1. -3. A 26 year old woman is brought into the emergency room after being found in her home lethargic with an empty bottle of tylenol (acetaminophen) and a half empty bottle of whisky next to her. She has a history of depression with one previous suicide attempt but it is not known if she currently takes medications. On examination she is somnolent but arousable. Her blood pressure is 100/60, pulse 110 bpm, respirations 10, and temperature 97.2°F. Her pupils are small, sluggishly reactive, and anicteric. Her neck is without lymphadenopathy or obvious meningismus. Chest is clear. Cardiac exam is normal except for tachycardia. Abdomen is soft, nontender, and the liver edge is palpated 2cm below the right costal margin (14cm span). No spleen or masses are appreciated. Extremities are mildly cyanotic. The patient suddenly vomits nonbloody, watery material with pill fragments in it, coughs weakly several times, then falls asleep again. An intravenous line is placed and fluids begun. A pulse oximeter reads 88% saturation. Routine blood tests, ethanol and acetaminophen levels, PT, PTT, toxin screen are sent. The next step is [1]:

   
   A. Sit the patient upright, draw a blood gas, start thiamin / folate / glucose
   B. Sedate the patient, intubate for airway protection, insert a gastric lavage tube
   C. Ask the patient to drink a charcoal solution
   D. Ask the patient if she takes any other medications
   E. Turn the patient on their left side, draw a blood gas, start thiamine / folate glucose

   
   

2. The pulse oximeter reads 100% with the patient breathing 100% oxygen. The next step is [2]:

   
   A. Gastric lavage with saline or water, followed by N-Acetylcysteine (Mucomist®)
   B. Administer N-Acetylcysteine via the gastric tube followed by charcoal
   C. Draw a blood gas and administer charcoal per NG tube
   D. Transfer the patient to the intensive care unit and establish ventilator settings
   E. Administer supportive care pending results of the blood tests

   
   

3. A complete course (seventeen doses) of N-Acetylcysteine (Mucomist®) are indicated for acetaminophen overdose [3]:

   
   A. When initial levels are in the toxic range
   B. In all patients who are suspected of taking an acetaminophen
   C. When 6 hour post-ingestion blood acetaminophen levels are in the toxic range
   D. In any patient with hepatitis
   E. In all patients with renal impairment

   
   

4. A 57 year old patient with a history of anterior myocardial infarction and reduced left ventricular ejection fraction is admitted to the medical intensive care unit with severe pneumonia with gram positive cocci in clusters in the sputum sample. The pulse is 120 and irregular; the blood pressure is 100/68mm in both arms. An ECG shows Atrial Fibrillation (new). A chest radiograph shows right middle and lower lobe consolidations with a small pleural effusion. A pulmonary artery catheter (Swan- Ganz) is inserted to aide in management. The following readings are obtained (pressures in cm of H20): RV Pressure 20/10, PA Pressure 25/15, PCWP (Wedge Pressure) 12, Systemic Vascular Resistance 500 (normal 1000-1400), Cardiac Output 6.2L/min (index 4.7L/min).The pulmonary artery catheter readings are most consistent with which diagnosis [4]:

   
   A. Cardiogenic Shock
   B. Mixed Cardiogenic and Septic Shock
   C. High Output Congestive Heart Failure
   D. Hypovolemic Shock
   E. Septic Shock

   
   

5. A pulmonary artery catheter is strongly contraindicated in which situation [5] ?

   
   A. Left Bundle Branch Block
   B. History of Stroke
   C. History of Malignancy
   D. Sepsis
   E. Mechanical Ventilation

   
   

6. Fluids are administered but the blood pressure drops to 90/60mm. The patient is less alert. Oxygen saturation on 50% non-rebreathing mask is 93%. A blood gas is drawn. The pH is 7.29, pO2 69mm, pCO2 28mm. The pulse is 110bpm in new onset atrial fibrillation. The following readings are obtained (pressures in cm of H20): RV Pressure 25/15, PA Pressure 30/15, PCWP (Wedge Pressure) 18, Systemic Vascular Resistance 400 (normal 1000-1400), Cardiac Output 5.8L/min (index 4.5L/min). The best choice for vasopressor agent in this setting is [6]:

   
   A. Dobutamine (Dobutrex®)
   B. High dose Dopamine (Intropin®)
   C. Phenylephrine (Neosynephrine®)
   D. Amrinone or Milrinone
   E. Norepinephrine

   
   

7. The patient is place on broad spectrum antibiotics initially; bacteria isolated from the sputum culture again shows gram positive cocci in clusters; Staphylococcus aureus, sensitive to oxacillin, cephalexin, and vancomycin is isolated. Vasopressors are weaned over the next two days and the patient's oxygenation improves. The patient is transferred out of the intensive care unit. A chest radiograph one week after transfer from the intensive care unit shows residual right middle and lower lobe infiltrates. Which of the other findings below is commonly associated with Staphylococcal pneumonia [7] ?

   I. Occult malignancy
   II. Sputum with marked neutrophilia
   III. Reactive Airways Disease
   IV. Cavitary Lesions
   V. Smoking Tobacco

   
   A. I, II and III are correct
   B. I and III are correct
   C. II and IV are correct
   D. IV alone is correct
   E. V alone is correct

   
   

8. Glucocorticoids are not beneficial in which of the following situations [8] ?

   
   A. Chronic Obstructive Pulmonary Disease Exacerbation
   B. Bacterial Sepsis
   C. Status Asthmaticus
   D. Pulmonary Eosinophilia Syndromes
   E. Pneumocystis carinii pneumonia

   
   

9. A 65 year old man is brought to the emergency room via ambulance with diffuse inspiratory and expiratory wheezing, cyanosis, and hypoxemia. His oxygen saturation on 50% oxygen through a non-rebreathing mask is 88%. His pulse is 130 and irregular, blood pressure is 140/90, respiratory rate is 40 per minute. Chest exam is notable for use of accessory muscles, diffuse wheezing, and left lower lobe "wet" crackles (rales). ECG shows multifocal atrial tachycardia (MAT) and diffuse non-specific ST abnormalitites without specific ischemic changes. An arterial blood gas (ABG) drawn on the 50% oxygen / non-rebreather shows a pH of 7.19, pO2 of 52mm, pCO2 of 70mm. A ß2-agonist is administered via nebulizer and the oxygen saturation increases to 89%; wheezes do not change. The next step is [9]:

   
   A. Intubation, mechanical ventilation on Assist/Control (A/C, demand) mode
   B. Intubation, mechanical ventilation on Pressure Support mode
   C. Change to continuous positive airway pressure mask and repeat ABG
   D. Increase mask oxygen concentration to 100% and repeat ABG
   E. Intubation, mechanical ventilation initially with Positive End Expiratory Pressure (PEEP)

   
   

10. The patient is transferred to the intensive care unit where a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation is made. Which of the following is not indicated [10] ?

    
    A. Aminophylline load 2-4mg/kg iv immediately
    B. MethylPrednisolone (Solumedrol®) iv every 8-12 hours
    C. Nebulized ß2-agonist with ipatropium bromide every 1 to 2 hours
    D. Intravenous second generation cephalosporin
    E. Repeat arterial blood gas

    
    

Answers

1. B
2. A
3. C
4. E
5. A (catheter insertion can injure the right bundle branch leading to complete heart block)
6. C (all of the others will increase the heart rate; peripheral resistance needs to be increased)
7. C
8. B
9. B
10. A