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

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