Critical Care Medicine

Questions

DIRECTIONS (Questions 457-530): Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case.

457. A previously healthy 18-year-old male presents to the emergency department with three days of dyspnea and facial swelling. He also reports a cough and hoarseness. His symptoms worsen with lying down. His chest x-ray reveals a widened mediastinum. Which one of the following is the most likely diagnosis?

(A) Angioedema

(B) Epiglottitis

(D) Pneumonia

(E) Tracheomalacia

458. An 81-year-old male has been in the hospital for treatment of a urinary tract infection and delirium. During the night he got out of bed unassisted and sustained a fall. A subsequent evaluation revealed a C3 vertebral fracture. He went to the operating room for repair of his fracture. Postoperatively he was kept intubated for concerns about airway edema. The plan is to reassess his ability to be extubated in 24 h. In the interim, he requires sedation for safety. His vital signs are T 37.1°C, HR 58, BP 122/78, SpO₂ 100%. Which choice of sedative agent is most appropriate in this situation?

(A) Dexmedetomidine

(B) Etomidate

(D) Propofol

459. A 66-year-old male is in the intensive care unit recovering from a ruptured abdominal aortic aneurysm repair. His postoperative course has been complicated by acute kidney injury and an NSTEMI. He remains intubated and mechanically ventilated. Four days into his course, his respiratory function worsens, and he is diagnosed with ventilator-associated pneumonia. Sputum culture grows Haemophilus influenza. Administration of which one of the following medications might have prevented this pneumonia?

(A) Oral chlorhexidine

(B) Systemic clindamycin

(D) Systemic omeprazole

460. Which one of the following statements about organ donation after cardiac death (DCD) is most accurate?

(A) Requires declaration of brain death by a neurologist

(B) Causes longer warm ischemic time than donation after brain death

(D) Does not involve extubation of the patient

(E) Cannot involve ICU physician in end-of-life care of the patient

DIRECTIONS: Use the following figure to answer Question 461:

461. For the ventilatory mode depicted in the figure, which statement is correct?

(A) The end of inspiration is determined by decrease to a set fraction of peak inspiratory flow.

(B) Minute ventilation is independent of patient effort.

(D) A bronchopleural fistula will not affect inspiratory time.

(E) Mandatory and spontaneous breaths are depicted.

DIRECTIONS: Use the following scenario to answer Questions 462-463: A 78-year-old man is admitted to the ICU following open repair of an abdominal aortic aneurysm. He has a history of coronary artery disease treated with a drug-eluting stent four years ago. His medications include aspirin, metoprolol, pravastatin, and lisinopril. A preoperative pharmacologic radionuclide myocardial stress test revealed no evidence of perfusion defects. His vital signs on arrival to the ICU are T 36.2°C, HR 68, BP 100/60, RR 12, oxygen saturation 99% on facemask oxygen. Pain score is 3/10. One hour later, his heart rate falls to 30 and blood pressure to 65/38; he is awake, alert, and has no complaints.

462. Which one of the following is the most appropriate first intervention?

(A) Transvenous pacing

(B) Endotracheal intubation

(D) Atropine

463. A few minutes later, the blood pressure is 180/110. An electrocardiogram is obtained and is shown in the figure below:

Appropriate interventions should include

(A) stat echocardiogram, dobutamine, blood transfusion

(B) thrombolysis, pulmonary artery catheter, dobutamine

(D) stat CT angiogram, esmolol, cardiac surgery consult

(E) nitroprusside, intravenous heparin, transfer to cardiac catheterization suite

DIRECTIONS: Use the following scenario to answer Questions 464-469: A 77-year-old male is being treated for ascending cholangitis resulting in gram-negative bacteremia. He is intubated, sedated, and mechanically ventilated. A pulmonary artery catheter is placed five hours after presentation to assist with management of his hemodynamics and resuscitation. His vital signs are T 38.7°C, HR 91, BP 76/43 and SpO₂ 90%. CVP is 4 mm Hg. CO is 5 L/min. His ABG is pH 7.29, PaCO₂ 37, PaO₂ 61. His hemoglobin is 9 g/dL.

464. Which one of the following would produce the greatest increase in oxygen delivery?

(A) An increase in arterial oxygen saturation to 100%

(B) An increase in heart rate to 110 beats/min

(D) An increase in stroke volume to 80 mL/beat

465. The cross sectional area of which one of the following is the primary determinant of systemic vascular resistance (SVR)?

(A) Arteries

(B) Arterioles

(D) Venules

(E) Veins

466. Which one of the following correctly describes arteriolar and vascular smooth muscle receptors?

(A) α₁– and β₂-adrenoceptors mediate vasoconstriction

(B) α₁-adrenoceptors mediate vasoconstriction while β₂-adrenoceptors mediate vasodilation

(D) α₁– and β₂-adrenoceptors mediate vasodilation

467. This patient would be expected to have which one of the following?

(A) Decreased angiotensin formation

(B) Decreased renin release

(D) Increased aldosterone release

(E) Increased sodium excretion

468. Which one of the following provides an index of total body tissue perfusion?

(A) Cerebral oximetry

(B) Central venous oxygen saturation

(D) Pulse oximetry

469. This patient would be expected to have which one of the following metabolic abnormalities?

(A) A decrease in hepatic lipogenesis

(B) A decrease in serum glucose concentrations

(D) An increase in pancreatic insulin release

(E) An increase in protein catabolism

470. A 47-year-old male is being treated for streptococcal pneumonia in the ICU. He is intubated and sedated for respiratory failure, and has had persistent fevers and an elevated white blood count. Diagnostic thoracentesis for a parapneumonic effusion revealed that the effusion was an empyema. As a result, he is scheduled to have a therapeutic thoracentesis in the interventional radiology suite. The patient has been on volume control ventilation with the following settings: TV 450, RR 20, PEEP 14, FIO₂ 0.6. Prior to transport to the interventional radiology suite, you are called to the bedside. The patient has had worsening oxygenation with decreased oxygen saturation when he is turned or placed flat. He has required FIO₂ 1.0 several times in the last several hours. Chest x-ray shows increasing size of the pleural effusion. Which one of the following is the most appropriate therapy?

(A) Arrange for open drainage of the effusion in the operating room

(B) Arrange for percutaneous drainage of the effusion at the bedside

(D) Delay thoracentesis until the patient is more stable

471. A 52-year-old male complains of nausea and a headache at work. He subsequently has an acute decline in wakefulness. His coworkers bring him to the emergency department. On evaluation, he opens his eyes to painful stimuli, makes incomprehensible sounds and localizes to pain. Select the patient’s GCS from the list below.

(A) 6

(B) 7

(D) 9

(E) 10

472. A 47-year-old female was admitted to the ICU 18 h ago with pancreatitis and SIRS. She required intubation for increased work of breathing and large volume IV fluid resuscitation for hypovolemia. Her clinical picture has worsened over the last several hours. She has poor urine output, is hypotensive and has decreased minute ventilation due to high airway pressures. A chest x-ray shows mild bilateral pulmonary edema. Which one of the following is the most likely cause of the patient’s symptoms?

(A) Abdominal compartment syndrome

(B) Cardiomyopathy

(D) Infection

(E) Pulmonary embolism

473. A 23-year-old female presents to the labor triage unit with premature rupture of membranes at 34 weeks and 6 days gestational age. She reports that her pregnancy has been uncomplicated except for a DVT diagnosed in her first trimester. She is currently taking prenatal vitamins and enoxaparin (1 mg/kg BID). Her vital signs are T 37.1°C, HR 71, BP 112/68, RR 22, SpO₂ 98%. A CBC, prothrombin time, partial thromboplastin time, and comprehensive metabolic panel done as part of her evaluation are unremarkable except for a platelet count of 57,000/mm³. Fetal heart tones are reassuring. What is the most likely cause of her laboratory abnormality?

(A) Vitamin B₁₂ deficiency

(B) Disseminated intravascular coagulation (DIC)

(D) HELLP syndrome

(E) Placental abruption

DIRECTIONS: Use the following scenario to answer Questions 474-478: A 41-year-old male motorcyclist is struck by a car. He is unconscious at the scene and intubated en route. On arrival to the emergency department trauma bay, his systolic blood pressure is 60 mm Hg. Bilateral chest tubes are placed without an improvement in his hemodynamics. A chest x-ray, pelvic x-ray, long bone films and a FAST exam are rapidly obtained. The exams are positive for multiple left sided rib fractures, pulmonary contusions, an open-book pelvic fracture, a left femur fracture, and fluid in the hepatorenal fossa. Transfusion of two units O-negative packed red blood cells is initiated, and the patient is brought emergently to the operating room. A laparotomy is performed and the patient is found to have profuse bleeding from a ruptured liver as well as an expanding retroperitoneal hematoma. Over the course of the surgery, the patient receives 25 units of PRBCs, 15 units of FFP, and 4 single donor units of platelets. His current vital signs are T 35.7°C, BP 81/42, HR 127, SpO₂ 95% on FIO₂ 0.7. Laboratory values are remarkable for Hb 8.9 g/dL, platelets 103,000/mm³, INR 1.7, fibrinogen 95 mg/dL, ABG pH 7.23, PaCO₂ 43 mm Hg, PaO₂ 64 mm Hg, K 4.4 mEq/L, creatinine 1.6 mg/dL, and ionized calcium 0.81 mmol/L. A TEE-probe is inserted. There is no pericardial effusion. Both ventricles appear well filled with normal size, but the systolic function of both ventricles appears reduced.

474. Which one of the following is most likely to improve the patient’s hemodynamic picture?

(A) Administration of bicarbonate

(B) Administration of calcium

(D) Transfusion of packed red blood cells

(E) Warming the patient to > 36°C

475. The patient begins to bleed from his IV line sites and his nose. Which one of the following would be most likely to improve the patient’s clotting ability?

(A) Administration of cryoprecipitate

(B) Administration of desmopressin

(D) Administration of platelets

(E) Warming the patient to 37°C

476. The patient undergoes damage control laparotomy and embolization of bleeding pelvic vessels. He is brought to the ICU for further stabilization. Over the next 6 h, the patient’s vasopressor requirement improves, and his transfusion requirement resolves. He is weaned from 32 to 7 mcg/min of norepinephrine. During that time frame, however, he develops oliguria. His laboratory data shows: Na 143 mEq/L, K 5.9 mEq/L, BUN 20 mg/dL, Cr 1.8 mg/dL, urine osmolality 332 mOsm/L H₂O, urine sodium 43 mEq/L, urine creatinine 18 mg/mL. Urinalysis is negative for leukocytes or red blood cells. What is the most likely cause of this patient’s oliguria?

(A) Acute tubular necrosis

(B) Glomerulonephritis

(D) Prerenal azotemia

(E) Urinary obstruction

477. There are peaked T waves on the ECG. Intravenous calcium is administered. What is the role of calcium in the treatment of hyperkalemia? Calcium

(A) antagonizes gastrointestinal absorption of potassium

(B) enhances renal excretion of potassium

(D) increases cardiac myocyte excitability

(E) raises the cardiac action potential threshold

478. Two days later the patient returns to the operating room for fixation of a tibial fracture. During the procedure, he is found to have compartment syndrome of his lower leg, and a fasciotomy is performed. Postoperatively his CPK is 9,562 IU/L. Which of the following laboratory abnormalities are most likely?

(A) Elevated calcium, decreased potassium, decreased phosphorus

(B) Elevated calcium, increased potassium, decreased phosphorus

(D) Decreased calcium, increased potassium, increased phosphorus

(E) Decreased calcium, increased potassium, decreased phosphorus

479. A 26-year-old female presents to her oncologist’s office with worsening dyspnea and chest pain. She is on warfarin for a history of DVT diagnosed six months ago, and she is being treated for breast cancer with chemotherapy. She is otherwise healthy. Physical exam reveals T 37.1°C, HR 122, BP 80/40, and peripheral edema. She is admitted urgently to the hospital. Her INR is 3.2. ECG shows sinus tachycardia with low QRS voltage and no ST changes. Which one of the following is most likely to lead to a diagnosis?

(A) Cardiac enzymes

(B) Chest x-ray

(D) Echocardiography

(E) Urinalysis

480. A 35-year-old, previously healthy female is brought to the emergency department after a seizure. She has no memory of the event. She currently has no complaints. Her vital signs are T 37°C, HR 82, BP 126/75, RR 17, SpO₂ 98%. Her neurologic examination is normal, including a GCS of 15. Her optic disks are sharp. Skin examination reveals a suspicious lesion on her right thigh. CBC and comprehensive metabolic panel (CMP) are unremarkable. Head CT shows a frontal mass consistent with metastasis. What is the most appropriate next step in management?

(A) CSF diversion

(B) Dexamethasone

(D) Mannitol

(E) Decompressive craniectomy

481. Which one of the following measures is recommended during central venous catheter insertion, based on evidence supporting a reduction in the rate of central line-associated blood stream infection?

(A) Sterile head to toe draping of patient, chlorhexidine skin preparation, subclavian site

(B) Full barrier precautions, hand washing prior to line insertion, prophylactic antibiotic administration

(D) Chlorhexidine skin preparation, removal of unnecessary catheters, avoidance of internal jugular site

(E) Hand washing prior to line insertion, head to abdomen draping of patient, removal of subclavian site catheters after 7 d

482. A 4-year-old boy with history of premature birth, asthma, and developmental delay is hospitalized in the PICU with respiratory failure due to respiratory syncytial virus (RSV). He has been intubated, sedated, and mechanically ventilated for 6 d. Vital signs are T 37.5°C, HR 92, BP 80/40. CVP is 6 mm Hg. He is ventilated in assist control pressure control mode at the following settings: FIO₂ 0.7, PC 25 cm H₂O, PEEP 10, RR 30. On exam, he is unresponsive, has soft bilateral rales, and his urine is dark. ABG shows pH 7.18, PaCO₂ 56 mm Hg, PaO₂ 65 mm Hg. Laboratory values are Na 146 mEq/L, K 5.4 mEq/L, Cl 110 mEq/L, BUN 28, Cr 1.9, CPK 6500 IU/L. Chest radiograph shows diffuse lobar infiltrates and low lung volumes. Which is the most appropriate next step in management?

(A) Transition from pressure control to pressure support ventilation

(B) Perform bedside echocardiogram

(D) Discontinue propofol

(E) Begin continuous venovenous hemo-filtration

DIRECTIONS: Use the following scenario to answer Questions 483-486: A 59-year-old man is admitted to the ICU following a hepatic resection complicated by hemorrhage. Surgery was aborted, the abdomen packed with laparotomy sponges, and he was transported intubated, sedated, and pharmacologically paralyzed to the ICU. Vital signs are T 34.5°C, HR 127, BP 80/45, RR 20, SpO₂ 90% on FIO₂ 0.8. He is oliguric with cool extremities; abdominal exam is significant for increasing distention. He is placed on mechanical ventilation in the mode depicted in the following figure:

483. Following two hours of continuous resuscitation with blood products, which one of the following ventilatory alarms is most likely?

(A) Increased peak airway pressure over set limit

(B) Apnea > 30 sec

(D) High tidal volume

(E) Excessive inspiratory time

484. An arterial blood gas drawn on this patient shows pH 7.18, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, base deficit 9. The patient’s disorder is best described as

(A) respiratory acidosis

(B) mixed respiratory acidosis and metabolic alkalosis

(D) mixed respiratory acidosis and metabolic acidosis

485. The figure below depicts the patient’s arterial waveform.

The following equation is derived from the measurements depicted in the figure:

The value determined by the equation is:

(A) stroke volume variation

(B) pulse pressure variation

(D) respiratory variation

(E) systolic pressure variation

486. Based on the findings from the patient’s arterial waveform, the next management should be

(A) inotrope administration

(B) vasopressor administration

(D) pulmonary artery catheterization

(E) fluid administration

487. A 44-year-old female presents to the emergency department with one hour of severe headache and mental status changes. Initial CT scan shows subarachnoid hemorrhage (SAH) that is likely due to aneurysmal rupture. Her initial Fisher Grade is 2. She is intubated in the emergency department due to concerns that she is unable to effectively manage her secretions. A subsequent repeat head CT shows that she has progressed to Fisher Grade 3. Which one of the following is the most likely mechanism for this change?

(A) Aneurysmal rebleeding

(B) Elevated intracranial pressure

(D) Vasospasm

488. Synchronized intermittent mandatory ventilation (SIMV) is associated with which beneficial effect as compared to controlled ventilation?

(A) Resting of the diaphragm

(B) Decreased work of breathing

(D) Absence of patient-ventilator dyssynchrony

(E) Increased mean intrathoracic pressure

489. A 41-year-old woman underwent resection of an acoustic neuroma under total intravenous anesthesia (TIVA). The surgical procedure was notable for 12-h duration with 500 mL blood loss. She is admitted to the ICU postoperatively, is extubated, breathing comfortably, and is neurologically intact. Vital signs are normal. An ABG reveals pH 7.30, PaCO₂ 42 mm Hg, PaO₂ 150 mm Hg on supplemental oxygen, base deficit 4. A metabolic panel shows Na 143 mEq/L, K 3 mEq/L, Cl 115 mEq/L, HCO₃ 20 mEq/L. Which one of the following is the most likely explanation for the patient’s acid-base disturbance?

(A) Crystalloid resuscitation fluid administered during operation

(B) Loop diuretic administered to reduce brain swelling

(D) Hypovolemia due to underresuscitation

(E) Nitroprusside treatment of intraoperative hypertension

490. Compared with norepinephrine in the treatment of septic shock, dopamine

(A) diminishes mortality

(B) diminishes incidence of renal failure

(D) causes more tachydysrhythmias

DIRECTIONS: Use the following scenario to answer Question 491: A 19-year-old previously healthy man presents after crashing his moped into a stone wall. He was found without a helmet, ejected from the moped with GCS 4 (E1V1M2). Vital signs are T 35.8°C, HR 156, BP 79/45. He is being mask ventilated at rate 12 breaths per minute; SpO₂ 99% with bag mask ventilation at FIO₂ 1.0. A noncontrast brain CT is obtained with findings depicted below:

491. Following endotracheal intubation, which one of the following should be employed for immediate management of this patient?

(A) Mechanical ventilation to PaCO₂ 26 mm Hg, 23.4% saline bolus, furosemide bolus, head of bed elevation to 30 degrees

(B) Mechanical ventilation to PaCO₂ 35 mm Hg, ventriculostomy, 23.4% saline bolus, phenylephrine infusion to MAP > 80 mm Hg

(C) Mechanical ventilation to PaCO₂ 18 mm Hg, Trendelenberg position, emergent neurosurgical decompression, volume resuscitation with 0.9% saline

(D) Mechanical ventilation to PaCO₂ 35 mm Hg, methylprednisolone bolus, volume resuscitation with 0.9% saline, emergent neurosurgical decompression

(E) Mechanical ventilation to PaCO₂ 35 mm Hg, mannitol bolus, volume resuscitation with 5% albumin, emergent neurosurgical decompression

DIRECTIONS: Use the following scenario to answer Questions 492-494: A 74-year-old male presents to the emergency department from his nursing home with new onset confusion. His vital signs are T 38.5°C, HR 94, BP 92/61, RR 24, SpO₂ 96%. His white blood count is 14,000/mm³. Blood, urine and CSF cultures are obtained. A urinary catheter is placed yielding scant dark urine. Gram stain of the urine specimen reveals many gram-negative rods. After volume resuscitation, the patient’s heart rate and blood pressure are 87 and 104/65, respectively. A central venous line is placed, and the CVP is 12 mm Hg. Urine output remains low at 15 mL/h for 2 h.

492. This patient would most accurately be described as having:

(A) septicemia

(B) systemic inflammatory response syndrome (SIRS)

(D) severe sepsis

(E) septic shock

493. Which one of the following would be the most appropriate next step in management?

(A) Flush the urinary catheter

(B) Perform a head CT

(D) Perform a renal ultrasound

(E) Start antibiotics

494. Which one of the following resuscitation fluids has been associated with an increased incidence of acute renal failure in critically ill patients?

(A) Albumin

(B) Hydroxyethyl starch

(D) Fresh frozen plasma

(E) Lactated Ringer solution

DIRECTIONS: Use the following scenario to answer Questions 495-498: A 44-year-old man with BMI = 40 kg/m² is now on postoperative day 1 following elective ventral hernia repair. The rapid response team is called to assess him for possible ICU transfer. His nurse reports that 3 h prior, he was sleepy, easily arousable, hemodynamically stable but complaining of 7/10 incisional pain that was treated with intravenous morphine delivered by PCA. One hour ago, he became disoriented and agitated, pulling out his intravenous access and urinary catheter. At that time, lorazepam 5 mg IM was administered and new intravenous access established. Now he is very somnolent. Vital signs show T 37.6°C, HR 92, BP 98/60, RR 7, SpO₂ 85% on supplemental oxygen via nonrebreather mask.

495. Which one of the following is the most likely finding on preoperative pulmonary function tests (PFTs) in this patient?

(A) Increased residual volume (RV)

(B) Decreased diffusing capacity (DLCO)

(D) Increased total lung capacity (TLC)

(E) Decreased expiratory reserve volume (ERV)

496. The patient’s wife volunteers a preoperative history of snoring at night, daytime sleepiness, and a referral for a sleep study that the patient has not yet undergone. Which one of the following combination of conditions is the most likely explanation for hypoxemia in the PACU in this patient?

(A) Atelectasis and anemia

(B) Intracardiac shunt and increased oxygen consumption

(D) Hypoventilation and hypermetabolism

(E) Intrapulmonary shunt and decreased diffusing capacity

497. Which of the following are most appropriate in initial management of this patient?

(A) Administer flumazenil, provide noninvasive positive pressure ventilation (NIPPV), position head of bed at 45 degrees

(B) Position head of bed at 45 degrees, place nasogastric tube, draw ABG

(D) Administer naloxone, provide noninvasive positive pressure ventilation (NIPPV), position head of bed at 45 degrees

(E) Change to hydromorphone analgesia, perform endotracheal intubation, and transfer to ICU

498. The patient fails to improve from the initial management strategy. He is transferred to the ICU. Following uneventful endotracheal intubation using etomidate, he becomes severely hypotensive, and unresponsive to fluid resuscitation. Vital signs are T 37°C, HR 110, BP 75/45, RR 18, SpO₂ 88% on FIO₂ 1.0. ABG reveals pH 7.40, PaCO₂ 60 mm Hg, PaO₂ 59 mm Hg, base excess 14. CXR shows no evidence of atelectasis or infiltrate. ECG reveals sinus rhythm, R axis deviation, and evidence of right ventricular strain. Which one of the following would be the most likely findings from bedside echocardiogram?

(A) Normal right ventricular size and function, dilated left atrium, small and hypercontractile left ventricle

(B) Normal right ventricle size and function, left ventricular apical ballooning

(D) Large pericardial effusion

(E) Normal right ventricular size and function, dilated, hypocontractile left ventricle with significant mitral regurgitation

DIRECTIONS: Use the following scenario to answer Questions 499-501: A 58-year-old man with COPD and diabetes mellitus is admitted to the ICU with the diagnosis of necrotizing fasciitis of the perineum. His vital signs are significant for T 39.1°C, HR 125, BP 79/52, RR 34, SpO₂ 88% on facemask oxygen.

499. Which one of the following is the explanation for a fall in mean arterial pressure following endotracheal intubation and mechanical ventilation?

(A) Catecholamine release associated with direct laryngoscopy

(B) Histamine release induced by ketamine administration

(D) Decreased work of breathing causing a worsened lactic acidosis

(E) Increased left ventricular afterload associated with positive pressure ventilation

500. Mechanical ventilation of the patient is complicated by patient-ventilator dyssynchrony. What is the most likely cause?

(A) Rapid inspiratory flow rise time at the initiation of a breath

(B) Decelerating flow pattern with volume targeted ventilation

(D) Auto positive end-expiratory pressure

(E) Ventilator inspiratory time matched to patient inspiratory time

501. During pressure assist/control mode ventilation, the endotracheal tube becomes partially obstructed by secretions. Which one of the following is most likely to result?

(A) Increased tidal volume

(B) Increased plateau pressure

(D) Decreased peak inspiratory pressure

(E) Decreased minute ventilation

DIRECTIONS: Use the following scenario to answer Questions 502-503: A 65-year-old man is admitted to the ICU following percutaneous nephrostomy tube placement to treat ureteral obstruction. Immediately following the procedure, he developed fever and hypotension. Vital signs upon arrival to the ICU are T 39.2°C, HR 130, BP 80/40, RR 38. Oxygen saturation is unobtainable. CVP is 3 mm Hg. He is awake and oriented and complains of 5/10 pain at the tube site. He has a Grade II/VI systolic ejection murmur at the left sternal border, cool extremities and poor peripheral pulses. Urine from the nephrostomy tube is cloudy yellow. Laboratory values show Na 138 mEq/L, K 4.6 mEq/L, Cl 108 mEq/L, BUN 32 mg/dL, Cr 2.2 mg/dL, WBC 22,000/mm³, Hb 13 g/dL, platelet count 198,000/mm³.

502. Which one of the following should be performed next?

(A) Fluid resuscitate to CVP 15 mm Hg

(B) Transfuse 1 unit packed red blood cells

(D) Fluid resuscitate to CVP 10 mm Hg

(E) Operative exploration for bleeding

503. Two hours later, the following vital signs are recorded: T 38°C, HR 118, BP 105/60, RR 32. CVP is 12 mm Hg, and ScvO₂ is 55%. Norepinephrine is infusing at 10 mcg/min to support the blood pressure. Which one of the following is the next most appropriate step?

(A) Administer milrinone

(B) Increase norepinephrine dose

(D) Administer vasopressin

(E) Administer epinephrine

DIRECTIONS: Use the following scenario to answer Questions 504-505: A 34-year-old woman with systemic lupus erythematosus presents with dyspnea and chest pain. Vital signs are T 37.5°C, HR 128, BP 85/40, RR 36, SpO₂ 95% on nasal cannula oxygen. A bedside TTE is performed, with a subcostal image depicted below:

504. Which one of the following findings is most likely on physical examination?

(A) Right ventricular heave along left sternal border

(B) Diminished right sided breath sounds

(D) Palpable liver edge

(E) Pulsus paradoxus > 12 mm Hg

505. Which one of the following treatments is most appropriate?

(A) Thoracentesis

(B) Thrombolysis

(D) Diuresis

(E) Inotropic support

DIRECTIONS: Use the following scenario to answer Questions 506-507: A 28-year-old woman with a history of Roux-en-Y gastric bypass presents with nausea, vomiting, and abdominal pain. Imaging suggests a small bowel obstruction. On induction of anesthesia for exploratory laparotomy, she has an observed aspiration of particulate contents. Following rapid intubation, her vital signs are T 37.2°C, HR 136, BP 80/40, SpO₂ 91% on mechanical ventilation with FIO₂ 1.0. Physical exam reveals diffuse expiratory wheezing and rhonchi. A nasogastric tube drains copious feculent contents.

506. What is the next most appropriate intervention?

(A) Bronchoalveolar lavage

(B) Prone ventilation

(D) Bronchoscopy with particulate removal

(E) Hyperbaric oxygen

507. Which one of the following is the most appropriate pharmacologic intervention?

(A) Sodium bicarbonate

(B) Intravenous heparin

(D) Methylprednisolone

(E) Inhaled nitric oxide

DIRECTIONS: Use the following scenario to answer Questions 508-513: You are responding to an overhead page reporting a code in the PACU. On arrival, you find a 47-year-old male who has just undergone a Whipple procedure. He had been doing well, but as the nurses were preparing his transfer to the ICU for further monitoring, he suddenly became unresponsive. They called a code, initiated CPR, and began reconnecting him to the monitors. You arrive as they are reconnecting the arterial line.

508. Critical myocardial blood flow is associated with an aortic diastolic blood pressure greater than which one of the following?

(A) 15 mm Hg

(B) 20 mm Hg

(D) 40 mm Hg

(E) 50 mm Hg

509. Which one of the following describes the attributes of effective chest compressions in adults?

(A) Rate 80, 2 cm depth, 25% compression time

(B) Rate 80, 5 cm depth, 50% compression time

(D) Rate 100, 5 cm depth, 50% compression time

(E) Rate 120, 2 cm depth, 25% compression time

510. The patient is placed back on telemetry. The rhythm is ventricular fibrillation (VF). What is the most appropriate next step in management?

(A) Administer amiodarone

(B) Administer epinephrine

(D) Biphasic defibrillation at 200 J

(E) Endotracheal intubation

511. The respiratory therapist suggests end-tidal CO₂ monitoring. During CPR, end-tidal CO₂ correlates with which one of the following?

(A) Arterial CO₂

(B) Cardiac output

(D) Arterial systolic blood pressure

(E) Venous CO₂

512. Patients who are intubated and receiving CPR should be ventilated at which one of the following rates?

(A) < 4 breaths/min

(B) 4-6 breaths/min

(D) 8-10 breaths/min

(E) 10-12 breaths/min

513. If a patient fails to regain consciousness after return of spontaneous circulation following VF arrest, which one of the following is the most appropriate next step in management?

(A) Administer mannitol

(B) Begin therapeutic hypothermia, if no contraindications

(D) Provide 100% FIO₂

(E) Schedule a cardiac catheterization to be performed after the patient regains consciousness

DIRECTIONS: Each group of items below consists of lettered headings followed by a list of numbered phrases or statements. For each numbered phrase or statement, select the ONE lettered heading or component that is most closely associated with it. Each lettered heading or component may be selected once, more than once, or not at all.

(A) Syndrome of inappropriate antidiuretic hormone (SIADH)

(B) Hepatorenal syndrome

(D) Cerebral salt wasting

(E) Hypovolemia

(F) Nephrogenic diabetes insipidus

(G) Central diabetes insipidus

For each of the following clinical scenarios, select the most likely diagnosis.

514. A 48-year-old woman presented 7 d ago with nausea, vomiting, and the worst headache of her life. She underwent a neurosurgical procedure, and is now obtunded with a Glasgow Coma Score (GCS) of 4 (E1VTM2). Her vital signs are T 37°C, HR 99, BP 120/80, RR 14. CVP is 2 mm Hg. Other relevant laboratory values include serum sodium 134 mEq/L, urine sodium 43 mEq/L, plasma osmolality 270 mOsm/kg, and urine osmolality 350 mOsm/kg.

515. A 67-year-old man is hospitalized in the ICU following colon resection for perforated sigmoid diverticulitis. He is intubated and mechanically ventilated. His vital signs are T 36.8°C, HR 88, BP 94/52, RR 16, SpO₂ 92%, FIO₂ 0.6. Systolic pressure variation from a radial arterial line is 4 mm Hg. He has pitting peripheral edema. He has serum sodium 133 mEq/L, urine sodium 10 mEq/L, plasma osmolality 270 mOsm/kg, and urine osmolality 600 mOsm/kg.

516. A 26-year-old man with a history of schizophrenia has suffered traumatic brain injury after jumping from a height of 50 feet. He has GCS 3(E1VTM1), no pupillary light reflexes, no corneal responses, and no gag or cough response. On apnea testing, arterial pH = 7.28 after 8 min with no observed respiratory effort. Several hours later, urine output is > 400 mL/h for 3 h, diminishing to 50 mL/h when intravenous vasopressin is administered. Laboratory values are serum sodium 158 mEq/L, urine sodium > 20 mEq/L, plasma osmolality 320 mOsm/kg, and urine osmolality 100 mOsm/kg.

517. A 56-year-old man with a history of non-alcoholic steatohepatitis (NASH) is hospitalized in the ICU following total colectomy to treat toxic megacolon. He is intubated and mechanically ventilated. His vital signs are T 37.5°C, HR 110, BP 90/52, RR 22, SpO₂ 100%, FIO₂ 0.4. Pulse pressure variation from a radial arterial line is 18%. He has a serum sodium 130 mEq/L, urine sodium 10 mEq/L, plasma osmolality 290 mOsm/kg, and urine osmolality 50 mOsm/kg.

518. A 66-year-old woman with a history of hepatitis C infection is transferred to the ICU on postoperative day 1 following laparoscopic cholecystectomy. Her vital signs are T 37.2°C, HR 125, BP 85/42, RR 18, SpO₂ 94% on facemask oxygen. Urine output has been 5-20 mL/h for the past 12 h. She has received 1.5 L normal saline resuscitation over the past 4 h without increase in urine output or blood pressure. Her exam is notable for abdominal distention with shifting dullness. Laboratory values are notable for serum sodium 128 mEq/L, urine sodium 5 mEq/L, plasma osmolality 285 mOsm/kg, and urine osmolality 400 mOsm/kg.

(A) Anaphylactic shock

(B) Cardiogenic shock

(D) Hypovolemic shock

(E) Neurogenic shock

(F) Obstructive shock due to pulmonary embolism

For each patient with shock, select the most likely mechanism causing the symptoms.

519. A 46-year-old male is brought to the emergency department by paramedics. He was found down in his home after sustaining a 45% total body surface area burn. He was unresponsive at the scene and was intubated en route. His vital signs are T 36.1°C, HR 126, BP 81/42, RR 21, SpO₂ 97%. A bedside hematocrit is 52%. A central line and an arterial line are placed to assist with care. His CVP is 6 mm Hg. Arterial waveform analysis suggests a decreased cardiac output. Central venous oxygen saturation is 47%.

520. A 26-year-old female is in the postpartum unit 12 h after delivering a healthy 39-week male via elective repeat cesarean section under spinal anesthesia. Her past medical history includes asthma, GERD and chronic low back pain. Her initial postoperative course was uneventful. She was ambulatory and had good oral intake. Over the past several hours, however, she has become increasingly fatigued and lethargic. Her vital signs are T 37.1°C, HR 118, BP 79/51, RR 22, SpO₂ 94% on room air. Her extremities are cool and edematous. Her hemoglobin is 9 g/dL. An intravenous fluid bolus did not improve her vital signs. Central venous and arterial lines are placed to assist with care. CVP is 15 mm Hg. Arterial waveform analysis suggests a decreased cardiac output. She begins to complain of dyspnea that worsens with lying flat.

521. A 62-year-old female is in a rehabilitation facility recovering from a right total hip replacement performed 3 weeks ago. Her past medical history is significant for obesity, hypertension, hypercholesterolemia, hypothyroidism and osteoarthritis. While working with the physical therapist, she develops dyspnea and chest pain. Emergency medical personnel arrive, finding her heart rate 105 bpm and blood pressure 89/59 mm Hg. She requires a non-rebreather oxygen mask to maintain her oxygen saturation > 90%. ECG done en route to the hospital shows sinus tachycardia without acute ST changes.

522. A 22-year-old male with a history of meningomyelocele is scheduled for correction of an Arnold-Chiari malformation. After an uneventful induction of anesthesia, arterial and central catheters are placed. The patient is then positioned, prepped and draped. One hour after incision, the patient develops hypotension, hypoxemia and increased airway pressures. The CVP is 1 mm Hg.

523. A 56-year-old male is brought to the emergency department by his brother due to progressive somnolence over the past 2 d. The patient is too lethargic to give a history but his brother reports that he avoids medical care. He is known to have a penicillin allergy since childhood. He had an ankle fracture repaired in the past. He smokes 2 packs/d and drinks a pint of whiskey daily. His vital signs are T 37.9°C, HR 113, BP 89/40, RR 26, SpO₂ 88% on 4 L/min by nasal cannula. There are rhonchi in the right lung. His feet are warm with bounding pulses.

524. A 16-year-old male is brought to the emergency department by paramedics. He was the unrestrained driver in a high speed motor vehicle accident. He was unresponsive at the scene and required intubation. On arrival, his vital signs are T 36.2°C, HR 61, BP 82/43, SpO₂ 100% while being ventilated with an Ambu bag. His GCS is 4 (E2VTM1). His initial chest x-ray and long bone films do not show any traumatic injuries. His FAST scan is negative. His feet are warm.

(A) Subarachnoid hemorrhage

(B) Hypercarbia

(D) Middle cerebral artery infarction

(E) Septic shock

(F) Meningitis

(G) Alcohol intoxication

(H) Epidural hematoma

(I) Concussion

(J) Postseizure state

For each patient with coma, select the most likely diagnosis.

525. A 79-year-old woman with COPD and abdominal pain underwent exploratory laparoscopy under spinal anesthesia. In the PACU, she is unresponsive with no focal or lateralizing signs. T 36.5°C, HR 110, BP 160/90, RR 6, SpO₂ 94% on supplemental oxygen.

526. A 22-year-old man presented to the emergency department following crashing his motorcycle into a utility pole. When emergency medical personnel responded, he reported that he struck his helmeted head into the pole without loss of consciousness. Vital signs at the scene were T 37.2°C, HR 130, BP 160/98, RR 22, SpO₂ 98% on room air, GCS 15 (E4V5M6). On arrival to the hospital, he is comatose with a left temporoparietal scalp laceration.

527. A-54-year old man with a history of glioblastoma is brought to the emergency room by family who found him unresponsive at home on the floor. Vital signs are T 37.8°C, HR 98, BP 150/80, RR 28, SpO₂ 98% on facemask oxygen. There are no visible traumatic injuries, but his clothing is saturated with urine. Head CT reveals no significant change from three weeks ago where a 2 cm lesion is seen in the right temporal lobe with minimal surrounding edema.

528. An 80-year-old woman with a history of prosthetic aortic valve and severe carotid stenosis who is prescribed warfarin anticoagulation presents after being found on her floor at home unresponsive. Her daughter reports that she had run out of her medications one week ago. T 35.2°C, HR 88 irregular, BP 170/90, RR 16, SpO₂ 95% on room air. Laboratory values are notable for sodium 145 mEq/L, glucose 130 mg/dL, BUN 40 mg/dL, creatinine 1.8 mg/dL, WBC 8,000/mm³, hemoglobin 12 g/dL, INR 0.9.

529. A 43-year-old woman presents with a history of subarachnoid hemorrhage 3 weeks prior due to ruptured cerebral aneurysm. She was treated with coil embolization of the aneurysm and subsequently developed obstructive hydrocephalus that has been treated since with an external ventricular drain. She was neurologically intact and recovering well until 8 h ago when her nurse noticed increasing drowsiness, progressing to obtundation and coma. Vital signs are T 39.2°C, HR 120, BP 110/70, RR 30, SpO₂ 100% on room air. She has no focal or lateralizing neurologic findings. Laboratory values show sodium 145 mEq/L, WBC 27,000/mm³, hemoglobin 9.2 g/dL, platelet count 110,000/mm³, INR 1.0.

530. A 21-year-old man has a history of bone marrow transplant 2 weeks ago presents with coma without focal or lateralizing neurologic findings. Vital signs show T 38.8°C, HR 100, BP 80/40, RR 32, SpO₂ 96% on room air. Exam is notable for alopecia, rigors, and cool extremities. Laboratory values reveal sodium 140 mEq/L, WBC 800/mm³ with differential count 50% neutrophils, 30% lymphocytes, 10% monocytes, 6% eosinophils, and 3% basophils.

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