CCM-practice test 2

A 39-year-old woman with no significant past medical history presents to the Emergency Department with fevers, chills, and a new cough. She is febrile with a heart rate of 110 bpm, a blood pressure of 70/40 mm Hg, and an oxygen saturation on room air of 90% which increases to 95% on 5L/min of supplemental oxygen. Her chest X-ray shows a right lower lobe infiltrate. You prescribe antibiotics and prepare to administer a fluid bolus. Which is the initial fluid of choice for resuscitation?

Which one of the following statements about hemodynamic waveforms is correct?

A 20-year-old male is admitted to the surgical ICU following a repair and packing of liver laceration. 6 packs were left around the liver injury. A temporary abdominal closure was completed using a VAC. Intra-op the patient received 12 units of PRBC, 12 units of FFP, and 2 6-packs of platelets. Vital signs: BP 100/60 mm Hg, HR 115, temperature is 33.50 C. Lab studies: hemoglobin 8.5g/dL, platelets 100,000/mm3, PT 14, PTT 30, INR 1.3 VAC output for the first hour was 150cc of serosanguinous output in the ICU. The next most appropriate treatment for this patient in the ICU is?

Which of the following steps has been shown to reduce mortality in patients with myocardial infarction complicated by cardiogenic shock?

Which of the following is associated with mortality benefit in ARDS management regardless of severity of disease?

An 85 year old man with lung cancer is admitted to the ICU immediately post op from a lobectomy. He remains intubated for post op hypercarbia. He has a history of CAD, COPD. You are called to the bedside acutely when his ventilator alarms for high peak airway pressures. The patient is in mild distress and dyssynchronous with the ventilator. His peak airway pressure is 49 cm H2O; plateau pressure is 26 cm H20. Which of the following seems most likely:

Which of the following patients is the most appropriate candidate for chronic use of nocturnal non-invasive ventilation?

A 27 year old woman is admitted to a hospital after being found unconscious and smelling of vomitus. Toxin screen is positive for heroin. The patient is intubated for respiratory protection. Which of the following strategies are most likely to prevent complications from mechanical ventilation?

All of the following are true regarding high-sensitivity cardiac troponin (hs-cTn) assays as compared with conventional assays EXCEPT:

A 90-year-old man with hypertension, right bundle branch block (RBBB) and severe aortic stenosis underwent transcatheter aortic valve replacement (TAVR). On POD#0, he develops symptomatic bradycardia. 12-lead ECG demonstrates complete heart block with ventricular escape of 45 bpm. He is asymptomatic and hemodynamically stable. Which of the following is correct?

In patients who are comatose after successfully resuscitated cardiac arrest, the neurologic exam and early neurologic imaging (within 24 hours of arrest) are in general reliable at predicting long-term neurologic recovery.

For PE patients who are hypotensive due to evolving cardiogenic shock, the European Society of Cardiology guidelines recommend using the following pressor:

You are caring for a patient with acute necrotizing pancreatitis who is developing worsening sepsis and organ failure despite maximal intensive care and broad spectrum antibiotic administration 12 days after the onset of pancreatitis. You obtain a percutaneous, CT-guided fine needle aspirate of his pancreatic necrosis that demonstrates bacterial infection. The optimal intervention at this time is:

A 76year-old woman with a history of diabetes, depression, atrial fibrillation, MI with drug-eluting cardiac stents placed 4 months ago on sertraline, aspirin, clopidogrel, and warfarin presents with melena and lightheadedness. Laboratory data reveals hemoglobin 6 g/dL, platelet 176,000, INR 4.9. Which of the following is appropriate management?

A 26 year old patient with ALF due to unintentional acetaminophen overdose is admitted to ICU, intubated due to declining mental status, on IV NAC. Head CT on Day #2 shows mild loss of sulci concerning for early cerebral edema. Your initial management steps include:

The five D’s are five important steps clinicians should follow when assess a patient for an FMT to ensure best practices. The 5 Ds include all of the following except:

What is the most practical cerebral imaging study within 3 hours of stroke signs and symptoms?

Which is the most reliable intracranial pressure monitor?

What is the etiology of seizures that cause the most mortality?

To make the diagnosis of brain death, which is the most appropriate choice?

Which of the following patients would be most likely to benefit from a prophylactic platelet transfusion?

Which of the following steps has been shown to reduce mortality in patients with disseminated intravascular coagulation (DIC) due to bacterial sepsis?

In Continuous Veno Venous Hemodiafiltration which of the following is present?

A 73 year old man presented with acute on chronic CHF. Patient had vomiting for 5 days. Patient stopped taking his medications. He was tachypneic and uncomfortable on oxygen. Lytes: Na 128, K 5.2, Cl 78, HCO3 20, urea 50, creatinine 6, glucose 108 pH 7.57, pCO2 22, pO2 145 Acid base disorder present is:

You have been asked by the director of your ICU to review the literature on VAP prevention and to suggest potential initiatives that will decrease VAP rates and improve patient outcomes. Which of these interventions is most likely to lead to better outcomes for patients?

A 52 year old woman with a history of depression which is well-controlled on citalopram, as well as history of COPD (current smoker) is hospitalized with pneumonia. She requires mechanical ventilation for hypoxic respiratory failure. After intubation on admission an endotracheal tube aspirate is sent for culture and grows MRSA. She is treated with linezolid. A radial arterial catheter is placed for monitoring purposes. On hospital day #5 she develops temperature of 103.5F, as well as tachycardia and hypertension. Her ventilator requirements are unchanged. What is the most likely cause of the fever, tachycardia, hypertension?

A 37-year-old woman is admitted to the hospital with gallstone pancreatitis. She tests negative for SARS-CoV-2 on admission and is managed on standard precautions. Her providers consistently wear a mask when seeing her but she is inconsistent in her use. She was fully vaccinated with an mRNA vaccine 4 months ago. The patient is treated with IV fluids and pain medications and steadily improves. A surgical consultant advises cholecystectomy before discharge. She is retested for SARS-CoV-2 before the procedure on hospital day 6. The test is positive with a cycle threshold of 39. SARS-CoV-2 precautions are initiated. The SARS-CoV-2 test is repeated the next day and is again positive with a cycle threshold of 38. What would you advise the providers who looked after this patient regarding their risk of having been infected?

A 36 year old woman with a lifelong history of type 1 DM complicated by severe renal insufficiency and new onset multiple sclerosis is admitted with an MS flare. At home she is on glargine 24 units a day and aspart 4-6 units with meals and she uses a continuous glucose monitor which she brings to the hospital. She gets 1 gram methylprednisolone iv on night of admission and labs the next morning show: Na 126 meq/L K 4.8 meq/L Cl 93 meq/L HCO3 18 meq/L BUN 63 mg/dl Cr 7.0 mg/dl Glucose 663 mg/dl Beta-hydroxybutyrate 0.3 mmol/L Which of the following statements is true?

A 65 year old woman has known osteoporosis and is on calcium 1250 mg a day and vitamin D 1000 units a day. She falls and develops a pubic ramus fracture. She is admitted for pain control and is found to have Calcium 12.1mg/dl , Phos 3.1mg/dl, creatinine 1.3 mg/dl, eGFR of 60 ml/min/1.73m2, 25-OH, vitamin D level of 28 ng/ml (sufficient levels 30-50 ng/ml) and PTH of 56pg/ml(nl 14-65). She is treated with fluids and pain medicine and sent to a rehab facility with calcium 1250 mg a day and vitamin D 5000 units a day. 4 weeks later she develops change in mental status and is found to have calcium of 15.5 mg/dl, phos 3.3 mg/dl, creatinine 1.5 mg/dl, and eGFR of 40 ml/min/1.73m2. PTH is 36 pg/ml and vitamin D is 144 ng/ml. Her initial management should include all of the following except:

A 70 y.o woman with ischemic colitis and pneumonia is in the ICU. She is ventilator-dependent and paralyzed. She requires specialized nutrition support and the Harris Benedict equation has been used to calculate her Basal Metabolic Rate (BMR). Her daily caloric needs are:

You are the attending for a 92yo woman who has a history of DM, CHF, atrial fibrillation, and mild cognitive impairment, who was admitted to the ICU following hip replacement after a fall. Prior to this fall, the patient lived independently at home and managed light housework activities, such as laundry and cooking, without difficulty. Her operative course was significant for persistent bleeding and hypotension. These issues were managed intraoperatively by transfusion of 4 units PRBCs and pressor support with norepinephrine. A central venous line and arterial line were placed intraoperatively to facilitate management. Her initial ICU evaluation shows MAP 75, HR 110, RR 20; the surgical site has a small amount of blood on the dressing. The patient reports mild to moderate dyspnea and severe pain at the surgical site. Which of the following will be most effective approach to minimize this patient’s risk of delirium?

Which of the following are criteria for referral to a Burn Center?

A 60-year-old man is admitted to the ICU for severe alcohol induced pancreatitis. A CT scan demonstrates nonenhancement of 50% of the pancreatic body and tail. Which statement regarding antibiotic prophylaxis in necrotizing pancreatitis is most accurate?

38 yo G2P0010 at 30+3 weeks of pregnancy admitted to the ICU with ARDS in the setting of urosepsis with new diagnosis of preeclampsia with severe features. She was progressing towards extubation on morning rounds. You are rounding on another patient when you are called to her bedside in the setting of PEA arrest. Which of the following do you advise in addition to standard ACLS interventions?

Your patient is a 75yo man with a long-history of diabetes complicated by neuropathy, COPD, and coronary artery disease. He is currently intubated following a pneumonia. His course has been significant for renal insufficiency, delirium and the development of a stage IV sacral pressure ulcer. He has intermittent agitation during the day, but he consistently grimaces and becomes agitated with dressing changes. These symptoms resolve with fentanyl; however, he consistently becomes somnolent after receiving this. His daughter, who is his health care agent, has asked that he not receive fentanyl because of the somnolence. His nurse objects, stating that the dressing changes are painful. His daughter turns to the patient and asks if he wants the pain medicine before the dressing changes, and he shakes his head, “no”. What is true about this patient’s ability to give or refuse consent?

Which of the following medications is least likely to be subject to a large pharmacokinetic alteration in a patient with cirrhosis based on the hepatic extraction ratio?

A patient is admitted to the ICU altered after an overdose. He arrives in the ICU and is found tachycardic to 140, with a blood pressure of 100/80, respiratory rate of 40 and temperature of 102. His exam is significant for diaphoresis, dilated pupils, bilateral lower extremity clonus and erythematous skin. Because of his worsening mental status, he is intubated in the ICU and started on sedation. Shortly afterwards, his heart rate increases to 180, he remains febrile and he develops inextinguishable clonus. Identify the toxidrome and etiology behind his worsening course?

The ABCDE(F) bundle has been shown in multiple large studies to reduce ICU delirium, coma, length of stay, duration of mechanical ventilation, hospital mortality and ICU readmissions. Which of the following bundle definitions is NOT correct?

A 69 years old female with emphysema who underwent an uncomplicated bilateral lung transplant 3 days ago is being evaluated for altered mental status. She was extubated on post-operative day 0 but since then has been having worsening confusion. On examination, her BT is 36.5 C, BP is 140/75, HR 92, RR 16, SpO2 = 93% on nasal cannula 3 LPM, she only withdraws to painful stimuli, pupils are 2 mm reactive to light bilaterally, she moves both sides equally, reflexes are 1+ bilaterally, her incision appears clean and intact, lungs are clear to auscultation bilaterally, the rest of the exams are normal. Chest tube output is serosanguinous and is decreasing. CXR with mild pulmonary edema. CBC with WBC of 11,000 cells/uL, Hb of 9 g/dL, and platelet of 180,000 /uL. LDH 364 U/L, Haptoglobin 120 mg/dL. BUN 42 mg/dL, Cr 1.4 mg/dL (from baseline of 0.6), ammonia is 100 umol/L. She has negative retrospective crossmatch. Donor and explant cultures have been negative to date. Currently she is on ciprofloxacin, metronidazole, vancomycin, micafungin, and inhaled amphotericin B. For immunosuppression she is on tacrolimus with a trough level of 9 (within range per protocol), mycophenolate, and prednisone. She is electively intubated. What is the most appropriate management?

A 49-year-old male with no past medical history complained of chest pain and then sustained a witnessed cardiac arrest. EMS was activated and patient had successful return of spontaneous circulation after ACLS was initiated. Post-arrest EKG demonstrated anterior STEMI. Patient was transported to the hospital and was taken to the cardiac catheterization lab and had a successful primary percutaneous coronary intervention to the LAD. He was then transferred to the ICU in critical condition. In the ICU the patient had rapidly escalating vasopressors and inotropes (norepinephrine 30 mcg/min, epinephrine 10 mcg/min, vasopressin 0.04 U/min) to achieve mean arterial pressure of 65 mm Hg. He additionally had progressive hypoxemia. He was placed on assist control volume control mode of ventilation with the following settings: FIO2 100%, tidal volume 450 cc, PEEP 14 cm H20, and respiratory rate of 30. Despite these settings SpO2 is 84%. The shock team was activated, and decision was made to place the patient on temporary mechanical circulatory support. Which of the following is the most appropriate form of support for this patient?

Which one of the following aspects is commonly assessed as part of a point-of-care ultrasound examination in patients presenting to the Emergency Department with undifferentiated dyspnea?

A patient comes to your clinic. She was recently discharged home after an ICU stay where she was intubated due to respiratory failure from COPD. Which psychiatric problems is she most likely to face as a result of post-intensive care syndrome?

An interprofessional group convenes to revise postoperative pain management strategies for post-operative sleeve gastrectomy surgery in the ICU. The group is looking to develop a multimodal analgesia template with a goal of reducing opioid utilization due to the ongoing opioid crisis. Which of the following should be considered for implementation in the standardized order sets based on the recommendations from the 2018 Society of Critical Care Medicine (SCCM) pain, agitation, delirium, immobility, and sleep disturbances (PADIS) guidelines for adult critically ill patients?

A 60 y.o. male with obesity BMI=32, hypertension and hyperlipidemia is admitted to the MICU with severe Covid pneumonia. His symptoms (malaise, dyspnea and cough) started 5 days prior to presentation to the emergency room. Upon arrival to the emergency room his oxygen saturation was 86% on room air, HR=100, BP 124/ 78 and temparture=38 degrees Celsius. Supplemental oxygen was provided (4LPM). CXR revealed bilateral pulmonary infiltrates and his nasopharyngeal PCR was positive for Cvoid-19. He was admitted to hospital and started on remdesivir and dexamethasone. On hospital day 2 he was noted to have worsening hypoxemia and new confusion. His supplemental oxygen has been increased to 7 LPM nasal cannula. You are called to evaluate. On exam his RR=20, HR=110, BP=92/66 with SpO2=90%. He is arousable to sternal rub. He opens his eyes but does not interact or follow any commands. Auscultation of lungs is notable for scattered anterior rhonchi without wheezes. Next best step in management would be: