Q: 69 year male is admitted to ICU with COPD exacerbation. Patient developed Pseudomonas aeruginosa in his sputum. What is the clinical significance? 


Answer:  Hospitalized patients with COPD exacerbation who grew Pseudomonas aeruginosa in their sputum have a higher risk of mortality at 3 years independent of other factors.


 Reference: 

 Almagro P, Salvadó M, Garcia-Vidal C, et al. Pseudomonas aeruginosa and mortality after hospital admission for chronic obstructive pulmonary disease. Respiration 2012; 84:36.

Q: All of the following is diagnostic of Preeclampsia with systolic blood pressure of more than or equal to 140 mmHg or diastolic blood pressure more than or equal to 90 mmHg except

A) Proteinuria more than or equal to 0.3 grams in a 24-hour urine specimen
B) Protein:creatinine ratio more than or equal to 0.3
C) Platelet count less than 100,000/microliter, 
D) Serum creatinine more than 1.1 mg/dL or doubling of the serum creatinine, 
E) Elevated serum Bilirubin to twice normal concentration


Answer: E

Diagnosis of preeclampsia is certain when a woman with normal blood pressure pre pregnancy develops hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation. Criteria for diagnosis includes all of the above except bilirubin level. Instead it requires elevated serum transaminases to twice normal concentration.


 Reference: 

Magee LA, Pels A, Helewa M, et al. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can 2014; 36:416.

Q: 45 year old male is admitted to ICU with probable cardiogenic shock. Decision was made to insert Pulmonary Artery Catheter (PAC). Patient EKG showed Left Bundle Branch Block (LBBB). Which one precaution should be taken?


Answer: About 5 percent of patients develop Right Bundle Branch Block (RBBB) on PAC insertion. Patients with already documented LBBB on EKG may develop complete heart block. In such patients, backup rescue plan should be made to counter such situation promptly by having  a transthoracic or transvenous pacer. Ideally, such patients should have PAC insertion with pacer port - and if clinical situation allow, under fluoroscopic guidance.



Reference: 

Sprung CL, Elser B, Schein RM, et al. Risk of right bundle-branch block and complete heart block during pulmonary artery catheterization. Crit Care Med 1989; 17:1.

Q: 29 year old female with previous history of Migraine presented with 'sudden onset' of headache. CT scan reported normal. ER called you to evaluate patient before discharging her to follow up as an outpatient, as patient continue to insist that this headache is different from her migraine and is worse headache of her life. Your next step?


Answer:  Lumbar puncture

If patient's clinical history match with subarachnoid hemorrhage, lumbar puncture becomes mandatory if CT scan is negative. Xanthochromic supernatant in CSF is highly diagnostic of SAH.

Q: You have been called to ER for a trauma consult for an 82 year old male with Motor-Vehicle-Accident. On clinical exam patient has some mild ecchymosis on perineal and scrotal area. Plain radiographs obtained by ER physician are normal. Your next step is?



Answer:  CT scan 

In pelvic injury, extent of bleeding in elderly patient doesn't co-relate with clinical and radiologic findings. Even a low energy level fall or trauma can cause life-threatening bleeding. Plain X-rays are not reliable and CT scan should be obtained in all such cases.

Q: 24 year old female is admitted to ICU with exacerbation of Multiple Sclerosis (MS). As patient is getting ready to get transfer out of ICU, she asked your advice about her plan to get pregnant in view of her underlying disease

A) Advise her against pregnancy
B) Encourage her for pregnancy
C) Recommend 2 years of resting period
D) Recommend stable serial MRIs before pregnancy
E) Advise her C-section and avoid normal vaginal delivery 



Answer: B

Pregnancy is actually found to be protective in MS, as it decreases the number of relapses, particularly in the second and third trimesters. MS does not cause spontaneous abortions or congenital malformations. Though there are reports that MS relapse rates may be higher in the postpartum period but overall it does not cause any increase morbidity or mortality. Labor and delivery are usually the same as in other women. Though it is always advisable to continue neurologist care during pregnancy for the management of medications.

Q: You have been called to ER to evaluate a 42 year old female - known as a frequent flyer to ER - for complaint of severe headache. Medical record shows multiple normal CT scans. Patient described her headache as pulsatile, started few hours ago, unilateral and is associated with severe nausea. What would be the best way to avoid unnecessary workup and ICU admission and to document migraine?




Answer:  The mnemonic POUND has been used widely as an evidence-based criteria for diagnosis of Migraine

• Pulsatile quality of headache 
• One-day duration (four to 72 hours if untreated) 
• Unilateral location 
• Nausea or vomiting 
• Disabling intensity

Probability of migraine is 92 percent in patients who report at least four of the five POUND symptoms.



 Reference: 

Ebell MH. Diagnosis of migraine headache. Am Fam Physician. 2006;74(12):2087–2088.

Q: What is the ideal position for the femoral venous catheter tip?


Answer:  Femoral central line can be used immediately after insertion, given all ports provide good blood return. But ideally, distal tip of  catheter should generally be located above the confluence of the iliac veins. More importantly, if it is way far advanced proximally, like into a renal vein, as suspected from abdominal X-ray, it should be repositioned. Commonly, femoral central line travels to contralateral iliac vein - either it can be replaced over a guidewire or can stay there, if only short term use is anticipated.

Q: Type A acute ascending aortic dissection is a surgical emergency. What's the rate of mortality for delay?


Answer:  Type A acute ascending aortic dissection is a surgical emergency. Mortality rate  rises 1 to 2 percent per hour in early hours after symptom onset.



 References: 

1.  Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part I: from etiology to diagnostic strategies. Circulation 2003; 108:628. 

2. Mehta RH, Suzuki T, Hagan PG, et al. Predicting death in patients with acute type a aortic dissection. Circulation 2002; 105:200.

Q:  52 year old male, an employee at LA international airport is admitted to ICU with spiking fever, chills, headache, nausea and vomiting and hypotension. There was concern for hemolytic Anemia. Patient get diagnosed with Malaria after blood smear report. Patient has no history of travel, contact, IV drug abuse or living in an infested area?


Answer:  "Airport malaria"

"Airport malaria" is a blanket term to explain the malaria transmission when a mosquito infected with the disease bites a human within an international airport vicinity. Victim (patient) has no history of visit to a malarious area, or of blood transfusions or IV drug abuse etc. It starts with a mosquito getting transported in an international flight from a malaria-endemic region. Once the infected female mosquito leaves the aircraft, it can survive long enough to seek blood meals and transmit the disease to other humans within the airport, mostly employees. Risk of other disease like dengue cannot be ruled out.

Q: Follow up CXR is usually not required to document resolution of pneumonia after discharge from hospital. Which group of patients should be considered for follow up CXR?


Answer: Follow up CXR is usually not required to document resolution of pneumonia after discharge from hospital. But, patients over 50 years of age, and in particular male and smokers should be considered for follow up CXR to rule out  malignancy or any other underlying diseases. 



References:

1. Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis 2000; 31:347.

2. Tang KL, Eurich DT, Minhas-Sandhu JK, et al. Incidence, correlates, and chest radiographic yield of new lung cancer diagnosis in 3398 patients with pneumonia. Arch Intern Med 2011; 171:1193.

Q: Intrapleural administration of fibrinolytics cause systemic thrombolysis. True or False?


Answer: False

Intrapleural administration of fibrinolytic agents has been used commonly to improve drainage of loculated parapneumonic effusions and empyemas. Literature is a mix bag of its benefit. Concern is always raised about possible systemic thrombolysis. but studies have confirmed that intrapleural administration of fibrinolytics does not cause systemic thrombolysis.


References:

1. Gervais DA, Levis DA, Hahn PF, et al. Adjunctive intrapleural tissue plasminogen activator administered via chest tubes placed with imaging guidance: effectiveness and risk for hemorrhage. Radiology 2008; 246:956. 

2. Davies CW, Lok S, Davies RJ. The systemic fibrinolytic activity of intrapleural streptokinase. Am J Respir Crit Care Med 1998; 157:328.

Q: Babesiosis is a malaria-like parasitic disease which resides inside erythrocytes. It can be differentiated from Malaria by "Maltese cross formations" on the blood film. What are  "Maltese cross formations"?


Answer:  "Maltese cross formations" are pathognomonic of babesiosis, since they are not seen in malaria, though both resides inside the erythrocytes. Peripheral blood smear shows RBC with parasitic inclusions forming a piroplasmic tetrad, also known as "maltese cross formations".

Q: Antiretroviral treatment for HIV is contraindicated in pregnancy. True or False? 



 Answer: false

Antiretroviral therapy (ART) should be given, if indicated during pregnancy to treat  the maternal HIV disease.  ART lowers the maternal viral load and decreases the perinatal transmission.



References: 

 Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions To Reduce Perinatal HIV Transmission in the United States. July 31 2012

Q: What is the most common form of Anthrax?


Answer:  Cutaneous anthrax 

Cutaneous anthrax is the most common form of Anthrax and is usually sites are head, neck, forearms, and hands. Though it is the least dangerous form of anthrax but without treatment 20% of people with  may die.

Q: What is the clinical significance of ABCD2 score in Transient Ischemic Attack (TIA)?


Answer:   Patient with score above 3 should be admitted to hospital (or ICU depending on severity of symptoms).

Q: 63 year old male in ICU recovering from pneumonia, developed severe epistaxis. As a a first measure, you applied pressure over the nose. What other maneuver beside applying pressure may help in epistaxis?


Answer:  Tilting the head forward

In severe epistaxis along with applying pressure, tilting the head forward not only decreases the danger of airway obstruction, it also decreases the chance of vomiting (which may cause aspiration pneumonia) - as swallowed blood can irritate the stomach.



Reference: 

 Corry J. Kucik; Timothy Clenney (January 15, 2005). "Management of Epistaxis". American Academy of Family Physicians. Retrieved January 31, 2010.

Q: What does "Time Zero" means in Upper GI bleed management?


Answer:   According to guidelines, "Time Zero" technically means the time of admission to a medical care facility. All other terms like 'clinically significant bleeding', 'acute bleeding episode', 'treatment failure', 'fresh hematemesis', 'early or late  rebleeding' etc. get defined from "time Zero" for a better perspective.


Reference: 

1. de Franchis R, Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53:762.

Q: How Bilirubin level can be used to predict appendiceal perforation?


Answer:  Total bilirubin level more  than 1.0 mg/dL is a marker for appendiceal perforation with a sensitivity of 70 percent and a specificity of 86 percent!



Reference: 

 Sand M, Bechara FG, Holland-Letz T, et al. Diagnostic value of hyperbilirubinemia as a predictive factor for appendiceal perforation in acute appendicitis. Am J Surg 2009; 198:193.

Q: Which side is preferred to place Inferior Vena Cava (IVC) filter at bedside, if femoral approach is selected?


Answer:  Right 

Frequently, in ICU patients are unstable to travel out of ICU and may necessitate the insertion of IVC filter at the bedside.  Firstly , before attempting femoral approach for IVC filter, DVT should be ruled in common femoral vein. If ruled out, the right femoral vein has a very direct course to the IVC. Placement of a filter from the left femoral vein may cause some tilting of the filter.

Q: What is Parkinsonism-hyperpyrexia syndrome?

Answer: If a patient with Parkinson disease suddenly stops or decrease the dose of levodopa or dopamine agonists, - may develop neuroleptic malignant syndrome. It may become a life threatening situation and requires ICU admission. Clinical pearl to remember is replacing antiparkinson drug at the dose that was used prior to the onset of the syndrome, via any route including IV.  Dantrolene or bromocriptine can be used if there is no response to restart of patient's previous medicines.


References:

1. Factor SA. Fatal Parkinsonism-hyperpyrexia syndrome in a Parkinson's disease patient while actively treated with deep brain stimulation. Mov Disord 2007; 22:148. 

2. Newman EJ, Grosset DG, Kennedy PG. The parkinsonism-hyperpyrexia syndrome. Neurocrit Care 2009; 10:136.

Q: What is Phlegmasia cerulea dolens?

Answer:  Phlegmasia cerulea dolens, described more than 7 decades ago, refers to massive proximal (iliofemoral) venous thrombosis of the lower extremities with sudden severe leg pain, swelling, cyanosis, edema, compartment syndrome - resulting in circulatory collapse, shock, limb loss and death. This is a life and limb emergency. As arterial compromise turns leg white, it is also known as milk leg. Women in the third trimester of pregnancy or immediate postpartum are at particular risk.



Reference:

1. Gregoire R. La phlebite bleue (phlegmasia caerulea dolens). Presse Med. 1938. 46:1313-5. 

2Sarwar S, Narra S, Munir A. Phlegmasia cerulea dolens. Tex Heart Inst J 2009; 36:76.

Q: Which of the following valvular heart disease is associated with angiodysplasia in GI tract

A) Aortic regurgitation
B) Aortic stenosis
C) Mitral regurgitation
D) Mitral stenosis
E) Pulmonic stenosis


Answer:  B

Bleeding from angiodysplasia in aortic stenosis is also known as Heyde's syndrome. Fortunately, with surgical repair (AVR), bleeding usually subsides. The Cause of this association has been questioned many times in literature but remained controversial.





References: 

1. Pate GE, Mulligan A. An epidemiological study of Heyde's syndrome: an association between aortic stenosis and gastrointestinal bleeding. J Heart Valve Dis 2004; 13:713.

2. Cappell MS, Lebwohl O. Cessation of recurrent bleeding from gastrointestinal angiodysplasias after aortic valve replacement. Ann Intern Med 1986; 105:54.

Q: After Cardiac surgery which side of pleural effusion is of more concern. Right or Left?


Answer:  Right

Pleural effusions after cardiac surgery is almost a norm and rarely requires major intervention beside possible thoracentesis for symptomatic relief. Symptomatic Right sided pleural effusion without any obvious explanation like CHF should be looked into with more concern.


References:

1. Sadikot RT, Rogers JT, Cheng DS, et al. Pleural fluid characteristics of patients with symptomatic pleural effusion after coronary artery bypass graft surgery. Arch Intern Med 2000; 160:2665. 

2. Labidi M, Baillot R, Dionne B, et al. Pleural effusions following cardiac surgery: prevalence, risk factors, and clinical features. Chest 2009; 136:1604.

Q: Name few conditions where lipiduria may be seen?



Answer: 

1. Nephrotic syndrome: This is due to increase glomerular permeability to macromolecules.
2. ADPKD (autosomal dominant polycystic kidney disease)
3. Interstitial nephritis (less likely)
4.  Prerenal azotemia (rare)

Q: Risk of CAUTI (Catheter Associated Urinary Tract Infection) rises with what rate of everyday insertion?


Answer: 

Risk of CAUTI  rises 3% to 7 % with each day of insertion. Best prevention is to remove the catheter as soon as it is not needed.

Q: Why ophthalmic exam is necessary for patients suspected of meningitis?


Answer: If papilledema is evident on ophthalmic exam, CT scan of head should be performed before lumbar puncture. Usually CT scan of head is not required before performing LP in patients suspected of meningitis, but in few situations, it should be done in following and other situations

•  history of HIV 
•  Patients on immunosuppressive therapy,
• history of solid organ or hematopoietic stem cell transplantation
• history of central mass lesion
• new onset seizure
• papilledema
• focal deficit

References: 

1.  Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis. N Engl J Med 2001; 345:1727. 

2. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.

Q: Almost 75 percent of post transplant patients, who get treated with with cyclosporine and tacrolimus develop some sort of hyperkalemia. What is the mechanism of action?


Answer: By aldosterone inhibition who receive immunosuppressive therapy with cyclosporine and tacrolimus develop some degree of hyperkalemia via two mechanism, patially due to diminished secretion of, and partially due to decreased responsiveness to, aldosterone.



References: 

1. Kamel KS, Ethier JH, Quaggin S, et al. Studies to determine the basis for hyperkalemia in recipients of a renal transplant who are treated with cyclosporine. J Am Soc Nephrol 1992; 2:1279. 

2. Heering PJ, Kurschat C, Vo DT, et al. Aldosterone resistance in kidney transplantation is in part induced by a down-regulation of mineralocorticoid receptor expression. Clin Transplant 2004; 18:186.

Q: What is Duke Treadmill score?

Answer: The Duke Treadmill Score (DTS) is an index combining treadmill exercise time using standard Bruce protocol, maximum net ST segment deviation (depression or elevation), and exercise-induced angina. It provides diagnostic and prognostic information in patients with suspected coronary heart disease. 

DTS = Exercise Time - (5 x Max ST) - (4 x Angina Index)

• Treadmill exercise time in minutes
• Max ST = Maximum net ST deviation (except in lead aVR) 
• Angina Index has 3 levels :: 0 = No angina during exercise,  1 = Non-limiting angina,   2 = Exercise limited angina 

 DTS Duke treadmill score

• More than or equal to +5 is Low risk 
• +4 to -10 is Moderate risk
• Less than or equal to -11 High risk