Patho Student Questions Flashcards by Nicole Dehaan

IV Fluids in Septic Shock Exam
A patient with a 3 day hx of PNM presents with HR of 110, temo 38.3 and WBC of 12,500. You also notice that they have elevated liver enzymes and altered cerebral function. what is you dx for this patient

Severe sepsis

Sepsis is 
Temp above 38.3 or below 36
Rr over 20
Hr over 90
WBC over 12,000 or under 4000

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IV Fluids in Septic Shock Exam Questions

After giving several boluses of lactated ringer’s to a patient with septic shock due to a UTI, you notice that their MAP is 50 mmHg and has remained at this pressure. Your next move is to . . .

Give norepinephrine in addition to continuing their ringer’s infusion

Norepinephrine MOA:allows increase ca in to increase contraction and binds to alpha to vasoconstrict
Epinephrine: binds to beta 2 receptors cause sequestration of Ca from SR so not enough to constrict
Dopamine: increase hr and contraction by binding to adrenergic and dopamine receptors
Phenylephirie: Alpha 1- doesn’t affect the heart only the vessels

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IV Fluids in Septic Shock Exam Questions

It is important to know that saline infusion for septic shock can cause

Hyperchlorremia acidosis and Edema

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IV Fluids in Septic Shock Exam Questions

A 45 year old female presents with bacteremia and sepsis who has begun to show signs of pulmonary edema. She has a MAP of 58, an irregular heart rhythm with rates from 140-160 bpm, and altered mental status. Which of the following is the most appropriate next treatment for this patient?

Phenylephrine

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IV Fluids in Septic Shock Exam Questions

First line treatment for a patient in septic shock on high doses of labetalol is:

0.9% saline, 30 mL/kg mL

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IV Fluids in Septic Shock Exam Questions

Beta-adrenergic agents, like norepinephrine, work by:

Increasing calcium conductance in nodal myocytes, increasing calcium storage and potential contractile force

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Nausea & Vomiting in the ED Exam Questions

A 22 yo male patient presents to the ED with a history of excessive alcohol intake and vomiting for the past 2 hours. He appears confused and does not always respond appropriately. He has an unsteady gait, an elevated pulse rate, and complains of nausea.
What is the best test to determine if the patient’s symptoms are due to dehydration or primarily due to the alcohol intake?

BUN/Creatinine ratio

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Nausea & Vomiting in the ED Exam Questions

A mother presents with her child to ED, the child is 5 yo and has been vomiting intermittently for the last day with a fever. On exam, the child is responding appropriately and complains of a dry mouth. Pulse rate and respirations are normal. The mother notes that the child hasn’t urinated in the past 5 hours. Based on the clinical presentation, what treatment would you administer for their dehydration status?

Oral Rehydration Solution 50 ml/kg and ongoing losses over 4 hours as tolerated

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Nausea & Vomiting in the ED Exam Questions

Hypernatremia can occur following rehydration of patients who are hypovolemic. This occurs due to ___________ and should be treated with ________________.

Fever/dilute diarrhea; 0.9% IV saline`

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Nausea & Vomiting in the ED Exam Questions

A 4 year old child presents to the ED with her mother following profuse vomiting for the past 24 hours and failure of ORT. On PE it was noted the child had tachypnea, a rapid and weak pulse, in addition to hypotension. Based on the presentation, the stage of dehydration is best categorized as?

Severe dehydration

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Nausea & Vomiting in the ED Exam Questions

A father of a 15 lbs 1 yo called your office with concerns about his child being dehydrated. After obtaining the necessary clinical information from him you determine the child is mildly dehydrated. As the PA you recommend ORT and tell the parent to give how much total ORS every two minutes as tolerated?

75 tsp

Dosage is 5 tsp/ lbs

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Questions for Acute Spinal Cord Injury
1.) A 26 yr. old male who was involved in a MVA gets brought into the ED while you are working. You check the Babinski reflex and notice that his hallux dorsiflexes while his other toes fan out. This indicates:

C. Upper motor neuron damage

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Questions for Acute Spinal Cord Injury

2.) A 34 yr. old male presents to the ED by ambulance after a 2 story fall from a building. You quickly assess that he has fractured his spine and is now in neurogenic shock. What is your first line treatment?

A. 0.9% Normal Saline

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Questions for Acute Spinal Cord Injury

3.) In the treatment of the patient in question #2, what do you want to keep his MAP at/above?

D. 85-90 mmHg

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Questions for Acute Spinal Cord Injury

4.) When Spinal Cord Injury occurs, at which level of injury will autonomic dysreflexia be more likely to occur?

above T6

answer is B. C3

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Questions for Acute Spinal Cord Injury

T/F A person having a C3 spinal injury is likely to have respiratory complications?

True

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Questions for Acute Spinal Cord Injury

You are seeing a 21 yr. old male 2hrs after he was brought into the ED after a motorcycle accident that left him with a spinal cord injury. You are trying to decide if/when to administer Methylprednisolone. What do you decide?

Administer it now

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Fever control:
A 75 year old woman presents to the family practice office with chills, body aches, loss of appetite, and claims she just hasn’t been feeling well the last couple days. While reviewing her medical record, you noticed she has a temperature of 98.6ºF.

b. This temperature is concerning because elderly typically run low within the normal range.

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Fever control:

Body temperature usually is 0.9ºF higher in the afternoon. Which of the following best explains the reasoning behind this?

Cortisol inhibits phospholipase A, which decreases prostaglandin typically in the early morning and at night.

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Fever control:
_____ is the most accurate location to take body temperature while _____ is the least accurate location to take body temperature.

c. Rectal; Forehead

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Fever control:

Fevers and hyperthermia both exhibit high body temperatures. Which of the following explains the main difference between a fever and hyperthermia?

d. Fever is caused by a true change in the set point.

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Fever control:

You are currently doing a post-operative assessment on a 55 year old man who just had open thoracic surgery. After reviewing his vitals, you realize he has a low-grade fever of 100.5ºF.

This is an expected finding due to the release of inflammatory mediators and cytokines.

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Fever control:

Which of the following medications contains anti-inflammatory properties?

Two of the above!

ASA and NSAIDS ( motrin)

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Fever control:
A 10 year old boy presented today to the ER with Reye Syndrome where you are currently doing a rotation as a PA student. The boy presented with an altered mental status, vomiting, and a recent history of ASA use. It was determined he had a fast progressing encephalopathy. After beginning to manage the patient, your preceptor asked you what was causing the encephalopathy. Which of the following would be an appropriate response?

The damage to hepatocytes slows the removal of waste products resulting in an increase of ammonia, which crosses the blood brain barrier

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Fever control: Which of the following explains the MOA for Motrin and ASA?

Inhibitors of COX

Fever control: | What is the therapeutic dose of Tylenol in children?

10-15 mg/kg

Fever control: | What is the single toxic dose of Tylenol for a young child?

150 mg/kg

Fever control: | What is the single lethal dose of Tylenol for a child?

338 mg/kg

Fever control: | TRUE OR FALSE. In an extremely compliant patient, Motrin and Tylenol can be alternated every two hours.

ture

Fever control: TRUE OR FALSE. After a night of heavily drinking alcoholic beverages, it would be appropriate to recommend the patient take Tylenol before bed to avoid a morning hangover

FALSE

Fever control: You are currently on your ER rotation as a PA student when a mother rushes in her four year old daughter who got into the medicine cabinet and ate multiple grape flavored Tylenol chewable tablets while with the babysitter. The doctor begins to give the little girl oral medication. Due to the rotten eggs smell that takes over the room, you know it was acetylcysteine. How would you best explain how this medication works?

Provides substrate so that the liver can metabolize the toxic metabolite and excrete it.

Fever control: | Tylenol is toxic to _____ while ASA is toxic to _____.

Liver; Kidneys

Fever control: You are working as PA in a primary care office when you notice that a patient has been taking maximum dose Tylenol every single day for the last 10 years for pain relief. What would be an appropriate lab to order?

CHEM 7 to look at kidney function

Fever control: | What is the single toxic dose for Aspirin?

150 mg/kg

Fever control: | What is the single lethal dose for Aspirin?

400 mg/kg

Fever control: An 18 year old boy was brought into the ER today where you are currently doing a rotation as a PA student after his girlfriend found him unconscious next to an empty ASA bottle. Among other things, the physician ordered sodium bicarbonate. Which of the following would be the main reason this was ordered?

To neutralize the charge of the ASA to help eliminate it from the body.

Fever control: An 8 week year old child presents to the ER today where you are currently doing a rotation as a PA student with a 103ºF fever (rectally). What would be included in an appropriate septic work-up?

a. Blood culture b. UA c. Spinal Tap d. CBC All of the Above

Fever control: | Which of the following explains when it would be most appropriate to get a septic work-up in an adult with a fever?

When the physical exam doesn’t explain the fever

Fever control: Which of the following are reasons potentially seen in a patient’s past medical history that would trigger the provider to tell a patient NOT take Tylenol?

Hepatitis and G-6-P Deficiency

Fever control: Currently, you are working as a Physician Assistant at a Grand Rapids Family Practice office. During the weekend you are the on-call provider that patients may contact. At 8 P.M. Saturday, you receive a call from a frantic, crying, first-time mother of a 4 month year old infant who claims her baby has been sick and is experiencing a temperature of 100.8ºF (Axilla). What medication do you recommend?

Tylenol

Fever control: You are working in Grand Rapids as an OB-GYN Physician Assistant when a mother urgently brings in her 6 week old son who she claims “just hasn’t been acting right.” She took his temperature at home and states it was 101.4ºF (forehead). What is your next step?

send them to the ER for admission

Fever control: You are a Physician Assistant working in the Emergency Room and a 30-year-old male patient presents with confusion. During your assessment you notice that his skin has a yellow tint to it. You order an ALT/AST, total bilirubin, and a serum acetaminophen level. You diagnose this patient has acetaminophen toxicity, what stage do you think he is currently in?

stage 3

Fever control: You are evaluating a 42- year- old female patient that admits to taking more than the recommended dose of her Aspirin that morning at 8am. It is now 9:30 am and she is experiencing some nausea, vertigo and diarrhea. What is your next step in managing this patient?

Stabilize the airway, breathing and circulation followed by administering Activated charcoal

Fever control: | Which of the following is not an indication for hemodialysis in a patient who has Aspirin toxicity?

Tinnitus

Stroke: A 65 year old man presents to the ED with facial paralysis, arm weakness, and speech difficulty, after ruling out other causes you determine a stroke has occurred. What is the next step in treating this patient? a. Initiate rtPA bolus, followed by IV infusion b. Initiate aspirin 325 mg c. Order emergent non contrast head CT d. Order emergent contrast head CT

c. Order emergent non contrast head CT

Stroke: A 65 year old man presents to ED two hours after onset of stroke symptoms. He has diabetes, hypertension and hyperlipidemia. He is currently taking metformin 500 mg BID, lisinopril 10 mg, aspirin 81 mg and simvastatin 25 mg. His history was noncontributory. Vitals were taken: HR- 89, RR- 13, BP-198/117, POC glucose was 120 mg/dL, o2 sat – 97%. The CT did not reveal any signs of hemorrhage; what is the next best step in his treatment? a. Attempt to lower his blood pressure b. Prep the patient for intra-arterial thrombolysis c. Initiate rtPA bolus, followed by infusion d. Initiate heparin and admit for observation

a. Attempt to lower his blood pressure | 185/110

``` Stroke: A patient presents with contralateral homonymous hemianopia and sensory loss. You suspect that this patient has had a stroke, after initiating proper treatment and MRA was preformed. Where was the infarct located? a. Middle cerebral artery b. Anterior cerebral artery c. Basilar artery d. Posterior cerebral artery ```

d. Posterior cerebral artery

Stroke: An Anterior Cerebral Artery aneurysm will most likely cause: a) Contralateral Hemianopsia b) Ipsilateral CN III Palsy c) Pressure on the Pituitary Gland leading to hormone imbalance d) Ipsilateral CN IV Palsy

b) Ipsilateral CN III Palsy

Stroke: Which of the following is not in the 3hr tPA exclusion criteria? a) CT showing multilobar infarction. b) Blood Pressure >185mmHg systolic or >110mmHg diastolic. c) Venipuncture at a non-compressible site d) Head trauma in the last 3 months

c) Venipuncture at a non-compressible site

``` Stroke: Methods of controlling vasospasm after aneurysm coiling include all of the following except: a) Propranolol b) Nefedipime c) Hypervolemia d) All of the above control vasospasm. ```

a) Propranolol

Monitoring ICP Which of the following would most likely be an indication for invasively monitoring ICP? a. Patient that presents to the ED with a severe headache b. Trauma patient with a Glascow Coma score of 5 c. Patient with an abnormal CT (shows midline shift of 3 mm) d. A teenager who was just diagnosed with meningitis that is responding to antibiotic treatment

b.Trauma patient with a Glascow Coma score of 5

Monitoring ICP Your patient in the ICU is suffering from an obstructive, non-communicating hydrocephalus. Which method of ICP monitoring would be the best choice for this patient?

Intraventricular catheter

Monitoring ICP | In which of the following situations would it be most appropriate to intervene with a decompressive craniotomy?

Patient in the hospital recovering from an acute ischeic stroke with ICP of 25 mmHg over the last 10 min

Monitoring ICP Which of the following regarding non-invasive measures to lower ICP is FALSE? a. Hyperventilation is effective short-term by causing vasodilation of cerebral blood vessels b. Head elevation is a quick and easy way to try to decrease ICP c. Mannitol is an osmotic diuretic that is best used by bolus administration where an acute reduction in ICP is necessary d. Hyperventilation creates an alkaline environment

a. Hyperventilation is effective short-term by causing vasodilation of cerebral blood vessels

Monitoring ICP | Which of the following is a common manifestation of elevated intracranial pressure due to meningitis?

CN 6 paulsy

Monitoring ICP A 25 yr old 100kg male presented to the ED via ambulance from the scene of an accident in which he, a motorcycle driver, was struck by an SUV. Luckily, he was wearing a helmet. At the time of presentation, he had a Glasgow Coma score of 9, bilateral papilledema, and numerous distracting injuries (cracked rib, broken right femur to name a few). Conservative ICP treatment was initiated…head elevation, sedation, and a dose of mannitol (20% solution, 1g/kg over 15 minutes). 20 minutes following the mannitol administration, his BMP comes back with the following information: BUN 20 mg/dL, CO2 25 mmol/L, creatinine 1.1 mg/dL, glucose 125 mg/dL, chloride 107 mmol/L, potassium 4.5 mEq/L, and potassium 155mEq/L. Should you repeat mannitol treatment?

No, his serum osmolarity is too high (>320 mmol/L)

Monitoring ICP In regards to monitoring ICP, what is the main purpose of sedation?

Sedation helps maintain a physiologic basic enviroment leading to cranial vessel vasodilation, maintaing cerebral blood flow

Hemodynamic monitoring in the ICU A peripheral arterial line should be placed in all of these patients except: a) 56 y/o with CHF receiving IV dobutamine b) 2 y/o undergoing a VSD repair c) 31 y/o admitted with ARDS d) 47 y/o receiving IV Daptomycin for osteomyelitis

d) 47 y/o receiving IV Daptomycin for osteomyelitis

``` Hemodynamic monitoring in the ICU You are a PA working within the hospital and are asked to insert an arterial line on a patient. After successfully gaining access to the radial artery, you suture the catheter and attach the tubing to the transducer and flush system. You remember that the flush solution: a) keeps the IV site moist b) prevents clotting c) is bacteriostatic d) stops bleeding ```

b) prevents clotting

``` Hemodynamic monitoring in the ICU An increased CVP can be caused by an increase in _________ and/or a decrease in __________. a) arterial volume; compliance b) compliance; arterial volume c) venous volume; compliance d) compliance; venous volume ```

c) venous volume; compliance

Hemodynamic monitoring in the ICU The v wave seen within the CVP waveform is indicative of: a) blood filling the right atrium as the tricuspid valve is closed b) right atrial contraction c) blood filling the left atrium as the mitral valve is closed d) right ventricle contraction

c) blood filling the left atrium as the mitral valve is closed

Hemodynamic monitoring in the ICU | which of the following condictions would result in a decreased PAWP?

Hypovolemic shock

``` Hemodynamic monitoring in the ICU Patient with refractory heart failure is put on the IABP (Intra-aortic balloon pump). You expect to see all of the following changes as a result of using this device EXCEPT: Increased coronary blood flow Decreased afterload Increased cardiac output Decreased diastolic aortic pressure ```

Decreased diastolic aortic pressure

Hemodynamic monitoring in the ICU What is the best way to differentiate between a patient in hypervolemic shock vs. cardiogenic shock? PAP=pulmonary artery pressure PAWP= pulmonary artery wedge pressure Patient in cardiogenic shock would have increased PAWP, while patient in hypervolemic shock would have decreased PAWP Patient in cardiogenic shock would have decreased PAWP, while patient in hypervolemic shock would have increased PAWP Patient in cardiogenic shock would have decreased PAP, while patient in hypervolemic shock would have increased PAP Patient in cardiogenic shock would have increased PAWP, while patient in hypervolemic shock would have decreased PAWP

Patient in cardiogenic shock would have increased | PAWP, while patient in hypervolemic shock would have decreased PAWP

Temporary cardiac pacing 1. ) Jasmin, a 34 year old female, comes to the ER complaining of chest pain, fatigue, and SOB. She claims that she just got back from a hiking trip and she has a bulls-eye rash on her left leg. What is your main concern in regards to this patient? a. ) Anaphylactic reaction b. ) Complete heart block c. ) Atrial fibrillation d. ) Second degree heart block

Complete heart block d/t lyme disease

Temporary cardiac pacing 2. ) What is the most important reason why is temporary cardiac pacing more beneficial than beta blockers in Jasmin’s father Arinze (67 year old male) after an MI? a. ) Pacing has fewer side effects than beta blockers b. ) Pacing helps decrease contractility better c. ) Pacing keeps cardiac output at a level that can sustain the organs d. ) Pacing is not more beneficial than beta blockers

c.) Pacing keeps cardiac output at a level that can sustain the organs

Temporary cardiac pacing 3. ) Nick, a 43 year old male, presents to the ER with SOB, lightheadedness, and angina for the past hour. A 12-lead ECG is performed, and you have decided to try overdrive pacing. Which arrhythmia was seen on the ECG? a. ) Complete heart block b. ) Atrial flutter c. ) Ventricular fibrillation d. ) Ventricular tachycardia

Ventricular tachycardia

Temporary cardiac pacing 4. ) EMS brings in a 58 year old female who believes that she is having a heart attack. An ECG reveals that she has an anterior wall STEMI, and she must be taken to the cath lab. Once she is in recovery your Cardiology preceptor asks you if he should try transvenous cardiac pacing with this patient to get her heart rhythm under control. What could impede your treatment plan? a. ) The patient’s use of Coumadin for the past year b. ) The patient losing consciousness after leaving the cath lab c. ) Symptomatic bradycardia d. ) None of the above

The patient’s use of Coumadin for the past year

Temporary cardiac pacing 5. ) You are rounding at West Michigan Heart and one of your patients is a 72 year old male who has been hooked up to a transvenous cardiac pacemaker for 2 days. You check the monitor and notice that there is a failure to capture. What should you do first? a. ) Increase the mA on the pulse generator b. ) Decrease the mA on the pulse generator c. ) Increase the mV on the pulse generator d. ) Decrease the mV on the pulse generator

Increase the mA on the pulse generator

Temporary cardiac pacing 6. ) Which of the following is a mode of demand cardiac pacing? a. ) AAI b. ) VOO c. ) AOO d. ) DOO

AAI

Temporary cardiac pacing 7. ) You decide to place a transcutaneous pacemaker on a 50 year old female who was admitted to the hospital for observation after a CABG. You notice that that she is diaphoretic and anxious. You order a 12-lead ECG and notice that she has ventricular tachycardia. You set the pacer at 100 bpm to prevent the development of torsades des pointes. Why? a. ) This patient has a decreased cardiac output from the CABG which predisposes her to develop torsades b. ) Overdrive pacing will prolong the QT interval which will maintain a healthy rhythm c. ) Setting a higher pace rate will prevent early heartbeats d. ) 2 of the above are true

d.) 2 of the above are true b. ) Overdrive pacing will prolong the QT interval which will maintain a healthy rhythm c. ) Setting a higher pace rate will prevent early heartbeats

Stem Cell 1. In which of the following disease states would hematopoietic stem cell transplantation not be an appropriate treatment course? a. Sickle cell anemia b. Non-Hodgkin lymphoma c. Acute lymphoblastic leukemia d. Hepatocellular carcinoma

d. Hepatocellular carcinoma

Stem Cell 2. The graft vs. tumor effect is one the main advantages of hematopoietic stem cell transplant via what type of donor? a. Allogeneic b. Syngeneic c. Haploidentical d. All of the above

all of the above a. Allogeneic b. Syngeneic c. Haploidentical d. All of the above

Stem Cell 3. Which of the following most accurately describes the graft vs. tumor effect? a. Autologous cells will attack any remaining cancer cells after the completion of chemo/radiation therapy. b. Allogeneic cells will attack any remaining cancer cells after the completion of chemo/radiation therapy. c. Autologous cells will attack cancer cells prior to the initiation of chemo/radiation therapy. d. Allogeneic cells will attack cancer cells prior to the initiation of chemo/radiation therapy.

b. Allogeneic cells will attack any remaining cancer cells after the completion of chemo/radiation therapy.

Stem Cell 4. The ideal donor for a patient who requires allogeneic stem cell transplantation is: a. a complete matched sibling donor b. a haploidentical donor c. a complete matched unrelated donor d. the patient himself/herself

a. a complete matched sibling donor

Stem Cell 5. A patient presents for pre-transplant counseling regarding autologous hematopoietic stem cell transplantation. You plan to harvest the stem cells from the patient’s peripheral blood rather than the bone marrow. In describing this procedure to the patient, you explain: a. The procedure will be no more involved than a simple blood draw b. The procedure will be performed over several days in order to harvest enough stem cells from peripheral blood c. The patient will need to be pre-treated with G-CSF or chemotherapy to mobilize stem cells from the bone marrow d. The patient will need to be under general anesthesia for the harvesting procedure

c. The patient will need to be pre-treated with G-CSF or chemotherapy to mobilize stem cells from the bone marrow

Stem Cell 6. Which of the following is incorrect regarding the infusion process of hematopoietic stem cells? a. The bone marrow product is typically infused through a central vein. b. The side effects during the infusion process are generally from dimethylsulfoxide and include facial flushing, tickling sensation of the throat, and strong garlic taste. c. Infusing the hematopoietic stem cells into the bone cavity typically produces better results. d. Allogeneic hematopoietic stem cells are infused at a slower rate than autologous stem cells.

c. Infusing the hematopoietic stem cells into the bone cavity typically produces better results.

Stem Cell 7. A patient that is 30 days post-hematopoietic stem cell infusion with myeloablative preparatory regimen complains of difficulty swallowing. The patient also presents with painful ulceration of the oral cavity, hyposalivation, nausea, abdominal cramping, and diarrhea. This patient is most likely suffering from which of the following conditions: a. Acute graft vs. host disease b. Mucositis c. Chronic graft vs. host disease d. Oral candidiasis

b. Mucositis

Stem Cell 8. Myeloablative regimens differ from the nonmyeloablative regimens in that: a. Myeloablative regimens are typically used in cases where graft-versus-tumor treatment is needed. b. Nonmyeloablative regimens result in a chimerism that is the concurrent presence of donor and host hematopoietic cells. c. Myeloablative regimens have higher rates of graft rejection. d. Nonmyeloablatve regimens tend to be a harsher process due to higher doses of chemotherapy and radiation.

b. Nonmyeloablative regimens result in a chimerism that is the concurrent presence of donor and host hematopoietic cells.

Stem Cell 9. Patients’ immune systems can be suppressed for years after the hematopoietic stem cell transplant process. Therefore, vaccinations are a great way to help prevent infections and should be administered in these patients: a. the day of the infusion of the stem cells b. one month after the infusion of the stem cells c. six months after the infusion of the stem cells d. one year after the infusion of the stem cells

d. one year after the infusion of the stem cells

Stem Cell 10. There are many side effects associated with the hematopoietic stem cell transplant process including skeletal effects. Osteoporosis is a common late effect and is best prevented and treated with: a. Bisphosphonates b. Calcium and Vitamin D supplements c. IM Forteo injections d. Hormone replacement therapies

a. Bisphosphonates

VAD in the ICU 1) How does an arterial waveform while on a nonpulsatile continuous flow ventricular assist device differ from an arterial waveform of a heart that is not mechanically assisted? A. Diastolic waveform will increase resulting in decreased ability to palpate a pulse. B. Diastolic waveform will increase resulting in an increased ability to palpate pulse. C. Systolic waveform will increase resulting in a decreased ability to palpate pulse. D: Dicrotic notch will have a smoother shape and occur later in the cycle.

Dicrotic notch will have a smoother shape and occur later in the cycle.

VAD in the ICU 2) Which of the following does not account for right ventricular failure after LVAD placement? A) Release of inflammatory mediators B) Hemorrhage and trauma from surgery C) Pump speed set too low D) Electrical remodeling

D) Electrical remodeling

``` VAD in the ICU 3) Which of the following measures is NOT appropriate for controlling blood pressure while on a VAD. A) Altering the pump speed B) Inotropes C) ACE Inhibitors D) Fluids E) Beta Blockers ```

Altering the pump speed

VAD in the ICU 4) Which of the following is not associated with increased incidence of gastrointestinal bleeding after VAD placement? A) Reduced pulse pressure causing arteriovenular dilation B) Infusing normothermal blood products interoperatively C) Increased shear stress cleaving multimers of vonWillebrand factor D) Prolonged cardiopulmonary bypass time depleting clotting factors

B) Infusing normothermal blood products interoperatively

VAD in the ICU 6) A 76 year-old patient who received an LVAD implantation 3 days ago is now experiencing PVCs. He has no history of arrhythmia in his medical history. Which of the following is NOT responsible for the new onset of arrhythmia? A) Re-expression of fetal genes associated with the acute unloading of the left ventricle B) Pump speed set too high, causing suction-induced arrhythmia C) Subendocardial tissue regression D) Changes in the functional balance of sarcoplasmic Ca2+-ATPase and Na+/Ca2+ reuptake

C) Subendocardial tissue regression

VAD in the ICU 8) An elderly man with severe congestive heart failure needs a heart transplant but he may not be a candidate due to his kidney disease that does not require dialysis. He also suffers from pulmonary hypertension. What type of ventricular assist therapy would be most appropriate? A) Bridge to recovery B) Bridge to decision C) Bridge to transplantation D) Destination therapy

B) Bridge to decision

Sedation in the ICU 1) What is NOT a common medication used for sedation in the ICU? a. Propofol b. Barbiturates c. Benzodiazapines d. Fentanyl

Barbiturates

Sedation in the ICU 2) It is decided that a patient will be weaned off from sedation in the ICU. What medication should be removed LAST? a. Haldol b. Midazolam (Versed) c. Fentanyl d. Dexmedetomidine

Fentanyl

Sedation in the ICU | 3) The sedative drug most likely to cause hypotension is:

Dexmedetomidine

Sedation in the ICU | 4) Why is it important to alleviate pain and anxiety in ICU patients?

Pain and anxiety induce a sympathetic response which results in greater workload of the heart, hyperglycemia, protein catabolism and cardiac remodeling

Sedation in the ICU 5) You are doing a clinical rotation in the ICU and notice that the elderly patient you have been taking care of has become very agitated despite being on a high dose of fentanyl and midazolam. You have ruled out any medical causes for the delirium and now consider pharmacological reasons for the episode. He still requires sedation and is hemodynamically stable. You should: a. Discontinue midazolam b. Discontinue fentanyl c. Give quitiapine and dexmedetomidine d. A and C e. All of the above f. None of the above

d. A and C a. Discontinue midazolam c. Give quitiapine and dexmedetomidine

Sedation in the ICU 6) Which is the correct location of alpha-2 receptors? a. Raphe nuclei b. Locus coeruleus c. Presynaptic axon d. Postsynaptic axon e. 2 of the above f. 3 of the above

Presynaptic axon Post synaptic Locus Coeruleus

Sedation in the ICU 7) Which is NOT a potential effect of pain and anxiety? a. Hyperglycemia due to increased insulin desensitivity b. Bradypnea in response to hyperventilation and increased PaO2 c. Protein catabolism d. Fluid retention due to increased aldosterone and cortisol secretion e. Cardiac remodeling due to proliferation of cardiac fibroblasts

Bradypnea in response to hyperventilation and increased PaO2

Sedation in the ICU 8) Which intervention does NOT result in a decreased duration of mechanical ventilation? a. Administering a benzodiazepine b. Administering sedative meds based on observed distress c. Intermittent infusion d. Daily interruption of continuous infusions

Administering a benzodiazepine

Sedation in the ICU 9) Which of these statements is true regarding the potency of the medications? a. Morphine>Sufentanil>Fentanyl b. Sufentanil>Fentanyl>Morphine c. Fentanyl>Morphine>Sufentanil d. Fentanyl>Sufentanil>Morphine

Sufentanil>Fentanyl>Morphine

Sedation in the ICU 10) Which of these sedative medications does NOT agonize GABA receptors? a. Benzodiazepines b. Propofol c. Barbiturates d. Dexmedetomidine

Dexmedetomidine

Sedation in the ICU 11) Labs from a sedated ICU patient come back revealing hypertriglyceridemia. Which of these medications is the most likely to cause this? a. Fentanyl b. Midazolam c. Propofol d. Dexmedetomidine

Propofol

Sedation in the ICU 12) Which is NOT one of the recommendations for sedation in the ICU by the most recent guidelines? a. Maintaining deeper levels of sedation is associated with improved outcomes b. Sedation with non-benzodiazepines may result in improved clinical outcomes in mechanically ventilated patients c. Avoid over-sedating patients to prevent prolonged duration of mechanical ventilation d. Objective measures of brain function, like bispectral index, should not be the primary method to monitor non-comatose, non-paralyzed patients

Maintaining deeper levels of sedation is associated with improved outcomes

AP 1. A 59-year-old male presents with a 24-hour history of severe epigastric pain. Past medical history reveals 20-year history of cirrhosis and HTN. Labs show a serum Amylase level of 350 U/L. (normal 30-110U/L). You have determined the patient has acute pancreatitis and decide to start fluid replacement. What is the appropriate solution for this patient? a. Lactated Ringer b. Normal Saline c. D5W d. None of the above

b. Normal Saline

AP 2. What pain medication would you choose to treat the above patient? a. Hydromorphone (Dilaudid) IV b. Morphone IV c. Fentanyl IV d. Two of the above are appropriate choices e. A, B, or C are appropriate

d. Two of the above are appropriate choices

AP 3. During morning rounds you are completing a PE on a patient 48 H post admission for severe acute pancreatitis. While examining the abdomen you notice a blue/grey discoloration around the umbilicus. Which of the following is correct about the physical exam finding? a. This is Grey Turner’s sign, indicating intra- abdominal bleeding b. This is Cullen’s sign, indicating bowel ischemia c. This is Grey Turner’s sign, indicating bowel ischemia d. This is Cullen’s sign, indicating intra-abdominal bleeding

d. This is Cullen’s sign, indicating intra-abdominal bleeding

AP 4. Which of the following inhibits trypsin activation? a. Enterokinase b. SPINK 1 c. Cathepsin d. Calcium

b. SPINK 1

AP 5. All of the following would be appropriate recommendations for a patient who has acute pancreatitis, EXCEPT? a. Initiate probiotic therapy b. Cholecystectomy c. Initiate a low fat diet d. Decrease alcohol consumption

a.Initiate probiotic therapy

AP 6. A 52-year-old female presented to the ED 7 days ago with N/V, acute epigastric pain which radiated to the back; labs showed a serum Amylase level of 400 U/L. (normal 30-110U/L). You admitted her with the diagnosis of acute pancreatitis and initiated aggressive hydration therapy and Hydromorphone (Dilaudid) IV. She is showing improvement and would like to eat, which of the following would be appropriate? a. Start prophylactic antibiotics to prevent infected necrosis b. Switch from Normal Saline to Lactated Ringers c. Start the patient on a low fat soft diet d. All of the above are indicated at this time.

c.Start the patient on a low fat soft diet

AP 7. You get the labs back on a patient with acute pancreatitis and the triglyceride level is 1,100 mg/dL (normal 150mg/dL). This is a typical finding in a patient with this condition due to amylase entering the blood stream and breaking down fats. a. True b. False

b.False Lipase does this.

Bronchial Thermoplasty Questions Why is the right middle lobe not treated with bronchial thermoplasty?

a) Research has shown there is little to no benefit with treatment in this location. b) Increased risk of bronchiectasis, atelectasis, PNM d) 2 of the above are correct

Bronchial Thermoplasty Questions The late phase response to an allergen which can occur up to 24 hours after exposure to an allergen is most commonly thought to be due to which inflammatory mediator?

b) Leukotrienes

Bronchial Thermoplasty Questions A 55 year old female comes to your office today to discuss the new surgical procedure, Bronchial Thermoplasty. After reviewing her past medical history you decide she is a great candidate for the procedure. In describing the procedure, which of the statements listed would be false? a) Periprocedural corticosteroids, a bronchodilator, and sedatives are all necessary in the procedure. b) In order to eliminate cough and ensure comfort, we will apply 1% aliquots of Lidocaine to the vocal cords and tracheobronchial tree. c) After the procedure, we will set up a follow up appointment in one week to assess the airways. d) You will need to continue on your medications even after the procedure, however the dosages may be decreased. e) Two of the above

c) After the procedure, we will set up a follow up appointment in one week to assess the airways. It is in one to two days not one week

Bronchial Thermoplasty Questions . A 15-year-old boy comes to the office because of occasional shortness of breath every few weeks however he currently feels well. He uses no medications and denies any other medical problems. Physical examination reveals a pulse of 70 and a respiratory rate of 12 per minute. Chest examination is normal. Which of the following is the most accurate diagnostic test to check whether his condition is obstructive or restrictive disease at this time? A) Peak expiratory flow B) Increase in FEV1 with albuterol C) FEV1 and FVC ratio below 7 D) Increase in FVC with albuterol

C) FEV1 and FVC ratio below 7 - Looks at chages in lung compacity by checking the amount of air one can exhale after a ddeep breath in and how fast one can breath out. Obstructive: FEV1 reduced so the ratio will be smaller Restictive : both will be smaller, ratio minimall changed Others: A) Peak expiratory flow: Measures the pressure one can breath out. Lower than usual peak flow readings are a signs that lungs may not be working aduquately and asthma is getting worse B) Increase in FEV1 with albuterol D) Increase in FVC with albuterol

Bronchial Thermoplasty Questions A 50 year female with a history of asthma comes to the emergency department with several days of increasing shortness of breath, cough, and sputum production. On physical examination her respiratory rate is 34 per minute and she has diffused expiratory wheezing. Which of the following would you use as the best indication of the severity of her asthma?

a ) Respiratory rate

Bronchial Thermoplasty Questions A 27 year old female is started on an asthmatic drug that inhibits leukotriene synthesis. This drug is: a) Cromolyn b) Montelukast c) Salmeterol d) Prednisone e) pratropium

a) Cromolyn- Mast cell stabiliazer b) Montelukast- Leukotriene modifers c) Salmeterol- Long acting B agonist d) Prednisone- steroid e) Ipratropium- anticholinergic

Tracheostomy in the ICU Patient Which of the following is true about tracheostomy tubes: A. The smallest size tube should be used and the cuff should be inflated as much as possible to prevent aspiration. B. Fenestrated tubes can be appropriately used on patients who are being mechanically ventilated C. Cuffed tubes are best indicated for patients who can protect their own airway D. They can be used in patients with laryngeal carcinoma who are having difficulty breathing.

D. They can be used in patients with laryngeal carcinoma who are having difficulty breathing.

Tracheostomy in the ICU Patient An 85 y/o female presents to the ED with complaints of progressive dyspnea and cough. Past medical history is significant for recurrent pneumonia. Her BMI is 26, heart rate 90, respirations is 30 and pulse ox is 84% however she is able to communicate with you. She is receiving O2 by nasal cannula. What is the best immediate management of her condition? A. Transfer her to an OR for surgical placement of a tracheostomy tube B. Begin a nebulizer treatment and prophylactic antibiotics C. Perform an emergent tracheostomy at the level of the 2nd-5th tracheal ring D. Sedate the patient and intubate with an ET tube and provide mechanical .

D. Sedate the patient and intubate with an ET tube and provide mechanical - Unessisary

Tracheostomy in the ICU Patient Which of the following is not an indication for percutaneous tracheostomy placement? A. A cerebral palsy patient who develops pneumonia and is having difficulty clearing their secretions. B. Expected intubation period of 3 weeks C. A patient with a BMI of 42 who uses CPAP to treat sleep apnea without complications D. A TBI patient who can lift their head but has CN XI and X deficits.

C. A patient with a BMI of 42 who uses CPAP to treat sleep apnea without complications

Tracheostomy in the ICU Patient All of the following are true of accidental decannulation, except: A. Can result in rapid airway loss B. Is less of a concern if it occurs soon after placement (

B. Is less of a concern if it occurs soon after placement (5 days no bug deal put it back in

Options for decannulation of a tracheostomy tube include all of the following except: A. Use of a fenestrated tube/speaking valve B. Decreasing size of tubing prior to removal C. Providing intermittent periods of low pressure support as tolerated D. Capping off the end of the tracheostomy

C. Providing intermittent periods of low pressure support as tolerated

Tracheostomy in the ICU Patient T/F You are a PA working in the ICU and one of your intubated patients is being considered for weaning off of mechanical ventilation. Intermittent low pressure support was started, but you have not seen the patient. You order a consult with a respiratory therapist who provided the information below. Based on these values alone, it is appropriate to extubate this patient. SaO2= 91% PaO2= 70 RR= 25 HR= 100 BP= 120/80

False

Alcohol Withdrawal in the ICU MC Questions 1. You admit a patient to the ICU with a diagnosis of alcohol withdrawal. What electrolyte abnormality is most common in these patients?

Hypomagnesemia

Alcohol Withdrawal in the ICU MC Questions 2. An agitated patient presents to the emergency department with a history of chronic alcohol use that describes “bugs crawling on the walls.” You decide to give this patient a benzodiazepine. What receptor does this drug bind to in order to be effective?

a. GABA receptors

Alcohol Withdrawal in the ICU MC Questions 3. You are rounding on an ICU patient admitted for alcohol withdrawal. When re-assessing the neurological exam, you notice the patient’s cognitive state has declined and that that patient is also presenting with ataxia and ocular dysfunction. How should this patient be treated?

a. IV Ethanol Not a recommended treatment of withdrawal a/w adverse metabolic and end organ effects. b. IV Thiamine c. Benzodiazepine d. This patient does not require treatment – this is a normal response to alcohol withdrawal.

Alcohol Withdrawal in the ICU MC Questions 4. True or False – Korksakoff Syndrome is a reversible alcohol induced disorder and therefore, immediate treatment of symptoms is not indicated.

fALSE- IRRIVERABLE

Alcohol Withdrawal in the ICU MC Questions 5. You have admitted a patient to the ICU for alcohol withdrawal. They have experienced tachycardia, insomnia, tremors, anxiety, seizures, and visual hallucinations. The chronic alcohol use has caused their CNS to adapt. What does chronic alcohol use do to GABA and glutamate in the CNS?

b. Chronic alcohol use causes an insensitivity to GABA causing less inhibition and an increased sensitivity to glutamate causing more excitation.

Alcohol Withdrawal in the ICU MC Questions 6. You are working on your first day in the trauma bay and have an unresponsive car accident victim who you are assigned to assess. You go to check his pupillary reflex and notice a strong smell of alcohol. How should this patient be treated?

c. This patient should be treated like any other trauma patient.

Alcohol Withdrawal in the ICU MC Questions 7. You seem to be having a very bad day in the trauma bay when you have another patient who comes in and smells like alcohol. The EMS stated that it was a drug bust that turned into a car chase and he was thrown from his car. How should this patient be treated?

a. CT/MRI b. Tox screen c. Primary and Secondary Surveys

Dabigatran and Warfarin Questions 1. When considering a patient for anticoagulation therapy, what things must you keep in mind? a.

a: Bleeding Risk/Fall risk b. Access to care/monitoring c. Compliance with administration and monitoring d. Clot formation risk

Dabigatran and Warfarin Questions When trying to decide what type of therapy to use, how does the SAMe-TT2R2 score help you?

Both: c. High score suggests that the patient is less likely to remain in the therapeutic range if on warfarin therapy and may require alternative interventions d. Low score suggests that the patient is more likely to remain in the therapeutic range if on warfarin therapy, and is therefore a good candidate.

Dabigatran and Warfarin Questions 3. If your patient has a CrCl of 40, how do you switch them from Dabigatran to Warfarin?

c. Start Warfarin 2 days before you discontinue Dabigatran If CrCl> 50 then start 3 days before discontinuing Dabigatran If CrCl 30-50 then start 2 days before discontinuing Dabigatran If CrCl 15-30 then start 1 day before discontinuting dabigartran

Dabigatran and Warfarin Questions | 4. If your patient has a CrCl of 40, how do you switch them from Warfarin to Dabigatran?

d. Discontinue warfarin and begin dabigatran when INR is <2

Dabigatran and Warfarin Questions 5. Your patient is a 78 year old female with CHF for the last 10 years and diabetes. She has HTN but does not consume any alcohol, her liver is functioning well and her CrCl is WNL. What is the CHADS2 score? CHA2DS2-VASc? What therapy do you recommend?

c. CHADS2 of 4, CHA2DS2-VASc of 6, OAC treatment recommended unless contraindicated

Dabigatran and Warfarin Questions 6. Your patient is a 67 year old female who lives alone, has limited transportation availability, consumes 3 beers per night and had a hemorrhagic stroke 3 years ago. What is her CHADS2, CHA2DS2-VASc and HAS-BLED score? How do you go about deciding what treatment regimen to initiate if any – what are your approach considerations? *

c. CHADS2 = 0, no treatment required. CHA2DS2-VASc 2, OAC recommended, HAS-BLED of 3 with a moderate chance of bleeding event. Weigh the risk and benefit of treatment with the moderate chance of a bleeding event.

Dabigatran and Warfarin Questions 7. Where is Warfarin metabolized and how is it excreted?

a. Metabolized in the liver and excreted in the urine

Dabigatran and Warfarin Questions | 8. Where is Dabigatran metabolized and how is it excreted if given orally?

b. Metabolized in the liver and excreted in the feces

Dabigatran and Warfarin Questions | 9. How does Warfarin inhibit coagulation?

`c. Inhibits Vitamin K Dependent factors

Dabigatran and Warfarin Questions | 10. How does Dabigatran inhibit coagulation?

d. Direct Thrombin Inhibitor

Dabigatran and Warfarin Questions | 11. What is the CrCl your patient needs to be considered for an average 150mg dose BID of Dabigatran?

b. CrCl > 30ml/min

Dabigatran and Warfarin Questions | 12. Why is Dabigatran given BID and why is it so important for the patient to take it at the same time every day?

b. It has a short half life so it can fall out of therapeutic range if doses are missed

Dabigatran and Warfarin Questions | 13. Why can’t you use Dabigatran with valvular atrial fibrillation?

b. There is an increased risk of thromboembolic events

Dabigatran and Warfarin Questions | 14. What instructions should you give your patient regarding dietary choices when you are starting them on Warfarin?

a. Maintain your regular diet so that you can become regulated on warfarin with that diet

Dabigatran and Warfarin Questions | 15. How do you treat a patient on Warfarin that is hemorrhaging?

d. Give Vitamin K | e. Give FFP

Dabigatran and Warfarin Questions | 16. How do you treat a patient on Dabigatran that is severely hemorrhaging?

a. Perform Dialysis | c. Give FFP

ECHO/ARDS 1. A 65 yo female presents to the ER with a 4 day history of worsening shortness of breath. On exam she has an altered mental status, bilateral crackles in the lungs, slight peripheral cynanosis, and a grade III systolic murmur heard best at the apex of the heart. Her initial SaO2 on room air is 75% and you begin by putting her on 15L O2 via non-rebreather mask (FiO2= 100). This elevates the SaO2 to 95%. You then draw an ABG showing PaO2 of 100 mmHg. The CXR shows diffuse bilateral lung infiltrates and enlarged cardiac silhouette. The X-ray tech leans over and says, "I think she's got ARDS." You respond correctly with...

a. “False, she does not have ARDS because cardiac etiology is likely contributing to her pulmonary edema.” Acute onset (within 1 week) 2: bilateral lung opacities 3: No cardiac etiology 4: Pao2/FiO2

ECHO/ARDS 2. A 27yo male circus performer presents to the ER after inhaling the gasoline he used for his fire breathing stunts. He complains of severe chest pain and is coughing up blood and breathing heavily. His SaO2 is 85% and so you place him on 4L O2 via nasal cannula (FiO2 = 40%). You are crazy smart and remember the hemoglobin dissociation curve well enough to recall that an SaO2 of 85% puts his PaO2 at around 60 mmHg. You classify him as having MODERATE ARDS because his PaO2/FiO2 ratio is estimated to be:

a. 150 mmHg Mild: less than 300 Moderate: 100-200 Severe less than 100

ECHO/ARDS | ARDS is best described as respiratory failure due to lung injury causing…

b. leukocyte migration and cytokine release that enhances lung damage and causes pulmonary edema.

ECHO/ARDS 4. A 35yo previously healthy male presented to the ER with the flu and rapidly progressed into severe acute respiratory distress. After 3 days on a ventilator with no signs of improvement it was decided that ECMO was the next line of treatment. After being placed on ECMO which of the following ventilator settings should be avoided:

d. Tidal volume increase, with low peep (2-3)

ECHO/ARDS 5. A 57 yo slightly overweight female with a history of diabetes, HTN, and basal cell carcinoma that was removed from her right cheek developed severe ARDS after a diagnosis of community acquired pneumonia. After being on the ventilator for 9 days with no signs of improvement the family asks about a treatment they heard about on the news, ECMO. You tell the family that the patient is:

a. Not a good candidate for ECMO because she has been on a ventilator for >7 days

ECHO/ARDS | 6. In a patient with severe acute respiratory distress syndrome, which of the following is true:

b. VV ECMO is utilized with access via the right common femoral vein or the right internal jugular vein

7. After placement on ECMO for treatment of ARDS which of the following IS a concern:

a. Risk PTSD after successful treatment b. Early mobilization c. Bleeding due to consumption of platelets d. Two of the above e. All of the above

NMBA Questions: 1. Okere, a 76 yr old male is being transferred to the ICU after being given the diagnosis of ARDS. She has a GFR of 35 mL/min, HR=110, and BP 85/50. What neuromuscular blocking agent would you recommend to be used for paralysis? * Normal GFR > 60 mL/min

Cisatracurium | because her Bp is low this one is one that prevents more drops

NMBA Questions: 2. You are working the night shift in the Spectrum ICU and have accidentally given an overdose of Succinylcholine to patient A and an overdose of Rocuronium to patient B. What should be done to try and immediately reverse the paralytic effects in each of these patients?

Stop the infusion of succinylcholine while giving IV NS to patient A, Physostigmine to patient B

NMBA Questions: You are just beginning your morning rounds in the ICU and come across a paralyzed patient on mechanical ventilation whose K+=6.0, HR = 53, and is showing VFIB on the EKG monitor. There is no documentation of what paralytic was administered to the patient. What could be the possible neuromuscular blocking agent causing these SE?

Succinylcholine- all the K leaves the cell when depolarized

NMBA Questions: 4. You come to check on your 80 kg patient 2 hours after administrating a sedative and Pancuronium necessary for intubation. His labs show slightly elevated CPK enzymes, a BP of 100/60, serum Creatinine of 2.0 mg/dL, and a TOF response of zero. How should his dosage of Pancuronium be adjusted?

decrease the dose by 10%

NMBA Questions: 5. Place the following events in order of occurrence, at the NMJ, after the administration of Succinycholine to a patient who needs to be intubated.

depolarization, fasciculation, desensitization, flaccid paralysis

NMBA Questions: 6. At the NMJ, Acetylcholine is released from the motor nerve terminus and binds to_______________cholinergic receptor on the postsynaptic endplate. The Ach molecules bind to the two__________ protein subunits of the receptor and causes the ion channel to open, allowing_________ to enter and __________ to exit.

Nicotinic, alpha, Na+, K+

Nutrition in the Critically Ill Patients Questions 1. You are taking your first few shifts alone as a new PA working in the ICU. One of your patients is receiving TPN and you are drawing several labs on this patient. As you review the labs, you notice the glucose level is 190 mg/dL. Which of the following is the MOST appropriate treatment and reasoning?

b. stop the TPN infusion because it contains dextrose

Nutrition in the Critically Ill Patients Questions 2. You have a patient who has been receiving EN support for 48 hours. They have had diarrhea for the past 24 hours, what is the BEST course of action?

c. Consider supplemental TPN

Nutrition in the Critically Ill Patients Questions 3. P.B., a 24yo female, was admitted to the ER with fever, dehydration and abdominal cramping. She has had 2 episodes of hematochezia and was sent to endoscopy. She was found to have a severe GI bleed and has been fully resuscitated but has now developed ileus. The PA doesn’t think that she will be eating for at least the next week. What nutritional support regimen listed should be implemented in this patient?

c. start early parenteral support within 24-48 hours of ICU admission

Nutrition in the Critically Ill Patients Questions | 4. To determine a patient’s tolerance to TPN, you should assess for which of the following?

b. Urine output of at least 30cc per hour

Nutrition in the Critically Ill Patients Questions A.N., an 85 yo male, was admitted to the ICU six weeks ago following complications of his open heart surgery. He had a percutaneous endoscopic gastrostomy tube placed five weeks ago, and is now beginning to recover and resume oral feedings. He is swallowing well and receiving an adequate amount of nutrition orally. What is the proper procedure for removing his PEG tube?

a. Deflate the internal bolster, remove the tube and cover the site with a clean dressing

Nutrition in the Critically Ill Patients Questions 6. N.S., a 92 yo female is admitted to the ICU after falling down the stairs and sustaining a head injury. On physical exam, you notice she is very thin, has dry skin, fissured nails, and thin hair. After starting her on enteral nutrition for a few days, you notice that her respiratory rate has increased and she has developed bilateral rales on auscultation of the lungs. Which of the following electrolyte abnormalities would confirm your suspicion?

a. hypokalemia b. hypermagnesemia c. hypophosphatemia d. ALL OF THE ABOVE

c diff Oral treatment is preferred for C. difficile infection, but if a patient has severe and/or recurrent disease and is not able to handle oral intake, which treatment would NOT be preferred?

a. IV Vancomycin 125mg Q 8hrs

c diff A 70-year old female patient was admitted to the hospital for treatment of severe pelvic inflammatory disease and was put on 900 mg IV q8hr Clindamycin therapy. After one week in the hospital she developed severe diarrhea, abdominal pain/cramping and a re-emergent low grade fever. She has never experienced this before and as the Internal Medicine PA rounding on the floor today, you must put into place the proper protocol to prevent the spread of her infection to other patients. Which of the following is the best first order for your patient?

d. Order a stool sample and culture to test for C. difficile infection and start IV Metronidazole

c diff Clostridium difficile is a gram-positive spore forming pathogen that invades the human gastrointestinal tract. Choose the correct pathophysiological mechanism which leads to GI distress and severe diarrhea in symptomatic carriers.

b. Spores enter the human body through oral contamination and survives the acidic stomach environment before entering the colon, becoming a vegetative cell releasing cytotoxins and causing the recruitment of inflammatory cells to disrupt the normal gut flora and produce pseudomembranous colitis.

c diff In regards to C diff stool testing, which of the following is incorrect A)Stool cytotoxicity cultures are the “gold standard” as they are highly sensitive and specific B)Although PCR is expensive, it produces fast results that are highly sensitive and specific C)Enzyme immunoassays for C. difficile’s antigen GDH produce fast results that are highly specific but not sensitive so a enzyme immunoassay for the C. difficile toxin should be run to confirm diagnosis. D)Since a anaerobic stool culture has a high sensitivity, a negative result can be used to rule out C. Diff infection without additional testing.

C)Enzyme immunoassays for C. difficile’s antigen GDH produce fast results that are highly specific but not sensitive so a enzyme immunoassay for the C. difficile toxin should be run to confirm diagnosis.

c diff You are in the first day of your ER clinical rotation. The first three patients that you see have a complaints of diarrhea. Which patients should you order C diff stool tests on? a) 55yo female diagnosed with pyelonephritis one month ago. She completed Bactrim PO q12hr x 14days and symptoms resolved. Yesterday morning she began having “watery bowel movements” and has had 10 of these episodes since then. b) A 75yo male who was hospitalized overnight two weeks ago to monitor his chest pain and have repeated troponins draw. He has not had any antibiotics in the last 3 months. Today he complains he has had “loose bowels” four times a day for the last 48 hours. c) A otherwise healthy 25 year old male complains of abdominal pain. In the ROS he admits to having unformed bowel movements three times a day for the last three days. d) 2 of the above e) All of the above

e)All of the above

c diff You’re on a first date with a med student and they decide to bring up conversation about C diff. Besides the fact that they brought up C. diff on a first date, you’re not sure they have their C. diff facts correct so you decide the relationship isn’t going to work. Which of his/her statements about C. diff are incorrect? a) Constipation can exclude a C diff diagnosis b) C. diff may present as ileus c) Chemotherapy can increase a patient’s risk for C diff infection d) Acute kidney injury is a complication of C. diff infection e) You get home and check the C diff literature. To your surprise all of their facts were correct. Call them up for a second date.

a) Constipation can exclude a C diff diagnosis

c diff 7. Which of the following lab values is not expected with a severe C diff infection? a) Significant leukocytosis b) Hypokalemia c) Hyperalbuminemia d) elevated creatinine e) All of the above may be expected

c) Hyperalbuminemia

Erectile Dysfunction Questions . A 55 y/o patient has contacted you with a concern of priapism. He states he ingested several pills his friend gave him to help with his performance in bed an hour prior to intercourse, but his erection did not subside and his penis has begun feeling very sore. The best advice you could give him is:

C. There is a risk of penile ischemia in this patient. He should visit the nearest ER right away.

Erectile Dysfunction Questions | The mechanism of hypothyroid induced erectile dysfunction is thought to be related to:

D. Elevated TSH, ultimately causing low testosterone levels.

Erectile Dysfunction Questions True/False – High abdominal aortic aneurysms may cause decreased blood flow to the penis, resulting in the inability to perfuse the corpus cavernosum.

False

Erectile Dysfunction Questions A 47 male presents to the ED c/o an erection that he has had for 3 hours. He claims to have been trying a new penile ring his wife gave him but grew increasingly concerned when his erection remained after its removal. He is in severe pain and very embarrassed. He has never had anything like this before and medical history is mostly benign except for HTN controlled with lisinopril and 3 months ago was put on Prozac for his depression after his recent job loss. What should your course of treatment be?

Administer IM morphine and inject alpha-agonist

Erectile Dysfunction Questions | Tadalafil is often preferred by men with ED over the other PDE5-Is for what reason?

It’s longer half-life allows for men to have more spontaneity with their sex life

Erectile Dysfunction Questions Hypogonadism can occur concominantly/contribute to erectile dysfunction; when is testosterone replacement indicated in these patients?

When testosterone level is <300 ng/mL

Erectile Dysfunction Questions A 62 year old male presents to the urgent care clinic because he thinks he is going color blind. For the last few weeks, he has noticed that colors are blending together. He wonders if it is just part of aging or if he may be at risk for glaucoma since he has a family history of that. You do a medical history which reveal s that 6 months ago he began taking a medication to help improve his sexual function. Which medication would cause these symptoms, and why?

Sildenafil, d/t the partial inhibition of PDE6, an enzyme located in the retina

Hemodialysis A young patient presents to you in the ER with her mom for flank pain and confusion. You draw a plasma creatinine and notice it was high and she had an abnormal UA. You diagnose her with acute kidney injury (AKI). Based on her current signs and symptoms and after reviewing some of her other lab values you decide that hemodialysis should be started now in the hospital. What type of blood stream access would be most appropriate in this patient?

Double lumen venous catheter Dont want to use the graphs becuase its acute.

Hemodialysis You are seeing one of your diabetic patients with chronic kidney disease (CKD) for a routine visit and review his routine labs. His creatinine was higher than usual, so you decide to calculate his GFR and found it to be 30. You decide to educate him about his options for renal replacement therapy, since he will probably need it within a year, and discuss bloodstream access options. What type of access would be PREFERRED in this patient?

Radial-Cephalic arteriovenous (AV) fistula

Hemodialysis You are rounding on one of your ESRD patients and decide to check her fistula. While doing so you notice that her arm is pale, cyanotic, cold, and radial pulses are diminished. What complication are you thinking is occurring?

Dialysis Access Steal Syndrome (DASS)

Hemodialysis When a patient is receiving hemodialysis, how often should they get blood work done to check their electrolyte levels, hemoglobin, BUN and creatinine?

Once a month

Hemodialysis | When assessing proper monitoring of dialysis and the patient’s response to dialysis the best analysis to look at is

Kt/V

Hemodialysis A patient you were performing dialysis on began to feel light headed, nauseated and trouble breathing. You take their blood pressure and you find they are hypotensive. What do you do?

Stop immediately and put patient in Trendelenburg position

Hemodialysis All of the following are absolute contraindications to Hemodialysis except a. No Vascular access b. Diabetes c. Unavailabilty of facilities d. Severe hemodynamic instability

b. Diabetes