Negative pressure systems

Which of the following statements is true regarding negative pressure ventilation

1.
Which of the following is the most common form of incomplete spinal cord injury?
1. A.
  Central cord syndrome
2. B.
  Cauda equina syndrome
3. C.
  Anterior spinal cord syndrome
4. D.
  Posterior spinal cord syndrome
5. E.
  Brown-Sequard lesion
2.
A 64-year-old male with a history of chronic alcohol abuse and congestive heart failure is currently recovering from excision of a large right shoulder lesion suspicious for melanoma. Postoperatively, he is experiencing bleeding and oozing from his surgical site that has persisted despite suture repair and direct pressure for an extended period of time. His labs are drawn, and are as follows: platelets 141 × 103/mL, INR 1.2, fibrinogen 90 mg/dL. Which of the following blood products should be administered next?
1. A.
  Fresh frozen plasma
2. B.
  Cryoprecipitate
3. C.
  Prothrombin complex concentrate
4. D.
  Recombinant activated factor VII
5. E.
  Aminocaproic acid
3.
A 75-year-old, 90 kg male with a history of peripheral vascular disease, coronary artery disease, and epilepsy following a recent cerebral infarction presents to the emergency department after having three witnessed seizures at home. He was intubated at the scene by the paramedics, and received 8 mg of intravenous lorazepam and 1 g of phenytoin. While you are evaluating him, he has another generalized tonic-clonic seizure, and the nurse asks if you would like to initiate a continuous propofol infusion. His blood pressure is 94/42 mmHg, and he is having numerous premature ventricular contractions [PVCs] on the electrocardiographic monitor. He has no history of platelet or liver dysfunction. Which of the following should be performed next?
1. A.
  Complete the phenytoin load to attain 20 mg/kg, then start propofol infusion
2. B.
  Complete the phenytoin load to attain 20 mg/kg only
3. C.
  Administer valproate, 30 mg/kg over 10 min, as well as midazolam 0.2 mg/kg
4. D.
  Start immediate midazolam infusion at 2 mg/kg/h
5. E.
  Give a 1 L normal saline bolus, and start a norepinephrine infusion to normalize blood pressure
4.
A 38-year-old male is brought to the emergency department after a motor vehicle accident. He is found to have significant ecchymoses on his chest and face, with multiple apparent rib fractures. He is in mild respiratory distress , with an oxygen saturation of 89% on room air, and hypotensive, with a systolic blood pressure of 88 mmHg. He has absent breath sounds on the right side. There is currently a delay in obtain a bedside portable chest x-ray. Which of the following should be performed next?
1. A.
  28-French chest tube placement
2. B.
  16-French chest tube placement
3. C.
  Obtain computed tomography [CT] of the chest
4. D.
  Administer 30 cc/kg crystalloid
5. E.
  Obtain urgent cardiothoracic surgery consult
5.
Stress ulcer prophylaxis is often undertaken to prevent clinically important upper gastrointestinal [GI] bleeding. Which of the following factors puts patients at highest risk for such bleeding episodes?
1. A.
  Respiratory failure
2. B.
  History of alcohol abuse
3. C.
  NPO status
4. D.
  Diverticulitis
5. E.
  All of the above
6.
In an intact heart, the Frank-Starling mechanism describes contractility increases in responses to:
1. A.
  Decreased preload
2. B.
  Increased afterload
3. C.
  Decreased left ventricular end-diastolic pressure
4. D.
  Increased left ventricular end-diastolic volume
5. E.
  Increased pulmonary vascular resistance
7.
A 68-year-old female with a history of hyperlipidemia, hypothyroidism, and gastric cancer on total parenteral nutrition is currently in the ICU following a small traumatic subdural hemorrhage . On hospital day 5, the patient begins to spike fevers that persist despite broad spectrum antibiotic coverage with vancomycin and piperacillin-tazobactam. She is otherwise hemodynamically stable. The lab calls you to notify you that multiple sets of blood cultures display budding yeast forms and pseudohyphae. Which of the following should be administered next?
1. A.
  Fluconazole
2. B.
  Posaconazole
3. C.
  Anidulafungin
4. D.
  Caspofungin
5. E.
  Amphotericin B
8.
A 56-year-old male with a past medical history of hypertension, hyperlipidemia, and morbid obesity is currently intubated in the ICU following a left middle cerebral artery infarct. The respiratory therapist alerts you the fact that the patient has become markedly dysynchronous with the ventilator, including breath holding episodes, breath stacking, and resisting ventilator-delivered breaths. A variety of pressure- and volume-regulated ventilator modes have been attempted without improvement, as well as boluses of both fentanyl and midazolam. The most recent arterial blood gas is as follows: pH 7.19, PaCO2 78 mmHg, PaO2 61 mmHg. The patient is now hypotensive to 91/66 mmHg with sinus tachycardia at 117 beats/min. A recent bedside chest x-ray shows no consolidation or pneumothorax . Which of the following should be performed next?
1. A.
  Prone the patient
2. B.
  Administer nitric oxide at 10 parts per million
3. C.
  Administer 10 mg of cisatracurium
4. D.
  Administer a mixture of 60% helium/40% oxygen
5. E.
  Administer a continuous infusion of phenobarbital
9.
Compared to lactulose for the treatment of hepatic encephalopathy , polyethylene glycol [PEG] has been shown to:
1. A.
  Decrease in-hospital mortality
2. B.
  More rapidly improve symptoms
3. C.
  Increase the rate of gastrointestinal complications
4. D.
  Increase the incidence of major electrolyte abnormalities
5. E.
  None of the above
10.
Which of the following neurologic insults is the least likely to cause central [non-infectious] fever in the ICU?
1. A.
  Intracranial neoplasm
2. B.
  Intraventricular hemorrhage
3. C.
  Normal pressure hydrocephalus
4. D.
  Subarachnoid hemorrhage
5. E.
  Traumatic brain injury
11.
A 57-year-old male with a history of epilepsy and medication noncompliance is admitted to a small community hospital after a brief tonic-clonic seizure. A non-contrast head CT on admission is normal. On the second hospital day, the patient begins to complain of severe substernal chest pressure, and an urgent bedside EKG shows evidence of an acute inferior myocardial infarction [MI]. The nearest percutaneous coronary intervention [PCI] capable center is approximately 150 min away by the fastest transport method available. Which of the following is the most appropriate next step in this patient’s care?
1. A.
  Arrange for transport to the closest PCI center with anticipated balloon time within 30 min of arrival
2. B.
  Prepare to administer fibrinolytic therapy
3. C.
  Consult cardiothoracic surgery for possible coronary artery bypass grafting [CABG]
4. D.
  Place the patient on a continuous nitroglycerine infusion and administer aspirin, clopidogrel, and heparin
5. E.
  Await serum cardiac biomarkers and repeat EKG in 1 h
12.
A 62-year-old male with unknown past medical history who recently immigrated from El Salvador is currently in the stroke unit after suffering from an acute left middle cerebral artery infarction . The patient is aphasic; his wife states that he been in his usual state of health lately, and denies any recent weakness, dizziness, chest pain, cough, shortness of breath, or fevers. On reviewing this patient’s belongings, the nurse discovers a bottle of isoniazid, as well as paperwork demonstrating a positive quantiferon gold test performed at a local clinic approximately 3 weeks ago. He does not appear to be on any other medications. A bedside portable chest x-ray is performed, which preliminarily appears normal. Which of the following should be performed next?
1. A.
  Move the patient to a negative pressure isolation room, continue isoniazid
2. B.
  Isolate the patient, continue isoniazid, add rifampin
3. C.
  Isolate the patient, continue isoniazid, add rifampin and pyrazinamide
4. D.
  Isolate the patient, continue isoniazid, add rifampin, pyrazinamide and ethambutol
5. E.
  None of the above
13.
A 56-year-old, 70 kg female patient in oliguric renal failure would be expected to have a daily urine output of:
1. A.
  No more than 50 mL
2. B.
  No more than 400 mL
3. C.
  No more than 800 mL
4. D.
  Less than 70 mL/h
5. E.
  Less than 35 mL/h
14.
A 37-year-old female with a history of epilepsy is admitted to the ICU with status epilepticus. She required several doses of lorazepam in the emergency department in addition to fosphenytoin, intubation, and a continuous propofol infusion. There was concern for aspiration in the prehospital setting. Approximately 3 days after being admitted to the hospital, her respiratory status has worsened; she is increasingly hypoxic, and her chest x-ray demonstrates diffuse bilateral interstitial infiltrates. The patient is afebrile with minimal secretions. Her most recent arterial blood gas is as follows: pH 7.21, PaO2 107 mmHg, PCO2 55 mmHg, 100% FiO2, and a positive end-expiratory pressure [PEEP] of 8 cm H2O. According to the Berlin criteria , how would you categorize this patient’s acute respiratory distress syndrome [ARDS]?
1. A.
  Acute lung injury [ALI]
2. B.
  Mild ARDS
3. C.
  Moderate ARDS
4. D.
  Severe ARDS
5. E.
  None of the above
15.
An 80-year-old male presents to the emergency department with multiple episodes of bright red blood per rectum. He is on aspirin and clopidogrel for a history of coronary artery disease and a previous transient ischemic attack. He underwent aortic graft surgery for repair of an abdominal aortic aneurysm 2 years ago. A complete blood count and coagulation profile are all within normal limits. His vital signs are as follows: blood pressure 102/58 mmHg, heart rate 98 beats/min, respiratory rate 18 breaths/min, oxygen saturation 98% on room air, and temperature 98.3 °F. Which of the following is the next best step in the care of this patient?
1. A.
  Transfuse platelets, fresh frozen plasma, and recombinant factor VIIa
2. B.
  Consult gastroenterology for emergent upper endoscopy
3. C.
  Consult gastroenterology for emergent colonoscopy
4. D.
  CT angiogram of the abdomen and pelvis
5. E.
  Expectant management with fluids and blood transfusions
16.
A thrombus in which of the following veins would not be considered a deep vein thrombosis [DVT]?
1. A.
  Popliteal vein
2. B.
  Soleal vein
3. C.
  Femoral vein
4. D.
  Gastrocnemius vein
5. E.
  Greater saphenous vein
17.
After partial resection of the pituitary stalk, secretion of which of the following hormones will be most affected?
1. A.
  Oxytocin
2. B.
  Adrenocorticotrophic hormone
3. C.
  Melanocyte-stimulating hormone
4. D.
  Thyroid-stimulating hormone
5. E.
  All will be equally affected
18.
A 58-year-old female with a history of hypertension, rheumatoid arthritis, metastatic ovarian cancer, and bilateral deep venous thrombosis status post recent inferior vena cava filter placement presents to the emergency department with right flank pain. She states the pain began approximately 1 h ago when bending down to pick something off the floor, and that it is constant and severe in nature. She denies dysuria or hematuria. Her vital signs are as follows: blood pressure 108/62 mmHg, heart rate 121 beats/min, respiratory rate 20 breaths/min, oxygen saturation 99% on room air, and temperature 99.6 °F. A CT scan of the abdomen is obtained [see Image 1]. Which of the following is the next best step in this patient’s management?
1. A.
  Administer vancomycin and cefepime, and draw two sets of blood cultures
2. B.
  Urgent vascular surgery consult
3. C.
  Immediately place the patient on her left side
4. D.
  Rapid sequence intubation with mechanical ventilation
5. E.
  Perform bedside diagnostic peritoneal lavage

Image 1

CT scan of the abdomen

Full size image

19.
Which of the following antiepileptic medications undergoes both hepatic metabolism and renal elimination ?
1. A.
  Phenytoin
2. B.
  Levetiracetam
3. C.
  Valproate
4. D.
  Pentobarbital
5. E.
  Lacosamide
20.
A 65-year-old male is brought to the emergency department by his family with several months of progressive behavioral changes and lethargy. On exam, he appears confused, and is minimally verbal. An MRI of the brain is performed, demonstrating a large homogenously enhancing lesion with a dural tail in the right frontal lobe with significant surrounding edema. The patient undergoes a right frontal craniotomy with gross total resection of the lesion. Surgical pathology is consistent with a World Health Organization [WHO] grade I lesion. All of the following are true regarding this patient’s pathology except:
1. A.
  This is the most common primary brain tumor in adults
2. B.
  This lesion is more common in men versus women [2:1 ratio]
3. C.
  This lesion often expresses progesterone and estrogen receptors
4. D.
  Risk factors for the development of this lesion include ionizing radiation exposure
5. E.
  Greater than 90% of these lesio ns are supratentorial
21.
A 69-year-old male with a history of hypertension, diabetes, and a recent left middle cerebral artery infarct is found to have a significant left internal carotid artery stenosis on further work-up. Which of the following represents the threshold amount of carotid stenosis to recommend this patient be evaluated for carotid endarterectomy ?
1. A.
  >10%
2. B.
  >40%
3. C.
  >70%
4. D.
  >90%
5. E.
  >99%
22.
“Massive” pulmonary embolism [PE] is best described as PE in the presence of:
1. A.
  Any single mean arterial pressure [MAP] less than 65 mmHg
2. B.
  Heart rate greater than 100 beats/min regardless of blood pressure
3. C.
  Systolic pressure less than 90 mmHg for greater than 15 min
4. D.
  Abnormal bowing of the interventricular septum on bedside echocardiography
5. E.
  Any single elevated serum troponin
23.
A 51-year-old male has been admitted to the ICU for a traumatic brain injury . The patient received a kidney transplant 3 years ago, and is on immunosuppression with mycophenolate mofetil and cyclosporine. On hospital day 3, the patient suffers a generalized tonic-clonic seizure which abates after administration of lorazepam, and you are now considering future seizure prophylaxis. Which of the following medications is not expected to interfere with this patient’s serum cyclosporine levels?
1. A.
  Fosphenytoin
2. B.
  Carbamazepine
3. C.
  Phenobarbital
4. D.
  Levetiracetam
5. E.
  All of the above
24.
According to the three column theory of spinal cord stability , the spinal cord can be divided into three segments that each contribute to cord stability in a different manner. All of the following are true regarding the three column theory except:
1. A.
  The anterior column consists of the anterior vertebral body, anterior annulus fibrosus, and anterior longitudinal ligament
2. B.
  The middle column includes the posterior longitudinal ligament, posterior annulus fibrosus, and posterior wall of the vertebral body
3. C.
  The posterior column comprises the pedicles, the facet joints, and the supraspinous ligaments
4. D.
  All three columns must be disrupted for the spine to be considered unstable
5. E.
  Spinal trauma is classified as minor or major depending on the ability of the injury to cause instability
25.
A 22-year-old female was admitted to the psychiatry service after presenting with 10 days of bizarre and disinhibited behavior, as well as auditory and visual hallucinations. While on the psychiatry service, she had a prolonged generalized tonic-clonic seizure requiring intubation and transfer to the ICU. Lumbar puncture was performed, and N-Methyl-D-aspartate [NMDA] receptor antibodies were positive in the spinal fluid. All of the following are accepted first-line treatments for this patient except:
1. A.
  Intravenous immunoglobulin [IVIG]
2. B.
  Tumor resection, if applicable
3. C.
  Corticosteroids
4. D.
  Plasma exchange
5. E.
  Rituximab
26.
A 54-year-old male is currently recovering from transphenoidal resection of a pituitary mass. A serum cortisol level is drawn the next morning. A value below which cutoff is associated with a significant risk of long-term hypothalamic-pituitary-adrenal [HPA] dysfunction ?
1. A.
  1 μg/dL
2. B.
  15 μg/dL
3. C.
  75 μg/dL
4. D.
  300 μg/dL
5. E.
  600 μg/dL
27.
A 71-year-old female in the ICU with an acute-on-chronic subdural hemorrhage develops acute kidney injury, and requires hemodialysis. Upon consultation with the nephrology service, the decision is made to initiate continuous renal replacement therapy [CRRT]. Which of the following is an advantage of CRRT compared to intermittent hemodialysis?
1. A.
  CRRT has a lower overall cost of disposables
2. B.
  CRRT is easier to implement without the use of anticoagulation
3. C.
  Rapid adjustments can be made to accommodate evolving patient needs
4. D.
  CRRT is more widely available
5. E.
  Nursing staff may be more familiar with the CRRT modality
28.
An irregular group of breaths followed by apneic periods of variable duration in a patient with a lesion in the pneumotaxic center of the upper medulla would be classified as which of the following?
1. A.
  Cheyne-Stokes respiration
2. B.
  Central neurogenic hyperventilation
3. C.
  Cluster breathing
4. D.
  Kussmaul respirations
5. E.
  Apneustic breathing
29.
Which of the following echocardiography findings is most consistent with Takotsubo cardiomyopathy ?
1. A.
  Apical ballooning
2. B.
  Bowing of the ventricular septum into the left ventricle
3. C.
  Hypoechoic area surrounding the pericardium
4. D.
  Enlargement of the left ventricular outflow tract
5. E.
  Hyperdynamic left ventricle
30.
A 27-year-old female with no prior medical history at 37 weeks gestation presents with hypertension and a dull frontal headache, and is admitted for the management of preeclampsia . A continuous magnesium infusion is started. Which of the following additional medications would be contraindicated in the treatment of this patient’s blood pressure?
1. A.
  Labetalol
2. B.
  Hydralazine
3. C.
  Hydrochlorothiazide
4. D.
  Captopril
5. E.
  Nicardipine
31.
A 28-year-old 50 kg female is currently hospitalized with a myasthenic crisis . While you are evaluating her, you note her to be mildly tachypneic with some accessory muscle use. Her oxygen saturation is 97% on room air. You obtain the following respiratory parameters: vital capacity 890 mL, peak inspiratory pressure 44 cm H2O, peak expiratory pressure 61 cm H2O. Which of the following is the next best step in management?
1. A.
  Intubate the patient
2. B.
  Place the patient on noninvasive positive pressure ventilation
3. C.
  Place the patient on 4 L supplemental oxygen
4. D.
  Check the patient’s rapid shallow breathing index
5. E.
  Check the patient’s carbon dioxide level
32.
A 62-year-old male with a history of cirrhosis, ascites, and prior spontaneous bacterial peritonitis is admitted to the ICU with worsening encephalopathy. Despite home therapy with rifaximin and lactulose, his mental status has been declining steadily, and he requires intubation for airway protection. A non-contrast head CT demonstrates mild diffuse cerebral edema. All of the following are reasonable strategies to reduce this patient’s cerebral edema except:
1. A.
  Elevate the head of the bed 30°
2. B.
  Intravenous mannitol
3. C.
  Intravenous hypertonic saline
4. D.
  Intravenous dexamethasone
5. E.
  Induced hypothermia
33.
Which of the following would lead you to incorrectly conclude that a patient with no prior medical history, based on their hemoglobin A1c , was actually a diabetic?
1. A.
  Surrepitious alcohol abuse
2. B.
  Severely elevated triglycerides
3. C.
  Recent blood transfusion
4. D.
  Erythropoietin administration
5. E.
  Hemolytic anemia
34.
A 77-year-old male from the nursing home has been admitted to the ICU for lethargy. The patient weighted 58 kg on admission, and the serum sodium was noted to be 177 mEq/L. About how much would you expect 1 L of 0.225% sodium chloride to reduce the serum sodium?
1. A.
  1.6 mEq/L
2. B.
  4.6 mEq/L
3. C.
  8.6 mEq/L
4. D.
  16.6 mEq/L
5. E.
  32.6 mEq/L
35.
A 52-year-female is admitted to the ICU after an anterior cervical discectomy and fusion surgery. On day 5 of her hospital stay, the patient was found to have a proximal deep venous thrombosis [DVT] in her left leg. Treatment was initiated with a continuous heparin infusion with target aPTT 1.5–2 times baseline. Her platelet count this morning was 130 × 103/μL; it was 280 × 103/μL on admission. Her 4T score was 6, and a heparin PF4 immunoassay is pending. What is the next best step in this patient’s management?
1. A.
  Discontinue unfractionated heparin infusion, initiate argatroban infusion
2. B.
  Discontinue unfractionated heparin infusion, initiate warfarin therapy
3. C.
  Discontinue unfractionated heparin infusion, initiate low-molecular weight heparin therapy
4. D.
  Continue unfractionated heparin infusion while awaiting PF4 immunoassay result
5. E.
  Continue unfractionated heparin infusion, initiate argatroban infusion
36.
Which of the following vasculitidies may present with central nervous system involvement?
1. A.
  Wegner’s granulomatosis
2. B.
  Polyarteritis nodosa
3. C.
  Churg-Strauss syndrome
4. D.
  Behcet’s syndrome
5. E.
  All of the above
37.
Which of the following describes correctly the radiologic findings in a developmental venous anomaly of the brain ?
1. A.
  MRI shows medullary veins converging on a dilated transcerebral vein with a characteristic “sunburst” pattern on enhanced T1 weighted images
2. B.
  Cerebral angiography shows a faint blush with an associated venous channel in the late arterial or early capillary phases
3. C.
  Cerebral angiography is normal, as these lesions are “angiographically occult” with minimal blood flow
4. D.
  MRI shows a “popcorn” pattern of variable image intensities in T1 and T2-weighted images consistent with evolving blood products
5. E.
  CT scan without contrast shows flow voids demonstrating enlarged tangled vessels with curvilinear or speckled calcification
38.
Which of the following definitions accurately describes renal “loss” based on the RIFLE [Risk, Injury, Failure, Loss, End-stage] classification scheme for acute kidney injury?
1. A.
  Tripling of serum creatinine
2. B.
  Serum creatinine ≥4 mg/dL
3. C.
  Urine output 4 weeks
4. E.
  Urine output 90%, and his CXR now shows bilateral alveolar opacities. His plateau pressure is 30. He is on piperacillin-tazobactam for antibiotic coverage, with a negative endotracheal aspirate gram stain. Which of the following should be performed next?
  1. A.
    Prone the patient
  2. B.
    Decrease the tidal volume to 500 and increase PEEP to 8
  3. C.
    Add vancomycin and azithromycin
  4. D.
    Start inhaled nitric oxide therapy
  5. E.
    Place the patient on extracorporeal membrane oxygenation [ECMO]
5. 41.
  Which of the following is the definition of Mallory-Weiss syndrome ?
  1. A.
    Linear mucosal lacerations of the esophagus at the gastroesophageal junction
  2. B.
    Full thickness tears of the esophagus due to retching at the gastroesophageal junction
  3. C.
    Esophageal variceal bleeding at the gastroesophageal junction
  4. D.
    Esophageal metaplasia at the gastroesophageal junction due to chronic exposure to acid reflux
  5. E.
    Peptic ulcer disease resulting in gastrointestinal bleeding
6. 42.
  A 19-year-old male with no significant past medical history presents to the emergency department with fever, confusion, and lethargy. The parents report that he had been complaining of headaches and nausea for several days before decompensating prior to arriving at the hospital. They also report that he has spent the last 6 weeks at an outdoor summer camp, and had not been ill recently otherwise. A lumbar puncture is performed, and while awaiting the results, the patient is started on ceftriaxone, vancomycin and acyclovir. Several hours later, the laboratory calls you urgently to report the presence of motile amebae in the cerebrospinal fluid [CSF] sample that was sent. Which of the following should be administered next?
  1. A.
    Mebendazole
  2. B.
    Miltefosine
  3. C.
    Doripenem
  4. D.
    Fidamoxicin
  5. E.
    Rifampin
7. 43.
  A 71-year-old male with a history of peripheral vascular disease and hypertension is currently hospitalized while recovering from a transient ischemic attack when he begins to complain of several hours of severe generalized abdominal pain. Surprisingly, his abdominal exam is relatively benign considering how uncomfortable he appears. His lab work is notable for a white blood cell count of 26.6 × 109/L with 17% bands, along with a lactate of 11.6 mmol/L. Which of the following is the gold standard for the diagnosis of the most likely etiology?
  1. A.
    Duplex ultrasound
  2. B.
    Flexible endoscopy and tissue biopsy
  3. C.
    Contrast-enhanced MRI
  4. D.
    CT arteriography
  5. E.
    Plain abdominal radiography
8. 44.
  Which of the following is true regarding the use of nimodipine in critically ill patients?
  1. A.
    It is widely used for antihypertensive purposes
  2. B.
    It has been proven to be equally effective versus magnesium in the treatment of preeclampsia
  3. C.
    It may be used to attempt to preserve cochlear nerve function following schwannoma surgery
  4. D.
    It is used as a continuous intravenous infusion for the prevention of delayed cerebral ischemia [DCI]
  5. E.
    None of the above
9. 45.
  A 21-year-old man presents to the emergency department with 1 day of abdominal pain, nausea and vomiting. His past medical history was unremarkable up until a few months ago, when he started to develop transient weakness in his extremities, and has been hospitalized twice since then with generalized tonic-clonic seizures. He has one sibling, who has also experienced similar episodes. His vital signs are as follows: temperature 36.6 °C, blood pressure 136/66 mmHg, pulse rate 96 beats/min, respiratory rate 14 breaths/minute. His abdomen is distended on exam, and a CT scan of the abdomen and pelvis demonstrates distended loops of bowel without any overt mechanical obstruction. Blood work demonstrates a normal leukocyte count with a markedly elevated serum lactate. All of the following are true about the patient’s condition except:
  1. A.
    This patient would be unlikely to pass this condition on to his children
  2. B.
    The majority of cases are caused by mutations in the MT-TL1 gene
  3. C.
    Half of all cases appear to be due to spontaneous mutations, without prior family history
  4. D.
    The patient’s condition is uniformly progressive and fatal
  5. E.
    The disease is frequently misdiagnosed, due to both rarity and heterogeneous presentations
10. 46.
  A 50-year-old male with a 100 pack-year smoking history presents to the emergency department with shortness of breath. He was diagnosed with primary lung adenocarcinoma 1 week ago. Computed tomography [CT] imaging of the chest shows extrinsic compression of the trachea by a left lung mass. The patient is able to speak in full sentences, though becomes short of breath while doing so. He is afebrile, with the following vital signs: heart rate 99 beats/min, blood pressure 140/90 mmHg, respiratory rate 20 breaths/min, and oxygen saturation of 97% on 2 L nasal cannula. On exam, there is intermittent inspiratory wheezing auscultated on the neck with otherwise clear lung fields. What is the best immediate treatment to alleviate the patient’s symptoms?
  1. A.
    Racemic epinephrine
  2. B.
    Helium-oxygen mixture
  3. C.
    Intravenous corticosteroids
  4. D.
    Surgical intervention of the lung mass
  5. E.
    Inhaled bronchodilators
11. 47.
  A 64-year-old male with a history of congestive heart failure is currently admitted to the hospital for work-up of a suspected transient ischemic attack. He is also complaining of urinary frequency and dysuria, and his urinalysis indicates the presence of a urinary tract infection on admission. Approximately 24 h later, urine cultures indicate the presence of Escherichia coli with the following minimum inhibitory concentration [MIC] susceptibilities [see Table 1 below]. According to the susceptibility chart alone, which of the following antibiotics is most likely to result in eradication of this patient’s infection?
Table 1 MIC susceptibilities
Full size table
1. A.
  Ceftriaxone
2. B.
  Cefepime
3. C.
  Cefo xitin
4. D.
  Piperacillin/tazobactam
5. E.
  None of the above
1. 48.
  An excess of all of the following may result in severe metabolic alkalosis except:
  1. A.
    Vomiting
  2. B.
    Nasogastric suctioning
  3. C.
    Diuretic use
  4. D.
    Mineralocorticoid administration
  5. E.
    Blood loss
2. 49.
  In the setting of traumatic brain injury [TBI], pretreatment with which of the following agents has been proven prevent elevation of intracranial pressure [ICP] associated with endotracheal intubation ?
  1. A.
    Lidocaine
  2. B.
    Fentanyl
  3. C.
    Succinylcholine
  4. D.
    Etomidate
  5. E.
    None of the above
3. 50.
  A 61-year-old male is currently admitted to the ICU following 18 months of progressive gait dysfunction, memory loss, and intermittent episodes of urinary incontinence. A non-contrast head CT performed on admission demonstrates moderate hydrocephalus, and a lumbar drain trial is being performed. 5 cc/h of spinal fluid is being drained. 48 h after lumbar drain insertion, the patient is being evaluated by the physical therapy and neurocognitive teams, who report no significant change from their initial evaluations on admission. Which of the following should be performed next?
  1. A.
    Continue lumbar drainage at current rate for an additional 72 h, reassess
  2. B.
    Increase drainage rate to 10 cc/h, continue for an additional 48 h, reassess
  3. C.
    Discontinue lumbar drain, schedule the patient for ventriculoperitoneal [VP] shunt placement, reassess the patient 3 months post-operatively
  4. D.
    Discontinue lumbar drain, as the patient is not a candidate for a VP shunt
  5. E.
    Discontinue lumbar drain and repeat lumbar drain trial in 3 months
4. 51.
  All of the following brain metastases are at a high risk for intracranial hemorrhage except:
  1. A.
    Melanoma
  2. B.
    Renal cell carcinoma
  3. C.
    Choriocarcinoma
  4. D.
    Thyroid carcinoma
  5. E.
    Breast carcinoma
5. 52.
  A 61-year-old female with a history of heparin-induced thrombocytopenia [HIT], polycythemia vera, and multiple prior thrombotic events including bilateral pulmonary emboli, is currently being evaluated for 4 weeks of chronic daily headaches. She is currently on daily aspirin and rivaroxaban for maintenance therapy. Her hemoglobin is 16.1 g/dL and her hematocrit is 48%. A CT venogram of the head is performed, demonstrating an acute superior sagittal sinus thrombus . Which of the following should be administered at this time?
  1. A.
    Fondaparinux
  2. B.
    Low molecular weight heparin
  3. C.
    Unfractionated heparin infusion
  4. D.
    Apixaban
  5. E.
    Eptifibatide
6. 53.
  During endotracheal intubation, in the absence of a view of the vocal cords, optimal bougie technique involves:
  1. A.
    Using the upturned end to put pressure on the valecula and lift the epiglottis
  2. B.
    Inserting the bougie at the corner of the mouth and sweeping the tongue out of the way
  3. C.
    Blindly inserting the bougie into the mouth advancing until resistance is felt
  4. D.
    Sliding the bougie under the visualized epiglottis and feeling for the tracheal rings
  5. E.
    Advancing the bougie under ultrasound guidance with the probe on the trachea
7. 54.
  A 44-year-old female with a history of metastatic breast cancer is currently being treated in the ICU for leptomeningeal disease , and her prognosis is grave. The patient asks that you do not discuss any aspect of her care with her family, as she does not believe they are emotionally equipped to handle the news, and you promise to uphold her wish. Your promise aligns with which of the following ethical principles?
  1. A.
    Beneficence
  2. B.
    Non-maleficence
  3. C.
    Autonomy
  4. D.
    Fidelity
  5. E.
    Justice
8. 55.
  Which of the following has been associated with a decreased risk of ventriculitis in patients with indwelling ventriculostomy catheters?
  1. A.
    Cerebrospinal fluid [CSF] surveillance daily
  2. B.
    CSF surveillance every third day
  3. C.
    Catheter exchange every 5 days
  4. D.
    Silver-impregnated catheters
  5. E.
    Insertion site antibiotic wafers
9. 56.
  A 62-year-old male with a history of myasthenia gravis is currently being evaluated for aspiration pneumonia in the setting of a myasthenic crisis, with evidence of a developing empyema on chest x-ray. Which of the following would be appropriate empiric antibiotic coverage in this setting?
  1. A.
    Cefepime and azithromycin
  2. B.
    Levofloxacin
  3. C.
    Piperacillin-tazobactam and ciprofloxacin
  4. D.
    Clindamycin and moxifloxacin
  5. E.
    Ampicillin-sulbactam
10. 57.
  A 23-year-old female presents to the emergency department with headache, lethargy and confusion. A non-contrast head CT demonstrates diffuse subarachnoid hemorrhage, and the patient subsequently undergoes clipping of an anterior choroidal artery aneurysm. Despite treatment, the patient continues to decline in the ICU, and her neurologic status is poor. The family decides [based on prior discussion with the patient] to withdraw life-sustaining treatment and undergo donation after cardiac death [DCD]. You will be accompanying the patient to the operating room. Which of the following medications would not be reasonable to bring with you?
  1. A.
    Glycopyrrolate
  2. B.
    Cisatracurium
  3. C.
    Morphine
  4. D.
    Lorazepam
  5. E.
    It is inappropriate to administer any medications that may hasten death in patients undergoing DCD
11. 58.
  Which of the following cranial nerve [CN] reflex sequences is correct?
  1. A.
    Oculocephalic reflex : sensory input from CN VIII, motor output from CN III/IV/VI
  2. B.
    Corneal reflex: sensory input from CN VII, motor output from CN V
  3. C.
    Gag reflex: sensory input from CN X, motor output from CN IX
  4. D.
    Pupillary light reflex: sensory input from CN III, motor output from CN II
  5. E.
    All of the above are correct
12. 59.
  A 35-year-old male with severe traumatic brain injury [TBI] and isolated traumatic subarachnoid hemorrhage experiences a sudden neurologic deterioration on post-injury day 2. An emergent non-contrast head CT demonstrates no significant changes from admission imaging. The patient is afebrile and normotensive; standard mechanical ventilation with volume assist control is being performed at 6 mL/kg, a rate of 12 breaths/min, and a positive end-expiratory pressure [PEEP] of 5 cm H2O. A recent arterial blood gas shows a PaO2 of 120 mmHg and PaCO2 of 40 mmHg with a pH of 7.37. Continuous EEG shows no epileptiform activity. Which of the following is the most likely cause of this patient’s deterioration?
  1. A.
    Ventilator associated pneumonia
  2. B.
    Myocardial dysfunction from the subarachnoid hemorrhage
  3. C.
    Hypercapnea-induced increase in cerebral blood volume
  4. D.
    Severe metabolic acidosis with respiratory compensation
  5. E.
    Cerebral vasospasm
13. 60.
  Which of the following is the most common hereditary stroke disorder?
  1. A.
    Hereditary hemorrhagic telangiectasia [HHT]
  2. B.
    Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes [MELAS]
  3. C.
    Cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy [CADASIL]
  4. D.
    Giant cell arteritis [GCA]
  5. E.
    Moyamoya disease
14. 61.
  Which of the following is true regarding amyotrophic lateral sclerosis [ALS]?
  1. A.
    The average age of onset is in the sixth through seventh decades of life
  2. B.
    The average life expectancy from time of diagnosis is 10 years
  3. C.
    Riluzole increases life expectancy by 3–5 years, on average
  4. D.
    Approximately 50% of cases are hereditary
  5. E.
    Positive pressure ventilation plays no role in disease management
15. 62.
  Which of the following patientsintracranial pressure [ICP] waveform with intracerebral hemorrhage [ICH] is at highest risk for the development of late/long-term seizure activity?
  1. A.
    An 83-year-old male with a noncortical 8 mL hemorrhage
  2. B.
    A 44-year-old female with a cortical 12 mL hemorrhage
  3. C.
    A 68-year-old male with a cortical 21 mL hemorrhage
  4. D.
    A 50-year-old female with a noncortical 5 mL hemorrhage who seizes twice within the first 3 days of ictus
  5. E.
    All of the above are equally likely
16. 63.
  Which of the following has been prospectively demonstrated regarding very early [10 days] tracheostomy for patients unlikely to be weaned from mechanical ventilation?
  1. A.
    Decreased 30-day mortality
  2. B.
    Decreased 2-year mortality
  3. C.
    Decreased ICU length-of-stay
  4. D.
    Decreased rate of tracheostomy-related complications
  5. E.
    None of the above
17. 64.
  In the intracranial pressure [ICP] waveform shown [see Image 2], which of the following is represented by the black arrow?
  1. A.
    Arterial pulsation
  2. B.
    Intracranial compliance
  3. C.
    Aortic valve closure
  4. D.
    Pulmonic valve closure
  5. E.
    None of the above
Image 2
ICP waveform tracing
Full size image
1. 65.
  Which of the following patients with cerebellar hemorrhage has the best chances of a good functional outcome ?
  1. A.
    A patient with a GCS of 9, no ventricular compression, moderate intraventricular extension but CSF visible in the fourth ventricle
  2. B.
    A patient with a GCS of 13, a totally compressed fourth ventricle, and no intraventricular extension
  3. C.
    A patient with a GCS of 11 and a noncompressed fourth ventricle completely casted with hematoma
  4. D.
    A patient with a GCS of 12, a partially compressed fourth ventricle, and no intraventricular extension
  5. E.
    A patient with a GCS of 7 and a compressed fourth ventricle that is completely casted
2. 66.
  What is the maximum amount of time that hyperventilation-induced hypocarbia may be expected to last before the PCO2 begins to normalize?
  1. A.
    2 h
  2. B.
    4 h
  3. C.
    6 h
  4. D.
    8 h
  5. E.
    24 h
3. 67.
  A 52-year-old female presents to the emergency department with a severe, sudden onset headache concerning for subarachnoid hemorrhage that started 3 days ago. A non-contrast head CT is unremarkable. Which of the following MRI sequences may be most useful in this scenario?
  1. A.
    T1 weighted images
  2. B.
    T2 weighted images
  3. C.
    Gradient echo
  4. D.
    Apparent diffusion coefficient mapping
  5. E.
    Diffusion-weighted imaging
4. 68.
  A 29-year-old, 84 kg male is in the ICU recovering from Guillain-Barre syndrome . He is currently intubated and undergoing a spontaneous breathing trial at a continuous positive airway pressure of 5 cm H2O with 30% inspired oxygen. His respirations are currently 20 breaths/min with an average tidal volume of 500 mL. He has not had any apneic episodes. What is this patient’s rapid shallow breathing index?
  1. A.
    40
  2. B.
    80
  3. C.
    105
  4. D.
    0.04
  5. E.
    0.08
5. 69.
  All of the following are true regarding Herpes simplex encephalitis [HSE] except:
  1. A.
    The majority of asymptomatic adults are seropositive for Herpex simplex virus
  2. B.
    There are no seasonal variations of disease incidence
  3. C.
    Generalized seizure activity is common
  4. D.
    It is the most common sporadic viral encephalitis in the Western world
  5. E.
    Patients who are immunocompromised are more prone to developing HSE
6. 70.
  A 50-year-old female presents to the emergency department after a fall at home. On further questioning, she endorses several months of worsening back pain and progressive paraplegia, as well as the recent onset of urinary retention. An MRI of the spine reveals an enhancing intradural extramedullary spinal cord lesion extending from the T1-T4 spinal cord level with spinal cord compression. Emergency surgical resection is performed. Which of the following is the least likely pathology of this patient’s lesion?
  1. A.
    Paraganglioma
  2. B.
    Ependymoma
  3. C.
    Schwannoma
  4. D.
    Neurofibroma
  5. E.
    Meningioma
7. 71.
  A 70 year-old female is intubated 5 days after hospital admission for hypoxemic respiratory failure after a witnessed aspiration event. Prior to admission, the patient lived in a nursing home, and recently was treated for left leg cellulitis with a short course of intravenous antibiotics. Her medications include metoprolol, metformin, glyburide, atorvastatin, and baby aspirin. Three days after intubation, the patient is noted to have a temperature of 102.5 °F, a blood pressure of 70/50 mmHg, a white blood cell count of 20.0 × 109/L, with purulent secretions suctioned from the endotracheal tube. You decide to initiate antibiotic therapy. Which of the following is the best antibiotic regimen to initiate at this time?
  1. A.
    Ceftriaxone and ertapenem
  2. B.
    Imipenem, levofloxacin and vancomycin
  3. C.
    Meropenem, cefepime, and piperacillin-tazobactam
  4. D.
    Cefepime and daptomycin
  5. E.
    Ceftriaxone and azithromycin
8. 72.
  In patients suffering from severe traumatic brain injury [TBI] with cerebral contusions, the addition of which of the following medications has been shown to cause harm in human studies?
  1. A.
    Progesterone
  2. B.
    Haloperidol
  3. C.
    Corticosteroids
  4. D.
    Furosemide
  5. E.
    Mannitol
9. 73.
  Assuming the peripheral white blood cell [WBC] count is normal, approximately how many WBCs should be expected from a suspected traumatic spinal tap in which 15,000 red blood cells [RBCs] are seen?
  1. A.
    20–30
  2. B.
    100–150
  3. C.
    200–300
  4. D.
    500–750
  5. E.
    1000–1500
10. 74.
  A 79-year-old male with a history of hypertension and hyperlipidemia presents to the emergency department with acute atraumatic bilateral lower extremity weakness over the past hour. He denies any recent illness and denies any prior difficulty with ambulation or urination. He is also complaining of severe low back pain. On exam, he has profound symmetric weakness of the bilateral lower extremities with intact vibratory sense and proprioception. He has not undergone any recent surgical procedures. Which of the following is the most likely cause of this patient’s pathology?
  1. A.
    Anterior spinal artery infarction
  2. B.
    Guillain-Barré syndrome
  3. C.
    Transverse myelitis
  4. D.
    Spinal epidural abscess
  5. E.
    Spinal cord neoplasm with mass effect on the cord
11. 75.
  Which of the following are accepted indications for veno-venous extracorporeal membrane oxygenation [ECMO] lung support in adults with hypoxemic respiratory failure?
  1. A.
    PaO2/FiO2 0.9 and Murray Score of 1
  2. B.
    PaO2/FiO2 200 but 100 but 20 mL/kg, peak inspiratory pressure >30 cm H2O, peak expiratory pressure >40 cm H2O]. While this is still a good guideline for patients with GBS, there is evidence to suggest that myasthenic patients who do not have hypercarbia may be trialed on noninvasive positive pressure ventilation first, and that this may be associated with improved in-hospital outcomes [15]. Therefore, it makes sense to check this patient’s CO2 before deciding whether to intubate her, particularly with normal oxygenation and only mild respiratory distress. The rapid shallow breathing index is one parameter used to determine extubation readiness in patients who are already intubated.
  3. 32.
    The correct answer is D. Simple head elevation is an easy maneuver that promotes venous drainage in order to reduce intracranial pressure [ICP]. Mannitol and hypertonic saline also have established roles in treating cerebral edema and reducing ICP. Hypothermia, while controversial, has been shown to reduce levels of inflammatory mediators and subsequently reduce ICP. Use of hypothermia may be limited by coagulopathy and cardiac arrhythmias. Dexamethasone has no proven benefit in treating ICP in this setting and may predispose to infectious and metabolic complications [16].
  4. 33.
    The correct answer is A. One must be careful when using a hemoglobin A1c alone to diagnose diabetes. Several factors may cause an elevated A1c, including alcohol abuse [interferes with assay], chronic kidney disease [decreased erythropoiesis], and prior splenectomy [increased red cell lifespan], in which case one might erroneously conclude a patient is diabetic. On the other hand, the A1c may be low in patients with severe hypertriglyceridemia [interferes with assay], recent blood transfusion, prior erythropoietin administration, or hemolytic anemia [decreased red cell lifespan], in which case one might erroneously conclude a patient is not a diabetic.
  5. 34.
    The correct answer is B. To calculate the estimate change in serum sodium from the infusion of 1 L of any replacement fluid, the following formula can be used: change in serum Na = [replacement fluid Na − serum Na]/[total body water + 1]. Total body water [TBW] usually accounts for 60% of lean body weight for men and 50% in women. The proportion of TBW decreases with age, becoming 50% in elderly men and 45% in elderly women. Therefore, in this patient, total body water can be calculated as 50% of his weight [58 kg] which is equal to 29 L. A liter of 0.225% sodium chloride solution contains 1/4 of the amount of sodium in normal saline [i.e. 154/4 = 38.5 mmol/L]. The change in serum sodium as calculated from the formula will be [38.5 − 177]/[29 + 1], which equals −4.6 mEq/L.
  6. 35.
    The correct answer is A. HIT is a serious medical condition, and needs to be treated as soon as possible once diagnosed. Although laboratory tests have not yet confirmed the presence of HIT, the suspicion of HIT is high based on her 4T score. The patient should therefore be initiated on a direct thrombin inhibitor [such as argatroban] for treatment of suspected HIT while awaiting further testing. Fondaparinux is an acceptable alternative. Warfarin therapy can be initiated after 5 days of treatment, with overlap therapy, and when platelet count is above 150 × 103/μL. Switching to enoxaparin therapy is not an option because of cross-reactivity between heparin antibodies and low-molecular weight heparin.
  7. 36.
    The correct answer is E. The vasculitidies are a broad class of diseases that involve the inflammatory destruction of both arterial and venous blood vessels. All of the disease listed may present with central nervous system involvement.
  8. 37.
    The correct answer is A. Developmental venous anomalies are usually not demonstrated in non-enhanced CT scans, but the enlarged veins are identified after administration of contrast. MRI shows medullary veins converging on the dilated transcerebral vein and a characteristic “sunburst” pattern is seen on enhanced T1 weighted images. Cerebral angiographic findings are pathognomonic, with a “caput medusa” appearance of the radially arranged small medullary veins found during the late capillary or venous phase. Capillary telangiectasias appear as low signal intensity “black dots” on T1 and T2 weighted imaging, but are not diagnostic of these lesions. With cerebral angiography, telangiectasias can be identified in the late arterial/early capillary phase as a faint blush with an associated venous channel. Cavernous malformations have minimal blood flow and thus may not be seen on angiography, often referred to as being “angiographically occult.” Characteristic findings on T1 and T2-weighted images include a “popcorn” pattern of variable image intensities consistent with evolving blood products. A dark hemosiderin ring on T2 or gradient echo sequences at the periphery of the lesion is suggestive of remote hemorrhage.
  9. 38.
    The correct answer is D. The RIFLE classification scheme for acute kidney injury includes separate criteria for creatinine and urine output. Renal failure is defined as an increase in serum creatinine threefold, a GFR decrease by 75% or serum creatinine ≥4 mg/dL; a urine output 4 weeks.
  10. 39.
    The correct answer is D. MVMS is an acute, rapidly progressive form of MS that usually presents in younger patients, and may be fatal within months from the time of diagnosis. When MVMS presents as a large, single brain lesion, it may be indistinguishable from a neoplastic process on conventional imaging. In these cases, craniotomy and biopsy is required to make the definitive diagnosis.
  11. 40.
    The correct answer is B. This patient is likely developing ARDS secondary to an acute aspiration related to his SAH. He would benefit most from low tidal volume ventilation, one of the few intervention proven to decrease mortality in ARDS. His ideal body weight is 80 kg; decreasing his tidal volume to 6 cc/kg yields a tidal volume of 500. Additionally, his PEEP needs to be increased in an attempt to decrease his FiO2 requirements. If the patient does not improve with these initial measures, PEEP could be further increased and proning could be considered.
  12. 41.
    The correct answer is A. Mallory-Weiss tears are mucosal or submucosal lacerations that occur at the gastroesophageal junction, and usually extend distally into a hiatal hernia. Patients generally present with initial nonbloody vomiting followed by hematemesis. Although approximately 50% of patients hospitalized with upper GI bleeding from a Mallory-Weiss tear receive blood transfusions, the hematemesis is often mild and self-limited in patients who do not seek medical care. Occasionally, patients with continued active bleeding require endoscopic therapy and repair [17].
  13. 42.
    The correct answer is B. Primary amebic meningoencephalitis by Naegleria fowlerii occurs after the parasite gains access to the central nervous system via the cribiform plate, typically after an individual goes swimming in a freshwater lake. Several days of a vague prodrome [including headaches, nausea and vomiting] eventually lead to confusion, coma, and within 1–2 weeks, death for the majority of individuals. Miltefosine, an antiparasitic agent originally approved for the treatment of leishmaniasis, is currently stockpiled by the Center for Disease Control [CDC] for the emergent treatment of suspected or confirmed Naegleria meningoencephalitis .
  14. 43.
    The correct answer is B. This vasculopathic patient presents with severe abdominal pain out of proportion to exam and a significantly elevated serum lactate, which is the classic description of ischemic colitis. Although CT arteriography is highly sensitive and often the first investigation performed in the emergency department, flexible endoscopy with tissue biopsies remains the diagnostic gold standard [18].
  15. 44.
    The correct answer is C. Nimodipine, initially developed as an antihypertensive, is rarely used for this purpose. Instead, it is primarily used to prevent DCI in the setting of subarachnoid hemorrhage, administered enterally every 4 h. It was previously studied in the setting of preeclampsia, but proved inferior to magnesium [19]. It has also been used to preserve facial and cochlear nerve function following schwannoma surgery, with mixed results in several studies [20].
  16. 45.
    The correct answer is C. Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes [MELAS] is a rare mitochondrial disorder characterized by headaches, muscle weakness, seizures, vomiting, and altered mental status. The majority of cases are caused by mutations in the MT-TL1 gene, and there is usually a family history of similar symptoms [though rare spontaneous cases are reported in the literature]. Like other mitochondrial cytopathies, the inheritance pattern is maternal. Unfortunately, there is no cure, and the disease is both progressive and fatal. Because MELAS is so rare, and the clinical presentation is so varied, it is often misdiagnosed.
  17. 46.
    The correct answer is B. The patient has a partial central airway obstruction secondary to the compressive tumor. Although he is hemodynamically stable and is able to maintain his airway at this time, the patient should admitted to an intensive care unit for aggressive monitoring as decompensation can happen quickly and unpredictably. Racemic epinephrine works both by stimulating alpha adrenergic receptors, resulting in mucosal vasoconstriction and by stimulating beta adrenergic receptors, resulting in relaxation of the bronchial smooth muscle. Racemic epinephrine has been proven to be most beneficial in treating laryngotracheobronchitis [croup] in the pediatric population, as well as laryngeal edema. Heliox is a 70:30 mixture of helium and oxygen, and is effective in reducing the work of breathing by decreasing airway resistance to turbulent flow generated across an airway obstruction. It has been used in post extubation laryngeal edema, tracheal stenosis, extrinsic compression, and acute severe asthma attacks [21]. Corticosteroids work by reducing airway edema, but this patient does not have any suggestion of airway edema; he has an airway obstruction secondary to mass effect. Also, they take several hours to take effect, and therefore steroid administration is not the most appropriate for the immediate relief of symptoms. The patient has lung adenocarcinoma that involves a mediastinal structure, and is unlikely to be a candidate for resection. Also, regardless of the resectability of this patient’s mass, surgery is not an immediate solution to the patient’s symptoms. Inhaled ß2 agonists will not provide relief, as the patient has a central airway obstruction.
  18. 47.
    The correct answer is E. MICs are used to report the sensitivity of an organism to various antimicrobial agents. Each agent has its own reference cutoff to determine whether the organism will be reported as sensitive, intermediate, or resistant to that agent. MICs cutoffs are not meant to be used to compare antimicrobial agents, and the absolute MIC does not take into account several other factors such as pharmacodynamics and the site of infection. Based only on a chart of antibiotic susceptibilities, none of the antibiotics listed can be considered “most likely” to be effective.
  19. 48.
    The correct answer is E. Vomiting, nasogastric suction, diuretic use, or mineralocorticoid excess may all result in the development of metabolic alkalosis. Blood loss, on the other hand, may result in a metabolic acidosis if it is significant enough to impair oxygen delivery.
  20. 49.
    The correct answer is E. When intubating a patient with TBI, the primary goals are to avoid causing or worsening secondary brain injury. As such, avoidance of hypoxia, hypotension, spikes in blood pressure, and elevated ICP are important. Lidocaine has often been used as pretreatment for the purposes of preventing ICP spikes during intubation; however, no direct evidence supports this approach in the setting of traumatic brain injury, nor is there evidence of any significant effect on patient outcomes [22].
  21. 50.
    The correct answer is D. Treatment for normal pressure hydrocephalus may include a lumbar drain trial , which involves lumbar drain placement and spinal fluid drainage for approximately 2–3 days. This is followed by physical therapy and neuropsychiatric testing to determine if there is any improvement in the patient’s clinical status compared to baseline. This patient did not benefit from lumbar drain placement; therefore, the correct answer is to discontinue the drain. The patient is unlikely to benefit from additional drainage, or from a repeat trial in 3 months.
  22. 51.
    The correct answer is E. It has long been recognized that brain metastases from certain malignancies are at a higher risk of bleeding episodes [23]. These include melanoma , renal cell carcinoma , choriocarcinoma , and thyroid carcinoma . Breast metastases are not considered high-risk lesions.
  23. 52.
    The correct answer is A. This patient presents with a cerebral venous sinus thrombosis in the face of antiplatelet and anticoagulation therapy, likely the result of her polycythemia vera. Given the history of HIT, it would be inappropriate to give this patient low molecular weight or unfractionated heparin; fonaparinux i s an appropriate alternative. Apixaban and eptifibatide are not used in this setting.
  24. 53.
    The correct answer is C. Bougie-guided intubation may be necessary in the absence of an adequate view of the vocal cords. The upturned end is slid under the epiglottis, feeling for the tracheal rings and eventual resistance when the bougie hits the carina. The laryngoscope blade can then be removed, and an endotracheal tube can be advanced along the bougie into the trachea.
  25. 54.
    The correct answer is D. Autonomy involves a respect for a patient’s wishes regarding their care, while the distinct [but closely related] principle of fidelity involves the concept that physicians and nurses will stay true to their promises and agreements. Beneficence refers to acts of compassion or healing, while non-maleficence refers to avoiding acts which may cause a patient harm. Justice refers to the fair and equal distribution of healthcare resources.
  26. 55.
    The correct answer is D. Many interventions have been studied in an attempt to reduce rates of iatrogenic ventriculitis . Routine CSF surveillance has not been demonstrated to be effective, either on a daily or 3-day interval basis. Similarly, routine catheter exchange has also failed to show benefit. Insertion site antibiotic wafers have been used in the setting of indwelling vascular catheters, but not ventriculostomy catheters. There is evidence that both antibiotic-coated and silver-coated catheters may reduce rates of ventriculitis [24], along with bundled protocols regarding catheter insertion and maintenance.
  27. 56.
    The correct answer is E. Treatment of aspiration pneumonia should include coverage of anaerobes and typical oral flora. Certain antibiotics, including aminoglycosides, fluoroquinolones, erythromycin, and tetracycline can aggravate weakness in myasthenic crisis, and should be avoided. Cefepime and azithromycin may be an effective regimen for community acquired pneumonia, but probably do not provide adequate anaerobic coverage.
  28. 57.
    The correct answer is B. Following withdrawal of life support, it is appropriate to administer any medications you would otherwise administer to a patient for purposes of palliation. This includes pre-extubation glycopyrrolate to dry secretions, as well as benzodiazepines or opiates titrated to patient comfort [or surrogates of possible discomfort, such as significant hypertension or tachycardia]. These drugs should never be administered solely for the purposes of hastening death and facilitating organ transplantation. Accordingly, paralytics serve no purpose other than inducing respiratory arrest, and may mask signs of patient discomfort.
  29. 58.
    The correct answer is A. The oculocephalic reflex involves sensory input from CN VIII and motor output from CN III/IV/VI. The corneal reflex involves sensory input from CN V and motor output from CN VII. The gag reflex involves sensory input from CN IX and motor output from CN X. Finally, the pupillary light reflex involves sensory input from CN II and motor output from CN III.
  30. 59.
    The correct answer is E. Up to one third of patients with traumatic subarachnoid hemorrhage may develop post-injury cerebral vasospasm. Unlike aneurysmal subarachnoid hemorrhage, TBI-induced cerebral vasospasm often occurs earlier, and can be seen as early as post-injury day 2 [25].
  31. 60.
    The correct answer is C. There are numerous hereditary disorders that predispose patients to developing strokes , particularly at younger ages than typical atherosclerotic or embolic processes. The most common of these is CADASIL, in which a defect in the NOTCH3 gene causes abnormal protein build-up in vascular smooth muscle cells. HHT, MELAS, Moyamoya, and GCA are less common hereditary stroke disorders [26].
  32. 61.
    The correct answer is A. ALS is a chronic disease characterized by motor neuron degeneration that affects patients in the sixth and seventh decade of life, on average. Unfortunately, most patient will die within 5 years of diagnosis. The majority of cases are sporadic, not hereditary. Disease management is largely supportive, including positive pressure ventilation and the use of riluzole [which may delay ventilator dependence and prolong survival by 2–3 months [27]].
  33. 62.
    The correct answer is C. The CAVE score may predict which ICH patients are at risk for the development of late seizures. Patients get 1 point for each of the following: age >65, hemorrhage volume >10 mL, cortical location, and seizure activity in the first 7 days following ictus. A higher score denotes a progressively higher risk of developing late seizures [28].
  34. 63.
    The correct answer is E. The TracMan study was a large, prospective, randomized, multicenter trial of very early [10 days, if still indicated] tracheostomy among ICU patients identified by the treating physician as likely to require >7 days of mechanical ventilation. The study did not demonstrate any significant differences in 30-day or 2-year mortality, nor were there any differences in ICU length-of-stay or the rate of tracheostomy-related complications [29]. It is noteworthy, however, that a recent Cochrane review using a much broader and more liberal definition of early vs. late tracheostomy [10 days] found moderate quality evidence for a mortality benefit in the former group [30].
  35. 64.
    The correct answer is B. A normal ICP waveform has three peaks of descending amplitude. The first represents arterial pulsation , the second represents intracranial compliance , and the third represents aortic valve closure . Pulmonic valve closure is not indicated in the waveform.
  36. 65.
    The correct answer is A. A study by Kirollos developed a risk-stratification schema for cerebellar hemorrhages based on the appea rance of the fourth ventricle. Grade I patients had a fourth ventricle that was midline, non-compressed, and contained visible CSF. These patients uniformly had good long-term outcomes. Grade II patients had fourth ventricles that were partially compressed or displaced, with intermediate prognoses depending on further details of their presentation. In the published protocol those with GCS > 13 were monitored, and with worsening GCS were either given an EVD [if they had hydrocephalus] or decompression [if no hydrocephalus or persistent poor GCS after EVD placement]. Grade III patients had either complete obliteration of the fourth ventricle or partial obliteration with compression of the pons and prepontine cistern, and had the worst prognoses with 38% good outcomes if GCS > 8 and 17% chance of good outcome with GCS 3 weeks old. Hyperacute bleeds [

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