Question 1

A 17-year-old boy is brought to the office by his mother for follow-up.  He was diagnosed with major depressive disorder 6 months ago; after failing to improve with cognitive-behavioral therapy, he was started on fluoxetine 20 mg daily 4 months ago.  The physician discussed the risks and benefits of antidepressants and how they work, as well as how to take the medication; the patient reported that he understood the discussion.  At today's visit, his mother says, "He was doing well on the medication at the start and really seemed to be improving.  He was going out again with friends and enjoying school.  He was smiling again and just seemed happier in general.  But for the past month he has struggled to wake up in time for school and seems to have really low energy, and his grades have been dropping.  He isn't smiling as much either.  I am worried that he is becoming depressed again."  When interviewed alone, the patient says, "My mother worries too much about me.  I'm just in a slump because I missed a lot of schoolwork when I was really depressed and I'm struggling to make it up.  I prefer not to take the medication every day and take it only when I have a really bad day."  He has no loss of appetite, no difficulty sleeping, and no suicidal ideation.  Which of the following is the most appropriate response to address this patient's nonadherence to medication?

Accepted Answer

Explanation: This patient has gone from taking his medication every day as counseled to taking it only sporadically. There are often multiple reasons why patients become nonadherent, including inadequate understanding of the illness or how the medication works, complicated treatment regimens, medication cost or side effects, and psychological factors such as denial of or stigma related to mental illness. Although this adolescent may not fully understand how to use the medication and may benefit from a review of instructions (Choice C), it is important to first rule out other possible reasons for nonadherence. For instance, sexual side effects are common with selective serotonin reuptake inhibitors such as fluoxetine and may be embarrassing to talk about. The best approach is to engage in a nonjudgmental, open-ended discussion to elicit the patient's perspective and specific concerns, rather than to assume the reason for nonadherence. The physician should create an environment that helps the patient feel comfortable discussing personal issues affecting medication use. When all reasons for nonadherence are understood, the physician can then work with the patient to make any necessary changes (eg, address side effects, simplify the regimen, reeducate the patient). (Choices A and B) These responses provide education without first exploring the patient's specific concerns. If the patient is having side effects, telling him to take the medication daily or for an additional period of time would not be helpful. (Choice D) Although this statement expresses concern, it is inappropriate to assume the patient is minimizing his symptoms so as not to worry his mother. An open-ended discussion about his reluctance to take his medication is the best initial approach. Educational objective: Common reasons for nonadherence to medication include lack of understanding, side effects, costs, complicated regimens, denial of illness, and stigma. Rather than make assumptions, physicians should explore patients' perspectives in an empathic, open-ended way. References: Physician communication and patient adherence to treatment: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/19584762)

Question 2

A 43-year-old man comes to the office due to a cough.  The patient started with symptoms of nasal congestion, sore throat, and cough about 10 days ago, and most of the symptoms have since improved.  However, the cough is persistent throughout the day and is productive of yellow sputum.  He has no fever, chills, weight loss, or night sweats.  The patient has had no prior respiratory problems, shortness of breath, sick contacts, or recent travel.  He has taken lisinopril for hypertension and metformin for type 2 diabetes mellitus for the past 5 years.  His last hemoglobin A1c was 6.6%.  The patient has smoked half a pack of cigarettes daily for 5 years and is currently trying to quit.  He drinks 1 or 2 cans of beer daily but does not use illicit drugs.  Family history includes diabetes in multiple family members.  Temperature is 36.1 C (97 F), blood pressure is 130/80 mm Hg, pulse is 65/min, and respirations are 14/min.  The patient's pulse oximetry shows 99% on room air.  On examination, the patient is in no apparent distress and appears his stated age.  Mucous membranes are moist, and no lymphadenopathy or jugular venous distension is present.  Heart rate is regular with normal S1 and S2.  Bilateral scattered rhonchi are auscultated, which clear after expectoration.  No crackles, wheezing, or rubs are heard.  Percussion is resonant throughout, and normal tactile fremitus is observed.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c06b_bf9a_8f63_bd7821ad6de1_MD0005_00 This patient most likely has acute bronchitis, which is characterized by cough lasting >5 days and up to 3 weeks. The vast majority of cases are due to a viral respiratory infection, and presentation is often with several days of viral upper respiratory symptoms (eg, sore throat, nasal congestion) that give way to cough as the predominant symptom. Purulent yellow or green sputum is commonly present due to epithelial sloughing and is not a sign of bacterial infection. Patients may also have mild dyspnea and chest wall discomfort (from coughing) as well as crackles that clear with cough, suggesting secretions that are easily mobilized (unlike in pneumonia). Fever is not typical and, when present, should raise suspicion for bacterial pneumonia or acute bronchitis due to influenza. The course of acute bronchitis is self-limited, and most of the time only symptomatic treatment (eg, nonprescription pain relievers, bronchodilators) is indicated. Except for acute bronchitis due to Bordetella pertussis (whooping cough), which represents 1% of cases and is suggested by infected contacts or a prolonged course, antibiotics provide no benefit; they are associated with adverse effects and increased bacterial resistance and should be avoided. (Choice A) ACE inhibitors (eg, lisinopril) can cause a cough due to increased bradykinin levels. However, this patient's cough in the setting of upper respiratory infection is more likely due to acute bronchitis. (Choices B and C) A course of either azithromycin or moxifloxacin is appropriate for the outpatient treatment of community-acquired pneumonia (CAP); however, the diagnosis is highly unlikely given this patient's lack of fever and absence of evidence of consolidation (eg, crackles, focal increased breath sounds) on lung auscultation. Mycoplasma pneumoniae and Chlamydia pneumoniae are rare but potential causes of acute bronchitis; however, there is no evidence that antibiotics provide benefit over supportive care even in patients who test positive for these organisms. (Choice D) Pulmonary function testing is indicated for the evaluation of chronic bronchitis, which is defined as cough for >3 months in 2 consecutive years. Although smoking increases the risk of chronic bronchitis, this patient has no previous lung problems and his cough in the setting of an upper respiratory infection is consistent with acute bronchitis. Educational objective: Acute bronchitis is typically a self-limited bronchial inflammation characterized by cough lasting >5 days and up to 3 weeks. The vast majority of cases are due to a viral respiratory infection, and only symptomatic treatment is needed. Antibiotics are rarely indicated and should be avoided. References: Diagnosis and treatment of acute bronchitis. (http://www.ncbi.nlm.nih.gov/pubmed/21121518) Evidence-based acute bronchitis therapy. (http://www.ncbi.nlm.nih.gov/pubmed/23076965)

Question 3

A 38-year-old woman comes to the office due to worsening asthma symptoms for 2-3 days.  She has shortness of breath, wheezing, and productive cough.  The patient describes thick sputum that was blood-tinged yesterday.  She was diagnosed with asthma 12 years ago but says that it had not been this bad until last year.  For the past year the patient has had 2 hospitalizations for asthma exacerbations but has never been intubated.  She completed a course of oral prednisone and azithromycin 2 months ago.  Current medications include a daily fluticasone inhaler and as-needed albuterol inhaler.  The patient reports no decrease in appetite or weight loss and has not travelled outside of her home state of New Jersey in the past 2 years.  She works as a school teacher and does not use tobacco, alcohol, or illicit drugs.  The patient has no second-hand tobacco exposure and no known allergies.  Her grandmother also has asthma.  Temperature is 37 C (98.6 F), blood pressure is 123/80 mm Hg, pulse is 94/min, and respirations are 16/min.  Pulse oximetry shows 95% on room air.  Pulmonary examination reveals scattered wheezes.  Heart sounds are normal.  There is no clubbing, peripheral edema, or skin rashes.  Complete blood count shows the following:  Further laboratory evaluation of the patient shows a serum total IgE level of >1,000 ng/mL.  High-resolution CT scan of the lungs confirms the presence of bilateral upper lobe infiltrates and central bronchiectasis.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: Treatment for allergic bronchopulmonary aspergillosis (ABPA) is directed at acutely stopping the underlying inflammation and decreasing fungal burden to reduce the risk of recurrence. Systemic glucocorticoids are the mainstay therapy and have been shown to improve symptoms during acute exacerbations. They also speed the resolution of lung opacities on radiographic imaging, normalize eosinophil levels, and significantly reduce total IgE, which is serially monitored to assess clinical response. Antifungal therapy with either itraconazole or voriconazole should also be considered as it has been shown to reduce the Aspergillus load and, therefore, the antigenic stimulus for ABPA. In addition, antifungal therapy has been demonstrated to decrease glucocorticoid requirements. Other therapeutic options include omalizumab, a monoclonal antibody against IgE, which may be helpful in patients with ABPA and poorly controlled asthma. (Choice A) Albendazole is appropriate treatment for infection due to many helminthic organisms (eg, Ascaris lumbricoides, Enterobius vermicularis), but it does not have any activity against Aspergillus. (Choices B and D) This patient has no evidence of active tuberculosis or pneumonia, and neither antituberculosis medications nor levofloxacin are indicated in the treatment of ABPA or its exacerbations. (Choice C) Although other azoles are appropriate, fluconazole has limited activity against Aspergillus and is not first-line therapy for any form of Aspergillus infection. Educational objective: Treatment for allergic bronchopulmonary aspergillosis is directed at acutely stopping the underlying inflammation and reducing Aspergillus burden. Systemic glucocorticoids are the mainstay therapy with consideration of antifungal therapy (itraconazole or voriconazole) to decrease fungal burden and antigenic stimulus. References: Practice Guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/27365388) Allergic bronchopulmonary aspergillosis: a perplexing clinical entity. (http://www.ncbi.nlm.nih.gov/pubmed/27126721) Pulmonary aspergillosis: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/21881144)

Question 4

A 28-year-old man with a history of bipolar I disorder is brought to the emergency department after being pulled over by police for driving erratically.  The police report indicates that the patient appeared alcohol-intoxicated and refused to cooperate with questions, stating, "I have the skills of a race car driver and a need for speed."  He has been on lithium for years and says he has been adherent.  The patient has a history of bilateral knee injuries sustained in an accident when he jumped from a high ledge.  He has no other medical history.  The emergency physician contacts the outpatient psychiatrist, who reports that the patient has been treated with lithium for the past 3 years.  He had a therapeutic lithium level and appeared stable at his last visit 2 weeks ago.  The patient is re-interviewed when he is sober.  He felt upset after his girlfriend left him and was turned down for a job, and so decided to "get drunk."  He is apologetic for driving recklessly and says he intends to follow up with his outpatient psychiatrist.  Although the patient admits to a history of crack cocaine use, he currently uses no illicit substances other than marijuana on weekends.  Temperature is 37.2 C (99 F), blood pressure is 140/80 mm Hg, and pulse is 88/min.  Physical examination is normal.  The patient is alert, and his speech is nonpressured.  Urine toxicology screen is negative for illicit substances. On further questioning, the patient acknowledges that he has been feeling very depressed since losing his job and breaking up with his girlfriend.  He has struggled with suicidal thoughts on and off and admits that his previous jump from a ledge was a suicide attempt that occurred during a period of severe depression.  He has had no suicidal thoughts for over a year until tonight, when he started drinking.  Which of the following questions is the most important to ask the patient at this time?

Accepted Answer

Explanation: 11ec2b69_c068_3d27_8f63_9340a67da433_MD0005_00 The patient now admits to having suicidal thoughts, and the physician should carefully assess him for safety. This involves a systematic assessment of suicidal ideation, intent (desire to act on a suicide plan), and plan (details of method, place, time, and access to means). The physician should also ask the patient how close he has come to acting on his plan, including rehearsals or aborted attempts (initiates act but then stops). In this case, it is imperative to determine if the patient's erratic driving indicated suicidal behavior. If there is reason to believe this is the case, the patient is at high risk for harm to himself and others and hospitalization is indicated. (Choice A) Although all suicidal patients should be assessed for access to guns, it is more important to determine whether the patient's erratic driving was actually suicidal behavior that would warrant immediate hospitalization. (Choices B and C) A history of suicide attempts is the strongest predictor of future suicide attempts. For this reason, the physician should obtain a detailed history of all previous attempts. A family history of suicide attempt is another risk factor. However, clarifying the seriousness of the patient's recent dangerous behavior is more important for immediate management. (Choice D) Patients who say that they would be "better off dead" have passive suicidal ideation (thoughts of death or a wish to die but no thoughts of killing self). However, this patient has expressed active suicidal thoughts that should be assessed first due to their severity. Educational objective: Patients brought to the emergency department for behavior indicating a high likelihood of self-harm should be systematically assessed for suicidal ideation, intent, and plan. Obtaining specific details of the incident is essential for evaluating the seriousness of suicidal risk. Patients who have attempted suicide or who endorse active suicidal ideation with a specific plan and intent require hospitalization. References: Reducing suicide risk: challenges and opportunities in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/27451339) Managing suicidal patients in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/26443554)

Question 5

A 75-year-old man is admitted to the intensive care unit due to septic shock and acute respiratory distress syndrome.  The patient's medical history is significant for relapsed refractory multiple myeloma and malignant bone pain requiring long-term opioid therapy.  Despite a prolonged course of mechanical ventilation, his condition deteriorates; he is transitioned to comfort-oriented care in accordance with his advance directive.  The patient is extubated to a simple oxygen face mask.  Morphine is administered intravenously to ease air hunger, and glycopyrrolate is given to reduce heavy secretions.  Thirty minutes later, he is gurgling loudly.  Pulse is 118/min and respirations are 8/min.  Oxygen saturation is 90%.  Examination reveals a cachectic, obtunded man with irregular, rattling respirations.  Pupils are pinpoint bilaterally.  Skin is diaphoretic.  In addition to suctioning the oropharynx, what is the most appropriate next step in management at this time?

Accepted Answer

Explanation: 11ec2b69_c06e_098b_8f63_a7eaa13e738e_MD0005_00 This patient with end-stage malignancy and acute respiratory failure has been transitioned to palliative comfort care, in which the focus shifts toward treatment of symptoms (eg, dyspnea, secretions, pain, anxiety). Close observation for signs and symptoms of distress is the cornerstone of palliative care. After the patient was extubated terminally and given morphine for palliation of dyspnea at the end of life, he developed expected adverse effects, including miosis and respiratory depression. However, he now also exhibits signs of distress (ie, tachycardia, diaphoresis, inability to clear secretions) and active dying, including coma and agonal respirations (ie, irregular, rattling breaths). To be consistent with the predefined goals of care, the patient's comfort should be prioritized over his respiratory status. Administering additional morphine may hasten death, but it still should be given to minimize suffering. This ethical framework is known as the doctrine of double effect: Interventions that have adverse effects (eg, respiratory depression) are justified if they promote patient well-being (eg, allowing for a comfortable death). (Choice B) Although administering a reversal agent such as naloxone may be tempting, doing so would precipitate acute opioid withdrawal. This could cause needless suffering contradictory to the patient's goals of care, especially one who has taken opioids long term for malignant bone pain. (Choices C and D) Noninvasive ventilation (NIV) can be a bridge to recovery in patients with potentially reversible causes of respiratory failure and do-not-intubate instructions. However, it is unlikely to benefit this patient with irreversible underlying disease and continued deterioration; NIV also is contraindicated in patients with decreased consciousness and copious secretions (aspiration risk). An oropharyngeal airway is a C-shaped tube, extending from the gums to the vallecula, that may be used to temporarily improve airway patency in unconscious patients; however, it is highly noxious and conflicts with palliative goals of care. oropharyngeal airway (Choice E) Palliative care interventions are based on signs and symptoms of discomfort (eg, dyspnea, tachypnea). Diagnostic tests may cause unnecessary discomfort (eg, pain during venipuncture or positioning for chest x-rays). Although the tests may reveal abnormalities, their results usually do not influence clinical symptom management. Educational objective: Opioids are used to relieve pain and dyspnea at the end of life. In actively dying patients with comfort-oriented goals of care, opioids may be used to promote comfort despite hastening the dying process.

Question 6

A 56-year-old, previously healthy man is admitted to the intensive care unit for acute respiratory distress syndrome due to viral pneumonia.  The patient requires prolonged mechanical ventilation with deep sedation, prone positioning, and paralytic agents.  He develops hypoactive delirium, which slowly improves with sedation washout.  After 7 days, the patient is successfully extubated and discharged to a skilled rehabilitation center.  A week later, he is participating in daily physical therapy.  The patient requires 2-person assistance to stand due to diffuse weakness.  He has been irritable and confused in the evenings and is prescribed zolpidem to assist with sleep.  Montreal Cognitive Assessment score is 25/30, with deficits in attention and memory.  Neurologic examination reveals flattened affect and mild psychomotor retardation.  He is on extended sick leave from his job as an air traffic controller.  Which of the following statements best represents this patient's long-term prognosis?

Accepted Answer

Explanation: 11ec2b69_c070_7a8e_8f63_f951c1293784_MD0005_00 Although advances in the intensive care unit (ICU) have improved survival for patients affected by critical illness, longitudinal follow-up shows that these patients are at risk for post-intensive care syndrome (PICS), which is characterized by chronic morbidities that can span the following 3 domains: Psychiatric: Many patients develop major depression (eg, dysphoria, flat affect, psychomotor retardation, irritability, sleep disturbances) and/or posttraumatic stress disorder, with diagnoses that can occur within 5 years of the ICU stay; sleep disturbances are common, particularly in the first few weeks(Choice B). Neurocognitive: Most patients have attention/memory deficits persisting for several years, with the average global cognition score falling by 1.5 standard deviations, similar to moderate traumatic brain injury. Physical: A majority lose functional independence, requiring daily assistance for months to years. About 50% of patients require community-based rehabilitation services such as outpatient physical therapy. Mild global weakness may persist, but most patients are able to walk independently again (Choice C). Most ICU survivors are impaired in ≥1 domains for several years, usually with major negative impacts on quality of life. PICS is a significant health concern: Many patients require chronic health services and are unable to return to work. These medical and financial burdens frequently extend to patients' families and caregivers. The pathobiology of PICS remains unclear. Well-established risk factors include ICU delirium, sepsis, acute respiratory distress syndrome (ARDS), and prolonged mechanical ventilation. Therefore, injury to the CNS due to cellular hypoxia, metabolic disruption, and massive inflammation likely play important roles. (Choice D) In most ARDS survivors, pulmonary function recovers fully over several months; 25% of patients have chronic mild impairments (restrictive defect and reduced diffusion), but long-term oxygen therapy requirements are uncommon. (Choice E) After hyperinflammatory sepsis, immune cell exhaustion leads to a state of immunoparalysis for several weeks. This heightens susceptibility to nosocomial pathogens (eg, Enterococcus urinary tract infection, hospital-acquired pneumonia) associated with institutional care settings such as skilled rehabilitation centers. Asymptomatic reactivation of latent viruses (eg, incidental cytomegalovirus viremia) may also occur. However, immune function recovers, and patients do not require antimicrobial prophylaxis for classic opportunistic infections (eg, Pneumocystis) associated with chronic immunodeficiency. Educational objective: Survivors of critical illness are often burdened by chronic (ie, years) psychologic, neurocognitive, and physical deficits, resulting in a reduced quality of life referred to as post-intensive care syndrome (PICS). Acute respiratory distress syndrome, prolonged mechanical ventilation, and delirium are the major risk factors for PICS. References: The adult respiratory distress syndrome cognitive outcomes study: long-term neuropsychological function in survivors of acute lung injury. (http://www.ncbi.nlm.nih.gov/pubmed/22492988)

Question 7

A 38-year-old woman comes to the office due to worsening asthma symptoms for 2-3 days.  She has shortness of breath, wheezing, and productive cough.  The patient describes thick sputum that was blood-tinged yesterday.  She was diagnosed with asthma 12 years ago but says that it had not been this bad until last year.  For the past year the patient has had 2 hospitalizations for asthma exacerbations but has never been intubated.  She completed a course of oral prednisone and azithromycin 2 months ago.  Current medications include a daily fluticasone inhaler and as-needed albuterol inhaler.  The patient reports no decrease in appetite or weight loss and has not travelled outside of her home state of New Jersey in the past 2 years.  She works as a school teacher and does not use tobacco, alcohol, or illicit drugs.  The patient has no second-hand tobacco exposure and no known allergies.  Her grandmother also has asthma.  Temperature is 37 C (98.6 F), blood pressure is 123/80 mm Hg, pulse is 94/min, and respirations are 16/min.  Pulse oximetry shows 95% on room air.  Pulmonary examination reveals scattered wheezes.  Heart sounds are normal.  There is no clubbing, peripheral edema, or skin rashes.  Complete blood count shows the following:  Chest x-ray reveals patchy bilateral upper lobe infiltrates and prominent bronchial markings.  Which of the following is the best next step in diagnosing the cause of this patient's worsening symptoms?

Accepted Answer

Explanation: 11ec2b69_c072_0132_8f63_cd533f6aaccc_MD0005_00 This patient is most likely suffering from allergic bronchopulmonary aspergillosis (ABPA). ABPA occurs when patients with either underlying asthma or cystic fibrosis become sensitized to Aspergillus antigens, resulting in an intense IgE- and IgG-mediated immune response. It should be suspected any time a patient with one of these preexisting conditions develops recurrent exacerbations with fever, malaise, cough with brownish mucoid sputum, wheezing, or symptoms of bronchial obstruction. Current diagnostic criteria for ABPA include an elevated Aspergillus-specific IgE with an elevated (eg, >417 IU/mL) total IgE, positive Aspergillus-specific IgG, eosinophilia, and positive skin test reactivity for Aspergillus. Consequently, the initial evaluation for ABPA should include either skin testing for Aspergillus or analysis of total and specific IgE concentrations. Chest radiography typically demonstrates upper lobe opacities, atelectasis due to mucus plugging, and signs of bronchiectasis such as bronchial wall thickening. In addition, CT imaging can be helpful to further identify specific radiographic abnormalities consistent with ABPA. bronchiectasis bronchial wall thickening (Choice B) It is important to verify appropriate inhaler technique in any patient with poorly controlled asthma; however, improper technique alone would not explain this patient's new onset of symptoms, radiographic findings, or peripheral eosinophilia. (Choice C) Bronchoscopy with bronchoalveolar lavage can be very useful in identifying the underlying cause of pneumonia in immunocompromised patients or in those whose clinical course is atypical. It can also be helpful in identifying lesions in patients who have frank hemoptysis (not blood-tinged sputum) or evidence of malignancy; however, it has no role in the evaluation of ABPA. (Choice D) Pulmonary function testing may reveal an obstructive pattern or a mixed obstructive and restrictive pattern in patients with ABPA; however, this study does not add significant diagnostic information to the evaluation of suspected ABPA. (Choice E) This patient lacks the significant risk factors (eg, immunosuppression, travel) and weight loss typically associated with pulmonary disease due to acid-fast bacteria (eg, tuberculosis, Mycobacterium avium complex infection, nocardiosis). Educational objective: Allergic bronchopulmonary aspergillosis should be suspected in patients with preexisting asthma or cystic fibrosis who develop recurrent episodes of fever, malaise, cough with brownish mucoid sputum, wheezing, or symptoms of bronchial obstruction. The initial evaluation should include either skin testing for Aspergillus or analysis of total and specific IgE concentrations. References: Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/27365388) Allergic bronchopulmonary aspergillosis: a perplexing clinical entity. (http://www.ncbi.nlm.nih.gov/pubmed/27126721) Pulmonary aspergillosis: a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/21881144)

Question 8

A 64-year-old man comes to the emergency department with a 3-day history of fever, shortness of breath, and worsening productive cough.  The patient also reports sharp, intermittent, right-sided chest pain.  He has a history of hypertension and type 2 diabetes mellitus.  The patient has smoked a pack of cigarettes daily for 20 years.  Temperature is 38.9 C (102 F), blood pressure is 110/60 mm Hg, pulse is 114/min, and respirations are 32/min.  The patient's pulse oximetry shows 86% on room air.  Examination reveals diffuse crackles over the lung fields.  Heart sounds are regular with no murmurs or gallops.  Chest x-ray reveals bilateral consolidation and infiltrates.  He is started on empiric intravenous antibiotics after obtaining cultures but requires endotracheal intubation due to respiratory failure.  Which of the following is most reliable for confirming tracheal (rather than esophageal) endotracheal tube placement in this patient?

Accepted Answer

Explanation: Capnography (quantitative waveform or colorimetric analysis) is a noninvasive technique used to measure CO₂ concentration in the exhaled breath. It is the most reliable method for the verification of proper endotracheal tube (ETT) placement. A normal capnogram has a characteristic rectangular waveform with 4 phases. Any variation in waveform morphology and/or end-tidal CO₂ (EtCO₂) can provide diagnostic information about ventilation/perfusion or metabolic status. A normal waveform with all 4 phases after intubation indicates proper ETT placement, whereas a flat-line waveform typically indicates improper esophageal placement. A colorimetric EtCO₂ detector consists of litmus paper that changes color when exposed to CO₂. CO₂ exhalation from an ETT properly placed in the trachea will lead to a color change (purple to yellow), whereas an ETT improperly placed in the esophagus will not deliver CO₂ to the detector, resulting in no color change. (Choice A) An anteroposterior chest radiograph is useful for determining the depth of ETT in the trachea, but it cannot reliably exclude esophageal intubation. (Choices B and D) The auscultation of breath sounds in both lung fields and visualization of chest wall rise with assisted ventilation can be misleading as they are not specific for tracheal rather than esophageal ETT placement. Fogging of the ETT on exhalation occurs commonly after intubation but is also not a reliable indicator of tracheal rather than esophageal ETT placement. (Choice E) Experienced providers may sometimes be able to confirm tracheal placement of an ETT by visualization of it passing between the vocal cords. However, due to variable patient anatomy or fluid in the oropharynx (eg, blood, vomitus), clear visualization of the vocal cords is not always possible. Educational objective: Capnography (measurement of CO₂ concentration over time) is the most reliable method for verification of endotracheal tube (ETT) placement in the trachea rather than the esophagus. Clinical findings, including auscultation of breath sounds over both lung fields, chest wall rise with assisted ventilation, visualization of the ETT passing through the vocal cords, and fogging of the ETT on exhalation, are not reliable indicators of correct placement in the trachea. References: Comparison of three different methods to confirm tracheal tube placement in emergency intubation. (http://www.ncbi.nlm.nih.gov/pubmed/12107674) Verification of endotracheal tube placement following intubation. National Association of EMS Physicians Standards and Clinical Practice Committee. (http://www.ncbi.nlm.nih.gov/pubmed/10424864)

Question 9

A 9-year-old boy is brought to the clinic by his parents due to difficulty at school.  According to his teachers, the boy has grunted frequently in class for the past year.  Recently, it has reached the point of significantly distracting other students.  His parents have also noted the grunting at home.  They are concerned that he is being teased by his classmates and have noticed that since the behavior started he seems less interested in playing with his classmates after school.  There is no family history of similar symptoms.  The patient's medical history includes attention-deficit hyperactivity disorder treated with behavioral therapy and mild asthma treated with an albuterol inhaler.  He takes no other medications and has no medication allergies.  Temperature is 36 C (96.8 F), blood pressure is 119/78 mm Hg, and pulse is 82/min.  The lungs are clear to auscultation.  During the physical examination, the patient makes several sudden grunting noises and frequently shrugs his shoulders.  Neurologic examination reveals normal strength and sensation in all extremities.  Although he has an increased rate of blinking, he has no nystagmus.  This patient is at greatest risk of developing which of the following?

Accepted Answer

Explanation: 11ec2b69_c06a_d539_8f63_dd7de23db94c_MD0005_00 The presence of both vocal and motor tics is consistent with a diagnosis of Tourette syndrome (TS), which typically manifests before age 11. Diagnosis of this condition is based on clinical symptoms alone, as there are no diagnostic laboratory tests. Vocal tics can range from simple sounds (eg, coughing, grunting, throat clearing, clicks, sniffing), as in this patient, to blurting out inappropriate comments or obscenities (coprolalia). Motor tics typically involve the face and head and may also include complex movements of the torso and limbs. TS is frequently associated with comorbid psychiatric conditions; attention-deficit hyperactivity disorder and obsessive-compulsive disorder (OCD) are the most common. Therefore, this patient is at greatest risk of developing OCD. Comprehensive management of TS requires careful screening for and treatment of these common comorbid disorders. (Choices A and E) Although anxiety and mood disorders are significantly more common in children with TS than in those without, they are not as common as OCD. (Choice C) Oppositional defiant disorder or conduct disorder is often coexistent in patients with TS. However, OCD is the more common comorbid condition. (Choice D) Schizophrenia is not commonly associated with TS. Educational objective: Tourette syndrome is associated with several comorbid conditions; attention-deficit hyperactivity disorder and obsessive-compulsive disorder are the most common. References: Tourette syndrome and comorbid neuropsychiatric conditions. (http://www.ncbi.nlm.nih.gov/pubmed/27891299) Lifetime prevalence, age of risk, and genetic relationships of comorbid psychiatric disorders in Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25671412)

Question 10

A 13-year-old boy is brought to the office by his parents due to their concern about his behavior and academic performance.  The patient is failing several classes in junior high school and has few friends.  His mother reports, "His teachers complain that he doesn't pay attention and disrupts the class.  One teacher says that he clears his throat repeatedly, distracting the other kids and making it difficult for her to teach.  She has asked him to stop but he keeps doing it."  The boy says, "I try in school but the kids are mean and make fun of me because they think I am weird or something."  Over the past year, his father has observed frequent repeated blinking, which he found unusual but assumed was a sign of fatigue.  His mother adds that several months ago the boy was grimacing frequently, but this seems to have passed.  In the office, the boy shrugs his left shoulder repeatedly.  Medical history is unremarkable.  A Stanford-Binet test administered 2 years ago measured the boy's intelligence quotient as 95.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 14/min.  Weight is 45 kg (99.2 lb) and height is 155 cm (5 ft 1 in).  Physical examination, including neurological examination, is normal. 
Which of the following is the most likely diagnosis?

Accepted Answer

Explanation: 11ec2b69_c069_c3c8_8f63_21d3f956b418_MD0005_00 Tourette syndrome typically appears at age 6-15 and is more common in boys. Diagnosis requires multiple motor tics and at least one vocal tic. Both simple (eg, blinking, grimacing, shrugging) and complex motor (eg, body gyrations, odd gait, obscene gestures) tics are seen. Vocal tics can range from simple sounds (eg, coughing, grunting, throat clearing, sniffing), as in this patient, to blurting out inappropriate comments and obscenities (coprolalia). Tics are typically preceded by irresistible urges and followed by feelings of relief. They can be suppressed voluntarily for brief periods and are exacerbated by fatigue and stress. Comorbidities (eg, attention-deficit hyperactivity disorder, obsessive-compulsive disorder) are common. (Choice A) Absence seizures are very brief generalized seizures in children that cause impaired consciousness. They may occur hundreds of times a day and present as brief staring spells. (Choice B) Chronic tic disorder involves one or more motor or vocal tics (but not both) for >1 year. This patient has both motor and vocal tics. (Choice C) Tics occur in approximately 25% of normal children and typically remit spontaneously in a few weeks or months. Tics present for <1 year are diagnosed as provisional tic disorder (formerly known as transient tic disorder). This patient has multiple motor and vocal tics that are more persistent. (Choice D) Stereotypic movement disorder is characterized by repetitive and seemingly purposeless movements (eg, hand flapping, head banging). It is often associated with other neurodevelopmental disorders (eg, autism, intellectual disability, fetal alcohol syndrome). Educational objective: Tourette syndrome is characterized by simple and complex motor tics and involuntary vocalizations. A minority of individuals with the condition utters obscenities or perform obscene gestures. References: Tics and Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/25150562) Clinical assessment of Tourette syndrome and tic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23206664)

Question 11

A 13-year-old boy is brought to the office by his parents due to their concern about his behavior and academic performance.  The patient is failing several classes in junior high school and has few friends.  His mother reports, "His teachers complain that he doesn't pay attention and disrupts the class.  One teacher says that he clears his throat repeatedly, distracting the other kids and making it difficult for her to teach.  She has asked him to stop but he keeps doing it."  The boy says, "I try in school but the kids are mean and make fun of me because they think I am weird or something."  Over the past year, his father has observed frequent repeated blinking, which he found unusual but assumed was a sign of fatigue.  His mother adds that several months ago the boy was grimacing frequently, but this seems to have passed.  In the office, the boy shrugs his left shoulder repeatedly.  Medical history is unremarkable.  A Stanford-Binet test administered 2 years ago measured the boy's intelligence quotient as 95.  Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 14/min.  Weight is 45 kg (99.2 lb) and height is 155 cm (5 ft 1 in).  Physical examination, including neurological examination, is normal. The diagnosis of Tourette syndrome is made.  The physician educates the patient and his parents about the disorder and provides counseling on behavioral techniques to suppress tics.  Six months later, the patient returns with his mother for a follow-up visit.  She reports that the tics are worse and very distressing.  Although his grades have improved somewhat, he is miserable at school and refuses to attend any afterschool activities.  Examination shows grunting, facial grimacing, and writhing of the left side of the body.  Which of the following medications would be most effective in reducing tics in this patient?

Accepted Answer

Explanation: The treatment of Tourette syndrome includes psychotherapy and/or medications. Habit reversal therapy (HRT), a form of cognitive-behavioral therapy, is the most effective nonpharmacological treatment. When tics are severe and interfere with social and academic functioning, or if the response to HRT is suboptimal or HRT is not available, pharmacological treatment may be required. First-generation antipsychotics (eg, fluphenazine, pimozide, haloperidol) have demonstrated efficacy and are approved by the Food and Drug Administration. However, second-generation antipsychotics (eg, risperidone, aripiprazole) are typically preferred due to first-generation side effect profiles (eg, extrapyramidal symptoms, QTc prolongation with pimozide). As a group, antipsychotics reduce the frequency and intensity of tics by 60%-80%. Other pharmacological treatments include alpha-2 adrenergic receptor agonists (eg, clonidine, guanfacine) and tetrabenazine (a dopamine depleter). (Choice A) Ethosuximide is effective in the treatment of absence seizures. (Choice B) Selective serotonin reuptake inhibitors (eg, fluoxetine) are appropriate for the treatment of comorbid obsessive-compulsive behavior, impulse control problems, and rage attacks in patients with Tourette syndrome. They are not effective in reducing the severity or frequency of tics. (Choice C) The stimulant methylphenidate is effective in the treatment of attention-deficit hyperactivity disorder, a common comorbidity of Tourette syndrome, but it would not treat tics. (Choice E) Valproate is used as a mood stabilizer in bipolar disorder and as an anticonvulsant. It is not effective in treating tics. Educational objective: The first-generation antipsychotics haloperidol and pimozide are approved by the Food and Drug Administration for the treatment of Tourette syndrome. However, second-generation antipsychotics (eg, risperidone, aripiprazole) are well studied and increasingly preferred in children due to their favorable side effect profile. Other treatments for Tourette syndrome include alpha-2 adrenergic agonists, tetrabenazine, and habit reversal therapy. References: Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26786936) Current pharmacotherapeutic approaches for the treatment of Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/24619591) Update on the role of antipsychotics in the treatment of Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/22442630)

Question 12

A 35-year-old man comes to the office due to weight loss and insomnia.  He has been depressed about his troubled marriage and stressed by his wife's complaints about his inability to provide for the family.  Lately he has had difficulty concentrating and fears that his productivity at work has fallen.  The patient says, "I drag myself into work late because I can't get out of bed.  Then I sit and stare at the papers piling up on my desk.  I used to enjoy biking and going out with friends, but now I just come straight home from work and lie on the couch.  At night, I have started having a couple of drinks to help me fall asleep."  Over the past month, the patient has wished that he could go to sleep and not wake up, and has thought that he would be "better off dead."  These thoughts last for several minutes when he is lying in bed awake at night.  He has no intent or plan to harm himself.  The patient has no history of suicide attempt or depression.  There is a family history of suicide in a paternal uncle who had depression and substance abuse.  The patient used cocaine and marijuana in his 20s but not in the past 8 years.  He is going through a divorce and is worried that he will not get joint custody of his 2 children.  Vital signs and physical examination are normal, with the exception of a 2.3-kg (5-lb) weight loss.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This patient has classic symptoms of major depression, including depressed mood, weight loss, insomnia, impaired concentration, low energy, and decreased interest. Determining an appropriate treatment setting requires a careful assessment of suicide risk. This patient has expressed the wish to go to sleep and not awaken as well as thoughts of being "better off dead." This is sometimes referred to as "passive" as opposed to "active" suicidal ideation. The patient has no thoughts of acting to kill himself or a suicide plan. Patients with suicidal thoughts who lack a specific plan and intent can usually be treated on an outpatient basis. It is important to initiate treatment with an antidepressant and/or psychotherapy, provide close follow-up to monitor response, and perform ongoing suicide risk assessment. Hospitalization (Choice C) is usually reserved for patients who have active suicidal ideation with some intent and/or a plan, inability to care for themselves or to adhere to outpatient treatment, or complex psychiatric and medical comorbidities. (Choice A) There is insufficient justification to breach confidentiality in this case. An exception to the duty to protect patient confidentiality would be if the patient is at high, imminent risk of suicide (ie, active suicidal ideation with intent and plan to act in the near future). (Choice B) Although the patient is having several drinks at night, this is most likely an effort to self-medicate his insomnia and depression rather than a cause of his depression. The physician should counsel the patient on the negative effects of alcohol on depression, but it would be inappropriate to defer treatment of his depression. (Choice E) Suicide prevention contracts (patient promises not to act on suicidal thoughts and notify the clinician instead) are not recommended. They provide a false sense of security and have not demonstrated efficacy in decreasing the risk of suicide. Educational objective: Depressed patients with suicidal ideation but no intent or plan require aggressive treatment, but not necessarily hospitalization. References: Contracting for safety with patients: clinical practice and forensic implications. (http://www.ncbi.nlm.nih.gov/pubmed/19767501)

Question 13

A 76-year-old woman is hospitalized due to a fracture of her right proximal femur from an accidental nonsyncopal fall.  Medical history is notable for breast cancer treated with a radical mastectomy 10 years ago, hypertension, and hyperlipidemia.  She drinks a pint of vodka daily, but does not use tobacco or illicit drugs.  The patient is started on thiamine and folic acid, and the next morning she undergoes orthopedic surgery for internal fixation of the right femur.  She experiences mild agitation postoperatively, which is managed with as-needed, low-dose benzodiazepines.  In addition, she is treated with low-molecular-weight heparin, opiates, and continued vitamin supplementation.  On her third postoperative day, the nurse finds her agitated and in significant distress.  The patient has an episode of nonbloody vomiting.  On initial evaluation, she appears restless and confused but follows commands.  Temperature is 36.7 C (98 F), blood pressure is 92/58 mm Hg, pulse is 122/min and regular, and respirations are 31/min.  Pulse oximetry is 75% on room air and improves to 82% with supplemental oxygen by non-rebreather mask.  Chest auscultation reveals no crackles or wheezes.  Cardiac examination demonstrates tachycardia with a regular rhythm and normal S1 and S2.  The abdomen is soft.  Her pupils are equal and reactive to light, and she is moving all extremities. 
Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This postoperative patient with tachycardia, tachypnea, and persistent hypoxemia following initiation of supplemental oxygen is in acute respiratory failure; she requires urgent stabilization, which is best accomplished with endotracheal rapid-sequence intubation (RSI). RSI makes use of a rapidly acting sedative (eg, etomidate, propofol, midazolam) and a paralytic agent (eg, succinylcholine, rocuronium) to facilitate emergent intubation while preventing aspiration. Once intubated and stabilized, the cause of this patient's acute respiratory failure can be diagnosed and managed. (Choices A and B) Testing for the possible etiologies of this patient's respiratory failure (eg, myocardial infarction, acute pulmonary embolism) cannot be performed until she has been intubated and stabilized. Excessive delay in endotracheal intubation and initiation of ventilatory support is likely to lead to cardiac arrest from respiratory failure. (Choice D) Benzodiazepines decrease respiratory drive and should be avoided in patients with respiratory failure, with the exception of short-acting benzodiazepines (eg, midazolam) for sedation during RSI. In addition, high-flow supplemental oxygen is unlikely to provide significantly more benefit to this patient than the non-rebreather mask is already providing. Ventilatory support with mechanical ventilation is needed. (Choice E) Noninvasive positive-pressure ventilation (eg, continuous positive airway pressure, bilevel positive airway pressure) uses a face or nasal mask to administer pressurized air into the lungs. It is often useful for ventilatory support in patients with acute respiratory failure due to chronic obstructive pulmonary disease or heart failure; however, it does not protect the airway and is contraindicated in this patient with impaired consciousness and risk of aspiration. Educational objective: Critically ill patients who are unstable with significant hypoxemia require rapid-sequence intubation for ventilatory support and/or airway protection. After initial stabilization of the airway, patients may be appropriately assessed for the underlying etiology of acute respiratory failure. References: Airway management of the critically ill patient: rapid-sequence intubation. (http://www.ncbi.nlm.nih.gov/pubmed/15821222)

Question 14

A 44-year-old man with a medical history of food allergy to peanuts is brought to the emergency department for an allergic reaction.  The patient developed the acute onset of dyspnea and wheezing shortly after ingesting a cookie.  His symptoms progressed to difficulty swallowing and swelling of the face and tongue.  On arrival, temperature is 36.9 C (98.4 F), pulse is 115/min, blood pressure is 85/74 mm Hg, and respirations are 28/min.  Oxygen saturation is 93% on a nonrebreather face mask.  He is anxious and pale with swollen lips, swollen tongue, and inspiratory stridor.  On lung auscultation, bilateral wheezing is present.  Intramuscular epinephrine, intravenous fluids, and racemic epinephrine via nebulizer are administered without improvement.  The patient's distress is increasing, and he is becoming more agitated.  The decision to intubate using awake fiberoptic nasotracheal intubation is made.  Which of the following medications would be the best choice to aid in awake fiberoptic nasotracheal intubation in this patient?

Accepted Answer

Explanation: This patient with acute onset of respiratory distress, angioedema, and shock following likely allergen exposure has anaphylaxis and an unstable respiratory status (eg, tachypnea, hypoxia, stridor, wheezing) that are worsening despite appropriate treatment. This situation necessitates a definitive airway. In contrast to rapid sequence intubation (RSI), awake intubation (either nasotracheal or orotracheal) is the preferred method of intubation for patients with difficult airways, such as this patient with upper airway obstruction (eg, swollen lips/tongue, stridor). In awake intubation, the patient independently maintains upper airway tone and spontaneous ventilation while the airway is visualized (typically using a fiberoptic endoscope) to determine whether intubation is possible. During RSI, a patient is fully anesthetized and paralyzed, causing loss of all upper airway tone, protective airway reflexes, and respiratory drive. If intubation is unsuccessful, as can occur in patients with difficult airways, the patient can rapidly become hypoxic and experience cardiac arrest. Ketamine, a phencyclidine derivative, is the preferred agent to use for awake intubations because it provides dissociation, amnesia, and analgesia (ie, dissociative anesthesia) while maintaining upper airway tone, protective airway reflexes, and respiratory drive. It also causes a sympathetic surge (by inhibiting reuptake of catecholamines) that increases blood pressure and causes bronchial smooth muscle relaxation, which are additional benefits in this patient with hypotension and bronchospasm. (Choice A) Fentanyl is a short-acting opioid analgesic sometimes used for pain management during short procedures (eg, fracture reduction). However, fentanyl can cause respiratory depression and exacerbate hypotension, making it undesirable in this patient. In addition, it does not provide dissociation or amnesia. (Choice C) Propofol can provide rapid-onset sedation and amnesia. However, it typically causes deep sedation, respiratory depression, and loss of airway reflexes, which would be dangerous in this patient. In addition, it can worsen hypotension. (Choices D and E) Rocuronium and succinylcholine are neuromuscular blocking agents typically used (along with a sedative) in RSI. Both cause complete paralysis, loss of upper airway tone, and cessation of all respiratory effort, which can lead to hypoxia and cardiac arrest if an airway is not secured immediately. This patient with a difficult airway should instead undergo awake intubation, with preservation of spontaneous breathing (vs paralysis). Educational objective: Awake intubation is the preferred intubation method for patients with difficult airways (eg, upper airway obstruction due to anaphylaxis). Ketamine facilitates awake intubation by providing dissociation, amnesia, and analgesia while also maintaining upper airway tone, protective reflexes, and respiratory drive. References: Ketamine activates breathing and abolishes the coupling between loss of consciousness and upper airway dilator muscle dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/22108392)

Question 15

A 71-year-old man is admitted to the intensive care unit due to influenza complicated by bacterial pneumonia and acute respiratory distress syndrome.  He has been receiving mechanical ventilation for 8 days.  The patient completed a course of intravenous antibiotic therapy, and his clinical status has steadily improved.  Ventilator settings have been weaned to minimal levels, and he is tolerating daily spontaneous breathing trials.  However, the patient remains intubated due to intermittent somnolence and thick secretions requiring frequent suctioning.  At night, he is agitated and pulls at his lines, requiring cloth mittens and soft restraints.  During the day, the patient is mostly alert and able to communicate by writing on a personal whiteboard.  Vital signs are within normal limits.  Cough strength is weak, and he has difficulty raising his head from the pillow.  Results of serum chemistry are within normal limits, and complete blood count reveals normocytic anemia with hemoglobin of 9.6 g/dL.  Which of the following interventions is most strongly indicated at this time to promote recovery and extubation?

Accepted Answer

Explanation: 11ec2b69_c071_3ddf_8f63_2535a11e9498_MD0005_00 After the acute phase of critical illness, the focus of care shifts to rehabilitation. For this patient, delirium and ventilator liberation are key issues for recovery. These clinical concerns are often encountered together: Delirium is a barrier to extubation, but invasive ventilation exacerbates delirium. Early physical therapy (PT) is an evidence-based practice that fosters global physical and cognitive recovery in the intensive care unit (ICU). PT should be initiated as soon as patients can participate (eg, daytime lucid interval). It can begin even in patients still intubated on minimal ventilator settings. Early mobility therapy is personalized to patients' level of frailty and can involve assisted walking, sitting upright, or even passive limb stretching to avoid contractures. Immediate benefits of early PT/mobility include the following: Physical/pulmonary: secretion mobilization, atelectasis recruitment, respiratory muscle strengthening, and decreased deep venous thrombosis Cognitive: restoration of normal sleep-wake cycle, improved swallowing These benefits are synergistic: Daytime mobility aids in clearance of delirium, setting the stage for pulmonary recovery and earlier extubation. Long-term benefits include favorable, patient-centered outcomes (eg, discharge home) with decreased symptoms of post-intensive care syndrome. For these reasons, early PT is a cornerstone of ICU recovery bundles established by multiple societies. post-intensive care syndrome (Choice A) Copious respiratory secretions can delay extubation. Anticholinergic agents (eg, scopolamine) are occasionally used to lessen secretions. However, due to their CNS effects, they may worsen delirium, especially in elderly patients. Physical measures (deep suctioning, chest percussion, early mobility) are preferred. (Choice B) Deep sedation should be used only as a last resort when agitation immediately threatens life (eg, self-extubation). Further sedation exacerbates delirium and delays recovery. (Choice D) Tracheostomy (within 14 days) may be considered if prolonged mechanical ventilation (eg, respiratory muscle weakness) or a long-term airway (eg, intractable delirium) is required. This patient is tolerating daily spontaneous breathing trials (SBT) (ie, breathing on his own through a tube), signaling adequate respiratory muscle function. Early PT can facilitate recovery from delirium, making extubation an achievable goal. (Choice E) Severe symptomatic anemia may hinder ventilator weaning (stress on cardiopulmonary system). A hemoglobin target ≥7 g/dL ("restrictive strategy") reduces volume overload and lung inflammation exacerbated by blood products, leading to improved outcomes. This patient has nonsevere (hemoglobin above goal), asymptomatic anemia (eg, tolerating SBT), so transfusion is not indicated. Educational objective: In patients recovering from critical illness, early physical therapy for progressive mobilization should be initiated as soon as possible to facilitate recovery from delirium and liberation from mechanical ventilation.

Question 16

A 28-year-old man with a history of bipolar I disorder is brought to the emergency department after being pulled over by police for driving erratically.  The police report indicates that the patient appeared alcohol-intoxicated and refused to cooperate with questions, stating, "I have the skills of a race car driver and a need for speed."  He has been on lithium for years and says he has been adherent.  The patient has a history of bilateral knee injuries sustained in an accident when he jumped from a high ledge.  He has no other medical history.  The emergency physician contacts the outpatient psychiatrist, who reports that the patient has been treated with lithium for the past 3 years.  He had a therapeutic lithium level and appeared stable at his last visit 2 weeks ago.  The patient is re-interviewed when he is sober.  He felt upset after his girlfriend left him and was turned down for a job, and so decided to "get drunk."  He is apologetic for driving recklessly and says he intends to follow up with his outpatient psychiatrist.  Although the patient admits to a history of crack cocaine use, he currently uses no illicit substances other than marijuana on weekends.  Temperature is 37.2 C (99 F), blood pressure is 140/80 mm Hg, and pulse is 88/min.  Physical examination is normal.  The patient is alert, and his speech is nonpressured.  Urine toxicology screen is negative for illicit substances. 
Which of the following is the most appropriate next step in management?

Accepted Answer

Explanation: 11ec2b69_c067_a0e6_8f63_417737003a06_MD0005_00 This patient has a number of risk factors for suicide, including major psychiatric illness, recent losses (job and relationship), impulsivity, and substance use. The possibility that his erratic driving and previous jump from a ledge were motivated by suicidal intent should be considered. Alcohol use is strongly associated with increased suicide risk as the disinhibiting effects of intoxication frequently contribute to suicide attempts. A suicide risk assessment is the most important intervention at this time and should be performed prior to discharge. Targeted questions regarding any suicidal thoughts, intent, means, or plan should be asked. Aside from static risk factors (eg, age, gender, race, marital status, past attempts, family history), the assessment should also focus on acute, modifiable risk factors such as impulsivity, hopelessness, and recent psychosocial stressors. (Choice A) Although checking this patient's lithium level would be important for management, performing a suicide risk assessment takes precedence as it would determine whether he can be discharged safely or needs to be admitted. If the patient displayed signs of lithium toxicity (eg, slurred speech, unsteady gait), a lithium level would be more urgent. (Choices B and C) Discharging this patient without performing a comprehensive suicide risk assessment would be unsafe. The outpatient psychiatrist's report that the patient was "stable" 2 weeks earlier is no assurance that he is not currently at risk. A referral for substance abuse counseling would be appropriate once he is determined to be psychiatrically stable. (Choice E) This patient has no signs suggestive of early alcohol withdrawal. Prophylactic treatment for alcohol withdrawal is indicated for patients with a history of chronic heavy alcohol use, seizures, or delirium tremens. Educational objective: A suicide risk assessment that focuses on acute risk factors should be performed in all patients who come to the emergency department with psychiatric symptoms or erratic behavior. The mixture of hopelessness, impulsivity, and disinhibition due to substance use is a particularly lethal combination. References: Literature-based recommendations for suicide assessment in the emergency department: a review. (http://www.ncbi.nlm.nih.gov/pubmed/23040403) Screening for suicidal ideation and attempts among emergency department medical patients: instrument and results from the Psychiatric Emergency Research Collaboration. (http://www.ncbi.nlm.nih.gov/pubmed/23413776)

Question 17

A 28-year-old man with a history of bipolar I disorder is brought to the emergency department after being pulled over by police for driving erratically.  The police report indicates that the patient appeared alcohol-intoxicated and refused to cooperate with questions, stating, "I have the skills of a race car driver and a need for speed."  He has been on lithium for years and says he has been adherent.  The patient has a history of bilateral knee injuries sustained in an accident when he jumped from a high ledge.  He has no other medical history.  The emergency physician contacts the outpatient psychiatrist, who reports that the patient has been treated with lithium for the past 3 years.  He had a therapeutic lithium level and appeared stable at his last visit 2 weeks ago.  The patient is re-interviewed when he is sober.  He felt upset after his girlfriend left him and was turned down for a job, and so decided to "get drunk."  He is apologetic for driving recklessly and says he intends to follow up with his outpatient psychiatrist.  Although the patient admits to a history of crack cocaine use, he currently uses no illicit substances other than marijuana on weekends.  Temperature is 37.2 C (99 F), blood pressure is 140/80 mm Hg, and pulse is 88/min.  Physical examination is normal.  The patient is alert, and his speech is nonpressured.  Urine toxicology screen is negative for illicit substances. The patient admits that he was, in fact, trying to get up the nerve to crash his car and kill himself.  He started to swerve on purpose but then straightened out when he thought of how his suicide would devastate his mother.  He explains, "When I am in a dark hole, it seems that nothing will ever get better for me; suicide seems like the only way out."  His psychiatrist confirms that the patient has had suicidal thoughts in the past, nearly always when he is drinking.  The patient agrees to hospitalization for further evaluation and treatment.  Which of the following is the most appropriate next step to reduce the risk of suicide in this patient?

Accepted Answer

Explanation: This patient has had no suicidal thoughts over the past year while on lithium, and the acute psychosocial stressors and disinhibiting effects of intoxication are most likely the causes of his recent suicidal behavior. The most appropriate next step is to continue lithium and address his alcohol use. The patient should be educated about the disinhibiting effects of alcohol and counseled to avoid it when feeling depressed. Randomized, controlled trials support the use of lithium as either monotherapy or augmentation in preventing suicide. Its protective effect may result from treating or preventing mood episodes and/or decreasing impulsivity and aggression. (Choice A) Electroconvulsive therapy is generally reserved for patients who have failed to respond to pharmacotherapy. (Choices B, C, and D) Discontinuing lithium would risk destabilizing this patient further. He was reportedly without suicidal ideation in the past year on lithium. Maintaining lithium and addressing his alcohol use and psychosocial issues would be the first step. If his depression persists, he may benefit from augmentation with a second mood stabilizer, antidepressant, or antipsychotic. Antidepressant monotherapy in patients with bipolar I disorder is contraindicated due to the risk of inducing mania. Educational objective: Lithium is an evidence-based treatment for reducing the risk of suicide in mood disorder patients. In suicidal patients already taking lithium, the drug should be maintained rather than discontinued. References: Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23814104) Suicidal behavior in mood disorders: response to pharmacological treatment. (http://www.ncbi.nlm.nih.gov/pubmed/27542851)

Question 18

A 44-year-old man with a medical history of food allergy to peanuts is brought to the emergency department for an allergic reaction.  The patient developed the acute onset of dyspnea and wheezing shortly after ingesting a cookie.  His symptoms progressed to difficulty swallowing and swelling of the face and tongue.  On arrival, temperature is 36.9 C (98.4 F), pulse is 115/min, blood pressure is 85/74 mm Hg, and respirations are 28/min.  Oxygen saturation is 93% on a nonrebreather face mask.  He is anxious and pale with swollen lips, swollen tongue, and inspiratory stridor.  On lung auscultation, bilateral wheezing is present.  Intramuscular epinephrine, intravenous fluids, and racemic epinephrine via nebulizer are administered without improvement.  The patient's distress is increasing, and he is becoming more agitated.  The decision to intubate using awake fiberoptic nasotracheal intubation is made. Severe swelling of the upper airway is seen on laryngoscopy, and 3 attempts to pass the endotracheal tube are unsuccessful.  The patient's blood pressure is 70/40 mm Hg, pulse is 75/min, and respirations are 40/min.  Oxygen saturation is 72% on a nonrebreather face mask.  What is the best next step in management of this patient?

Accepted Answer

Explanation: 11ec2b69_c06f_de4d_8f63_1f577ce2e1b3_MD0005_00 Several attempts to secure a definitive airway via awake intubation have failed, and this patient now has severe hypoxia (eg, oxygen saturation of 72% on a nonrebreather mask) and signs concerning for impending cardiac arrest (eg, severe hypotension, falling heart rate). Especially given this patient's rapidly progressive airway edema (which further airway instrumentation will only increase), additional intubation attempts are unlikely to succeed and will only increase the risk of deterioration (Choice A). Instead, cricothyrotomy should be performed immediately to bypass the upper airway obstruction and restore ventilation and oxygenation. The procedure involves incising the cricothyroid membrane and inserting an endotracheal or tracheostomy tube, which can be used for mechanical ventilation. cricothyroid membrane Management of the failed airway (ie, airway that cannot be intubated on initial attempts) is determined by the ability to oxygenate the patient using mask ventilation. In patients (such as this one) who cannot be adequately oxygenated ("can't intubate, can't oxygenate") due to upper airway obstruction, a surgical airway (ie, cricothyrotomy) should be performed. In contrast, patients who can be oxygenated via bag valve mask ventilation ("can't intubate, can oxygenate") may tolerate further intubation attempts. Adjunctive airway techniques (eg, video laryngoscopy) may increase the chance of success. (Choice C) Noninvasive positive pressure ventilation (eg, continuous positive airway pressure) can reduce atelectasis and ventilation/perfusion mismatch in certain patients with respiratory distress (eg, cardiogenic pulmonary edema). However, it will not bypass upper airway obstruction and is contraindicated when severe respiratory distress necessitates emergency intubation. (Choice D) A supraglottic device (eg, laryngeal mask airway) inserted into the pharynx may help provide ventilation in certain patients where intubation fails (eg, vocal cords cannot be visualized on laryngoscopy). However, it would likely be difficult to insert in this patient with a swollen tongue and stridor (ie, upper airway edema) and would not reliably bypass the upper airway obstruction, as cricothyrotomy would. (Choice E) Tracheostomy can bypass upper airway obstruction but is not typically performed in emergency situations because cricothyrotomy is faster and technically less difficult and has lower risk of hemorrhage than tracheostomy. In addition, cricothyrotomy can be converted to a tracheostomy if a surgical airway is still needed after the patient has stabilized. Educational objective: Cricothyroidotomy should be performed in hypoxic, unstable patients who cannot be oxygenated or ventilated due to an upper airway obstruction. References: The difficult airway with recommendation for management-Part 1-difficult tracheal intubation in an unconscious/induced patient. (http://www.ncbi.nlm.nih.gov/pubmed/24132407)

Question 19

A 72-year-old woman is being treated in the intensive care unit for lobar pneumonia, septic shock, and respiratory failure with intravenous fluids, antibiotics, vasopressors, and mechanical ventilation.  Her condition is improving and she is extubated on day 5.  Within a few minutes of extubation, the patient develops stridor and is given intravenous dexamethasone and nebulized epinephrine.  Her current examination shows blood pressure of 148/86 mm Hg, pulse of 102/min, and respirations of 30/min.  Pulse oximetry shows 94% on nonrebreather mask.  She has audible stridor and labored breathing with use of accessory muscles of respiration.  Which of the following is the best next step in management of this patient?

Accepted Answer

Explanation: Intubation causes direct mechanical damage to the laryngeal mucosa, leading to inflammation that may cause significant edema. Laryngeal edema typically presents with post-extubation stridor (PES) and respiratory failure. It occurs in up to 30% of patients, with approximately 5% requiring reintubation. Risk factors for laryngeal edema include female sex, small tracheal diameter or large endotracheal tube size, and prolonged duration of intubation. Administration of a multiple-dose regimen of glucocorticoids prior to extubation can prevent laryngeal edema and extubation failure. Reintubation should be considered early to secure the airway in all patients with signs of impending respiratory failure. This patient has several clinical features of impending respiratory failure and has PES with no improvement with conservative measures. PES and respiratory failure are consistent with extubation failure due to significant laryngeal edema and should be managed aggressively with immediate reintubation and mechanical ventilation. impending respiratory failure (Choice A) Emergency tracheostomy is reserved as a last resort for patients with severe laryngeal edema who fail attempts at endotracheal intubation. (Choice B) A helium and oxygen mixture has a lower density than oxygenated air and reduces airway resistance; however, there is no clinical evidence of its usefulness in patients with laryngeal edema and respiratory failure. (Choice C) The use of non-invasive positive-pressure ventilation in patients with chronic obstructive pulmonary disease has been shown to prevent reintubation and decrease mortality. Its use in patients with respiratory failure due to laryngeal edema leads to delay in reintubation and can be harmful. (Choice E) The efficacy of intravenous corticosteroids and epinephrine nebulization has not been confirmed in any randomized clinical trials. However, case control studies in patients with suspected PES have shown reduced risk of extubation failure when intravenous glucocorticoids are given prior to extubation. Epinephrine and corticosteroids may also be used after extubation to reduce inflammation and edema. However, patients with impending respiratory failure should be reintubated. Educational objective: Laryngeal edema typically presents with post-extubation stridor; reintubation should be considered early to secure the airway in all patients with signs of impending respiratory failure. References: Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. (http://www.ncbi.nlm.nih.gov/pubmed/20017891)

Question 20

A 67-year-old woman is evaluated in the intensive care unit for neck swelling.  An hour ago, the patient was admitted to the ICU for treatment of pyelonephritis complicated by septic shock and disseminated intravascular coagulation.  A central line catheter was placed in the right internal jugular vein.  The insertion was difficult, requiring multiple attempts.  X-ray after placement revealed the catheter to be in a good position.  Over the past 30 minutes, she has developed swelling at the site of the catheter and a feeling of tightness in her neck.  She also feels her voice is changing.  On examination, there is ballotable swelling under the site of the catheter with surrounding ecchymosis, and the trachea is deviating to the left.  The voice sounds hoarse.  Which of the following is the most appropriate next step in management of this patient?

Accepted Answer

Explanation: This coagulopathic patient with an enlarging fluid collection after difficult intravenous cannulation has an expanding neck hematoma. An expanding neck hematoma is life-threatening due to the potential for airway obstruction from: Direct mechanical airway compression collapsing the structural support of the airway and causing narrowing of the lumen Compression of the lymphovasculature, leading to impaired venous drainage, which causes vascular congestion and intrinsic laryngeal mucosal edema that narrows the airway lumen Signs of airway obstruction can include tracheal deviation and hoarseness (as seen in this patient); other clinical features include stridor, dysphagia, voice changes, and tripod positioning. However, patients can initially have few or no symptoms, including a normal peripheral blood oxygenation concentration, until rapid (secure the airway, typically via oral endotracheal intubation. Ideally, a surgical airway should be avoided due to the increased risk of bleeding, but it may become unavoidable if the larynx cannot be visualized for intubation. (Choices A and F) Treatment of acute disseminated intravascular coagulation (DIC) requires correction of the underlying disorder and supportive measures. For severe deficiencies, blood products (eg, cryoprecipitate, platelets) may be needed. However, tranexamic acid (an antifibrinolytic agent) is contraindicated in acute DIC due to the increased risk of thrombotic events. Regardless, protecting the patient's airway is the immediate concern. (Choice B) Compression via direct pressure or with a compressive dressing is often used to control bleeding at many sites. However, when bleeding is in the neck, compression can worsen the airway obstruction. (Choice C) A CT scan of the neck may show the hematoma and may characterize swelling and/or displacement of the airway and may be indicated after the airway is secured. However, it is not needed to diagnose an expanding neck hematoma and obtaining one would delay possibly life-saving treatment. (Choice E) Removing the catheter may worsen the hematoma because the catheter may be tamponading some of the blood flow. In addition, removal would not protect the airway, and its presence still may be needed to deliver resuscitative fluids and treatment medications. Educational objective: An expanding neck hematoma can be life-threatening due to upper airway obstruction. The first step in management is to secure the airway, usually with an endotracheal tube. References: Bleeding complications of central venous catheterization in septic patients with abnormal hemostasis. (http://www.ncbi.nlm.nih.gov/pubmed/24856739)

Exam 1: Advanced Clinical Medicine