catheterization with percutaneous coronary intervention 2 days ago. He denies any chest pain or shortness of breath.  On physical examination, temperature is 99.2F, HR 120/min and blood pressure is 80/40 mm Hg.  There is erythema at the site of  cardiac catheterization in the femoral area. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 1.8mg% one week ago. Which of the following is the most likely diagnosis?

A)  Toxic shock syndrome

B)  Atheroembolism

C)  Contrast Nephropathy

D) Ruptured femoral artery pseudo-aneurysm

E)  Retroperitoneal bleeding

Question of the Week # 228

228 )  A 70-year-old white man  with type 2 diabetes mellitus and hypertension is evaluated in the emergency room for lacy purplish discoloration of the lower extremities that developed few hours ago. He reports diffuse bodyaches and low grade fever. He denies chest pain or shortness of breath. His past medical history is significant for coronary artery disease for which he underwent cardiac catheterization with percutaneous coronary intervention one week ago.  He has a history of chronic atrial fibrillation for which he is on 5mg coumadin daily. His most recent INR has been therapeutic at 2.5. Physical examination reveals lacy purplish pattern on bilateral lower extremities shown in the image below.

The site of cardiac catheterization in the femoral area is clean and healing with out any tenderness or erythema. Neurological examination is normal. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 1.8mg% one week ago. Hemoglobin and platelet count are within normal limits. WBC count is 12.6k/µl with neutrophils 70%, bands of 2% , eosinophils 18% and lymphocytes 10%. Which of the following is the most likely diagnosis?

A)  Toxic shock syndrome

B)  Atheroembolism

C)  Contrast Nephropathy

D)  Anti-Phospholipid antibody syndrome

E)  Cryoglobulinemia

Question of the Week # 225

225 ) A 40 year-old man presents to office for routine follow-up visit. His past medical history is significant for hypertension for which he is on Hydrochlorthiazide. He denies any chest pain, palpitatations, shortness of breath or syncope. He is a journalist by occupation. A routine EKG  is obtained and is shown below:

Which of the following is the most appropriate managment of this patient?

A) Beta-blocker

B) Catheter ablation

C) Diltiazem

D) Observation

E) Electrophysiological studies

 

Question of the Week # 224

224 ) A 38 year old man presents to the emergency room with complaints of palpitations that started 5 hours ago and are persistent. He denies having similar episodes in the past. He has no fever or shortness of breath or chest pain. His past medical history is unremarkable and he is not on any medications. On examination, blood pressure is 110/60 mmHg, heart rate  130/min, RR 20/min  and temperature 98.6 F.   Cardiovascular examination reveals irregularly, irregular heart rate at 140beats/min.  An Electrocardiogram now is shown below :

An EKG that was done during a pre-employment health check-up upon patient’s own request two months ago is shown below:

The most appropriate next step in managing this patient:

A) Defibrillation

B) Intravenous metoprolol

C) Intravenous Diltiazem

D) Intravenous Procainamide

E) Synchronized Cardioversion

Question of the Week # 223

223 ) A 38 year old obese African American man presented to the emergency department with headache, blurred vision and weakness.  His past medical history was unremarkable. He smoked about 1 pack per day for 20 years.  On examination, this patient’s blood pressure was 210/140 mmHg, heart rate 98/min, RR 20/min  and temperature 98.6 F.  He is alert, awake and oriented. Physical examination is unremarkable. There are neurological deficits. Laboratory investigations showed Hemoglobin 8.2 g/dl, White cell count 10k/µl, Platelets 97000/µl, Sodium 140meq/L, Potassium 4.0meq/L, Bicarbonate 24meq/L,  BUN 34 and Creatinine 3.2mg% . Further investigations included a Lactic dehydrogenase which was elevated at 900U/L and a reticulocyte count of 7.0% . A periphreral smear is shown below :

The most appropriate next step in managing this patient:

A) Fresh frozen plasma

B) Intravenous Labetalol

C) Plasmapheresis

D) Intravenous Nitroprusside

E) Hemodialysis

Question of the Week # 222

222 )  A 70-year-old white man  with type 2 diabetes mellitus, hypertension, coronary artery disease, chronic kidney disease and severe chronic obstructive pulmonary disease is admitted with increasing shortness of breath. The patient lives by himself and he has not been very compliant with his medications. On examination, he is awake and oriented, blood pressure is 230/140 . Funduscopic examination reveals papilledema.  Chest exam reveals bilateral crepitations. Neurological examination is normal. An electrocardiogram reveals non specific ST segment changes. A chest x-ray shows bilateral pulmonary edema. Pulse oximetry reveals a saturation of 89% on room air. The patient is started on oxygen by nasal cannula. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 2.2mg%. Which of the following is the most appropriate next step in management?

A)  Non-contrast CT Scan, head

B)  Intravenous Sodium nitroprusside

C)  Intravenous Labetalol

D)  Fenoldapam

E)  Cardiac catheterization.

Question of the Week # 221

221 )  A 73-year-old white man with type 2 diabetes mellitus, hypertension, coronary artery disease is admitted with increasing shortness of breath and lower-extremity edema. A brain natriuretic peptide level is 1000 pg/ml. His medications include glyburide, aspirin, atorvastatin and enalapril. He is allergic to sulfonamides. On physical examination, he has bilateral crepitations more in the right chest. Extremity examination reveals 3+ edema bilaterally. An electrocardiogram reveals changes consistent with left venricular hypertrophy but no evidence of acute ischemia. Cardiac enzymes are negative. A chest x-ray reveals bilateral pulmonary edema. Pulse oximetry reveals a saturation of 89% on room air. The patient is started on oxygen by nasal cannula. Which of the following is the most appropriate next step in management?

A) Intubation

B) Intravenous Furosemide

C) Bilevel Positive Airway pressure (BIPAP)

D) Intravenous Ethacrynic acid

E) Cardiac catheterization.

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