!"#$%&' !

&") *++,
-.)/$01 2
A 48-year-old Afrlcan-Amerlcan woman wlLh a 3-year
hlsLory of meLasLauc breasL cancer ls admlued Lo Lhe
medlcal lCu wlLh severe dyspnea. 1he pauenL has no
oLher medlcal problems and ls a llfe-long nonsmoker.
1he pauenL has a 2-week hlsLory of worsenlng dyspnea
on exeruon. Per ward physlclan reporLs a rlghL-slded
pleural euslon aer earller chesL radlographs, a
normal LCC, and a recenL echocardlogram showlng
good le venLrlcular sysLollc funcuon.
-.)/$01 2
1he pauenL had a modled rlghL radlcal masLecLomy and
recelved chemoLherapy, lncludlng pacllLaxel and
doxorublcln, her lasL Lherapy lncluded anasLrozole,
dlsconunued 2 monLhs ago. She recelved radlauon Lo her
rlghL chesL 6 monLhs ago, Lhe dose ls unknown.1he physlcal
examlnauon reveals a LemperaLure of 36.7oC, pulse 133/
mln, blood pressure 107/64 mm Pg, and resplraLory raLe
26/mln and labored. Cxygen saLurauon ls 92 breaLhlng
room alr. 1he pauenL ls cachecuc wlLh markedly decreased
breaLh sounds ln Lhe rlghL chesL and wlLh rlghL anLerlor and
laLeral chesL wall changes compauble wlLh radlauon
Lherapy.
-.)/$01 2
Per lCu admlsslon chesL radlograph ls shown ln llgure 1A.
Clven Lhe pauenL's severe dyspnea and Lachypnea, Lhe lCu
Leam elecLs Lo place a chesL Lube Lo esLabllsh Lhe euology
of Lhe euslon and Lo remove uld Lo reduce her
resplraLory dlsLress, 3 L of pleural uld ls removed. llgure
18 ls Lhe chesL radlograph Laken lmmedlaLely aer chesL
Lube placemenL. Cver Lhe nexL 2 h, Lhe pauenL becomes
more dyspnelc and Lachypnelc and requlres an llC2 of 1.0
by nonrebreaLher mask Lo malnLaln an oxygen saLurauon of
moreLhan 92. A repeaL chesL radlograph ls shown ln
llgure 1C. ShorLly aer Lhls radlograph ls obLalned, Lhe
pauenL requlres urgenL endoLracheal lnLubauon.
-.)/$01 2
Whlch of Lhe followlng besL descrlbes Lhe underlylng
cause of Lhe pauenL's worsenlng hypoxemla and acuLe
changes on her chesL radlograph?
A. AcuLe radlauon pneumonlus.
8. AcuLe pulmonary edema due Lo cardlac lschemla.
C. AcuLe cardlogenlc pulmonary edema due Lo doxorublcln.
u. 8eexpanslon pulmonary edema.
L. Asplrauon pneumonlus wlLh rapldly developlng A8uS.
-.)/$01 3
A nonsmoklng, 20-year-old man wlLh no pasL medlcal
problems presenLs wlLh a 2-week hlsLory of le lower
exLremlLy swelllng and new-onseL shorLness of breaLh
and chesL paln. upon arrlval ln your emergency
deparLmenL, Lhe pauenL ls noLed Lo be hypoxemlc, wlLh
a room arLerlal oxygen saLurauon of 90. Cxygen
saLurauon lmproves Lo 93 whlle breaLhlng 100
oxygen vla face mask.
-.)/$01 3
1he pauenL has a blood pressure of 140/88 mm Pg,
pulse 110/mln, resplraLory raLe 18/mln, and
LemperaLure 37oC. Lung examlnauon ls unremarkable.
Pe has a le lower exLremlLy deep venous Lhrombosls
by uoppler sLudles. A pulmonary embolus proLocol C1
scan (llgure 2A) ls obLalned. 1he pauenL recelves
approprlaLely dosed low- molecular-welghL
heparln.1he pauenL ls admlued Lo Lhe lCu, and you are
asked Lo see Lhe pauenL Lo commenL upon Lhe besL
LreaLmenL approach, lncludlng Lhe posslble use of
Lhrombolyuc Lherapy.
-.)/$01 3
upon your evaluauon, Lhe pauenL's vlLal slgns and physlcal
examlnauon are unchanged. Pe has been conunued on low-
molecular-welghL heparln and ls able Lo speak ln compleLe
senLences buL complalns of mlld dyspnea. Whlch of Lhe
followlng would you recommend as Lhe mosL approprlaLe
Lherapy?
A. lacemenL of a vena cava lLer.
8. Conunue low-molecular-welghL heparln.
C. ulmonary embolecLomy.
u. CaLheLer fragmenLauon of Lhe pulmonary arLery cloL.
L. lv ussue plasmlnogen acuvaLor.
-.)/$01 4
A pauenL ls recelvlng
volume asslsL conLrol
mechanlcal venulaLory
supporL for Lhe acuLe
resplraLory dlsLress
syndrome (A8uS). Pe ls
heavlly sedaLed and noL
Lrlggerlng venulaLor breaLhs.
Pls venulaLor graphlcs are
shown ln llgure 3A.
-.)/$01 4
Cver Lhe lasL several hours, hls peak alrway pressure
has slowly rlsen and nally Lhe hlgh-pressure alarm ls
acuvaLed. A chesL radlograph reveals bllaLeral uy
lnlLraLes. ?ou examlne hlm and deLermlne LhaL
slgnlcanL pulmonary edema has developed.
-.)/$01 4
Whlch seL of graphlcs ln llgure 38 ls mosL conslsLenL
wlLh Lhese changes?
A. 8reaLh A
8. 8reaLh 8
C. 8reaLh C
u. 8reaLh u
L. 8reaLh L
-.)/$01 5
Whlch of Lhe followlng besL
descrlbes Lhe mechanlcal
venulauon mode deplcLed ln
llgure 4A?
A. ressure asslsL-conLrol
venulauon (ACv).
8. volume asslsL-conLrol
venulauon (vACv).
C. ressure supporL venulauon
(Sv).
u. ressure-LargeLed synchronlzed
lnLermluenL mandaLory
venulauon (SlMv).
L. Conunuous posluve alrway
pressure (CA).
-.)/$01 6
An 81-year-old man enLers Lhe lCu for chesL paln of 2
hours' durauon. Pls pulse ls 68/mln and lrregular and
hls blood pressure ls 130/80 mm Pg. Pls physlcal
examlnauon ls normal, and he shows no slgns of hearL
fallure. Pls LCC ls shown ln llgure 3A.
-.)/$01 6
Pe ls LreaLed wlLh asplrln, LenecLeplase (1nk-LA), and
heparln. Whlch of Lhe followlng should be added hls
LreaLmenL reglmen?
A. 1ransvenous paclng wlre.
8. ALroplne.
C. Lldocalne.
u. Amlodarone.
L. Amlodlplne.
-.)/$01 7
A 26-year-old prevlously healLhy man ls admlued Lo
Lhe lCu followlng blunL chesL Lrauma aer belng
Lhrown from a snowmoblle. Pe was sLopped by a Lree,
hlmng hls rlghL chesL and noL loslng consclousness. Pe
was broughL Lo Lhe emergency deparLmenL by hls
frlends because of hls chesL paln and shorLness of
breaLh. A rlghL-slded hemopneumoLhorax was noLed
wlLh evldence of a lung conLuslon, a rlghL Lube
LhoracosLomy resolved Lhe pneumoLhorax and dralned
Lhe rlghL pleural space of 300 mL of blood wlLh no
ongolng bleedlng (see llgure 6A).
-.)/$01 7
no lnLra-abdomlnal, splne, or oLher ln[urles were
noLed by lmaglng.Cver Lhe nexL 72 hours hls
hemoglobln ls sLable buL he requlres hlgh
concenLrauons of supplemenLal oxygen, analgesla, and
lnLermluenL nonlnvaslve mask venulauon Lo malnLaln
adequaLe arLerlal saLurauons. Pe ls Lransluoned Lo a
nasal cannula and appears comforLable aL 96 hours and
ls afebrlle. Pls chesL Lube ls removed and he has no
coughlng or hemopLysls. A new chesL radlograph
abnormallLy prompLs a C1 scan and a represenLauve
lmage ls shown (see llgure 68).
-.)/$01 7
Whlch of Lhe followlng ls Lhe mosL approprlaLe course of
acuon aL Lhls ume?
A. lsolauon for posslble Luberculosls unul Lhree negauve spuLa
are obLalned.
8. ulscharge from Lhe lCu and follow sympLomaucally and wlLh
anoLher chesL radlograph ln 2 Lo 4 weeks.
C. Lmplrlc anubloucs for hosplLal-acqulred pneumonla, gulded by
local blograms.
u. 8ronchoscopy and bronchoalveolar lavage and anubloucs lf a
paLhogen ls ldenued.
L. 1reaL for presumed blood sLream lnfecuon, wlLh blood
culLures rsL and Lhen vancomycln.
-.)/$01 8
All of Lhe followlng pauenLs have successfully passed
your lCu weanlng proLocol, whlch lncludes absence of
shock or vasopressor use, absence of conunuous
lnfuslon sedauve medlcauons, aC2:llC2 >200 mm Pg,
and compleuon of a 120 mln sponLaneous breaLhlng
Lrlal. ?our resplraLory LheraplsL has done some
addluonal LesLs on selecLed pauenLs, and Lhe nurses
have documenLed addluonal observauons on some
pauenLs.
-.)/$01 8
Whlch one of Lhe followlng pauenLs would you have Lhe greaLesL concern LhaL
Lhey wlll fall exLubauon and requlre relnLubauon?
A. A 70-year-old woman who was lnLubaLed for pneumonla 6 days ago and has
volumlnous secreuons (6 mL/h), sLrong cough, and normal menLal sLaLus.
8. A 30-year-old man wlLh CCu who ls 4 days posLbowel resecuon, has a cu-
leak of 160 mL (or 20), and has a rapld shallow breaLhlng lndex of 80
breaLhs/mln/L.
C. A 40-year-old alcohollc man who was lnLubaLed 8 days ago for asplrauon
pneumonla and has a large volume of secreuons (abouL 4 mL/h), a weak
cough, and opens eyes buL does noL Lrack, grasp hand, or proLrude Longue
on command.
u. A 73-year-old woman who was lnLubaLed 3 days earller for Lrauma-relaLed
lung conLuslon and rlb fracLures, and has mlnlmal secreuons, weak cough,
and normal menLal sLaLus.
L. A 70-year-old man 18 h aer lnLubauon for posLcardlac surgery wlLh a cu-
leak of 60 mL (or 8) and rapld shallow breaLhlng lndex of 103 breaLhs/mln/
L.
-.)/$01 9
A 43-year-old woman wlLh A8uS ls orally lnLubaLed and
placed on volume asslsL conLrolled mechanlcal venulauon.
Per predlcLed body welghL ls 163 lb (73 kg). lnlually, Lhe
venulaLor ls seL aL a raLe of 8, udal volume of 900 mL, llC2
of 1.0, and posluve end-explraLory pressure (LL) of 3 cm
P2C. Cn lCu arrlval, Lhe pauenL ls deeply sedaLed wlLh
equal bllaLeral breaLh sounds breaLhlng aL Lhe seL raLe.
ulse oxlmeLry saLurauon ls 100, peak alrway pressure ls
43 cm P2C, and plaLeau pressure ls 30 cm P2C. ArLerlal
blood gas measuremenLs on Lhese semngs reveal a C2 of
273 mm Pg, CC2 of 43 mm Pg, and pP of 7.33.
-.)/$01 9
WhaL changes would you make ln venulaLor semngs aL
Lhls ume?
A. none.
8. 8educe llC2 Lo 0.3, and lncrease LL Lo 10 cm P2C.
C. SwlLch Lo pressure supporL mode wlLh an lnsplraLory
pressure level of 20 cm P2C and LL of 8 cm P2C.
u. lncrease mlnuLe venulauon by 20 Lo reduce CC2 Lo 40
mm Pg.
L. 8educe udal volume Lo 430 mL, and lower llC2 Lo
malnLaln saLurauons >88.
-.)/$01 :
Whlch of Lhe followlng sLaLemenLs concernlng focused
assessmenL wlLh sonography for Lrauma (lAS1) ls correcL?
A. Conrmauon of a slgnlcanL hemoperlLoneum aer blunL abdomlnal
Lrauma by lAS1 may faclllLaLe Lhe pauenL belng Laken dlrecLly Lo Lhe
operaung room wlLhouL Lhe delay assoclaLed wlLh radlologlc
lmaglng.
8. ln Lhe early evaluauon of blunL abdomlnal Lrauma, lAS1 ls exLremely
rellable for deLecung hollow vlscous perforauon.
C. Abdomlnal free uld collecuons below 300 ml cannoL be deLecLed by
lAS1.
u. 8egardless of Lhe slLe of ln[ury, free abdomlnal uld ln Lhe semng of
Lrauma ls mosL readlly deLecLed by ulLrasonography lnLhe le lower
quadranL.
L. Lven ln experlenced hands, Lhe speclclLy of lAS1 for
hemoperlLoneum ls only 30 and hence ndlngs musL be conrmed
by uL (dlagnosuc perlLoneal lavage).
-.)/$01 2;
A 34-year-old male consLrucuon worker ls Lrapped
under dlrL and rubble aer a reLalnlng wall collapses
durlng demolluon of a bulldlng. uslng heavy
equlpmenL, lL Lakes approxlmaLely 6 h Lo exLrlcaLe hlm
from Lhe rubble. Pe recelved a bolus lnfuslon of 1 L of
0.9 sallne soluuon, followed by a conunuous lnfuslon
aL 230 mL/h ln Lhe eld. Cn admlsslon Lo Lhe Lrauma
unlL, hls blood pressure ls 112/36 mm Pg, hearL raLe
132 beaLs/mln. Pls lung elds are clear Lo ausculLauon,
and hls LranscuLaneous oxygen saLurauon ls 99 on 2 L
of supplemenLal oxygen by nasal cannula.
-.)/$01 2;
Pe has compound fracLures of hls le ubla and bula and a
fracLure of hls pelvls. Sensauon and caplllary rell ln hls
lower exLremlues ls lnLacL. LaboraLory daLa reveal sodlum
138 mLq/L (138 mmol/L), poLasslum 3.8 mLq/L (3.8 mmol/
L), chlorlde 102 mLq/L (102 mmol/L), blcarbonaLe 18 mLq/L
(18 mmol/L), 8un 22 mg/dL (7.9 mmol/L), serum creaunlne
1.8 mg/dL (139 mol/L), glucose 138 mg/dL (7.7 mmol/L),
calclum 8.2 mg/dL (2.03 mmol/L), phosphaLe 3.9 mg/dL (1.9
mmol/L), and creaune phosphoklnase 19,860 u/L. Pls urlne
ouLpuL ls 30 mL/h. Pls urlnalysls has 4+ blood by dlpsuck
buL only 3 Lo 3 88Cs per hlgh-powered eld on mlcroscoplc
examlnauon.
-.)/$01 2;
Whlch one of Lhe followlng lnLervenuons wlll have Lhe
greaLesL beneL ln prevenung Lhe developmenL of
progresslve acuLe kldney ln[ury?
A. lncrease lnfuslon raLe of 0.9 sallne soluuon Lo 1 L/h.
8. Change lv ulds Lo 0.43 sallne soluuon wlLh 73 mmol/L
sodlum blcarbonaLe and 10 mannlLol aL 230 mL/h.
C. 8egln conunuous lnfuslon of furosemlde Lo malnLaln urlne
ouLpuL of aL leasL 30 mL/h.
u. 8egln oral n-aceLylcysLelne 600 mg bld.
L. lnluaLe conunuous venovenous hemolLrauon.
-.)/$01 22
A 43-year-old gay man wlLh no pasL medlcal hlsLory
developed resplraLory fallure due Lo neumocysus
[lrovecl pneumonla and was LreaLed ln Lhe lCu wlLh
LrlmeLhoprlm-sulfameLhoxazole (1M-SMx),
corucosLerolds, and mechanlcal venulaLory supporL.
Plv lnfecuon was conrmed serologlcally, Lhe
admlsslon Cu4+ lymphocyLe counL was 4 cells/mm3
(0.004 x 109/L), and Lhe vlral load 130,000 coples/mL.
Pe lmproved and was exLubaLed on hosplLal day 13.
1he chesL radlograph ls shown ln llgure 11A.
-.)/$01 22
Cver Lhe nexL 7 days, he conunued Lo recelve 1M-SMx,
Lhe corucosLerolds were Lapered and dlsconunued,
anureLrovlral Lherapy wlLh zldovudlne, lamlvudlne, and
lndlnavlr was sLarLed, and he was dlscharged from Lhe
hosplLal on 1M-SMx, one double-sLrengLh LableL dally,
along wlLh hls anureLrovlral medlcauons. 1hree weeks laLer,
he reLurned Lo Lhe emergency deparLmenL wlLh lncreaslng
dyspnea for 3 days and fever Lo 39C. Pe sLaLes LhaL he Look
hls medlcauon rellglously." Pe requlred urgenL lnLubauon
and was readmlued Lo Lhe lCu. Pls chesL radlograph ls
shown ln llgure 118.
-.)/$01 22
Whlch of Lhe followlng ls mosL llkely Lo be found?
A. Serum LuP 900 u/L.
8. Serum amylase 400 u/L.
C. Cu4+ lymphocyLe counL 30 cells/mm3 (0.030 x 109/L),
vlral load undeLecLable.
u. 8lood culLures posluve for SLrepLococcus pneumonlae.
L. 8AL shows numerous acld-fasL bacllll.
-.)/$01 23
A 70-year-old woman ls admlued from Lhe emergency
deparLmenL (Lu) Lo Lhe medlcal lCu. She ls belng
venulaLed and ls on vasopressor agenLs. She has noLed
lnLermluenL dlarrhea for Lhe pasL 2 weeks LhaL ls
assoclaLed wlLh cramplng lower abdomlnal paln. Cn
Lhe day of admlsslon she had 3 eplsodes of non-bloody
dlarrhea followed by syncope and emesls. upon arrlval
Lo Lhe Lu she had a decreased menLal sLaLus and a
blood pressure of 76/40 mm Pg. ln Lhe Lu she recelved
3 L of normal sallne, dexameLhasone, dopamlne,
noreplnephrlne, and cerlaxone.
-.)/$01 23
asL medlcal hlsLory lncludes lnsulln-dependenL dlabeLes
melllLus, mlld chronlc obsLrucuve lung dlsease, and
hyperLenslon. 8esldes nP lnsulln, she ls Laklng an albuLerol
meLered-dose lnhaler and hormone replacemenL Lherapy.
ln Lhe medlcal lCu she ls afebrlle, and her blood pressure ls
110/32 mm Pg, hearL raLe 104/ mln, and cenLral venous
pressure 12 mm Pg. Per venulaLor semngs are llC2 0.30,
LL 3 cm P2C, and oxygen saLurauon 98. Per abdomen
ls so wlLh dlrecL Lenderness ln Lhe le upper, le lower,
and rlghL lower quadranLs.
-.)/$01 23
1here ls no rebound Lenderness and her bowel sounds are
hypoacuve. 8lood ls presenL ln her sLool. Per W8C counL ls
19,000/mm3 (19 x 109/L) wlLh 70 neuLrophlls. PemaLocrlL
ls 36 and plaLeleL counL ls normal. Abnormal LesLs lnclude
sodlum 129 mLq/L (129 mmol/L), blcarbonaLe 12 mLq/L (12
mmol/L), and glucose 408 mg/dL (22 mmol/L). 1he
creaunlne, llpase, and llver LesLs are all normal. ArLerlal
blood gas measuremenLs lndlcaLe C2 110 mm Pg, CC2
29 mm Pg, and pP 7.23 on an llC2 of 0.30. A rlghL upper
quadranL ulLrasound, chesL radlograph, plaln abdomlnal
lm, and abdomlnal C1 scan are all normal.
-.)/$01 23
1he nexL day Lhere ls worsenlng rlghL lower quadranL
paln, guardlng, rebound Lenderness, and resoluuon of
hypoLenslon. Whlch sLudy wlll besL ldenufy Lhe cause
of Lhls pauenL's abdomlnal paln?
A. A repeaL C1 scan of Lhe abdomen.
8. Abdomlnal anglography.
C. A repeaL abdomlnal aL plaLe.
u. Color ow duplex lmaglng of Lhe abdomen.
L. Colonoscopy.
-.)/$01 24
A 63-year-old ex-smoker wlLh CCu was Lransferred Lo
Lhe lCu because of progresslvely worsenlng
hypercapnlc resplraLory fallure. 1wo days before, he
had been admlued Lo a general medlcal oor because
of resplraLory fallure secondary Lo pneumonla. Cn
admlsslon, arLerlal blood gas measuremenLs wlLh Lhe
pauenL breaLhlng room alr were C2 38 mm Pg, CC2
64 mm Pg, and pP 7.28.
-.)/$01 24
uesplLe recelvlng lnLravenous sysLemlc corucosLerolds and
levooxacln, supplemenLal oxygen and non-lnvaslve
posluve pressure venulauon, and lnhaled albuLerol
(salbuLamol) and lpraLroplum by updra nebullzer, he was
more shorL of breaLh, hls C2 had only lmproved Lo 32 mm
Pg, and hls resplraLory acldosls had worsened Lo CC2 80
mm Pg and pP 7.14. asL hlsLory was remarkable for Lhe
pauenL havlng only one conLacL wlLh Lhe medlcal professlon
ln Lhe pasL 10 years. Cne year ago, he saw a prlmary care
physlclan for an lnsurance physlcal aL whlch ume
splromeLry revealed an lLv1 of 1.3 L, lvC 4 L, and lLv1/
lvC 37.
-.)/$01 24
AL LhaL ume, he was worklng full ume as a [anlLor ln a
capaclLy LhaL was approprlaLe for hls 9Lh grade
educauon. ?ou recommend endoLracheal lnLubauon
and mechanlcal venulauon. Powever, Lhe pauenL, who
ls alerL, refuses Lhls lnLervenuon even aer you predlcL
a 93 chance of deaLh wlLhouL lL and a 73 chance of
survlval wlLh lL
-.)/$01 24
Whlch of Lhe followlng courses of acuon ls Lhe mosL
approprlaLe Lo Lake nexL?
A. erform lmmedlaLe endoLracheal lnLubauon.
8. Conunue Lhe presenL LreaLmenL reglmen and wrlLe a do-
noL-resusclLaLe order.
C. Ask Lhe pauenL Lo clarlfy whaL he undersLands
endoLracheal lnLubauon and mechanlcal venulauon Lo
mean.
u. ueclare Lhe pauenL menLally lncompeLenL and seek
approval of Lhe pauenL's wlfe Lo perform endoLracheal
lnLubauon.
L. ConsulL Lhe hosplLal eLhlcs commluee.
-.)/$01 25
A 67-year-old man enLers Lhe lCu wlLh 1-week hlsLory
of recurrenL bouLs of non-exeruonal, reLrosLernal chesL
paln lasung 13 mlnuLes and subsldlng. Pe has a hlsLory
of hyperLenslon LreaLed wlLh hydrochloroLhlazlde, and
he has a famlly hlsLory of coronary dlsease. Cn
admlsslon, hls vlLal slgns and physlcal examlnauon are
normal. Pls admlsslon LCC ls shown ln llgure 14A.
-.)/$01 25
Slx hours aer admlsslon, he develops reLrosLernal
chesL paln and Lhe LCC ls shown ln llgure 148.
-.)/$01 25
1he pauenL recelves nlLroglycerln and Lhe paln
subsldes ln 10 mlnuLes. A posL paln LCC ls shown ln
llgure 14C.
-.)/$01 25
Pls blood Lroponln and serum enzymes are normal.
lans are lnsuLuLed for cardlac caLheLerlzauon. ln
addluon Lo long-acung nlLraLes (lsordll), whlch of Lhe
followlng should be admlnlsLered now?
A. Lldocalne.
8. Amlodarone.
C. MeLoprolol.
u. SLrepLoklnase.
L. ulluazem.
-.)/$01 26
A 43-year-old woman, wlLh a hlsLory of chronlc
pancreauus, ls admlued Lo Lhe lCu for masslve
hemaLemesls. She has no hlsLory of alcohol use. hyslcal
examlnauon reveals a blood pressure of 100/72 mm Pg,
pulse 110/mln, resplraLory raLe 20/mln, and she ls afebrlle.
Per abdomlnal examlnauon reveals no asclLes, mlld
Lenderness ln Lhe le upper quadranL, a llver span of 9 cm,
and splenomegaly. LaboraLory values reveal a leukocyLe
counL of 8,200/mm3 (8.2 x 109/L), hemoglobln 8.0 g/dL (80
g/L), and plaLeleLs 70,000/mm3 (70 x 109/L). Per llver
funcuon LesL resulLs and blllrubln levels are normal.
-.)/$01 26
Coagulauon parameLers are normal. An endoscopy ls
performed and reveals no ulcers or esophageal varlces,
buL many large bleedlng gasLrlc varlces, and an
ocLreoude lnfuslon ls begun. A C1 scan of Lhe abdomen
shows pancreauc calclcauons, a normal-appearlng
llver, splenomegaly, and splenlc veln Lhrombosls. Cver
Lhe nexL 4 h, she requlres Lransfuslon of a LoLal of 6 u
of packed 88Cs buL Lhen sLablllzes for Lhe subsequenL
24 h.
-.)/$01 26
WhaL ls Lhe besL sLep ln Lhe denluve managemenL of
Lhls pauenL?
A. Lndoscoplc band llgauon.
8. 1rans[ugular lnLrahepauc porLosysLemlc shunL.
C. Lndoscoplc scleroLherapy.
u. SplenecLomy.
L. 8alloon Lamponade.
-.)/$01 27
A pauenL ls belng evaluaLed for resplraLory dlsLress.
ArLerlal blood gas measuremenLs Laken wlLh Lhe
pauenL breaLhlng 2 L/ mln of oxygen reveal a C2 of
133 mm Pg, CC2 60 mm Pg, and pP 7.26. A chesL
radlograph ls obLalned and ls shown ln llgure 16A.
-.)/$01 27
1hese ndlngs are mosL
conslsLenL wlLh whlch cause of
resplraLory fallure?
A. AcuLe-on-chronlc
venulaLory fallure due Lo
CCu.
8. 1he acuLe resplraLory
dlsLress syndrome (A8uS).
C. neuromuscular dlsease.
u. upper alrway obsLrucuon.
L. Cardlogenlc pulmonary
edema.
-.)/$01 28
A 28-year-old man presenLs wlLh chesL paln and
palplLauons. Pls LCC ls shown ln llgure 17A.
-.)/$01 28
Whlch of Lhe followlng sLaLemenLs ls correcL?
A. 1he rlsk of degenerauon lnLo venLrlcular brlllauon ls
low.
8. 1he rlsk of recurrence ls low.
C. ulgoxln can be used safely Lo lower Lhe hearL raLe.
u. non-dlhydropyrldlne calclum channel blockers are
conLralndlcaLed.
L. rompL cardloverslon wlLhouL sedauon ls lndlcaLed.
-.)/$01 29
A 36-year-old woman was admlued Lo Lhe lCu wlLh
severe sLaLus asLhmaucus 4 days ago. She was LreaLed
wlLh meLhylprednlsolone, nebullzed bronchodllaLors,
and has been on venulaLory supporL wlLh asslsL-conLrol
venulauon aL 8 breaLhs/mln, udal volume 400 mL, and
llC2 0.6. 1o malnLaln venulaLor synchrony, she was
deeply sedaLed wlLh conunuous lnfuslon of lorazepam
aL raLes ranglng from 8 Lo 16 mg/h and paralyzed wlLh
clsaLracurlum. lnlually, her physlcal examlnauon
revealed markedly dlmlnlshed breaLh sounds
bllaLerally, whlch lmproved gradually over ume.
-.)/$01 29
Per neurologlc examlnauon was llmlLed due Lo sedauon
and paralysls, buL every mornlng Lhese agenLs were held
unul she sLarLed Lo move sponLaneously. A sponLaneous
breaLhlng Lrlal Lhls mornlng resulLed ln her belng aglLaLed
and Lachypnelc, and Lhe SpC2 decllned from 93 Lo 83.
When sedaLed and paralyzed agaln, Lhe physlcal
examlnauon revealed no fever, good breaLh sounds
bllaLerally, and reLurn of SpC2 Lo 93. 1he chesL lm
showed good endoLracheal Lube posluon and no pulmonary
abnormallues. 8epresenLauve laboraLory sLudles are shown
below:
-.)/$01 29
WhaL ls Lhe besL nexL sLep?
A. SLarL broad-specLrum anubloucs.
8. SLarL lnsulln lnfuslon.
C. SLarL lnfuslon of sodlum blcarbonaLe.
u. SLop lorazepam, and sLarL mldazolam.
L. SLop clsaLracurlum, and sLarL vecuronlum.
-.)/$01 2:
A new drug/lnLervenuon has recenLly been lnLroduced lnLo
cllnlcal pracuce. A number of small, slngle-lnsuLuuon Lrlals
numberlng under 100 pauenLs each have shown beneclal
eecL. 1o elucldaLe Lhe proper place ln cllnlcal pracuce for Lhe
drug/lnLervenuon, a large sysLemauc revlew ls publlshed,
comblnlng Lhe resulLs of Lhe prevlous Lrlals. A LoLal of 200
pauenLs were enrolled -- 100 ln Lhe lnLervenuon and 100 ln
Lhe conLrol group, 38 of 100 pauenLs beneLed/lmproved
from Lhe lnLervenuon, whlle 23 of Lhe 100 pauenLs ln Lhe
conLrol group lmproved. WhaL ls Lhe number needed Lo LreaL?
A. 6. 8. 9. C. 4. u. 3. L. 11.
-.)/$01 3;
Whlch one of Lhe followlng cllnlcal or laboraLory
ndlngs ls mosL sLrongly predlcuve of poor ouLcome
from fulmlnanL hepauc fallure due Lo aceLamlnophen
LoxlclLy?
A. ArLerlal pP <7.3.
8. roLhrombln ume >30 s.
C. Crade lll encephalopaLhy.
u. Serum creaunlne level >2.3 mg/dL (190 mol/L).
L. Serum blllrubln level >10 mg/dL (171 g/L).
-.)/$01 32
A pauenL ln Lhe lCu ls undergolng mechanlcal venulauon
for A8uS and ls on an llC2 0.6, posluve end-explraLory
pressure 14 cm P2C, udal volume 310 mL, and resplraLory
raLe 24/mln ln an asslsL-conLrol mode. 1he pauenL Lrlggers
frequenLly above Lhe seL raLe and ls requlrlng generous
sedauon for perlods of aglLauon and poor synchrony wlLh
Lhe venulaLor. A rlghL hearL caLheLer ls ln place, and Lhe
balloon ls lnaLed whlle Lhe occluslon pressure ls recorded,
and slmulLaneous wlLh Lhls, Lhe alrway pressure ls recorded
and superlmposed on Lhe vascular pressure Lraclng shown
ln llgure 21A.
-.)/$01 32
1he value of Lhe pulmonary arLery occluslon pressure ls
besL measured:
A. AL Lhe mldpolnL beLween llnes a and b.
8. 8y removlng Lhe pauenL from Lhe venulaLor and readlng
Lhe lowesL excurslon of Lhe wedge Lraclng durlng
sponLaneous breaLhlng.
C. AL Lhe polnL lndlcaLed by llne a.
u. 8y removlng Lhe pauenL from Lhe venulaLor and readlng
Lhe hlghesL excurslon of Lhe wedge Lraclng durlng
sponLaneous breaLhlng.
L. AL Lhe polnL lndlcaLed by llne b.
-.)/$01 33
A 44-year-old, prevlously healLhy man presenLs wlLh a 2-
day hlsLory of melena and nausea, wlLh an eplsode of
dlzzlness Lhe mornlng of admlsslon. Pe ls an avld maraLhon
runner, noung LhaL he LwlsLed hls ankle" a week ago buL
soughL no medlcal auenuon. uue Lo ongolng paln and
swelllng of hls ankle, he has been lngesung asplrln
frequenLly and conunulng dally walks. 1he physlcal
examlnauon ln Lhe emergency deparLmenL ls noLable for
orLhosLauc blood pressure changes and a suplne pulse of
110/mln. 1he remalnder of hls examlnauon ls normal,
excepL pale con[uncuva and a mlldly swollen buL palnful
rlghL ankle.
-.)/$01 33
nasogasLrlc Lube lavage reveals coee ground maLerlal.
LaboraLory values lnclude a hemaLocrlL of 20 (0.20) wlLh a
plaLeleL counL of 110,000/mm3 (110 x 109/L). 1roponln
measured ln Lhe emergency deparLmenL ls normal. 1he
emergency deparLmenL physlclan orders 2 u of packed
88Cs, a 300-mL bolus of normal sallne soluuon over 20 mln,
and a normal sallne soluuon lnfuslon aL 100 mL/h.
ApproxlmaLely 2 h aer arrlvlng ln Lhe lCu, whlle recelvlng
Lhe rsL unlL of packed 88Cs, Lhe pauenL complalns of
slgnlcanL shorLness of breaLh.
-.)/$01 33
Cxygen saLurauon ls 89 breaLhlng room alr, and a chesL
radlograph shows new bllaLeral lnlLraLes, when compared
wlLh Lhe chesL lm obLalned Lo assess nasogasLrlc Lube
placemenL. A subsequenL Lroponln measuremenL ls normal,
and an echocardlogram shows normal le venLrlcular
sysLollc funcuon. LCC shows slnus Lachycardla wlLh noacuLe
changes. 1he pauenL conunues Lo recelve a Lransfuslon
wlLh new unlLs of packed 88Cs. uoppler sLudles of Lhe
lower exLremlues are normal. 1he pauenL's oxygenauon
lmproves wlLh nonlnvaslve posluve pressure venulauon ln
comblnauon wlLh oxygen supplemenLauon.
-.)/$01 33
1hlrLy-slx hours laLer, a chesL radlograph ls normal.
WhaL ls Lhe mosL llkely explanauon for hls acuLe
hypoxemla?
A. Pemolyuc Lransfuslon reacuon.
8. AcuLe volume overload.
C. AcuLe pulmonary embolus wlLh assoclaLed pulmonary
edema.
u. 1ransfuslon-relaLed acuLe lung ln[ury.
L. AcuLe myocardlal lnfarcuon wlLh pulmonary edema.
-.)/$01 34
A 73-year-old man was admlued for elecuve aorLo-
blfemoral bypass surgery. llve days posLoperauvely he
developed dyspnea and hemopLysls. A C1-anglogram was
performed (see llgure 23A). Pe was sLarLed on
unfracuonaLed heparln lnLravenously. Pls plaLeleL counL
preoperauvely was 137,000/mm3 (137 x 109/L) (normal
range, 130,000 Lo 400,000/ mm3 or 130 Lo 400 x 109/L).
llve days laLer, hls plaLeleL counL was noLed Lo be 30,000/
mm3 (30 x 109/L). 1he pauenL was asympLomauc. Serum
creaunlne was elevaLed pre-operauvely aL 2.6 mg/dL (230
g/mL) and rose Lo 3.96 mg/dL (330 g/mL)
posLoperauvely.
-.)/$01 34
ln addluon Lo dlsconunulng heparln, whlch of Lhe
followlng should you add aL Lhls ume?
A. Low-molecular-welghL heparln.
8. uanaparold sodlum.
C. Leplrudln.
u. ArgaLroban.
L. Warfarln
-.)/$01 35
A 22-year-old college sLudenL wlLh mlld perslsLenL asLhma
has a sudden severe auack of resplraLory dlsLress relaLed Lo
splll of chlorlne bleach ln hls dormlLory room. Cn arrlval ln
Lhe emergency deparLmenL he ls lnLubaLed. Pe has never
requlred emergenL LreaLmenL of asLhma before. Pe ls
Lransferred Lo your care ln Lhe lCu, wlLh generous sedauon,
a venulaLory sLraLegy of permlsslve hypercapnea, lnhaled
beLa-agonlsLs, and lnLravenous corucosLerolds, he lmproves
rapldly and so dramaucally LhaL 18 hours aer lnLubauon,
ln Lhe mornlng, sedauves are held and he ls exLubaLed.
-.)/$01 35
lollowlng exLubauon he has mlld Lachypnea
(resplraLory raLe 24/mln), scauered wheezlng, and
frequenL coughlng (hls ma[or complalnL). Slx hours
laLer, followlng ongolng coughlng, he has Lhe onseL of
moderaLely severe, sharp, non-posluonal subsLernal
chesL paln. ?ou examlne hlm and he conunues Lo have
scauered wheezlng and coughlng. Pls resplraLory eorL
ls noL dlerenL Lhan earller ln Lhe day. ChesL
radlographs and an LCC are shown ln llgures 24A, 248,
and 24C.
-.)/$01 35
8ased on Lhls lnformauon, whlch of Lhe followlng ls Lhe
besL course of acuon?
A. CbLaln serlal LCCs and cardlac enzymes.
8. 1reaL Lhe pauenL wlLh non-sLeroldal anu-lnammaLory
drugs for perlcardlus.
C. erform bronchoscopy Lo exclude chemlcal
Lracheobronchlus.
u. Conunue Lo observe Lhe pauenL, LreaL wlLh analgeslcs
and oxygen, and follow sympLoms.
L. erform esophagogasLroscopy Lo exclude esophaglus.
-.)/$01 36
A 72-year-old man wlLh a hlsLory of hyperLenslon and
dlabeLes melllLus presenLed wlLh a severe headache,
followed by selzures, and coma. Pe was lnLubaLed and
recelved mechanlcal venulauon. A nonconLrasL C1 scan
of Lhe head lndlcaLed a large hemorrhage ln Lhe le
basal ganglla wlLh surroundlng edema and shl of
lnLracranlal mldllne sLrucLures Lo Lhe rlghL. 1here was
also blood ln Lhe cerebral venLrlcles. 1he pauenL was
comaLose, and Lhe blood pressure was 160/100 mm
Pg. 1he remalnder of Lhe physlcal examlnauon was
unremarkable.
-.)/$01 36
Whlch of Lhe followlng should be done?
A. SLarL labeLalol Lo malnLaln mean arLerlal pressure <100 mm
Pg.
8. SLarL corucosLerolds Lo reduce cerebral edema.
C. Ad[usL dellvered mlnuLe volume Lo malnLaln aCC2 aL
beLween 23 and 30 mm Pg for aL leasL 24 h.
u. lace an lnLracranlal pressure monlLor, and admlnlsLer
mannlLol Lo malnLaln lnLracranlal pressure <20 mm Pg.
L. Ask a neurosurgeon Lo evacuaLe Lhe hemaLoma.
!"#$%&' !&") *++,