Answer: C

Candida is an increasingly common pathogen found due to line infections. It is currently the fourth leading bloodstream pathogen. In this particular case, despite the patient not appearing ill, treatment directed toward Candida should be initiated. The most common antifungal agents used for the treatment of candidemia are fluconazole and the echinocandins. These include caspofungin, micafungin, and anidulafungin. Amphotericin B is given less often due to the risk of nephrotoxicity. Both the echinocandins and the azoles are better tolerated than amphotericin B formulations. Candidemia requires treatment with antifungal agents. Catheter removal alone is not adequate therapy for candidemia. Several studies have noted the high mortality rates associated with candidemia. Furthermore, prompt initiation of therapy is crucial.

Reference

Manolakaki D, Velmahos G, Kourkoumpetis T, Chang Y, Alam HB, De Moya MM Mylonakis, E. Candida infection and colonization among trauma patients. Virulence. 2010;1(5):367–75.

Answer: C

Enoxaparin 1 mg/kg SQ daily would be used if a patient had a CrCl < 30 ml/min. Enoxaparin 0.5 mg/kg SQ is the indicated dose for infants >2 months and children </=18 years of age for thromboembolism prophylaxis and would be dosed BID, not daily. Enoxaparin 1.5 mg/kg SQ daily is an appropriate outpatient dosing regimen for patients with a CrCl > 30 ml/min for treatment.

Reference

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

Answer: F

Intravenous methylprednisolone with a suggested dose of 1 g/day for 3–5 days has been the traditional treatment for acute exacerbations of multiple sclerosis. This patient is experiencing an acute exacerbation or relapse of her underlying multiple sclerosis. The data supports the use of high-dose intravenous corticosteroids. This treatment regimen has been demonstrated to speed the recovery from a multiple sclerosis attacks; however, it is uncertain whether this impacts long-term disability.

The 2011 American Academy of Neurology (AAN) Plasmapheresis Guideline Update states that plasmapheresis is effective and may be considered in fulminant demyelinating CNS disease as a first-line agent.

Plasmapheresis can also be considered in cases resistant to corticosteroid therapy, and clinical improvement should be followed closely. Previous clinical trials have demonstrated that oral prednisone is inferior to high-dose intravenous corticosteroids. A change in this patient’s chronic disease-modifying therapy may be considered in consultation with a multiple sclerosis specialist, but would be of no benefit in the acute multiple sclerosis flair.

Reference

Rodriguez M, Karnes WE, Bartleson JD, Pineda AA. Plasmapheresis in acute episodes of fulminant CNS inflammatory demyelination. Neurology. 1993;43(6):1100–4.

Answer: C

The symptoms and physical examination of this patient are typical of benign paroxysmal positional vertigo (BPPV). Referral to ENT or physical therapy for repositioning maneuvers is the best treatment.

BPPV is a common cause of vertigo. Episodes of BPPV are typically brief, lasting no more than 1 min. They are brought about by changes in position. Typical reported movements that elicit vertigo are lying down, rolling over in bed, rising from bed, sitting up and tilting the head to look upward. Vertigo is often accompanied by nystagmus that beats upward and torsionally toward the affected ear. This can be elicited by the Dix–Hallpike maneuver which was performed on physical exam.

The history and physical examination are not consistent with a central cause of vertigo. An MRI can probably be avoided. Methylprednisolone is the primary treatment of acute vestibular neuritis. It is of benefit if used within the first 3 days of symptoms. Vestibular neuritis often presents with more prolonged and persistent symptoms. Most patients recover spontaneously, but when used early, methylprednisolone will decrease the duration of symptoms. Antiviral therapy is not indicated unless there is an obvious herpes zoster infection. Likewise, the symptoms are not consistent with migrainous vertigo, which would be persistent for hours and not be affected by positional changes.

Reference

Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107(3):399–404.

Answer: C

Multiple neuromuscular disorders may affect respiratory function. Guillain–Barré syndrome usually presents as an ascending paralysis with respiratory symptoms occurring later and rarely as a presenting symptom. Although bilateral diaphragmatic paralysis would explain this patient’s shortness of breath, the proximal muscle weakness and ocular symptoms would remain unexplained. Duchenne muscular dystrophy is an X-linked disorder that exclusively affects males that presents by 12 years of age.

The majority of patients with ALS present clinically with progressive asymmetrical weakness, fasciculations, and prominent muscle atrophy. The distal musculature is primarily involved. Myasthenia gravis is an autoimmune disorder that interferes with the postsynaptic acetylcholine receptor. Patients usually present with intermittent symptoms that are usually worse at the end of the day. Respiratory symptoms may be the presenting symptom. The most common severe symptom of myasthenia gravis is respiratory failure. Exposure to bright sunlight, surgery, immunization, emotional stress, menstruation, infection and physical factors might trigger or worsen exacerbations.

Reference

Keesey JC. Clinical evaluation and management of myasthenia gravis. Muscle Nerve. 2004;29(4):484–505.

Answer: C

This patient has granulomatosis with polyangiitis (GPA), which was formerly known as Wegener’s disease. It is associated with both distinctive and nonspecific mucocutaneous signs. Palpable purpura suggestive of vasculitis is one of the most common skin findings. A variety of other dermatologic conditions have been reported including ulcers, papules, and nodules. In addition to upper and lower pulmonary symptoms, nasal ulcerations and septal perforation should suggest the diagnosis. Biopsy is required. Diagnosis is made by the demonstration of a necrotizing granulomatous vasculitis in a patient with upper and lower respiratory tract disease and glomerulonephritis. C-ANCA autoantibodies make several autoimmune diseases less likely.

The absence of asthma makes the diagnosis of Churg-Strauss syndrome unlikely. Patients with lymphomatoid granulomatosis present with a predominance of pulmonary and nervous system manifestations, and tests for ANCA autoantibodies are usually negative.

Reference

Cartin-Ceba R, Peikert T, Specks U. Pathogenesis of ANCA-associated vasculitis. Curr Rheumatol Rep. 2012;14(6):481–93.

Answer: D

Patients with pneumonia and exudative effusion resistant to drainage should be considered for video-assisted thoracoscopic surgery (VATS).

Approximately 15–40% of patients with exudative effusion require surgical drainage of the infected pleural space. Chest tubes often become clogged or effusions become loculated. Patients should be considered for surgery if they have ongoing signs of sepsis in association with a persistent pleural collection. VATS is used as a first-line therapy in many hospitals if cardiothoracic surgery support is available. Open thoracic drainage remains a frequently used alternative technique.

Reference

Ferguson AD, Prescott RJ, Selkon JB, Watson D, Swinburn CR. The clinical course and management of thoracic empyema. QJM. 1996;89(4):285–9.

Answer: B

Naloxone has an extremely rapid onset of action. The duration of naloxone is no greater than 1–2 h. This is of importance as patients who have received a one-time dose may have a return of intoxication symptoms. All opiates have a longer duration of action than naloxone. All patients with opiate overdose symptoms both in the emergency room and on the floor should be monitored for a return of symptoms after naloxone has been given.

Naloxone is most commonly injected intravenously for fastest action, which usually causes the drug to act within a minute. When IV access is not available, it can also be administered via intramuscular or subcutaneous injection. In emergency circumstances, it can be administered intranasally.

Reference

Orman JS, Keating GM. Buprenorphine/naloxone: a review of its use in the treatment of opioid dependence. Drugs. 2009;69(5):577–607.

Answer: E

This patient has an acute onset of Bell’s palsy. The current treatment of choice is prednisone. Mounting evidence suggests that Bell’s palsy is due to human herpes virus 1. It is often is seen after a viral prodrome. Physical examination reveals paralysis of both the upper and lower facial motor neurons which distinguishes it from a cerebrovascular accident.

The patient may also report dry mouth, impaired taste, and pain and numbness in the ear. Abrupt onset of symptoms usually occurs over 1–2 days. The most appropriate treatment is oral prednisone 40 mg per day, started within the first 72 h. Antiviral agents have been used in the past. There is no evidence to date that anti-herpes virus agents, such as acyclovir, as monotherapy for Bell’s palsy are of benefit. High-dose intravenous corticosteroids are not indicated for the treatment of Bell’s palsy.

Reference

Baugh RF, Basura GJ, Ishii LE, Schwartz SR, Drumheller CM, Burkholder R, et al. Clinical practice guideline: Bell’s Palsy executive summary. Otolaryngol Head Neck Surg. 2013;149(5):656–63.

Answer: C

Methamphetamine, which has multiple street names including crystal or crystal meth, presents with hypertension, tachycardia, hyperthermia, and often with poor dentition and evidence of skin excoriations. Other common symptoms are paranoia and diaphoresis. Methamphetamine ingestion is commonly seen in both urban and rural settings. Ingestions often occur at extended late night events, concerts, and within group settings. Methamphetamine users and addicts may lose their teeth abnormally quickly. This may be due to several factors that lead to dry mouth as well as specific behaviors that are induced by the drug.

5–15 % of users may fail to recover completely after cessation of drug use. Antipsychotic medications may effectively resolve the symptoms of acute amphetamine psychosis.

Reference

Darke S, Kaye S, McKetin R, Duflou J. Major physical and psychological harms of methamphetamine use. Drug Alcohol Rev. 2011;27(3):253–62.

Answer: E

Rivaroxaban may be a great choice for this patient due to his age and work lifestyle. It can be started without the need for bridging therapy. Coumadin monitoring can be problematic and leads to a great deal of noncompliance.

If agreeable to the patient, warfarin plus enoxaparin is also an acceptable option. This dosing regimen is well established and validated.

Current guidelines recommend that patients with upper extremity DVTs require treatment similar to lower extremity DVT. Option C is incorrect because of the lack of bridging required initially for this disease state.

References

Ansel J, et al. Pharmacology and management of the vitamin K antagonists – ACCP evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6_suppl):160S–98S.

The EINSTEIN Investigators. Oral Rivaroxaban for treatment of VTE. N Engl J Med. 2010;363:2499–510.

Answer: B

Peritonitis is a common complication seen in peritoneal dialysis patients. Unlike peritonitis seen in end-stage liver disease, the majority of infections are gram-positive bacteria. For this reason, vancomycin or other MRSA-covering antibiotic should be included in the initial therapy. Antifungal therapy should be initiated only if the gram stain reveals yeast. Catheter removal should be considered in certain circumstances but is not necessarily indicated with every infection. Indications for removal of catheter include a repeat infection after 4 weeks of antibiotic therapy, infection not responding to antibiotics, fungal peritonitis, or other resistant causes of peritonitis.

Reference

Piraino B, Bailie GR, Bernardini J, et al. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int. 2005;25(2):107–31.

Answer: A

Spontaneous bacterial peritonitis (SBP) is a common complication of end-stage liver disease. Initial treatment consists of antibiotics that have coverage of gram-negative bacteria. Common isolates are Escherichia coli and Klebsiella pneumonia. There is no evidence that large volume paracentesis improves outcomes in patients with spontaneous bacterial peritonitis. Diagnostic paracentesis should be undertaken to confirm the diagnosis. SBP is confirmed when a WBC count of >250 per microliter is found. Additional paracentesis can be considered to determine the efficacy of treatment or to relieve symptoms.

Reference

Cholongitas E, Papatheodoridis GV, Lahanas A, Xanthaki A, Kontou-Kastellanou C, Archimandritis AJ. Increasing frequency of Gram-positive bacteria in spontaneous bacterial peritonitis. Liver Int. 2005;25(1):57–61.

Answer: D

This patient has an atrial myxoma. Myxomas consist of benign scattered stellate cells embedded in a mucinous matrix. About 70 % of myxomas are in the left atrium. Myxomas often present clinically with mechanical hemodynamic effects, which often simulate mitral or tricuspid stenoses or regurgitation. Systemic symptoms include fatigue, fever, erythematous rash, myalgias, and weight loss, accompanied by anemia and an increased ESR. These symptoms may mimic endocarditis. About 10 % of myxomas are genetic. Surgery is the primary treatment.

Cardiac tumors are usually metastatic. Metastatic cardiac involvement occurs 20–40 times more frequently than primary tumors. Eighty percent of all primary cardiac tumors are benign. Myxomas account for more than half of these in adults.

Reference

Larsson S, Lepore V, Kennergren C. Atrial myxomas: results of 25 years’ experience and review of the literature. Surgery. 1989;105(6):695–8

Answer: A

The patient has acute pericarditis. The chest pain of acute pericarditis is sudden and severe. It is constant over the anterior chest. In acute pericarditis, the pain worsens with inspiration and is reliably positional. The absence of a significant effusion on echocardiography is not evidence against acute pericarditis. Salicylates or NSAIDs are the first-line agents for treatment. Corticosteroids should be reserved for severe cases that are unresponsive to initial therapy. Symptoms may recur after steroid withdrawal, making their use problematic. Low-grade fever and sinus tachycardia may be present.

If carefully auscultated, a pericardial friction rub can be detected in most patients when symptoms are acute. Electrocardiographic changes are common in infectious pericarditis and can occur with other etiologies as well. The characteristic change is an elevation in the ST segment in all leads. The absence of reciprocal ST segment depression distinguishes this characteristic pattern of acute pericarditis from acute myocardial infarction. Depression of the PR interval, which is not as obvious, is often the earliest electrocardiographic manifestation.

Reference

Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmüller R, Adler Y, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; the Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J. 2004;25(7):587–610.

Answer: B

The patient presented with hyperosmolar nonketotic acidosis and a hemoglobin A1c of 11 % meeting requirements to begin a basal-prandial insulin regimen. In patients with consistent extreme hyperglycemia greater than 300 mg/dl, hgbA1c greater than 10 %, insulin should be started immediately.

Metformin is contraindicated in men with a creatinine >1.5 mg/dL and women with creatinine >1.4 mg/dL. The glitazones are typically not recommended for diabetics in the setting of severe uncontrolled hyperglycemia.

Reference

American Diabetes Association. Standards of Medical Care in Diabetes-2015: Abridged for Primary Care Providers. Clinical Diabetes. 2015. 33(2)

Answer: E

Cocaine often induces vascular syndromes due to increased platelet aggregation and endothelial dysfunction. In this particular case, the patient is suffering an acute myocardial infarction due to cocaine. Urgent coronary arteriography, if available, is recommended. Avoidance of beta-blockers acutely after cocaine use is currently a part of the American Heart Association guidelines. This is due to the possibility that beta-blockers may lead to unopposed alpha-adrenergic stimulation with subsequent worsening coronary vasospasm. There have been no controlled trials on this issue yet. It is important to recognize that cocaine can induce myocardial infarctions and other thrombotic events in a low-incidence population such as the case here.

Reference

Hiestand BC, Smith SW. Cocaine chest pain: between a (crack) rock and a hard place. Acad Emerg Med. 2011;18(1):68–71.

Answer: A

This patient’s presentation is consistent with acute respiratory distress syndrome (ARDS). The most appropriate tidal volume is 300 mL. Survival in ARDS is improved when patients are ventilated with a tidal volume of 6 mL/kg of ideal body weight (IBW). A low tidal volume mechanical ventilation strategy is now the standard of care for ARDS.

Lung injury is presumed to arise from repetitive opening and closing of alveoli. Barotrauma may be limited by low tidal volumes. This can be achieved by delivering limited size tidal volumes, minimizing plateau pressure, optimizing PEEP, and reducing FIO₂ to less than 0.6. Ideal body weight rather than actual body weight should be used. Use caution in patients who are overweight or edematous. Calculating actual body weight will typically result in inappropriately large tidal volumes.

Reference

The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–8.

Answer: B

The characteristic infection involves ulcerative subcutaneous nodules that progress proximally along lymphatic channels. The primary lesion develops at the site of cutaneous inoculation, typically in the distal upper extremities. After several weeks, new lesions appear along the lymphatic tracts. Patients are typically afebrile and not systemically ill. The lesions usually cause minimal pain. Many affected patients have received one or more courses of antibacterial therapy without benefit.

Sporotrichosis may involve other organs, including the eye, prostate oral mucosa, paranasal sinuses, larynx and joints. In such patients, the clinical manifestations depend on the organs involved.

Soil, plants, moss and other organic material are common sources. The rose bush thorn has been described as the classic source.

Sporotrichosis occurs worldwide, with focal areas of hyperendemicity, such as Peru and China.

Treatment can be lengthy. One recent guideline recommends oral itraconazole 200 mg/d until 2-4 weeks after all lesions have resolved, usually for a total of 3-6 months.

Reference

Answer: C

She has toxic shock syndrome. The characteristic diffuse rash and systemic symptoms make Staphylococcus the most likely inciting agent. Antibiotic treatment should cover both the leading causes, S. pyogenes and S. aureus. This may include a combination of cephalosporins, vancomycin, or drugs effective against MRSA. The addition of clindamycin may reduce toxin production and mortality. Toxic shock usually has a prominent primary site of infection or source. Staphylococcal toxic shock can be associated with immunosuppression, surgical wounds, or retained tampons. Staphylococcus aureus colonization can incite toxic shock. In certain circumstances and location, it has been suggested that Rocky Mountain spotted fever and leptospirosis which can have a similar presentation be ruled out serologically to confirm the diagnosis. This patient is at very low risk for these diagnoses.

References

Schlievert PM, Kelly JA. Clindamycin-induced suppression of toxic-shock syndrome-associated exotoxin production. J Infect Dis. 1984;149(3):471.

Answer: A

Per package labeling by the pharmaceutical manufacturer, for patients with a CrCl > 30 ml/min and for the treatment of DVT/PE, take 15 mg PO BID × 3 weeks, and then 20 mg PO daily. 15 mg PO daily is a renally adjusted regimen for atrial fibrillation. A 10 mg daily dose is indicated for postoperative VTE prophylaxis.

Reference

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

Answer: C

Familial Mediterranean fever (FMF) also known as recurrent polyserositis presents with monoarticular arthritis and systemic complaints. It is episodic and recurrent which suggests an autoimmune disease. The symptoms presented here are most compatible with familial Mediterranean fever (FMF). It is an autosomal recessive disorder characterized by recurrent 12–72 h episodes of fever with serositis, synovitis, most often monoarticular. Ten percent of patients experience their first episode in early adulthood. FMF is most prevalent in persons of Mediterranean ethnicity. Laboratory studies are consistent with acute inflammation. Serology results are negative for autoimmune disease. Proteinuria may occur from renal amyloidosis. Colchicine is the standard therapy. It reduces both acute attacks and amyloidosis.

Adult-onset Still disease (AOSD) which may have a similar presentation is characterized by fever, rash, joint pain, and serositis. Pleuritis or pericarditis may occur. Fever associated with AOSD is quotidian, lasting less than 4 h, and often peaks in the early evening. The characteristic rash is evanescent, salmon-colored, and not painful. Abdominal pain is rare. Finally, a markedly elevated serum ferritin level occurs in most patients with AOSD.

Reference

Kuky O, Livneh A, Ben-David A, et al. Familial Mediterranean Fever (FMF) with proteinuria: clinical features, histology, predictors, and prognosis in a cohort of 25 patients. J Rheumatol. 2013;40:2083–7.

Answer: A

Factitious fever and self-induced infections are encountered in the hospital with some frequency. The literature suggests an increase in all forms of factitious illness. In factitious fever, high temperatures are often not associated with tachycardia or skin warmth. Many creative methods have been described in the literature to induce an elevated temperature. A high index of suspicion will usually reveal some unusual patterns.

Self-induced infection generally occurs by self-injection of body fluids, pyretic substances, or other contaminated materials. This includes various substances including materials contaminated with feces, pure microbiological cultures, coliform bacilli, and foreign proteins. Patients may have serial episodes of unexplained polymicrobial bacteremia or recurrent soft tissue infections. The underlying disorder for factitious fever may be the Munchausen syndrome and the Munchausen syndrome by proxy.

Reference

Aduan RP, Fauci AS, Dale DC, et al. Factitious fever and self-induced infection: a report of 32 cases and review of the literature. Ann Intern Med. 1979;90(2):230–42.

Answer: E

After acquiring HIV, infected persons may develop a nonspecific febrile illness. The incubation period is 7–14 days after acquiring HIV. The symptoms are similar to influenza or mononucleosis in character. Laboratory testing often reveals lymphopenia and thrombocytopenia, but these findings are not diagnostic. Results of HIV ELISA antibody testing are usually negative because it typically takes 22–27 days for the HIV antibody to become positive. The CD4+ T cell count is usually normal at time of seroconversion.

The plasma p24 antigen test is highly specific for HIV infection but is not as sensitive as the HIV RNA assay. Patients typically have a high level of viremia. They are highly infectious at this stage. Plasma HIV RNA level of several million HIV RNA copies per milliliter of plasma are usually seen. The combination of a positive HIV RNA test and a negative screening HIV antibody test result confirms the diagnosis of acute HIV infection.

Reference

Answer: C

This patient has ampicillin- or amoxicillin-related exanthematous eruption that can frequently occur with mononucleosis. This does not appear to be IgE mediated and is not a penicillin allergy. Patients may receive penicillins in the future. The etiology of the ampicillin rash that occurs in association with a viral infection is unknown.

Fever is not associated with simple exanthematous eruptions. These eruptions usually occur within 1 week after the beginning of therapy and generally resolve within 7–14 days. Scaling or desquamation may follow resolution. The treatment of exanthematous eruptions is generally supportive. Oral antihistamines used in conjunction with soothing baths may help relieve pruritus. Topical corticosteroids are indicated when antihistamines do not provide relief. Systemic corticosteroids are used only in severe cases. Discontinuance of ampicillin is recommended.

Reference

Kagan B. Ampicillin rash. West J Med. 1977;126(4):333–5.

Answer: C

This patient’s symptoms of fever, tremor, agitation, and rigidity are consistent with the neuroleptic malignant syndrome. This is a potential life-threatening condition. It is characterized by hyperthermia that is accompanied by autonomic dysfunction, as seen in this patient. This syndrome presents as a reaction to new antipsychotic neuroleptic medications or an increase in neuroleptic medications, as is the case here. The most common offending agents are the older antipsychotics such as haloperidol and fluphenazine. Neuroleptic malignant syndrome rapidly develops over a 24-h period and peaks within 72 h.

References

Gurrera RJ, Caroff SN, Cohen A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method. J Clin Psychiatry. 2011;72(9):1222–8

Trollor JN, Chen X, Sachdev PS. Neuroleptic malignant syndrome associated with atypical antipsychotic drugs. CNS Drugs. 2009;23(6):477–92.

Answer: B

Phencyclidine, or PCP, often presents with severe agitation, psychosis, and violent behavior. Often, multiple people are required to restrain the patient. Vertical or rotatory nystagmus is a unique finding characteristic of PCP intoxication. Management of phencyclidine intoxication mostly consists of supportive care. Benzodiazepines have been used for agitation and for the treatment of seizures that can occur with PCP ingestion.

Cocaine intoxication may present with similar symptoms but is not reported to cause nystagmus. Lysergic acid diethylamide (LSD) is a typical hallucinogen, but no significant amount of violent behavior is reported. MDMA and ecstasy are both hallucinogenic and a stimulant. Violent behavior is not usually seen. Heroin causes a typical opioid symptom profile consisting of constricted pupils, sedation, and respiratory depression.

Since its peak use in urban areas, the 1970s PCP use has declined.

Reference

Zukin SR, Sloboda Z, Javitt DC. Phencyclidine PCP. In: Lowinson JH, Ruiz P, Millman RB, et al., editors. Substance abuse: a comprehensive textbook, 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005.

Answer: C

For thromboprophylaxis with fixed-dose enoxaparin, there is a strong negative correlation between total body weight and anti-Xa levels in obese patients. Several prospective trials have examined this issue in patients undergoing bariatric surgery, with inconclusive findings. However, guidelines have stated that increasing the prophylactic dose of enoxaparin in morbidly obese patients (body mass index >/=40 kg/m²) is appropriate. The most common dosing recommendation for this scenario is 40 mg SQ BID. However, other indications, such as bariatric surgery, have recommended 60 mg SQ BID if BMI>/=50 kg/m². Early ambulation and sequential compression devices alone would not be appropriate DVT prophylaxis for a high VTE risk.

References

Frederiksen SG, Hedenbro JL, Norgren L. Enoxaparin effect depends on body-weight and current doses may be inadequate in obese patients. Br J Surg. 2003;90:547–8.

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

Nutescu EA, Spinler SA, Wittkowsky A, Dager WE. Low-molecular-weight heparins in renal impairment and obesity: available evidence and clinical practice recommendations across medical and surgical settings. Ann Pharmacother. 2009;43:1064–83.

Answer: D

This patient has moderate to severe Crohn’s disease. This is based on her symptoms of fever, weight loss, abdominal pain without obstruction, and ability to continue oral intake. For the treatment of moderate to severe Crohn’s disease, the current recommendations include the “top-down” approach. This differs from the conventional step-up approach in that more potent agents are administered initially. For symptoms of this severity, corticosteroids will be necessary. The use of 5-ASA for the treatment of Crohn’s disease is limited. In studies, only a small subset of patients have benefitted from this agent.

Infliximab may be used in patients who are not responsive to salicylates, antibiotics, or steroids. Unless the small bowel mucosal disease is very extensive, the macrocytic anemia is most likely caused by a deficiency of vitamin B12, which is absorbed in the terminal ileum.

Reference

Ford AC, Bernstein CN, Khan KJ, Abreu MT, Marshall JK, Talley NJ, et al. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. Am J Gastroenterol. 2011;106(4):590–9.

Answer: C

In a setting of significant hyponatremia with neurologic symptoms, consideration must be given to administering hypertonic saline. This patient’s condition is almost certainly due to syndrome of inappropriate antidiuretic hormone (SIADH) due to her small cell lung cancer. Isotonic normal saline would probably worsen the hyponatremia by the mechanism of water retention and sodium excretion. When hypertonic saline is administered, careful monitoring of her sodium levels should be done to prevent central pontine myelinolysis, which can occur with rapid correction. In less severe cases with no neurologic findings, water restriction would be the first line of treatment.

Reference

Zenenberg RD, Carluccio AL, Merlin MA. Hyponatremia: evaluation and management. Hosp Pract. 2010;38(1):89–96.

Answer: D

The treatment for Clostridium difficile infections is changing as new protocols and therapies are developed. The patient in this question is characterized as having moderate Clostridium difficile infection. First-line treatment is based on the severity of illness and initial clinical response. Symptoms of moderate disease include 6–12 bowel movements per day, fever of 37.5–38.5 °C, a WBC count between 15,000 and 25,000 cells/μl, or visible GI bleeding. Oral vancomycin is the treatment of choice for moderate disease. For severe disease, oral vancomycin 125 mg q 6 and IV metronidazole 500 mg q 6 is the treatment of choice. For mild disease, oral Flagyl can be used alone, 500 mg q 8. New treatment modalities, such as fidaxomicin as well as stool replacement therapy, have shown promising results and are currently undergoing trials.

Reference

Ananthakrishnan AN. Clostridium difficile infection: epidemiology, risk factors and management. Nat Rev Gastroenterol Hepatol. 2011;8(1):17–26.

Answer: D

This patient has triglyceride induced pancreatitis. The serum amylase level may be normal in some patients with acute pancreatitis associated with high triglycerides as marked elevations in the triglyceride level can interfere with the laboratory assay for amylase. The presence of a papular rash on this patient is consistent with eruptive xanthomas due to hypertriglyceridemia.

In the acute phase, the initial treatment of hypertriglyceridemia-induced acute pancreatitis focuses on good hydration and analgesia and is similar to the management of acute pancreatitis due to any etiology. The triglyceride levels usually rapidly decrease within 48 h of the onset of acute pancreatitis.

Gallstones and alcohol abuse combined account for 70–80 % of all cases of acute pancreatitis. Other etiologies include sphincter of Oddi dysfunction, strictures of the pancreatic duct, congenital anatomic abnormalities and genetic disorders, drugs, toxins, trauma, infections, and metabolic causes. Some cases are idiopathic. Metabolic causes of acute pancreatitis include not only hypertriglyceridemia but hypercalcemias well. Serum triglycerides generally need to be in excess of 1,000 mg/dl to produce acute pancreatitis. This is most commonly seen in type V hyperlipoproteinemia and is usually associated with diabetes mellitus. Acute pancreatitis can itself raise triglyceride levels, but not to this degree.

References

Suang W, Navaneethan U, Ruiz L, et al. Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol. 2009;104:984–91.

Toskes PP. Hyperlipidemic pancreatitis. Gastroenterol Clin North Am. 1990;19:783–91.

Answer: E

In this case, there are no absolute contraindications to thrombolytic therapy.

The patient meets ECG criteria for the administration of thrombolytic therapy. This includes ST segment elevation greater than 0.1 mm in two contiguous leads.

Age greater than 75 years is not a contraindication to thrombolysis. In patients older than 75 years, there is an increased risk of hemorrhagic stroke. Overall mortality is reduced in such patients without other contraindications. A prior history of hemorrhagic stroke is an absolute contraindication to thrombolytic. A history of an ischemic stroke less than 1 year is an absolute contraindication. A stroke more than 1 year before presentation is a relative contraindication. Blood pressure >180/110 mmHg is a relative contraindication to thrombolytic therapy.

Reference

O’Gara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362–452.

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.

Reference

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: C

Risk stratification for pulmonary embolism is the goal of many current studies. A reliable method is currently being developed. In patients who are hemodynamically stable, a number of tests have been examined in this effort. Clot size and location are not good at predicting mortality or right ventricular strain.

Examination of ventricular volumes comparing right to left may be the best measurement for predicting outcomes. A ratio >1.2 that is suggestive of right ventricular strain has utility in predicting adverse outcome and death. Echocardiograms may look for right heart strain as well. Other tools that are being considered include biomarkers such as troponin and pro-brain natriuretic peptide (proBNP) levels, and clinical models such as PESI (Pulmonary Embolism Severity Index) and PREP (prognostic factors for PE).

References

Aujesky D, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172:1041–6.

Becattini C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest. 2013. doi:10.​1378/​chest.​12-2938.

Sanchez O, et al. Prognostic factors for pulmonary embolism: the PREP study, a prospective multicenter cohort study. Am J Respir Crit Care Med. 2010;181:168–73.

Answer: B

This patient has legionella pneumonia, which should be treated with a quinolone or macrolide antibiotic. Legionella pneumonia presents with the common symptoms of fever, chills, and cough. Distinguishing features are loss of appetite, loss of coordination, and occasionally diarrhea and vomiting. Relative bradycardia has traditionally been considered a symptom. Laboratory tests may show significant changes in renal functions, liver functions, and electrolytes. This can include marked hyponatremia. Chest X-rays often show bi-basal consolidation. It is difficult to distinguish Legionnaires’ disease from other types of pneumonia by symptoms alone. Serology is often required for diagnosis. Many hospitals utilize the urinary antigen test for initial detection when legionella pneumonia is suspected.

It is not spread from person to person, but rather often through exposure to aerosolized cool water, such is the case here.

It acquired its name after a July 1976 outbreak of a then unrecognized disease, which afflicted 221 persons, resulting in 34 deaths. The outbreak was first noticed among people attending a convention the American Legion.

References

Fraser DW, Tsai T, Orenstein W, et al. Legionnaires’ disease: description of an epidemic of pneumonia. N Engl J Med. 1977;297:1186–96.

Woo AH, Goetz A, Yu VL. Transmission of Legionella by respiratory equipment and aerosol generating devices. Chest. 1992;102(5):1586–90.

Answer: C

This patient is volume depleted and not hemodynamically stable. Survival may be dependent upon the correct management sequence. Two large-bore peripheral catheters or a central line for volume repletion is urgently required. Fluid resuscitation should be started as well as an urgent type and match for blood transfusion. Although rapid diagnosis may be of benefit, early resuscitation measures should not be delayed by diagnostic workup.

A nasogastric tube may be considered after volume resuscitation, if an upper source of gastrointestinal bleeding is likely. Regardless of the source of bleeding at this point in the management, the first rule is to achieve hemodynamic stability.

Although a colonoscopy is the diagnostic test of choice to evaluate for sources of lower gastrointestinal bleeding, this should not occur before volume resuscitation. A bleeding scan may be indicated if an endoscopic evaluation is not immediately possible or if an endoscopic evaluation has been non-revealing. Diverticular bleed is certainly a possibility in this case. If a bleeding diverticulum is detected on colonoscopy, it can be treated with thermal coagulation or epinephrine injection. Up to 90 % of diverticular bleeding resolves without intervention.

References

Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010;105(12):2636–41.

Scottish Intercollegiate Guidelines Network (SIGN). Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. SIGN publication; no. 105. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2008.

Answer: B

Healthcare-associated pneumonia (HCAP) treatment with vancomycin requires higher trough levels of 15–20 mcg/ml.

References

ATS Board of Directors and IDSA Guideline Committee. Guidelines of the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388–416.

Ryback M et al. Therapeutic monitoring of vancomycin in adult patients. Am J Health-Syst Pharm. 2009;66:82–98.

Answer: D

This patient is neutropenic and febrile and warrants rapid initiation of antibiotics. A stepwise and logical approach is needed for the selection of antibiotics. Febrile neutropenia is a medical emergency. Patients may not present with overt signs of infection. However, septic shock and death can occur within hours of presentation.

Initial antibiotic choices may include a third-generation cephalosporin, penicillin with beta-lactamase inhibitor, or cefepime. Endogenous flora from the gastrointestinal tract is the probable cause for most cases of febrile neutropenia. Vancomycin may be considered but alone would not be sufficient coverage for this patient. Empiric antifungal therapy is usually reserved for patients who are febrile after the source of infection is not found following 4–7 days of broad-spectrum antimicrobial therapy. Viral infections are not common, and empiric therapy with antiviral agents such as acyclovir is not warranted.

Reference

Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis. 2002;34(6):730–51.

Answer: F

This patient has bradycardia and hypotension from beta-blocker toxicity. This is caused by a reduced clearance of atenolol, which is renally excreted and impaired because of her prerenal kidney failure. Glucagon is used to reverse beta-blocker toxicity and is often used as a first-line agent when beta-blocker toxicity is the confirmed issue. Atropine may be used according protocols as well.

She should also receive fluid resuscitation with intravenous normal saline solution. If she does not improve with glucagon and IV fluids, external pacemaker or transvenous pacemaker can also be used.

Reference

Hoot NR, Benitez JG, Palm KH. Hemodynamically unstable: accidental atenolol toxicity?. J Emerg Med. 2013;45(3):355–7.

Answer: F

This patient presents with frostbite of the left foot. One of the common presenting symptoms of this is sensory changes that affect both pain and temperature reception. Hemorrhagic vesicles are caused by injury to the vasculature. The prognosis is more favorable when the presenting area has a rapid return to normal temperature and color returns as well. Treatment of extremities is with rapid rewarming, which usually is accomplished with a 37–40 °C (98.6–104 °F) water bath.

The period of rewarming can be intensely painful for the patient, and often narcotic analgesia is warranted and should be anticipated to improve compliance. If the pain is intolerable, the temperature of the water bath may be lowered slightly. Compartment syndrome can develop. Rewarming should be closely followed. No medications have been shown to improve outcomes. This includes heparin, steroids, calcium channel blockers, and hyperbaric oxygen. Emergent surgical decisions about the need for debridement should be deferred until the boundaries of the tissue injury are determined. Neuronal injury often occurs with abnormal sympathetic tone in the extremity. This may be permanent or resolve over the course of several months.

References

McCauley RL, Hing DN, Robson MC, Heggers JP. Frostbite injuries: a rational approach based on the pathophysiology. J Trauma. 1983;23(2):143–7.

Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite. J Trauma. 2005;59(6):1350–4; discussion 1354–5.

Answer: C

This patient has a grade 3 concussion. A concussion is defined as trauma-induced alteration in mental status that may be associated with transient loss of consciousness. Neither a grade 1 nor a grade 2 concussion involves a loss of consciousness. A grade I concussion, or mild bruising of brain tissue, is the most common form of head injury. The athlete may briefly appear or act confused; however, he or she is able to remember all events following the impact. The difference between a grade II and a grade I concussion is the presence of post-traumatic amnesia. A grade 3 concussion, such as is seen in this patient, is defined by a brief or prolonged loss of consciousness. Current recommendations state that a grade 1 concussion are permitted to return to the contest on the same day as the injury. The athlete should be removed from competition for at least 20 min and examined every 5 min.

Those with grade 2 or grade 3 concussions are prohibited from returning that day. Grade 3 concussions are prohibited from returning to competition until the athlete is asymptomatic for 1 week. Hospitalization is indicated in the presence of traumatic findings, abnormal neuroimaging studies, or with persistent abnormalities seen on physical examination.

Reference

Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TS, Gioia GA, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(24):2250–7.

Answer: A

Syncope is a common admission to the hospital. The majority of cases are vasovagal in origin and warrant limited and focused workup. History and physical examination are the most specific and sensitive ways of evaluating syncope. These measures, along with 12-lead electrocardiography (ECG), are the only current level A recommendations listed in the 2007 American College of Emergency Physicians (ACEP) Clinical Policy on Syncope.

Several tests commonly ordered have little yield. Cardiac enzymes determine the etiology of syncope in only 0.5 % of patients. Carotid ultrasonography determines the etiology of syncope in 0.8 % of patients. Computed tomography of the brain determines the etiology of syncope in 0.5 % of patients. Electroencephalography determines the etiology of syncope in only 0.8 % of patients. The use of these tests is warranted only when there is evidence to suggest that vasovagal syncope is not the cause.

A common scenario is for vasovagal syncope to occur in the middle of the night while going to the bathroom, as is the case here. Confusion is often present and does not necessarily point toward a postictal state. Reassurance and lifestyle modifications are the best treatment. This includes methods to reduce nighttime bathroom use, which is common cause of syncope and injury inducing falls.

Measurement of postural blood pressure may confirm the diagnosis and is often a cost-effective test in determining the cause of syncope.

Reference

Huff JS, Decker WW, Quinn JV, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49(4):431–44.

Answer: E

Many patients with gastroesophageal reflux disease are appropriately treated with empiric therapy. Endoscopy is reserved for those with chronic symptoms who are at risk for Barrett’s esophagus and those with alarm symptoms.

Alarm symptoms include dysphagia, odynophagia, gastrointestinal bleeding or anemia, weight loss, and chest pain. Other alarm features are age greater than 55 years and family history of gastric cancer. This patient’s weight loss would warrant endoscopic evaluation.

Reference

DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 1999;94:1434–42.

Answer: D

Triphasic waves have been associated with a wide range of toxic, metabolic, and structural abnormalities. They were first described in a patient with hepatic encephalopathy.

The EEG can often provide clinically useful information in comatose patients. Certain EEG patterns may help in determining diagnosis and prognosis. The EEG becomes slower as consciousness is depressed, regardless of the underlying cause. The EEG is usually normal in patients with locked-in syndrome and helps in distinguishing this disorder from the comatose state. Epileptiform activity characterized by bursts of abnormal discharges containing spikes or sharp waves may be useful to diagnose and treat unrecognized nonconvulsive status in a presumed comatose patient. Patients with herpes simplex encephalitis may show a characteristic pattern of focal, often in the temporal regions or lateralized periodic slow-wave complexes.

Yang SS, Wu CH, Chiang TR, et al. Somatosensory evoked potentials in subclinical portosystemic encephalopathy: a comparison with psychometric tests. Hepatology. 1998;27:357–9.

Answer: E

Blood cultures are not beneficial for many patients admitted with uncomplicated cellulitis. They should be limited to certain high-risk populations. Any form of immunosuppression or underlying structural damage would increase the risk of bacteremia, and thus a blood culture should be performed and may be of benefit.

Reference

Phoenix G, Das S, Joshi M. Diagnosis and management of cellulitis. BMJ (Clinical Research ed.). 2012;345:e4955.

Answer: B

Lupus cerebritis can pose as a major diagnostic challenge, as many lupus patients have underlying neuropsychiatric symptoms. The case here has some classical findings, but many cases are elusive. Patients may present with acute confusion, lethargy, coma, chronic dementia, depression, mania, affective disturbances, or psychosis.

Prompt identification can be extremely difficult, mainly because there is no single laboratory or radiological confirmatory test. Inflammatory markers can be variable. Lupus cerebritis should be included as a possible diagnosis in any young female patient who presents with complicated neurologic manifestations and no alternative diagnosis.

Reference

Calabrese LV, Stern TA. Neuropsychiatric manifestations of systemic lupus erythematosus. Psychosomatics. 1995;36:344–8.

Answer: E

First episode with mild or moderate leukocytosis with a white blood cell count of 15,000 cells/mL or lower and a serum creatinine level less than 1.5 times the premorbid level – metronidazole 500 mg 3 times per day by mouth for 10–14 days

First episode, severe and leukocytosis with a white blood cell count of 15,000 cells/mL or higher or a serum creatinine level greater than or equal to 1.5 times the premorbid level – vancomycin 125 mg 4 times per day by mouth for 10–14 days

First episode, severe and complicated by hypotension or shock, ileus, megacolon – vancomycin 500 mg 4 times per day by mouth or by nasogastric tube, plus metronidazole 500 mg every 8 h intravenously

If complete ileus, consider adding rectal instillation of vancomycin.

Reference

Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC, Pepin J, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;3:431–55.

Answer: E

This patient has drug-induced lupus erythematosus (DILE). The most common drugs that cause DILE are hydralazine, procainamide, quinidine, isoniazid, diltiazem, and minocycline.

He has new-onset fever, arthralgia, myalgia, nonblanching purpuric rash, pleuritis, pancytopenia, and proteinuria with active urine sediment.

Testing for antinuclear antibodies (ANA), as well as anti-double-stranded DNA antibodies and complement levels, is indicated. This multiorgan pattern is suggestive of an autoimmune disorder, in particular of systemic lupus erythematosus (SLE). No specific criteria establish the diagnosis of DILE. Excluding other underlying autoimmune diseases must first be done. SLE is typically ruled out first.

Drugs that cause DILE may take months to years before the associated symptoms occur. In addition similar drugs can also induce flairs of SLE.

References

Fritzler MJ. Drugs recently associated with lupus syndromes. Lupus. 1994;3(6):455–9.

Lowe G, Henderson CL, Grau RH, Hansen CB, Sontheimer RD. A systematic review of drug-induced subacute cutaneous lupus erythematosus. Br J Dermatol. 2011;164(3):465–72.

Answer: E

A vegetative state “of wakefulness without awareness” was first described in 1972. In the vegetative state, patients may open their eyelids occasionally and demonstrate sleep-wake cycles, but completely lack cognitive function, communication, or purposeful movement. In addition, extensive neurologic and medical test must be made to rule out treatable causes.

In the minimally conscious state, unlike the vegetative state, there is evidence that patients are aware of themselves and/or their environment.

Traditionally, per informal US guidelines, a vegetative state that lasts greater than 1 month is considered to be a persistent vegetative state. A diagnosis of persistent vegetative state does not absolutely imply permanent disability because in very rare cases patients can improve, reaching a minimally conscious state or a higher level of consciousness.

Reference

Ashwal S. The Multi-Society Task Force On Pvs. Medical aspects of the persistent vegetative state – second of two parts 1994. N Engl J Med. 330(22):1572–9.

Answer: E

The current guidelines recommend that adults older than age 40 who are hospitalized for medical reasons and are expected to be less mobile for 3 days or more be given some form of deep venous thrombosis (DVT) prophylaxis. This is based on several randomized controlled trials.

However, whether these recommendations should apply to older adults is less uncertain. A systematic review and meta-analysis examined the evidence for harm and efficacy of pharmacologic prophylaxis of DVT in older adults. For the most part older adults with comorbidities have been excluded from studies. The majority of events prevented in studies are asymptomatic DVTs. There is no consistent reduction in fatal pulmonary embolism or mortality. When data from the three trials with patients older than age 75 are pooled, a similar reduction in endpoints to other trials is seen. However, two-thirds of these events are asymptomatic DVTs. In the general population, the absolute bleeding risk is generally increased by 2 % in the heparin treatment group. Older age with its comorbidities may increase this risk.

The current data suggest that this patient would gain a very small absolute risk reduction for symptomatic DVTs and an even smaller risk for pulmonary embolism. Given her wishes, it is reasonable to stop heparin and encourage ambulation.

References

Greig MF, Rochow SB, Crilly MA, Mangoni AA. Routine pharmacological venous thromboembolism prophylaxis in frail older hospitalized patients: where is the evidence? Age Ageing. 2013;42:428–34.

Wakefield TW, Proctor MC. Current status of pulmonary embolism and venous thrombosis prophylaxis. Semin Vasc Surg. 2000;13(3):171–81.

Answer: D

Cardiac arrhythmias in methadone users have been reported for several decades. The most serious have been wide complex tachycardias. Risk factors include female sex, hypokalemia, high-dose methadone, drug interactions, underlying cardiac conditions, and unrecognized congenital long Q-T interval syndrome.

In methadone patients, an ECG should be obtained on admission. QT prolongation may predict subsequent malignant arrhythmias and possible need to alter methadone treatment. Methadone has been used to treat heroin addicts for nearly 50 years, but little is known about its long-term side effects.

Reference

Justo D, Gal-Oz A, Paran Y et al. Methadone-associated torsades de pointes (polymorphic ventricular tachycardia) in opioid-dependent patients. Addiction. 2006;101:1333–8.

Answer: C

This patient is exhibiting a sympathomimetic presentation probably due to crack cocaine ingestion. This should be considered as an additive in someone with a history of smoking marijuana. His possible myocardial ischemia is due to endothelial dysfunction as well as aggregation of platelets. In this particular scenario, there is no evidence of segment elevation myocardial infarction, so PTCA, tPA, and GP IIb/IIIa are not indicated. A reasonable approach would be an aspirin with further cardiovascular workup considered.

Beta-blockers are relatively contraindicated in cocaine-induced chest pain as there is a possible risk of increased peripheral vascular resistance. This has not been well tested.

References

Hobbs WE, Moore EE, Penkala RA, Bolgiano DD, López JA. Cocaine and specific cocaine metabolites induce von Willebrand factor release from endothelial cells in a tissue-specific manner. Arterioscler Thromb Vasc Bio. 2013;33:1230–7.

2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344–e426.

Answer: D

Delirium and psychosis occur in about one-third of patients with Parkinson’s disease. There have been no conclusive studies on the best approach in the treatment of delirium in patients with Parkinson’s disease.

There is a strong contraindication for haloperidol, olanzapine, and risperidone because of potential exacerbation of extrapyramidal symptoms. There is also a lack of efficacy reported with olanzapine. Other atypical antipsychotics such as quetiapine have been commonly used with caution and slow titration. Most studies suggest that quetiapine is safe in Parkinson’s disease. Some reports suggest that there is an increased risk of adverse motor effects in these patients, predominantly in demented subjects.

Reference

David A. Quetiapine in the treatment of psychosis in Parkinson’s disease. Ther Adv Neurol Disord. 2010;3(6):339–50.

Answer: C

Venous thromboembolism, which includes pulmonary embolism and deep venous thrombosis, continues to be a common clinical problem. The American College of Physicians recommends pharmacologic prophylaxis with heparin or a related drug for venous thromboembolism in medical patients unless the assessed risk for bleeding outweighs the likely benefits. Aspirin and mechanical prophylaxis with graduated compression stockings have been shown to provide inferior coverage in comparison but in some circumstances may be the best option. Heparin 5000U SQ TID is recommended for patients with end-stage renal disease undergoing dialysis. Lovenox is cleared by hemodialysis in an irregular manner and is contraindicated in patients undergoing dialysis.

Reference

Qaseem A, et al. Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann InternMed. 2011;155(9):625–32.

Answer: E

This patient has developed acute renal failure secondary to contrast-induced nephropathy. Several causes of renal failure are possible. They include interstitial nephritis secondary to penicillin and infective endocarditis. Aminoglycoside toxicity should also be considered.

Normal complement levels (C2,3,4) and rapid onset point toward contrast-induced nephropathy. Aminoglycoside toxicity usually happens 4–5 days after the therapy.

Reference

Murphy SW, Barrett BJ, Parfrey PS. Contrast nephropathy. J Am Soc Nephrol. 2000;11(1):177–82.

Answer: D

This patient has normotensive ischemic kidney injury. The findings of elevated fractional excretion of sodium, fractional excretion of urea, and granular casts seen on urinalysis are all consistent with this diagnosis.

The patient’s medical history reveals evidence of an underlying chronic kidney disease possibly due to vascular disease. This places the patient at increased risk for normotensive ischemic injury. The patient’s lower blood pressure during hospitalization may be the result of a variety of factors, including infection, better medicine compliance, and the low-salt diet typically seen during a hospitalization.

Acute interstitial nephritis, which is often caused by a hypersensitive reaction to medication, is a possibility. However, the patient’s lack of fever, rash, and leukocytes on her urinalysis argues against this diagnosis. Prerenal azotemia is common in the consideration of this patient’s differential diagnosis. The patient’s fractional excretion of sodium of 2 % and fractional excretion of urea of 50 % argues against this. The fractional excretion of urea is a more sensitive test for patients on diuretics.

Reference

Abuelo JG. Normotensive ischemic acute kidney injury. N Engl J Med. 2007;357(8):797–805.

Answer: C

Acute mesenteric ischemia (AMI) is a syndrome caused by inadequate blood flow through the mesenteric vessels from a combination of preexisting vascular disease, emboli, and hypotension. This results in ischemia and eventual gangrene of the bowel wall. It is a potentially life-threatening condition. This patient’s drop in blood pressure due to morphine triggered the ischemic event.

AMI may be classified as either arterial or venous. CT scan and laboratory values in this case are consistent with an acute event. CT scan may reveal bowel wall thickening or, in some instances, intestinal pneumatosis as in this case. Treatment options for acute thrombosis can be surgical, stenting, or thrombolytics. Early and aggressive diagnostic imaging and early surgical consultation are warranted. Angiography is the test of choice for both diagnosis and possible therapeutic vasodilation and stenting.

Because of the high mortality and the difficulty of diagnosis, mesenteric ischemia has traditionally been considered a diagnostic challenge.

Reference

Answer: B

Moxifloxacin is a quinolone antibiotic that does not achieve adequate concentration in the urine, thereby eliminating its use in the treatment of urinary tract infections. It does not matter whether moxifloxacin is given either oral or IV – the bioavailability of the oral is 100 % and the IV formulation has no ability to concentrate in urine.

Reference

Gupta K, Hooton TM, Naber KG et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis pyelonephritis in women: a 2010 Update by the Infectious Disease Society of America and the European Society of Microbiology and Infectious Disease. Clin Inf Dis. 2011;52:e103–20.

Answer: C

Alcohol use disorders are common and can complicate postoperative recovery. In this particular case, the fever, tachycardia, hypertension, and tremor are suggestive of alcohol withdrawal. The alcohol level in trauma patients should be checked on admission, as withdrawal is a common source of delirium in this population.

About 9 % of US adults meet the criteria for an alcohol use disorder. Less than 50 % of alcohol-dependent persons develop any significant withdrawal symptoms that require pharmacologic treatment upon cessation of alcohol intake. Minor withdrawal occurs within 6–24 h following the patient’s last drink and is characterized by tremor, anxiety, nausea, vomiting, and insomnia. Major withdrawal occurs 10–72 h after the last drink. The signs and symptoms include visual and auditory hallucinations, whole body tremor, vomiting, diaphoresis, and hypertension.

The most objective and best-validated tool to assess the severity of alcohol withdrawal is the Clinical Institute Withdrawal Assessment for Alcohol.

Reference

Answer: C

This patient has Cushing syndrome due to excessive ACTH production. This is almost certainly due to underlying malignancy such as lung cancer which is the case here. Approximately half of all cases of ectopic ACTH secretion are due to small cell lung cancer, which has a long list of paraneoplastic syndromes associated with it.

Adrenal adenomas can be associated with hypercortisolism, but the features tend to cause a mild Cushing syndrome. Adrenal adenomas are associated with suppressed ACTH levels. Hyperpigmentation suggests excessive ACTH production.

A chest radiograph does not rule out the possibility of a lung malignancy and computed topography of the chest is needed.

Reference

Iias I, Torpy DJ, Pacak K, Mullen N, Wesley RA, Nieman LK. Cushing’s syndrome due to ectopic corticotropin secretion: twenty years’ experience at the National Institutes of Health. J Clin Endocrinol Metab. 2005;90(8):4955–62.

Answer: D

Aortic valve replacement is recommended for symptomatic patients with severe aortic stenosis. Severe aortic stenosis is defined as an aortic velocity 4.0 m per second or greater or by a mean pressure gradient 40 mmHg or higher. Symptoms of heart failure, syncope, exertional dyspnea, angina, or presyncope by history or on exercise testing are also indications.

Reference

Nishimura R, et al. 2014 AHA/ACC guidelines for the Management of patients with Valvular Heart Disease. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:57–185.

Answer: A

The patient has severe sepsis from pyelonephritis. Aggressive fluid resuscitation is indicated. Resolution of lactic acidosis within 6 h will have a beneficial effect on this patient’s survival. Resuscitation of the circulation should target a central venous oxygen saturation or mixed venous oxygen saturation of at least 70 %. Other goals include a central venous pressure of 8–12 mmHg, a mean arterial pressure of at least 65 mmHg, and a urine output of at least 0.5 mL/kg/h.

Fluid requirements are often as much as 5–6 L of fluid. Early goal-directed therapy sees the most benefits within the first 6 h. End points that improve survival include maintaining a SCVO₂ of greater than 70 % and resolution of lactic acidosis.

Blood transfusion may be part of resuscitation for anemic patients in shock. In stable patients who have not had major blood loss or further blood loss is anticipated, a transfusion threshold of 7 g/dL is an acceptable approach. There are no data to support that maintaining a lower PCO₂ is of any benefit. In addition placement of a pulmonary artery catheter would help to increase survival in this patient.

Reference

Rivers E, Nguyen B, Havstad S, Ressler J, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368–77.

Answer: E

Syncope accounts for 3 % of all emergency department visits and 1 % of all hospitalizations. Additionally, it is estimated that 35 % of all individuals will experience at least one syncopal event in their lifetime. Currently, no specific testing has sufficient power to be recommended for evaluation of syncope.

Syncope occurs when blood flow to the brain suddenly drops. Vasovagal syncope is one category without a clearly defined mechanism but can occur with intense emotions, strong odors, or orthostatic factors. Neurally mediated syncope can be brought about by specific mechanical events such as cough, micturition, swallowing, or carotid sensitivity. Reassurance and avoidance of triggers are the primary treatments. Liberal intake of fluids and salt and prevention of dehydration are protective against all forms of syncopal events.

In randomized controlled trials, isometric counterpressure maneuvers are also protective. In patients with refractory syncope, fludrocortisone, beta-blockers, and other vasoconstricting agents have been used with limited success. However, there are no clinical trial data to support their use.

References

Moya A, Sutton R, Ammirati F, et al. Guidelines for the diagnosis and management of syncope (version 2009): the Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009;30(21):2631–71.

Tan MP, Parry SW. Vasovagal syncope in the older patient. J Am Coll Cardiol. 2008;51(6):599–606.

Answer: E

It would be reasonable to try an increased diuretic dose in this patient. The recommended initial regimen is furosemide 40 mg plus spironolactone 100 mg daily. This patient is not at the maximum diuretic dose. Diuretics can be increased every 3–5 days, while maintaining the 40:100 mg ratio. In ascites due to end-stage liver disease, the maximum dose for furosemide is 160 mg daily and for spironolactone it is 400 mg daily. At the higher doses, decreasing efficacy will be seen. As the total diuretic dose is increased, it can be given once daily or divided as twice daily dosing.

Serum electrolytes and renal function tests should be carefully monitored as dose adjustments are made. The patient should discontinue diuretic therapy if the serum sodium decreases to less than 120 mmol/L, uncontrolled or recurrent encephalopathy develops, or the serum creatinine exceeds 2.0 mg/dL.

Reference

Runyon BA, AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009;49:2087–107.

Answer: B

Delirium is a common problem in the hospitalized patient, especially with a history of underlying dementia or psychiatric disease. So far, only simple interventions focused on maintaining normal environmental issues have been proven to be of any benefit. These include promoting sleep by decreasing nighttime stimuli, use of hearing aids and eyeglasses, and minimizing restraints. One study showed a reduction of sound during the night by using earplugs in patients in the ICU setting resulted in a decreased risk of delirium by 53 %.

Family can play a role in decreasing delirium. They can assist in orienting and reassuring the patient. Support from a familiar nurse and staff should also be encouraged.

There are no definitive studies that demonstrate the use of any prophylactic medicines, such as haloperidol or risperidone, provides any benefit. The use of these and other sedatives should be minimized. Pain can contribute to delirium as well as the excessive use of narcotics. Rivastigmine has been shown to worsen delirium in the hospitalized patient. Melatonin has had no clear clinical benefit in reduction of delirium. Early physical and occupational therapy may also be of some benefit.

Reference

Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 4 1999;340(9):669–76

Answer: C

This patient has post-infectious glomerulonephritis (PIGN). PIGN presents as an acute nephritic syndrome characterized by rapid onset of edema, hypertension, oliguria, and erythrocyte casts seen in the urine sediment. Low complement levels further suggest the exudative proliferative glomerulonephritis patterns can be seen by light microscopy on biopsy specimens.

Diabetic nephropathy does not explain the onset of this patient’s acute kidney injury. The decline of the glomerular filtration is predictable and usually no greater than 12–16 mL/min/1.73 m² per year. Patients with IgA nephropathy may present with an episode of acute renal injury precipitated by infection. Gross hematuria is often seen. Adult patients with primary membranous glomerulonephritis frequently present with a nephritic picture. In these patients, the urine sediment can be active and reveal granular casts. Erythrocyte casts are not seen. In addition, complement levels are normal.

It has been suggested that PIGN was the cause of death of the composer Wolfgang Amadeus Mozart.

References

Rodriguez-Iturbe B, Musser JM. The current state of post streptococcal glomerulonephritis. J Am Soc Nephrol. 2008;19(10):1855–64.

Zegers RH, Weigl A. Steptoe A death of Wolfgang Amadeus Mozart: an epidemiologic perspective. Ann Intern Med. 2009;151(4):274–8, W96-7 (ISSN: 1539–3704).

Answer: E

This patient has hepatopulmonary syndrome. In these cases, contrast- or bubble-enhanced echocardiography will reveal a intrapulmonary shunt. Hepatopulmonary syndrome is associated with platypnea, which is increased dyspnea in the upright position, and orthodeoxia, which is increased hypoxia when transitioning from the lying to the standing position. Hypoxemia, in this case due to intrapulmonary shunt, is not significantly affected by an increase in inhaled O₂ concentration. This syndrome may resolve with liver transplantation and does not exclude the patient from being considered for transplant.

Reference

Rodriguez-Roisin R, Krowka MJ. Hepatopulmonary syndrome – a liver-induced lung vascular disorder. N Engl J Med. 2008;358:2378–87.

Answer: C

The patient has Todd’s paralysis, which may take minutes to many hours to return to normal. The abnormal motor movements that begin in a restricted area and then progress to involve a larger area are termed Jacksonian march. If his symptoms were to persist beyond several hours, it would be reasonable to investigate a different etiology of his hand weakness with imaging studies. The symptoms are too limited to suggest conversion disorder. Magnetic resonance angiogram or cerebral angiogram may be useful to evaluate for cerebrovascular disorders, if symptoms persist.

Reference

Gallmetzer P, Leutmezer F, Serles W, Assem-Hilger E, Spatt J, Baumgartner C. Postictal paresis in focal epilepsies–incidence, duration, and causes: a video-EEG monitoring study. Neurology. 2004;62(12):2160–4.

Answer: E

This patient has a parvovirus B19 infection. This is the virus that causes the common childhood disease known as erythema infectiosum or fifth disease. It can cause aplastic crises in persons with hemolytic disorders, chronic anemia in immunocompromised hosts, and fetal loss in pregnant women.

The rash of erythema infectiosum usually appears without prodromal symptoms after an incubation period of 4–14 days. The rash starts as a fiery-red rash on both cheeks. It then extends as an erythematous maculopapular eruption on the proximal extremities and trunk in a reticular pattern. The rash may wax and wane for several weeks. Arthralgia and arthritis are seen in up to 80 % of infected adults.

Parvovirus B19 can cause an aplastic crises in patients who have sickle cell anemia, hereditary spherocytosis, thalassemia, and various other hemolytic anemias. These aplastic crises are abrupt in onset and are associated with giant pronormoblasts in the bone marrow. They generally resolve spontaneously after 1 or 2 weeks. In immunocompromised patients, acute infection may lead to viral persistence and chronic bone marrow suppression. In this patient, the anemia with a low reticulocyte count suggests a transient aplastic process and not a hemolytic crisis.

Reference

Servey JT, Reamy BV, Hodge J. Clinical presentations of parvovirus B19 infection. Am Fam Physician. 2007;75(3):373–6.

Answer: E

The current recommendations do not support the use of prophylactic antibiotics to prevent pancreatic infection among patients with necrotizing pancreatitis. Some studies suggest that the use of potent antibiotics may lead to a superimposed fungal infection. The current guidelines recommend medical management during the first 2–3 weeks. After 3 weeks, if symptoms persist or clinical condition deteriorates, a surgical debridement should be considered. If symptoms worsen or fail to improve, repeat imaging or biopsy can be considered.

References

Telem DA, Bowman K, Hwang J, Chin EH, Nguyen SQ, Divino CM. Selective management of patients with acute biliary pancreatitis. J Gastrointest Surg. 2009;13(12):2183–8.

Tenner S, Baillie J, Dewitt J, et al. American College of Gastroenterology guidelines: management of acute pancreatitis. Am J Gastroenterol. 2013;108(9):1400–15.

Answer: E

It is important to recognize the treatment sequence in the management of suspected bacterial meningitis. Imaging and lumbar puncture should not delay empiric antibiotic coverage and steroids. The necessity of a CT scan prior to a lumbar puncture in all instances has been debated. The management algorithm for adults with suspected bacterial meningitis per Infectious Disease Society of America (IDSA) guidelines is as follows:

Reference

Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice Guidelines for the management of bacterial meningitis. IDSA. Clin Infect Dis. 2004;39:1267–84.

Answer: C

Quetiapine can be used for agitation in critically ill patients. In a prospective, randomized, double-blind, placebo-controlled study conducted on 36 adult critically ill patients with delirium, quetiapine in escalating doses was shown to be effective in palliating agitation.

The use of lorazepam may worsen her agitation in her medically fragile state. The use of zolpidem will address this patient’s disrupted sleep but may increase her agitation. Supporting the family with rapid control of behavior issues is needed. While inclusion of psychosocial support is helpful, this patient is rapidly declining and medication can provide immediate benefit.

References

Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety of quetiapine in critically ill patients with delirium: a prospective, multicenter, randomized, double-blind, placebo-controlled pilot study. Crit Care Med. 2010;38(2):419–27.

Larson AM, Polson J, Fontana RJ, Davern TJ, Lalani E, Hynan LS, Reisch JS, Schiødt FV, Ostapowicz G, Shakil AO, Lee WM, Acute Liver Failure Study Group. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology. 2005;42(6):1364–72.

Answer: A

This patient has Behçet disease. Behçet disease is characterized by the triad of recurrent oral aphthous ulcers, genital ulcers, and uveitis.

Behçet disease is a systemic disorder characterized by vasculitis and multiple organ involvement. The diagnostic clues are intermittent mucous membrane ulcerations and ocular involvement. Gastrointestinal, pulmonary, musculoskeletal, and neurologic manifestations may be present. This patient has a 2-year history of recurrent oral ulcerations. The skin lesions are erythema nodosum. She now presents with panuveitis. Pulmonary artery aneurysm also strongly suggests Behçet disease.

Exposure to an infectious agent may trigger a cross-reactive immune response. Proposed infectious agents have included herpes simplex virus, Streptococcus species, Staphylococcus species, and Escherichia coli. There may be relationship to flora of the mouth.

The treatment approach depends on the severity of the disease and major organ involvement. This may include systemic corticosteroids, azathioprine, pentoxifylline, dapsone, interferon-alfa, colchicine, and thalidomide.

References

Hatemi G, Silman A, Bang D, et al. EULAR recommendations for the management of Behçet disease. Ann Rheum Dis. 2008;67(12):1656–62.

Study Group for Behçet’s Disease. Criteria for diagnosis of Behçet’s disease. International Study Group for Behçet’s Disease. Lancet. 1990;335(8697):1078–80.

Answer: D

This patient has disseminated C. canimorsus infection due to a dog bite and asplenia. C. canimorsus is a normal colonizing bacterium of dog and cat saliva. Canimorsus is Latin for “dog bite.”

Clinical symptoms usually begin 5–6 days after the dog bite, scratch, or other exposure. Patients typically present with signs of sepsis including fever, vomiting, and abdominal pain. There is progressive cutaneous hemorrhage with infarction that leads to extensive skin necrosis.

Several other organisms can produce purpura fulminans including endotoxin-producing Neisseria meningitidis and encapsulated Streptococcus pneumoniae and Haemophilus influenzae.

References

Pers C, Gahrn-Hansen B, Frederiksen W. Capnocytophaga canimorsus septicemia in Denmark, 1982–1995: review of 39 cases. Clin Infect Dis. 1996;23(1):71–5.

Eefting M, Paardenkooper T. Capnocytophaga canimorsus sepsis. Blood. 2010;116(9):1396.

Answer: A

Synthetic cathinones, drugs known as “bath salts,” were first described in the United States in 2010. Users of bath salts experience vivid disturbing hallucinations, agitation, paranoia, and extreme pain intolerance. They are more potent as compared to other hallucinogens. Episodes of intoxication are unpredictable and are often prolonged lasting several days. Large dose of sedatives are often required as well as careful use of physical restraints. Decreased pain sensation makes physical restraint difficult and reports of injury during sedation are common.

Reference

Coppola M, Mondola R. Synthetic cathinones: Chemistry, pharmacology and toxicology of a new class of designer drugs of abuse marketed as “bath salts” or “plant food”. Toxicol Lett. 2012;211(2):144–9. doi:10.​1016/​j.​toxlet.​2012.​03.​009. PMID 22459606.

Answer: E

This patient has juvenile myoclonic epilepsy. A history of rapid, unprovoked jerks and generalized tonic-clonic seizures on awakening is a common presentation. Onset is usually in adolescence, but may occur in an early adulthood.

Juvenile myoclonic epilepsy may affect 5–10 % of all patients with epilepsy. Seizures are often provoked by sleep deprivation, alcohol, video games, or exposure to flickering lights.

Recognizing the specific epilepsy syndrome affecting a patient is important in selecting the appropriate therapy.

Alcohol withdrawal seizures develop in chronic users of alcohol. It is generally seen in combination with other signs and symptoms of alcohol withdrawal, such as delirium, tremor, tachycardia, and diaphoresis.

Benign rolandic epilepsy is a syndrome seen in younger children who have seizures, usually during sleep. Temporal lobe epilepsy is the most common of the localization-related epilepsies. This often is due to a specific brain malformation, such as trauma, infarct, or congenital. The most common seizure occurring with temporal lobe epilepsy is complex partial seizure. Patients with complex partial seizures are awake but exhibit altered awareness, such as unresponsiveness or staring.

References

Prasad A, Kuzniecky RI, Knowlton RC, et al. Evolving antiepileptic drug treatment in juvenile myoclonic epilepsy. Arch Neurol. 2003;60(8):1100–5

Proposal for revised classification of epilepsies and epileptic syndromes. Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia. 1989;30(4):389–99.

Answer: B

This patient has spontaneous bacterial peritonitis and acute kidney injury . The diagnosis of spontaneous bacterial peritonitis (SBP) is made in the setting of an elevated ascitic fluid absolute polymorphonuclear (PMN) cell count of greater than 250/μl without evidence of secondary causes of peritonitis. A positive bacterial culture of the ascitic fluid is not needed. Intravenous cefotaxime or a similar third-generation cephalosporin is the treatment of choice for SBP. However per Cochrane review, this class has not been shown to be superior to other classes of antibiotics. Most common isolates are Escherichia coli, Klebsiella pneumoniae, and pneumococci. Vancomycin is not needed for initial treatment. Oral fluoroquinolone treatment may be indicated in mild cases treated as an outpatient.

Several strategies may be employed to improve renal vascular flow in the setting of SBP. Intravenous albumin is the most widely used.

The use of cefotaxime plus intravenous albumin at 1.5 g/kg on day 3 has been shown to decrease in-hospital mortality by 20 % in patients with serum creatinine values of 1.5 mg/dL or greater. There is no evidence that large-volume paracentesis improves outcomes in patients with SBP and should be done with caution. Excessive fluid shifts may worsen kidney function.

References

Chavez-Tapia NC, Soares-Weiser K, Brezis M, Leibovici L. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. Cochrane Database Syst Rev. 2009;1:CD002232.

Sort P, Navasa M, Arroyo V, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med. 1999;341(6):403–9.

Answer: A

Patients who have a large territory infarcts are at risk for herniation and should have frequent neurologic checks to follow for signs of deterioration. Early repeat imaging and neurosurgical consult is warranted with significant clinical decline. Three separate European studies reveal that hemicraniectomy reduces mortality and severe disability in patients with malignant middle cerebral artery infarction. This benefit is greatest if performed within the first 48 h after stroke and optimally before clinical herniation has occurred. This patient has evidence of elevated clinical intracranial pressure, and urgent neurosurgical consultation is needed as well as repeat imaging. The neurosurgical consult should come first while arranging for imaging, intensive care unit transfer, and further supportive measures.

Reference

Gupta R, Connolly ES, Mayer S, Elkind MSV. Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. Stroke. 2004;35:539–43.

Answer: B

Initial diabetic therapy is guided by hemoglobin A1C and symptoms. According to the American Diabetes Association (ADA), the recommended goal A1C for this patient is less than 7 %. Metformin as monotherapy, if not contraindicated, may be first-line therapy. However, in newly diagnosed type 2 diabetics with marked symptoms and/or highly elevated blood glucose or A1C, insulin therapy is indicated.

The American Association of Clinical Endocrinology has more specific guidelines with respect to initiating therapy. Specifically, when the entry level A1C is greater than 9 % and/or the patient is symptomatic (urinalysis 2+ glucose, polydipsia, polyuria), insulin plus or minus other agents is recommended. Monotherapy is recommended when the entry A1C is less than 7.5 %. Similarly, dual therapy is recommended when the entry level A1C is greater than or equal to 7.5 %, but less than 9 %. Additionally, the oral agents will drop the A1C by approximately 1–2 % (not all oral agents); therefore, this would not be an adequate decrease for a patient with an A1C of 9 % or greater.

References

ADA Professional Practice Committee. Clinical practice recommendations. Diabetes Care 2014;37: S1–155.

American Association of Clinical Endocrinology. Comprehensive diabetes management algorithm 2013. Endocr Pract. 2013;19:1–48.

Answer: B

Beta-blockers are the best initial antihypertensive agent to use when the possibility of cardiac ischemia is present. This would be a reasonable first-line choice until the possibility of coronary artery disease is explored.

Reference

Marik PE, Varon J. Hypertensive crises: challenges and management. Chest. 2007;131(6):1949–62.

Answer: D

When a rapid ventricular response does not respond promptly to pharmacologic measures for patients with atrial fibrillation with ongoing myocardial ischemia, symptomatic hypotension, angina, or heart failure, immediate R-wave synchronized direct-current cardioversion is recommended.

Reference

Anderson J et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:1916–26.

Answer: D

References

Bakken JS. Fecal bacteriotherapy for recurrent Clostridium difficile infection. Anaerobe 2009; 15:285–289.

Crooks NH, Snaith C, Webster D, et al. Clinical review: probiotics in critical care. Crit Care. 2012;16:237.