Answer: C

Thresholds for platelet transfusions are undergoing close examination. Some areas continue to provoke debate especially concerning the use of prophylactic platelet transfusions for the prevention of thrombocytopenic bleeding. Guidelines recommend maintaining platelet count at 100,000 after a central nervous system bleeding event. This would also be the case immediately prior to and after surgery performed on the central nervous system. This patient has a potentially life-threatening intracranial bleeding. The bleeding source is probably secondary to hypertensive disease and not thrombocytopenia. However, the patient is at continued risk for extension of the intracerebral bleeding because of her thrombocytopenia. Guidelines do not suggest additional benefits to maintaining platelet counts >100,000.

British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for the use of platelet transfusions. Br J Haematol. 2003;122:10–23.

Vavricka SR, Walter RB, Irani S et al. Safety of lumbar puncture for adults with acute leukemia and restrictive prophylactic platelet transfusion. Ann Hematol 2003;82:570–3.

Answer: E

This patient has IGA deficiency. The most appropriate product to minimize the risk of an anaphylactic transfusion reaction in this case is washed erythrocytes. Most patients with an IgA deficiency are asymptomatic. They are prone to gastrointestinal infections such as giardia. They also have an increased risk of autoimmune disorders such as rheumatoid arthritis and systemic lupus erythematosus. Some patients with IgA deficiency have anaphylactic reactions to blood products containing IgA. Fresh frozen plasma (FFP) is the main blood component containing IgA antibodies. Anaphylaxis may occur with a variety of transfusions including FFP, platelets, and erythrocytes. Washing erythrocytes and platelets removes plasma proteins and greatly decreases the incidence of anaphylaxis.

Answer: C

This patient has thromboangiitis obliterans, also called Buerger’s disease. This results from inflammatory blockage of arterioles in the distal extremities and is usually seen in male smokers who are typically less than 40 years of age. Other typical features include a history of recurrent thrombophlebitis and rest pain. Distal pulses are often absent.

Plantar fasciitis is usually relieved with rest. Weight bearing and exercise exacerbate it. Spinal stenosis usually occurs in older patients. It is exacerbated by standing or walking and is relieved by rest. Atherosclerotic claudication is also seen in older patients. It has a steady progression. It starts with exercise-related pain and progresses slowly to pain at rest. Raynaud phenomenon is seen mostly in women. It is caused by vasospasm of small arterioles. It more commonly occurs in the hands but can be seen in the feet. The vasospasm is precipitated by cold, temperature change, or stress. Color changes, which can be profound, occur in the digits from white to blue to red. Pain is usually not severe and peripheral pulses remain intact even during episodes of vasospasm.

In Buerger’s disease, among patients who stop smoking, 94 % avoid amputation. In contrast, among patients who continue using tobacco, there is an 8-year amputation rate of 43 %.

Espinoza LR. Buerger’s disease: thromboangiitis obliterans 100 years after the initial description. Am J Med Sci. 2009;337(4):285–6.

Olin JW, Young JR, Graor RA, Ruschhaupt WF, Bartholomew JR. The changing clinical spectrum of thromboangiitis obliterans (Buerger’s disease). Circulation. 1990;82(5 Suppl):IV3–8.

Answer: D

Good nutritional status is an important factor in the outcome of gastrointestinal surgery. Several studies have confirmed this. Preoperative malnutrition is an independent predictor of length of hospital stay, 30-day, and 60-day mortality, as well as minor medical complications, in patients undergoing gastrointestinal surgery. Preoperative nutrition including total parenteral has been proven to be beneficial in malnourished patients undergoing gastrointestinal surgery.

Burden S, Todd C, Hill J, Lal S. Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev. 2012;(11):CD008879.

Answer: C

This patient has several factors that suggest malingering. He presents with two relatively easy to mimic symptoms. First, he has a seizure with no eleptiform activity and then paralysis with a normal MRI. His recent travel from another area is also suggestive of the diagnosis.

Malingering is not considered a mental illness and its diagnosis and treatment can be difficult. Direct confrontation may not work best. Hostility, lawsuits, and occasionally violence may result. It may be best to confront the person indirectly by remarking that the objective findings do not meet the objective criteria for diagnosis. It is important to demonstrate to the patient that his abnormal behavior has been observed and will be documented. At the same time an attempt should be made to allow the patient who is malingering the opportunity to save face. Obviously this can be a challenge.

Invasive diagnostic maneuvers, consultations, and prolonged hospitalizations often do more harm than good and add fuel to the fire. People who malinger rarely accept psychiatric referral, and the success of such consultations is minimal. It may be considered to address a specific psychiatric complaint.

The most common goals of people who malinger in the emergency department are obtaining drugs and shelter. It may be beneficial to offer the patient some limited assistance in these areas. In the clinic or office, the most common goal is financial compensation.

McDermott BE, Feldman MD. Malingering in the medical setting. Psychiatr Clin North Am. 2007;30(4):645–62.

Purcell TB. The somatic patient. Emerg Med Clin North Am. 1991;9(1):137–59.

Answer: A

American College of Chest Physician guidelines for chronic obstructive pulmonary disease exacerbation support inhaled beta agonists and steroids alone for mild flares. In this particular case, the patient is having a mild exacerbation of his typical chronic obstructive pulmonary disease. Antibiotics should be reserved for moderate to severe cases. The criteria for moderate disease exacerbation include cough, change in color of sputum, and increased shortness of breath.

Vollenweider DJ, Jarrett H, Steurer-Stey CA, Garcia-Aymerich J, Puhan MA. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(12):CD010257.

Walters JA, Tan DJ, White CJ, Wood-Baker R. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(12):CD006897.

Answer: E

Comparisons of enteral nutrition with parenteral nutrition have consistently shown fewer infectious complications with enteral nutrition. Several studies have looked at specialized feeding formulas in the treatment of the critically ill. There is little evidence to support their use over standard high-protein formulas.

In one study among adult patients breathing with the aid of mechanical ventilation in the ICU, immune-modulating formulas compared with a standard high-protein formula did not improve infectious complications or other clinical end points.

Elderly patients require special consideration. A trial in 501 hospitalized elderly patients randomized to oral supplements or a regular diet showed that, irrespective of their initial nutritional status, the patients receiving oral supplements had lower mortality, better mobility, and a shorter hospital stay.

Langer G, Schloemer G, Knerr A, Kuss O, Behrens J. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2003;(4):CD003216.

Zanten AR, Sztark F, Kaisers UX et al. High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomized clinical trial. JAMA. 2014;312:514–24.

Answer: D

Amniotic fluid embolism is a rare complication of pregnancy. It presents acutely during and immediately after delivery, usually within 30 min. The exact mechanisms are unclear, but it is thought that amniotic fluid gains entry into the maternal circulation. This triggers an intensive inflammatory reaction, resulting in pulmonary vasoconstriction, pulmonary capillary leak, and myocardial depression. Patients present with acute hypoxemia, hypotension, and decreased mental status. Treatment is supportive but may be improved by early recognition and cardiopulmonary resuscitation. The other answers do occur in pregnancy, but the severity, rapid onset, and timing to delivery strongly suggest amniotic fluid embolism. The mortality rate may exceed 60 %. Immediate transfer to an intensive care unit with cardiovascular resuscitation is recommended.

Conde-Agudelo A, Romero R. Amniotic fluid embolism: an evidence-based review. Am J Obstet Gynecol. 2009;201(5):445.e441–3

Answer: C

Patients who have undergone significant bowel resection should receive acid suppression in the postoperative period with a proton pump inhibitor.

This patient has short-bowel syndrome. Any process that leaves less than 200 cm of viable small bowel or a loss of 50 % or more of the small intestine as compared to baseline places the patient at risk for developing short-bowel syndrome. In short-bowel syndrome, there is an increase in gastric acids in the postoperative period. This can lead to inactivation of pancreatic lipase, resulting in significant diarrhea. Stopping the patient’s oral intake may lead to temporary improvement. It is important that the patient continues her oral feedings, as this will eventually allow the gut to adapt and hopefully resume normal function.

Howard L, Ament M, Fleming CR et al. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States. Gastroenterology. 1995;109(2):355–65.

Lord LM, Schaffner R, DeCross AJ et al. Management of the patient with short bowel syndrome. AACN Clin Issues. 2000;11(4):604–18.

Answer: B

This patient has an unexplained deep vein thrombosis. Current guidelines recommend treatment for 6 months. Recent studies have revealed that factor V Leiden and prothrombin mutation are not sufficiently predictive of future recurrence. They are currently not recommended unless the patient has a family history of thrombosis. Even with a family history, the utility of these tests is of uncertain benefit. Future studies may clarify the predictive value of these tests.

Kearon C, Crowther M, Hirsh J. Management of patients with hereditary hypercoagulable disorders. Annu Rev Med. 2000;51:169–85.

Answer: A

A 2010 study compared lenient control of heart rate less than 110 beats per minute to more strict control of less than 80 beats per minute. The study found that achieving strict heart rate control resulted in multiple admissions with no perceivable benefit outcomes. In this particular case, a heart rate of 108 bpm is acceptable, and patient the can be discharged on her current medications. Follow-up with her primary care physician should be obtained to monitor heart rate.

Digoxin can be used in the acute setting but does little to control the ventricular rate in active patients. It is rarely used as monotherapy. Caution should be exercised in elderly patients with renal failure due to toxicity. Digoxin is indicated in patients with heart failure and reduced LV function.

Van Gelder IC, Groenveld HF, Crijns HJ et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362:1363–73.

Answer: C

The use of actual body weight in determining the caloric needs of obese patients in the ICU routinely leads to overfeeding. The use of ideal body weight leads to underfeeding. Morbidly obese patients have, on average, 20 % to 30 % increased lean body mass compared with individuals of the same sex and similar height. Adjusted body weight would be the best starting point for determining caloric needs.

Judicious underfeeding such as using 22 kcal/kg, adjusted body weight of morbidly obese patients who are receiving mechanical ventilation may improve outcome. This may include reducing obesity-related hyperglycemia in the setting of critical illness, reducing infectious complications, decreasing ICU length of stay (LOS), ventilator days, and duration of antibiotic therapy.

Alberda C, Gamlich L, Jones N et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009;35:1728.

Martindale RG, McClave SA, Vanek VW et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: SCCM and ASPEN: executive summary. Crit Care Med. 2009;37:1757.

Port AM, Apovian C. Metabolic support of the obese intensive care unit patient: a current perspective. Curr Opin Clin Nutr Metab Care. 2010;13:184.

Answer: A

This patient has likely developed transfusion-related acute lung injury (TRALI). The patient developed dyspnea, diffuse pulmonary infiltrates, and hypoxia acutely during the blood transfusion. It usually occurs shortly after the transfusion or can be delayed for several hours. Both the classic and delayed TRALI syndromes are among the most frequent complications following the transfusion of blood products. They are associated with significant morbidity and increased mortality.

Antileukocyte antibodies in the donor blood product directed against the recipient leukocytes cause this reaction. TRALI can occur with any blood product. Treatment of TRALI is supportive, with expected recovery within several days.

An acute hemolytic transfusion reaction is commonly caused by clinical error, leading to ABO incompatibility. This occurs early in the transfusion. Patients present with hypotension, disseminated intravascular coagulation, and hypoxia. This patient’s symptoms are primarily shortness of breath, which does not suggest an acute hemolytic transfusion reaction. It can be difficult to distinguish TRALI from transfusion-related volume overload. In this particular case, the patient had only received a limited volume of one unit of packed blood cells. Per her history, there is no reason to believe she couldn’t tolerate the volume given.

Curtis BR, McFarland JG. Mechanisms of transfusion-related acute lung injury (TRALI): anti-leukocyte antibodies. Crit Care Med. 2006;34:S118–23.

Answer: A

Per package labeling by the pharmaceutical manufacture, discontinue warfarin and initiate rivaroxaban as soon as INR falls to <3.0. Answer B represents the correct conversion from warfarin to dabigatran.

INR is not used to monitor rivaroxaban; however, it’s an indicator of warfarin’s effectiveness, thus aiding in predicting a safe time to initiate a different anticoagulant. Rivaroxaban starts working in 2–4 h. Warfarin takes 3–5 days to start working and 3–5 days to be eliminated.

Garcia DA et al. CHEST guidelines – parenteral anticoagulants. Chest. 2012;141(2_suppl):e24S–43S.

Answer: E

Vitamin and other nutritional deficiencies are common after bariatric procedures. This may be due to diet changes, change in gastric function, or malabsorption. In these patients, notable deficiencies occur with iron, zinc, and B12. Lifelong nutritional supplementation is essential.

Many patients often stop taking supplements after a few years after being lost to follow up. Despite improved surgical outcomes, complications from weight-loss surgery are frequent. A study of insurance claims of patients who had undergone bariatric surgery showed 21.9 % complications during the initial hospital stay. Over the next 6 months, 40 % developed complications. This occurred more often in those over 40. The rate of complications is reduced when the procedure is performed by an experienced, trained surgeon. Guidelines recommend that surgery be in a dedicated unit.

Chauhan V, Vaid M, Gupta M, Kalanuria A, Parashar A. Metabolic, renal, and nutritional consequences of bariatric surgery: implications for the clinician. South Med J. 2010;103(8):775–83; quiz 784–5.

Answer: B

Patients with cirrhosis of all causes and stage are at an increased mortality risk from surgery. Even though this patient has a low MELD score and is a child A patient, there is clear evidence that he is at increased risk. Since he has severe morbidity, elective surgery is a reasonable option. He should be informed of the small but significant increased risk of death associated with surgery as compared to a someone without cirrhosis. Treatment for hepatitis C would not have an impact on surgical outcomes. Waiting for transplant, which is many years away, is not the best option.

Teh SH, Nagorney DM, Stevens SR et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132(4):1261–9.

Answer: A

Postoperative cognitive dysfunction (POCD) is common in adult patients of all ages, recovery in the younger age group is usually within 5 days, and complete recovery is the norm for patients less than 60 years old.

Patients older than 60 years of age are at significant risk for long-term cognitive problems, and in this group recovery from POCD may last as long as 6 months and may be permanent.

Patients with POCD in all age groups are at an increased risk of all-cause death in the first year after surgery.

Newfield P. Postoperative cognitive dysfunction. F1000 Med Rep. 2009;1(14):281.

Answer: D

Deafness, tinnitus, or hearing loss is typically absent with central lesions. Dizziness is a common complaint affecting approximately 20 % of the population over the course of the year. It results in many emergency room visits and hospitalizations.

Most dizziness is benign and is self-limited. Vertigo is often described as an external sensation such as the room is spinning. Vertigo is most commonly from peripheral causes which affect labyrinths of the inner ear.

Focal lesions of the brainstem and cerebellum can also lead to vertigo.

Vertical nystagmus with a downward fast phase and horizontal nystagmus that changes direction with gaze suggest central vertigo. Significant non-accommodating nystagmus is most often a sign of central vertigo but can occur with peripheral causes as well.

In peripheral vertigo, nystagmus typically is provoked by positional maneuvers. It can be inhibited by visual fixation. Central causes of nystagmus are more likely to be associated with hiccups, diplopia, cranial neuropathies, and dysarthria.

Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am. 2009;27(1):39–50. doi:10.​1016/​j.​emc.​2008.​09.​002.

Answer: C

Gastrointestinal complaints are common with Parkinson’s disease. Efforts should be made to minimize worsening of motor symptoms with pharmaceuticals. Prochlorperazine, metoclopramide, and promethazine are antidopaminergic medicines and can exacerbate or worsen Parkinson motor symptoms and should be avoided. Ondansetron has been used with minimal side effects.

Cooke CE, Mehra IV. Oral ondansetron for preventing nausea and vomiting. Am J Hosp Pharm. 1994;51(6):762–71.

Grimes DA, Lang AE. Treatment of early Parkinson’s disease. Can J Neurol Sci. 1999;26 Suppl 2:S39–44.

Answer: A

Mortality of patients diagnosed with end-stage dementia is significant. In a 2009 study, 323 nursing home residents with advanced dementia were followed. The patients were assessed at baseline and quarterly for 18 months through chart reviews, nursing interviews, and physical examinations. Mortality from all causes was greater than half at 54.8 %. In the last 3 months of life, 40.7 % of subjects underwent one or more intensive interventions that were defined as hospitalization, ED visit, parenteral therapy, or tube feeding.

Families and designated surrogate decision-makers were also followed and questioned on an understanding of the prognosis. Those families that demonstrated an understanding of the prognosis had fewer interventions.

Mitchell SL, Teno JM, Kiely DK et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529–38.

Answer: B

This patient has peripartum cardiomyopathy. This occurs in approximately 0.03 % of all pregnancies. Risk factors include greater maternal age, multiparity, and frequent pregnancies. Clinical management is the same as that of congestive heart failure due to dilated cardiomyopathy. Patients are at high risk of developing peripartum cardiomyopathy in subsequent pregnancies as well. This particular patient would warrant transfer to the cardiac care unit and aggressive fluid management.

The most recent studies indicate that the survival rate is very high at 98 %. In the United States, over 50 % of peripartum cardiomyopathy patients experience a complete recovery of heart function with conventional treatment protocols.

The cause of peripartum cardiomyopathy is unknown. Currently, researchers are investigating cardiotropic viruses, immune system dysfunction, trace mineral deficiencies, and genetics as possible causes.

Elkayam U, Akhter MW, Singh H et al. Pregnancy-associated cardiomyopathy: clinical characteristics and a comparison between early and late presentation. Circulation. 2005;111(16):2050–5.

Murali S, Baldisseri MR. Peripartum cardiomyopathy. Crit Care Med. 2005;33(10 Suppl):S340–6.

Answer: A

There is no indication for antiepileptic therapy for primary prevention in patients who have brain metastasis who have not undergone resection. Past studies have revealed no difference in seizure rates between placebo and antiepileptic therapy in patients who have brain tumors. Antiepileptic therapy has high rates of adverse reactions and caution should be used in their use.

Sirven JI, Wingerchuk DM, Drazkowski JF, Lyons MK, Zimmerman RS. Seizure prophylaxis in patients with brain tumors: a meta-analysis. Mayo Clin Proc. 2004;79(12):1489–94.

Answer: E

A patient with a suspicion of a CIED infection should have two sets of peripheral blood cultures drawn before prompt initiation of antimicrobial therapy. The implantable device should be removed by an expert and the generator-pocket tissue and lead tip should be cultured on explanation. It is appropriate to obtain a transesophageal echocardiogram (TEE) to assess for CIED infection and valvular endocarditis. Percutaneous aspiration is not needed, as the device will be removed.

Baddour LM et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121:458–77.

Answer: E

Postoperative confusion and delirium are common in cardiac surgery patients. A 2012 study revealed that all postoperative cardiac surgery patients experienced some degree of postoperative cognitive decline as measured by the Mini-Mental State Examination (MMSE). Most returned to baseline within 5 days with supportive care alone. For patients who had significant postop delirium, a return to baseline was delayed 6 months. Most non-delirious patients had a return to baseline in a few days. Risk factors for delirium include age, lower level of education, female, and having a history of stroke or transient ischemic attack.

Saczynski JS, Marcantonio ER, Quach L et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012;367:30–9.

Tully P, Baune B, Baker R. Cognitive impairment before and 6 months after cardiac surgery increase mortality risk at median 11 year follow-up: a cohort study. Int J Cardiol. 2013;168(3):2796–802.

Answer: D

One of the most widely used preoperative risk assessment tools is the Revised Cardiac Risk Index (RCRI). The RCRI scores patients on a scale from 0 to 6. The patient here has a RCRI score of 3. His score includes high-risk surgery, creatinine greater than 2 mg/dl, and diabetes mellitus requiring insulin. The six factors that comprise the RCRI are high-risk surgical procedures, known ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus requiring insulin, and chronic kidney disease with a creatinine greater than 2 mg/dL.

0 predictor = 0.4 %, 1 predictor = 0.9 %, 2 predictors = 6.6 %, ≥3 predictors = >11 %

Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, Burke DS, O’Malley TA, Goroll AH, Caplan CH, Nolan J, Carabello B, Slater EE. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845–50.

Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–9.

Answer: B

Despite a possible prior reported history of mononucleosis, this patient has acute infectious mononucleosis from EBV. This is confirmed by the positive heterophile test.

More than 90 % of patients with primary infectious mononucleosis test positive for heterophile antibodies. The monospot test is commonly used to test for heterophile antibodies. Patients may test positive for 3–4 months after the onset of illness, and heterophile antibodies may persist for up to 9 months. Patients with other forms of mononucleosis such as CMV or toxoplasmosis rarely test positive for heterophile antibodies.

Heterophile antibodies may be falsely positive. They are occasionally positive in patients with rheumatoid arthritis. The heterophile titer does not correlate with the severity of the illness.

Most patients with Epstein-Barr virus infectious mononucleosis are asymptomatic. Therefore, 90 % of adults show serological evidence of previous EBV infection.

Straus SE, Cohen JI, Tosato G et al. NIH conference. Epstein-Barr virus infections: biology, pathogenesis, and management. Ann Intern Med. 1993;118(1):45–58.

Answer: B

Hospitalists are often asked to provide guidance regarding the postoperative risk of complications after a variety of noncardiac surgical procedures. A “frailty score” for older patients may be more predictive than current models.

It is useful to categorize the surgical procedures into a low, intermediate, or higher risk category. Individuals who are at the highest risk include those undergoing an emergent major operation. This risk is amplified in elderly adults. High-risk procedures include aortic and other noncarotid major vascular surgery and surgeries with a prolonged operative time. Surgeries that are an intermediate risk include major thoracic surgery, major abdominal surgery, head and neck surgery, carotid endarterectomy, orthopedic surgery, and prostate surgery. Lower risk procedures include eye, skin, and endoscopy.

Seymour DG, Pringle R. Post-operative complications in the elderly surgical patient. Gerontology. 1983;29(4):262–70.

Answer: C

Other considerations in this case may be to obtain a CT scan and possible colorectal surgery consultation.

Answer: C

Abnormal residual bladder volumes have been defined in several ways. No particular definition is clinically superior. Some authorities consider volumes greater than 100 mL to be abnormal. Others use a value greater than 20 % of the voided volume to indicate a high residual. In normal adults, the post-void residual volume should be less than 50 ml. Over the age of 60, a range of 50 ml to 100 ml can be seen but is not known to cause significant issues. Post-void residual (PVR) volume increases with age but generally do not rise to above 100 ml unless there is some degree of obstruction or bladder dysfunction. Urinary retention is common after several days of catheter placement, particularly in males. Caution should be used when placing urinary catheters, as they are a significant cause of urinary retention. Whenever possible urinary catheters should be removed. Bladder training and time may improve the retention. Some consideration may be given to starting the male patient on medications to reduce benign prostatic hypertrophy as well.

Ultrasound can be used as a noninvasive means of obtaining PVR volume determinations, especially if a precise measurement is not required. The error using this formula, compared with the standard of post-void catheterization, is approximately 21 %. In patients with ascites bedside measurement by ultrasound of PVR can be inaccurate due to an inability to differentiate bladder fluid from ascitic fluid.

Lisenmeyer TA, Stone JM. Neurogenic bladder and bowel dysfunction. In: De Lisa J, editor. Rehabilitation medicine. Philadelphia: Lippincott-Raven; 1998. p. 1073–106.

Answer: A

This patient has ongoing moderate pancreatitis. With his possible underlying poor nutritional status due to alcoholism and expected inability to eat, the patient will need nutritional support. This patient will likely be unable to take in oral nutrition for several days.. Enteral nutrition is preferred over parenteral nutrition because of its lower complication rate and proven efficacy in pancreatitis.

Enteral nutrition is provided through a feeding tube ideally placed past the ligament of Treitz so as not to stimulate the pancreas.

Broad-spectrum antibiotics such as imipenem therapy are primarily of benefit in acute pancreatitis when there is evidence of pancreatic necrosis. Randomized, prospective trials have shown no benefit from antibiotic use in acute pancreatitis of mild to moderate severity without evidence of infection. Pancreatic debridement is undertaken with caution and is not indicated here.

Eatock FC, Chong P et al. A randomized study of early nasogastric vs. nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005;100:432–9.

Eckerwall GE, Axelsson JB, Andersson RG. Early nasogastric feeding in predicted severe acute pancreatitis: a clinical, randomized study. Ann Surg. 2006;244:959–65.

Answer: A

At 3 months, new-onset pain signals a mechanical complication of the prosthesis. Orthopedics consult is indicated. Infection is certainly possible, but a prosthetic joint infection would have localized or systemic signs of infection.

Lentino JR. Prosthetic joint infections, bane of orthopedists, challenge for infectious disease specialists. Clin Infect Dis. 2003;36:1157–61.

Answer: D

The benefits of early enteral tube feedings in the critically ill patient are uncertain. Studies have revealed inconsistent results. There is some suggestion that the incidences of infection can be reduced, but there is no data to suggest long-term mortality improvement. In patients with ARDS, trophic tube feedings at 10 ml/h seem to concur the same benefit as early full-enteral tube feedings.

Elpern EH, Stutz L, Peterson S, Gurka DP, Skipper A. Outcomes associated with enteral tube feedings in a medical intensive care unit. Am J Crit Care. 2004;13(3):221–7.

Gramlich L, Kichian K, Pinilla J, Rodych NJ, Dhaliwal R, Heyland DK. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition. 2004;20(10):843–8.

Answer: B

Urinary tract infections (UTIs) are the most common hospital-acquired infections. Most attributed to the use of an indwelling catheter. There should always be a justifiable indication for placement of a urinary catheter, and whenever possible prompt removal should occur. This may be assisted by hospital protocols that trigger automatic reviews of catheter use.

Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319–26.

Answer: B

This patient is enrolled in hospice. Every effort should be made to ensure comfort and limit unnecessary treatments. Dyspnea is one of the most common symptoms encountered in palliative care. Opioids are effective in reducing dyspnea in patients with chronic pulmonary disease. A 5-mg dose of oral morphine given four times daily has been shown to help relieve dyspnea in patients with end-stage heart failure. Extended-release morphine, starting at a 20 mg given daily has been used to relieve dyspnea in patients with advanced COPD.

Bronchodilator therapy should be continued to maintain comfort. Antibiotics and corticosteroids are not indicated. They would not provide immediate relief and would also be inconsistent with care focusing primarily on comfort measures.

Benzodiazepines have not demonstrated consistent benefit in treating dyspnea. They may be useful in specific patients who have significant anxiety associated with their dyspnea.

Currow DC, McDonald C, Oaten S, Kenny B, Allcroft P, Frith P et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage. 2011;42(3):388–99.

Answer: C

This patient has Stevens-Johnson syndrome (SJS). There is no definitive evidence that any initial therapy changes outcomes in SJS. Early data suggested that intravenous immunoglobulin (IVIG) was beneficial, and this traditionally has been the recommended treatment. However, more recent studies have not shown consistent benefit with IVIG.

Immediate cessation of the offending agent or possible agents is necessary. Systemic corticosteroids may be useful for the short-term treatment of SJS, but these drugs increase long-term complications and may have a higher associated mortality. Therapy to prevent secondary infections is important. In principle, the symptomatic treatment of patients with Stevens-Johnson syndrome does not differ from the treatment of patients with extensive burns, and in many instances, these patients are often treated in burn wards.

Future studies are required to determine the role of IVIG in the treatment of SJS. The lesions typically begin with blisters developing over target lesions with mucosal involvement. In SJS, the amount of skin detachment is between 10 and 30 % . Mortality is directly related to the amount of skin detachment with a mortality of about 10 % in SJS. Other risk factors for mortality in SJS include older age and intestinal or pulmonary involvement. The most common drugs to cause SJS are sulfonamides, allopurinol, nevirapine, lamotrigine, and aromatic anticonvulsants.

Mockenhaupt M. The current understanding of Stevens–Johnson syndrome and toxic epidermal necrolysis. Expert Rev Clin Immunol. 2011;7(6):803–15.

Ward KE, Archambault R, Mersfelder TL. Severe adverse skin reactions to nonsteroidal antiinflammatory drugs: a review of the literature. Am J Health Syst Pharm. 2010;67(3):206–13.

Answer: C

Meigs’ syndrome is the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor. Typical diagnostic paracentesis reveals a serum-ascites albumin gradient < 1.1 suggesting a non-portal hypertension-mediated process. Of the possibilities for that, ovarian mass is the most likely here. Transdiaphragmatic lymphatic channels are larger in diameter on the right. This results in the pleural effusion being typically classically located on the right side. The etiologies of the ascites and pleural effusion are poorly understood. Further imaging is indicated.

Riker D, Goba D. Ovarian mass, pleural effusion, and ascites: revisiting Meigs syndrome. J Bronchology Interv Pulmonol. 2013;20(1):48–51.