12. ICU

Question 1

1.
you review a hypotensive patient in intensive care. The arterial line trace appears over-damped.

In order to improve the waveform the next action
is:

A. Examine tubing for air bubbles
B. Flush the tubing and catheter
C. Lengthen the tubing
D. Use wider diameter tubing
E. Reinsert arterial line

Answer 1

A. Examine tubing for air bubbles

Question 2

Damping

Answer 2

Some damping is a feature of every arterial line system and is useful in counteracting the amount of resonance, i.e. optimal damping.

It acts to slow down the rate of change of signal between the patient and pressure transducer.

An over-damped trace can be caused by occlusion such as kinks or clots, a bubble interrupting the saline column, or using a soft cannula and tubing.

The anaesthetist should first check for air and clots. before flushing any line.

Lengthening or widening the tubing will worsen the damping.
Ultimately it may be appropriate to reinsert the arterial line if the trace cannot be improved

Question 3

2. You perform an internal jugular central line on an adult under ultrasound guidance.

The ultrasound machine has a number of probes
attached. Which is the best ultrasound probe to
use?

A. Hockey stick footprint
B. Linear array
C. Curvilinear array
D. Micro curvilinear array
E. Phased array

Answer 3

B. Linear array

Question 4

Probe for CVC

Answer 4

In general, the higher the frequency of probe, the better the resolution of image but always at
the expense of depth of penetration into the body.

The target in question is relatively superficial
to the skin’s surface which indicates that a high-
frequency probe should be used in order to give
a high- resolution image with shallow penetration.

Question 5

Types of probes and frequencies

Answer 5

The linear probe can be placed flat on the neck
and has a high frequency (6– 13 MHz).

A phased array is more useful for moving structures such as in echocardiography.

A curvilinear probe is of lower frequency (2–
5 MHz) allowing deeper examinations such as abdominal ultrasound.

A hockey stick has a small footprint and is useful in
paediatrics.

Question 6

3.
Regarding severe community- acquired pneumonia.
The best risk stratification tool for identifying patients who may require invasive respiratory support in critical care is:

A. SMART- COP
B. CURB- 65
C. Pneumonia Severity Index (PSI)
D. APACHE II
E. Severe Community Acquired Pneumonia
Score

Answer 6

A. SMART- COP

Question 7

Pneumonia predictors for ICU

Answer 7

Pneumonia Severity Score Index and BTS CURB-
65 have been more extensively validated to
recognize low- risk patients and are not good at predicting need for critical care support.

SMART- COP and Pneumonia Severity Index perform well in identifying patients who require ICU admission.

SMART- COP was created to identify patients who may require respiratory or vasopressor support, a score of 3 or more identifies 92% of those who will require intensive respiratory support.

Question 8

4. A 30- year- old woman presents to the ED having taken an overdose of 16 paracetamol tablets with half a bottle of vodka about three hours
   ago. She has a history of epilepsy for which she has been on long- term phenytoin.
   She is crying and saying she doesn’t want to die. The most effective initial management would be?

A. Once paracetamol level available and confirmed as toxic start treatment with N-acetylcysteine

B. Start N- acetyl cysteine treatment immediately

C. Give activated charcoal orally and then once paracetamol level back treat with N-
acetyl cysteine if required

D. Perform gastric lavage and then if paracetamol level toxic treat with N-
acetyl cysteine

E. Start N-acetyl cysteine treatment immediately and perform haemodialysis as soon as possible

Answer 8

A. Once paracetamol level available and confirmed as toxic start treatment with N-acetylcysteine

Question 9

Significant dose is how much / kg

When is activated charcoal useful

Answer 9

The patient has ingested 8,000 mg of paracetamol. This is 100 mg/ kg.

The paracetamol guidance
changed in 2012, made by the Commission for Human Medicines

A significant ingestion is that above 75 mg/ kg,
which therefore necessities medical assessment.

Activated charcoal is only useful within 1 hour of ingestion and the calculated dose should be above
150 mg/kg. Lavage is not indicated

Question 10

Risk factors and paracetamol toxicity

Answer 10

Assessment of liver risk, i.e. alcohol or other medication is no longer required having been removed from most recent guidance to simplify them.

Risk factors for paracetamol toxicity
(e.g. starvation, hepatic enzyme induction)

have previously been used for risk stratification.

However, not all are well characterized and they have not always been applied consistently.

For this reason, the Commission for Human Medicines has advised that the presence of risk factors should no
longer be considered in assessing risk of toxicity after a single acute overdose

Question 11

NAC Guidance

When to start

When to start without level?

Answer 11

This patient has an accurate history of single overdose within 3 hours.

Guidance suggests to wait for
the 4- hour paracetamol level before starting N-
acetyl cysteine.

If the patient is at risk, i.e. above single treatment line on graph give intravenous acetyl cysteine.

There is normally no indication to start acetyl cysteine without a paracetamol blood concentration
provided the result can be obtained and acted upon within 8 hours of ingestion.

If there is going to be undue delay in obtaining the paracetamol concentration, treatment should be
started if more than 150 mg/
kg paracetamol has been ingested.

Question 12

5.
A 59- year- old man is on airway pressure release ventilation (APRV) mode of ventilation for respiratory failure. The current ventilatory settings are
FiO2 = 0.4,
P high = 30 cmH2O,
P low = 0 cm H2 ,
T high = 4.8 s,
and T low = 0.8 s.

He is not over sedated and is making good
spontaneous respiratory effort. His pCO2
is 11.1 and his pO2 is 12.9 on his last arterial blood gas.
How would you best adjust the ventilator settings to
now?

A. Set termination of expiration flow to 90% maximum

B. Increase the FiO 2 to 0.6

C. Increase the P low by 5 cmH2O

D. Decrease the P high by 2 cmH2O

E. Increase the P high by 2 cmH 2 O

Answer 12

E Increase the P high by 2 cmH2O

Question 13

APRV

Uses

advantages

Answer 13

Airway pressure release ventilation is

commonly used in the ICU setting to
treat ARDS and other conditions associated with severe hypoxia and low compliance.

Its advantages include
lower airway pressures,
lower minute ventilation,
and ability to breathe spontaneously throughout
ventilatory cycle.

Question 14

How to start APRV

Answer 14

When starting APRV the termination of expiration flow should be set to 75% and this can be
decreased towards 50% if hypercarbia is a problem.

Question 15

Altering P settings APRV

Control CO2

Answer 15

P low should always be kept at zero to allow minimal resistance to exhalation.

Increasing P high to 40 cmH2O

and

then increasing T high in 0.5 increments
up to 8 seconds would provide best chances of controlling CO2.

Question 16

Altering P and T times haven’t helped clearance CO2
Next step

Answer 16

If increasing P high and T high has not worked then increasing the T low to allow more time for alveolar emptying may help.

Question 17

6.
A 71 year- old lady is in ICU for management of severe respiratory failure secondary to community acquired pneumonia. She has been ventilated for eight days and her ventilatory settings are an FiO 2 of
0.9 and a PEEP of 10 cmH2O.

This has not improved despite a trial of
prone positioning.

Which of the following would be a contraindication to
extracorporeal membrane oxygenation (ECMO) in this patient?

A.
Presence of a bronchopleural fistula

B.
FiO2>0.8 for >7 days

C. Age>65

D.
Four quadrant infiltrates on her chest
X-ray

E .Murray score >3

Answer 17

B.
FiO2>0.8 for >7 days

Question 18

ECMO C/I

Answer 18

ECMO is contraindicated when
there has been high- pressure ventilation
with peak inspiratory pressure
>30 cmH2O for >7 days or high FiO2 for >7 days.

ECMO is also contraindicated if there
is an acute or recent intracranial bleed
because it requires anticoagulation.

Question 19

Murray Score

Answer 19

The Murray score is used when considering
referral and a score >3 would
be a reason for referral.

Scores are given for number
of chest X- ray quadrants infiltrated,
PaO 2 / FiO 2 (P/F) ratio,
level of PEEP and compliance.

Question 20

Indications ECMO

Answer 20

ECMO is indicated for potentially reversible causes of severe respiratory failure including those with
a bronchopleural fistula and when there has been failure of prone ventilation

Age is not a contraindication to
ECMO.

Question 21

A 52- year- old man in ICU required intubation and ventilation three days ago following aspiration of gastric contents. He has bilateral infiltrates on his chest X- ray and a PaO 2 / FiO 2 ratio of <200 mmHg.

You decide to try prone ventilation. Which statement best describes ventilation in the prone position?

A. The patient must have an infusion of muscle relaxant

B. Carbon dioxide clearance is usually decreased

C. Oxygenation is improved by reducing anatomical dead space

D. It improves patient survival

E. It is contraindicated in patients requiring renal replacement therapy

Answer 21

D. It improves patient survival

Question 22

Paralysed for proning?

O2 improvement?

Answer 22

The patient does not need to be paralysed to tolerate the prone position.

Carbon dioxide clearance is usually increased.

Oxygenation is improved by
enhancing alveolar recruitment
and
reducing ventilation/ perfusion mismatch

while also reducing overdistension of lung areas.

Prone ventilation does not alter anatomical dead
space.

Question 23

Trial in ARDS showed

Answer 23

The PROSEVA trial demonstrated that in
severe ARDS,
early and prolonged prone positioning was
associated with significant decrease in 28-
and 90- day mortality.

It is not contraindicated in patients with RRT although care must be taken with line position.

Question 24

An unknown adult male is presented to the emergency department by ambulance with GCS 10.

He has multi- organ failure and is in need of
organ support.

There is no history from the patient.

His initial results reveal:

Na +150 mmol/ L
K +6.0 mmol/L
Cl– 106 mmol/L
HCO –13 mmol/ L

Urea 38 mmol/L
Creat 467 μmol/L

H +78 nmol/ L
pO2 12.1 kPa
pCO 2 2.4 kPa
HCO3 13 mmol/ L.

Which potential diagnosis can be excluded?
A. Salicylate poisoning
B. Severe diarrhoea
C. Rhabdomyolysis
D. Ethylene glycol poisoning
E. Diabetic ketoacidosis

Answer 24

B. Severe diarrhoea

Question 25

How to calculate AG

What derangement in Q not a/w HAGMA

Answer 25

This patient has a metabolic acidosis with a raised anion gap of 37 mEq/L (normal range 5– 12;

anion gap = [Na + ] + [K + ] – ([Cl – ] – [HCO 3 – ]).

Severe diarrhoea results in a loss of bicarbonate and
a normal anion gap. All the others provide an additional source of acid which raises the anion Gap

Question 26

Anticoagulation on dialysis

Risk with main 1

Answer 26

Systemic heparin anticoagulation is the most commonly used method; however, patients are at
risk of haemorrhage.

Heparin resistance and heparin- induced thrombocytopenia mean alternative
forms of anticoagulation must be available.

Question 27

Advantage of Citrate

Risks with

Answer 27

Citrate’s main advantage is that it provides regional anticoagulation within the RRT circuit and avoids
the risks mentioned above.

Citrate chelates calcium and therefore platelet aggregation and coagulation.

Most of the citrate–calcium complex is
removed in the effluent so
systemic calcium infusion is
often necessary to avoid hypocalcaemia.

It can also cause acidosis, alkalosis, and hypomagnesaemia.

There must be protocols to monitor and manage these metabolic disturbances.

While using citrate patients will still need prophylaxis against deep venous thrombosis.

Question 28

A 68- year- old male is admitted to intensive care with sepsis causing multi- organ failure.

He requires central venous access for a low- dose noradrenaline (norepinephrine) infusion which is currently running through a peripheral cannula.

His blood results reveal platelets 62 and
INR 1.6. The most appropriate action
is:

A. Proceed to femoral line by most experienced operator
B. Platelet transfusion before internal jugular
line
C. Platelet transfusion and fresh frozen plasma before internal jugular
D. Platelet transfusion and fresh frozen plasma before subclavian
line
E. Proceed to internal jugular line by most experienced operator

Answer 28

A

Question 29

Coagulopathy and CVC insertion

Answer 29

In the presence of a coagulopathy,

the more experienced operator
available should insert the
central venous catheter (CVC),
ideally at an insertion site that allows easy compression of vessels.

Femoral access may have a
lower risk in this situation.

Question 30

Routine reversal of deranged coag and CVC

Answer 30

Routine reversal of coagulopathy is only
necessary if platelet count <50 ×10^9 L-1

activated partial thromboplastin time >1.3 times normal,
and/or international normalized ratio >1.8, as the risk of haemorrhage is otherwise not increased.

Waiting for arrival of blood products and subsequent transfusion will create delay in the ongoing
management of this patient.

Question 31

Is there one approach to all coagulopathies

Answer 31

In selected patients, different thresholds for
correction may be acceptable.

Bleeding risks of insertion and removal vary with the site, size of device, and operator experience.

The risks of correction
(e.g. infection, lung injury, thrombosis)
may exceed that of local bleeding, and it may be preferable to give blood products if problems
occur, rather than prophylactically.

Question 32

11.
You have intubated a 43-
year- old male who presented to the
Emergency Department having been rescued from a fire in his living room.

He had lost consciousness at the scene and smelt strongly of alcohol.

He had minor burns but had soot in his nose and mouth and a carboxyhaemoglobin level of 22%. What is the most important intervention to improve outcome?

A. Prone ventilation
B. Early administration of steroids
C. Early bronchoscopy and washout
D. Prophylactic antibiotics
E. Regular nebulized heparin and acetyl cysteine

Answer 32

C. Early bronchoscopy and washout

Question 33

Burns and Bronchoscopy

Answer 33

Early bronchoscopy diagnoses
and grades the severity of inhalational injury
and evidence suggests
improved outcomes with

bronchoscopy and early
clearance of particulate matter and washout.

Question 34

Things without benefit evidence in burns…

Answer 34

Lung protective strategies as per ARDS guidelines would be common sense but there is little
evidence to support this or prone ventilation.

An inhalational protocol with nebulized heparin and
acetyl cysteine may be of benefit but no large trials support its widespread adoption.

There is no place for prophylactic antibiotics. Steroids are not recommended in treatment but may have a rolein preventing post- extubation stridor caused by laryngeal oedema

Question 35

12. A 36- year- old brainstem dead patient is in ITU awaiting organ harvest.

He suffered a traumatic brain injury. He is 70 kg. The urine output is 400 mL/hour for the last 3 hours.

The serum sodium is 155 mmol/ L,

serum osmolality is 321 mosmol/kg,
and urine osmolality is 120 mosmol/kg.

The most likely diagnosis is:
A. SIADH (syndrome of inappropriate antidiuretic hormone secretion)
B. Cerebral salt wasting
C. Dehydration/
hypovolaemia
D. Furosemide administration
E. Diabetes insipidus

Answer 35

E. Diabetes insipidus

Question 36

Diabetes insipidus

Answer 36

Diabetes insipidus.
The diuresis is >4 mL/kg.
This patient has a resultant
high serum sodium (>145 mmol/L),
increased serum osmolality (>300),
and a reduced urine osmolality (<200).

It is due to excess water loss from the body.
Fluid replacement with enteral or IV solutions containing minimal sodium needs to treat both
fluid deficit and ongoing losses.

Early use of vasopressin may prevent the need for additional treatment, but if diabetes insipidus persists, desmopressin is indicated.

Question 37

SIADH and Cerebral salt wasting

How distinguish

Answer 37

SIADH and cerebral salt wasting are
associated with hyponatraemia.

The primary distinction between cerebral salt wasting and SIADH is volume status. SIADH = fluid retention, low urine output, serum <35, serum osmolality <275, urine osmolality > serum osmolality, high urinary
sodium (>25 mEq/
L). In cerebral salt wasting the primary pathogenic mechanism is renal loss
of sodium, which leads to hyponatraemia and a decrease in extracellular volume. Indications of
volume depletion (hypotension, weight loss, and decreased skin turgor) occur with cerebral salt
wasting, whereas indications of volume expansion occur with SIADH (decreased urine output
and generalized weight gain due to fluid retention). Signs and symptoms are remarkably similar;
however, patients with cerebral salt wasting experiences a true loss of sodium and intravascular
fluid. Both sodium and fluid must be replaced to correct the imbalance. In patients with SIADH,
sodium is replaced, but fluid is restricted

Question 38

SIADH and Cerebral salt wasting

How distinguish

SIADH

Answer 38

SIADH and cerebral salt wasting are
associated with hyponatraemia.

The primary distinction between cerebral salt wasting and SIADH is volume status.

SIADH = fluid retention,
low urine output,
serum <135,
serum osmolality <275,
urine osmolality > serum osmolality,
high urinary sodium (>25 mEq/L).

In patients with SIADH,
sodium is replaced, but fluid is restricted

whereas indications of volume expansion
occur with SIADH
(decreased urine output and generalized weight gain due to fluid retention).

Question 39

Cerebral Salt Wasting

Rx

Answer 39

In cerebral salt wasting the

primary pathogenic mechanism is renal loss
of sodium,

which leads to hyponatraemia
and a decrease in extracellular volume.

Indications of volume depletion
(hypotension, weight loss, and decreased skin turgor) occur with cerebral salt wasting,

Signs and symptoms are remarkably similar;
however,

patients with cerebral salt wasting
experiences a true loss of
sodium and intravascular fluid.

Both sodium and fluid must be replaced to correct the imbalance.

Question 40

13. A 39- year- old woman presents with a two-
    day history of gradual onset weakness.

She had an upper respiratory tract infection two weeks ago but is otherwise well.

Clinical examination elicits symmetrical reduction
in tone and power in all four limbs which is worse in the upper limbs than the lower limbs.

What is the most likely diagnosis?
A. Myasthenia Gravis
B. Eaton–
Lambert syndrome
C. Multiple sclerosis
D. Guillain– Barré syndrome
E. Critical care neuropathy

Answer 40

D. Guillain– Barré syndrome

The time scale, history of preceding minor viral illness, and clinical findings support a diagnosis of
Guillain–
Barré syndrome

Question 41

A previously fit and well 21- year-
old female presents to the Emergency Department having taken ecstasy tablets.

Her temperature is 40.°C and she has been fitting.

She has a GCS of 5 prior to intubation and you
have commenced cooling measures. Her sodium level is 114 mmol/L.

The best way to treat this hyponatraemia
is:
A. Give hypertonic saline 3%
B. Give furosemide
C. Give demeclocycline
D. Start haemofiltration
E. Give normal saline

Answer 41

A. Give hypertonic saline 3%

Question 42

Rx hypoNa seizures

Answer 42

Severe hyponatraemia can occur due to over-
ingestion of water and can lead to cerebral oedema.

Given that this is due to a rapid change in sodium concentration it can be reversed quickly.

When hyponatraemia has occurred slowly it must be corrected in a controlled manner to prevent
central pontine demyelination.

Question 43

15. A 69- year- old female presents to the Emergency Department with fever, dyspnoea, a productive cough, and right sided pleuritic chest pain.

A chest X- ray confirms a right middle lobe pneumonia.

The most likely infective pathogen in this case
is:

A. Haemophilus
influenza
B. Legionella
C. Streptococcus
pneumoniae
D. Klebsiella
pneumoniae
E. Influenza A virus

Answer 43

C. Streptococcus
pneumoniae

All of these pathogens can cause community-
acquired pneumonia but
Streptococcus
pneumoniae
is
the most common aetiological agent in the
UK

Question 44

16. A 60- year- old male with an exacerbation of chronic obstructive pulmonary disease has required ventilation in the Intensive Care Unit for 18 days.

He is proving difficult to wean from the ventilator. He is
sedated with a propofol infusion, but with any reduction in the infusion rate he becomes intolerant of the endotracheal tube and coughs persistently.

The best strategy to increase the chances of weaning
successfully is:
A. Stop propofol, extubate, and assess. Reintubate if necessary

B. Start a morphine infusion before reducing propofol

C. Start a remifentanil infusion before reducing propofol

D. Start a dexmedetomidine infusion

E. Transfer to theatre for a surgical tracheostomy

Answer 44

D. Start a dexmedetomidine infusion

Question 45

Dexdor use

Answer 45

Dexmedetomidine is indicated for light sedation on intensive care as a bridge to extubation.

It does not cause respiratory depression nor airway compromise and patients sedated with it are more
cooperative and better able to obey commands.

It also depresses the gag reflex and improves
tracheal tube tolerance compared to other sedative agents and
can facilitate a smooth non- combative extubation.

Question 46

Opioids and extubation

Answer 46

A failed extubation will cause significant setback for the patient. Morphine will reduce respiratory drive and CO
2 responsiveness.

Remifentanil, an ultra- short-
acting opioid, can be helpful to facilitate
extubation but must be titrated exactly and stopped immediately post extubation to avoid airway
obstruction, apnoea, and over sedation

Question 47

Q on extubation and trach

Answer 47

A surgical tracheostomy is a more invasive procedure, better performed in the early days of
admission to intensive
care

Question 48

17. You admit a patient with pneumonia and respiratory failure to ICU and start enteral feeding as part of your general management. Which of the
    following factors confer the highest risk of refeeding syndrome?
    A. Body mass index (BMI) of 18 kg/ m 2

B. Chronic alcohol abuse
C. A potassium level of 3.3 mmol/L prior to feeding
D. Unintentional weight loss of 10% in the last six
months
E. Minimal nutritional intake for 15 day

Answer 48

E. Minimal nutritional intake for 15 day

Question 49

Risk refeeding

Severe Risk

High risk

Moderate risk

Answer 49

Little or no nutritional intake
for greater than 15 days confers
severe high risk of developing
refeeding syndrome.

As does a BMI <14 kg/m2

A BMI <16 kg/m2
unintentional weight loss of >15%
in the previous three to six months,

and low levels of potassium, magnesium, or phosphate prior to feeding confer high risk.

A history of alcohol abuse or drug therapy with insulin or chemotherapy agents confer moderate risk

Question 50

18. A 63- year- old female is declared brainstem dead following a massive intracranial bleed. She is now being optimized for organ harvest in your
    ICU. Her blood pressure is 81/ 45 mmHg despite fluid resuscitation.
    What would be the next step in cardiovascular management?

A. Start a vasopressin infusion
B. Give a bolus of methylprednisolone
C. Start an infusion of thyroid hormone T3
D. Start a noradrenaline (norepinephrine) infusion
E. Start an adrenaline (epinephrine) infusion

Answer 50

A. Start a vasopressin infusion

Question 51

Brain Stem Death and pressor

Answer 51

Early use of a vasopressor helps haemodynamic stability and reduces risk of excess fluid
administration.

Vasopressin is considered the first-
line agent where hypotension is resistant
to fluid therapy.

It is less likely to cause myocardial damage metabolic acidosis or pulmonary hypertension than other inotropes.

Thyroid hormone may improve cardiac function but its benefit is questionable

Question 52

19. An ICU patient has a pleural effusion noted on chest X- ray.
    You perform a diagnostic tap.

The biochemistry of the pleural fluid
reveals a

lactate dehydrogenase of 510 U/L
(serum normal range 250– 540),

pH 7.1,
and a glucose of 1.2 mmol/ L.
The most likely cause of the effusion is:

A. Pancreatitis
B. Congestive heart failure
C. Nephrotic syndrome
D. Empyema
E. Cirrhosis

Answer 52

D. Empyema

Question 53

Pleural fluid

Answer 53

Pleural fluid is classically
described as either a transudate or exudate.

Exudative pleural effusions
meet at least one of the
following criteria (Light’s criteria),

whereas transudative pleural effusions meet none:

Question 54

Exudative pleural effusions
meet at least one of the
following criteria (Light’s criteria)

Answer 54

(i) the ratio of pleural fluid protein to serum protein
is 0.5

(ii) the ratio of pleural fluid lactic dehydrogenase (LDH) and serum LDH is 0.6

(iii)
pleural fluid LDH is more than two-
thirds normal upper limit for
serum

Question 55

Empyema vs pancreatitis

Answer 55

This patient has an exudate according to Light’s criteria. The low glucose and pH indicate this
is more likely to be an empyema than pancreatitis as the cause of exudate. The others are
transudates

Question 56

20. A 27- year- old woman presents with breathlessness and generalized
    weakness of rapid onset over 48 hours.

Her only history is of chronic intravenous drug misuse.

On examination she has fixed dilated pupils,
diplopia, ptosis, symmetrical flaccid paralysis of arms/
neck, and normal sensation. She is afebrile. The most likely diagnosis is:

A. Botulism
B. Guillain– Barré syndrome
C. Myasthenia Gravis
D. Viral encephalitis
E. Eaton– Lambert syndrome

Answer 56

20. A
    Botulism should be suspected in an IV drug user. The classic signs are acute symmetrical, descending
    paralysis with no sensory deficit, no fever, and no lack of awareness. Guillain– Barré syndrome
    patients usually have a history of a febrile illness then ascending muscle weakness starting in the
    hands and feet with accompanying loss of sensation and pain. Patients with myasthenia or Eaton–
    Lambert syndrome demonstrate fatigability in skeletal muscles. This means they worsen with
    repetitive muscle contraction and improve with muscle resting. Viral encephalitis is associated with
    fever, altered mental state, and asymmetrical weakness.

Question 57

Botulism

Answer 57

Botulism should be suspected in an IV drug user.
The classic signs are acute symmetrical, descending
paralysis with no sensory deficit, no fever, and no lack of awareness.

Question 58

Guillain Barre

Answer 58

Guillain– Barré syndrome
patients usually have a history of a febrile illness then ascending muscle weakness starting in the
hands and feet with accompanying loss of sensation and pain.

Question 59

myasthenia or Eaton– Lambert syndrome

Answer 59

Patients with myasthenia or Eaton– Lambert syndrome demonstrate fatigability in skeletal muscles.

This means they worsen with repetitive muscle contraction and improve with muscle resting.

Question 60

Viral encephalitis

Answer 60

Viral encephalitis is associated with
fever, altered mental state, and asymmetrical weakness