| Abstract |
1. A 73-year-old male with a history of hypertension and hyperlipidemia is currently in the stroke unit after suffering a right middle cerebral artery infarct. His symptoms started 2 h prior to arrival at the hospital, and tPA was administered. The patient is plegic on the left side and with mild dysarthria, but is otherwise neurologically intact. His labwork is within normal limits. Which of the following describes the optimal deep venous thrombosis (DVT) prophylaxis regimen for this patient? A. Wait 6 h post tPA, then administer unfractionated heparin (UFH) along with intermittent pneumatic compression (IPC). B. Wait 24 h post tPA, then administer UFH along with IPC. C. Wait 6 h post tPA, then administer low molecular weight heparin (LMWH) along with IPC. D. Wait 24 h post tPA, then administer LMWH along with IPC. E. IPC only for the first 72 h, then LMWH or UFH after obtaining follow-up imaging. 2. All of the following causes of acute encephalitis have the matching characteristic radiological features except: A. Autoimmune limbic encephalitis: T2/FLAIR hyperintensity in the mesial temporal lobes. B. Cytomegalovirus: T2/FLAIR hyperintensity in the subependymal white matter. C. JC virus: T2/FLAIR hyperintensity in the parieto-occipital lobes and corpus callosum. D. Herpes simplex virus type 1: restricted diffusion in frontal/temporal lobes and insular cortex. E. Varicella zoster: T2/FLAIR hyperintensity in the brainstem. 3. Which of the following categorizations is most accurate regarding acute respiratory distress syndrome (ARDS) in the setting of subarachnoid hemorrhage (SAH)? A. Non-neurogenic, non-cardiogenic. B. Neurogenic, non-cardiogenic. C. Neurogenic, cardiogenic. D. Non-neurogenic, cardiogenic. E. None of the above accurately reflect ARDS in SAH. 4. A 52-year-old female is admitted to the ICU with a Hunt-Hess 1, modified Fisher 2 subarachnoid hemorrhage. Her past medical history is significant for hypertension, diabetes mellitus, and chronic renal insufficiency. She undergoes craniotomy for surgical clipping of an anterior cerebral artery aneurysm, and does not experience any additional complications. Two weeks later, she begins complaining of left calf pain, and a lower extremity sonogram demonstrated a proximal deep venous thrombosis (DVT). The patient weighs 60 kg. Her laboratory values are as follows: sodium 142 mEq/L, potassium 3.4 mEq/L, carbon dioxide 18 mEq/L, blood urea nitrogen (BUN) 70 mg/dL, and serum creatinine 2.5 mg/dL. What would be the optimal treatment for this patient’s proximal DVT? A. Unfractionated heparin infusion for at least 5 days concomitantly with warfarin therapy. B. Low molecular weight heparin 60 mg twice a day for at least 5 days concomitantly with warfarin therapy. C. Fondaparinux 7.5 mg daily for 5 days followed by warfarin therapy. D. Apixaban 10 mg twice daily for 7 days followed by 5 mg twice daily. E. Rivaroxaban 15 mg twice daily for 21 days followed by 20 mg once daily. 5. All of the following are currently implicated in uremic encephalopathy except: A. Derangements in cerebral metabolism. B. Alterations in the blood-brain barrier. C. Accumulation of circulating toxins. D. Imbalance of endogenous neurotransmitters. E. Recurrent lobar hemorrhages. 6. A 70-year-old female is hospitalized with a recent ischemic infarct. As part of stroke core measures, you obtain a hemoglobin A1c of 10.0. What is an approximate estimation of this patient’s average blood glucose level over the last several months? A. 70 mg/dL. B. 100 mg/dL. C. 130 mg/dL. D. 190 mg/dL. E. 240 mg/dL. 7. A 28-year-old female with no known past medical history is in the ICU in status epilepticus, with anti-N-methyl D-aspartate (NMDA) receptor antibodies isolated in the cerebrospinal fluid. Which of the following is most likely to identify the root cause of her illness? A. Transvaginal ultrasound. B. Contrast-enhanced CT of the chest. C. Contrast-enhanced CT of the brain. D. Virtual colonography. E. Thorough examination of the skin, particularly in sun-exposed areas. 8. A 17-year-old male with no significant past medical history collapses during a high school football game, and goes into cardiac arrest. He did not have any complaints earlier in the day. The patient is brought to a nearby hospital, where is he resuscitated, intubated, and transferred to the ICU for further management. The patient is currently undergoing therapeutic hypothermia, and a work-up is underway to determine the cause of his sudden collapse. Which of the following is the most likely diagnosis? A. Rupture of a previously undiagnosed cerebral aneurysm. B. Hypertrophic cardiomyopathy. C. Commotio cordis. D. Severe hyponatremia and cerebral edema. E. Brugada syndrome. 9. A 31-year-old female at 38 weeks gestation is currently hospitalized for the treatment of preeclampsia. Due to her medical condition, her obstetrician is currently considering induced labor. At which point will this patient no longer be at risk for developing frank seizure activity as a result of her condition? A. 48 h postpartum. B. 1 week after delivery. C. 2 weeks after delivery. D. 4 weeks after delivery. E. 6 weeks after delivery. 10. A 38-year-old male with no prior medical history presents to the emergency department with fever and severe headaches for several days. A CT scan of the brain is unremarkable, and the results of a lumbar puncture are pending. What is the most appropriate empiric antimicrobial regimen at this time? A. Cefazolin and vancomycin. B. Ceftriaxone and vancomycin. C. Ceftriaxone, vancomycin and ampicillin. D. Piperacillin/tazobactam and vancomycin. E. Meropenem and vancomycin. 11. The majority of intramedullary spinal cord neoplasms are: A. Astrocytomas. B. Meningiomas. C. Metastatic lesions. D. Ependymomas. E. Hemangioblastomas. 12. Which of the following derived parameter formulas is correct? A. Cardiac index = cardiac output x body surface area. B. Stroke volume = cardiac output/heart rate. C. Systemic vascular resistance = 80 × (mean arterial pressure/cardiac output). D. Pulmonary vascular resistance = 80 × (mean pulmonary artery pressure/cardiac output). E. All of the above are correct. 13. A 23-year-old female marathon runner is currently in the ICU after suffering from heat stroke following an outdoor run on a particularly hot summer day. She was initially delirious in the emergency department, but progressed to coma and respiratory failure requiring mechanical ventilation. Her oral temperature is 42.1 °C. Which of the following would be most effective in reducing this patient’s severe hyperthermia? A. Regularly scheduled alternating acetaminophen and ibuprofen. B. Spraying room temperature water on the patient, followed by fanning. C. Ice water immersion. D. Dantrolene sodium, 2.5 mg/kg. E. Application of ice packs to the groin and axilla. 14. Hyperinsulinemia-euglycemia (HIE) therapy may be useful for toxicity related to which of the following? A. Tricyclic antidepressants. B. Calcium channel blockers. C. Aspirin. D. Digoxin. E. Lithium. 15. A 71-year-old female with a history of alcohol abuse is currently intubated in the ICU following a catastrophic spontaneous left basal ganglia hemorrhage with resultant herniation. You have just declared her brain dead. The patient’s family agrees to make her an organ donor, and the organ donation coordinator requests you initiate levothyroxine therapy. Which of the following benefits would be expected with this treatment? A. Increase the number of solid organs available for transplant. B. Eliminate the need for hepatic biopsy prior to liver transplant. C. Eliminate the need for cardiac catheterization prior to heart transplant. D. Eliminate the need for bronchoscopy prior to lung transplant. E. Reduce the need for supplementation of sodium, potassium, calcium, and magnesium. 16. Which of the following is not an element of the Full Outline of Unresponsiveness (FOUR) score? A. Eye opening. B. Respiratory function. C. Brainstem reflexes. D. Motor response. E. Verbal response. 17. A 23-year-old female is currently in the ICU with status asthmaticus. She was initially on noninvasive positive pressure ventilation, with an arterial blood gas (ABG) as follows: pH 7.13, pCO(2) 60 mmHg, PaO(2) is 61 mmHg, HCO(3) 24 mmol/L, and oxygen saturation of 90%. She is given continuous inhaled albuterol, intravenous steroids, and magnesium sulfate. She subsequently becomes more lethargic and is intubated, with settings as follows: volume assist-control, rate of 12 breaths/min, tidal volume of 500 cc, PEEP of 5 cm H(2)O, and FiO(2) of 50%. Peak airway pressure is 50 cm H(2)O and plateau pressure is 15 cm H(2)O. A stat portable chest x-ray shows hyperinflation with no pneumothorax. A repeat ABG after 30 min of invasive ventilation shows the following: pH of 7.24, pCO(2) 49 mmHg, PaO(2) 71 mmHg, HCO(3) A. Increase rate to 16. B. Increase tidal volume to 600 cc. C. Initiate bicarbonate infusion. D. Switch to pressure assist-control. E. Maintain current settings. 18. Which of the following mechanisms is implicated in super-refractory status epilepticus? A. Influx of proinflammatory molecules. B. Upregulation of NMDA receptors. C. Upregulation of molecular transport molecules. D. Downregulation of GABA receptors. E. All of the above. 19. A 85-year-old male with a history nephrolithiasis, mild dementia, and alcohol abuse presented to the emergency department after a fall from standing, and was found to a right holohemispheric subdural hematoma. His clot was evacuated successfully, in spite of his oozing diathesis in the operating room (INR on arrival was 1.4 with a platelet count of 88 × 10(3)/μL). His serum transaminases are twice the normal value, and he has had refractory chronic hyponatremia. He has had three convulsions during this week of hospitalization, in spite of levetiracetam therapy at 1.5 g twice a day. Over the past 24 h, he has had a marked increase in agitation. He has also just had a 5-s run of non-sustained ventricular tachycardia, and his systolic blood pressure is now 85 mmHg. You are considering discontinuing his levetiracetam and starting a new agent. Which of the following would be the best choice in this scenario? A. Carbamazepine. B. Phenytoin. C. Valproate. D. Lacosamide. E. Topiramate. 20. A 65-year-old male with a history of COPD on rescue albuterol and ipratropium is diagnosed with myasthenia gravis, and started on an acetylcholinesterase inhibitor. He returns several days later complaining of increased salivation and worsening bronchial secretions in the absence of fevers, purulent sputum, or increasing dyspnea. These symptoms are not relieved by use of his albuterol. On exam, he has slightly decreased air movement throughout both lung fields without any clear wheezing, no focal rales, and a normal inspiratory to expiratory ratio. Which treatment option is most likely to be beneficial? A. Increase frequency of short-acting ß(2) agonist use. B. Add a standing long-acting inhaled ß(2) agonist. C. Add glycopyrrolate as needed. D. Add inhaled corticosteroids. E. Add oral systemic corticosteroids. 21. Regarding states of impaired consciousness, which of the following statements regarding arousal and awareness is correct? A. Coma: intact arousal, but impaired awareness. B. Minimally conscious state: impaired arousal and impaired awareness. C. Persistent vegetative state: intact arousal, but impaired awareness. D. Locked-in state: intact arousal, but impaired awareness. E. All of the above are correct. 22. A 62-year-old female is currently in the ICU following craniotomy for clipping of a cerebral aneurysm. Postoperatively, she is noted to have an oxygen saturation of 92% on 50% non-rebreather face mask, and her respiratory rate is 32 breaths/min. She denies chest pain. Her blood pressure is 96/72 mmHg and heart rate is 120 beats/min. Nimodipine has been held according to blood pressure parameters. A portable chest x-ray shows hazy opacities bilaterally, and bedside echocardiogram shows decreased left ventricular systolic function with apical, septal, lateral, anterior, anteroseptal and inferolateral wall akinesis, along with apical ballooning. Which of the following should be performed next? A. Intubate the patient and begin mechanical ventilation. B. Call urgent cardiology consult for cardiac catheterization. C. Start noninvasive positive airway pressure ventilation. D. Administer broad spectrum antibiotics. E. Administer albuterol and systemic corticosteroids. 23. Which of the following is the most common etiology of acute spinal cord ischemia and infarction? A. Atherosclerotic disease. B. Rupture of an abdominal aortic aneurysm. C. Degenerative spine disease. D. Cardioembolic events. E. Systemic hypotension in the setting of other disease processes. 24. A 62-year-old female with a history of coronary artery disease has just been admitted to the ICU with a left-sided spontaneous basal ganglia hemorrhage. The patient takes 325 mg of aspirin daily at home, and you are considering platelet transfusion. Which of the following has been demonstrated regarding platelet transfusion in this setting? A. Improved chances of survival to hospital discharge. B. Decreased hospital length-of-stay. C. Improved chances of survival at 3 months. D. Improved modified Rankin scale at 3 months. E. None of the above. 25. Which of the following therapies has been shown to decrease the incidence of delayed cerebral ischemia (DCI) in the setting of subarachnoid hemorrhage (SAH)? A. Atorvastatin. B. Magnesium. C. Methylprednisolone. D. Nicardipine. E. None of the above. 26. A 70-year-old male with a history of diabetes, hypertension, and cigarette smoking (one pack per day for the last 40 years) is currently in the ICU with a COPD exacerbation. This is his third exacerbation this year, and was discharged from the hospital only 3 weeks prior. On your examination, he is alert, his breathing is labored, and he has rales at the right lung base. His vital signs are as follows: blood pressure 90/60 mmHg, heart rate 120 beats per minute, respirations 28 per minute, and temperature 38.3 °C. His oxygen saturation on 50% face mask is 93%, and his most recent PCO(2) is 55 mmHg. Labs are notable for the following: white blood cell count 14.4 × 10(9)/L with 90% neutrophils, blood urea nitrogen (BUN) 30 mg/dL, serum creatinine 1.2 mg/dL, and glucose 240 mg/dL. Ketones are negative. He is currently on noninvasive positive pressure ventilation at 10/5 cm H(2)O and 50% FiO(2), and broad spectrum antibiotics have been administered. An hour later, the nurse pages you because his heart rate is now 140 beats per minute and irregular, blood pressure is 85 systolic, oxygen saturation is 85%, and he is minimally responsive. You now hear bilateral rales, most prominently in the right lung base, and scattered wheezes. Which of the following should be performed next? A. Increase inspiratory pressure to 15 and FiO(2) to 100%. B. Start a continuous diltiazem infusion and give intravenous furosemide. C. Start a continuous phenylephrine infusion targeting a mean arterial pressure (MAP) > 65. D. Give 125 mg of solumedrol and administer albuterol via nebulizer. E. Intubate the patient and initiate mechanical ventilation. 27. A 57-year-old male with a history of epilepsy is currently in the stroke unit following a large right middle cerebral artery infarction. A nasogastric tube has been inserted, and 24 h continuous enteral feeds have been initiated. The patient is currently on 100 mg of phenytoin every 8 h for seizure prophylaxis. Which of the following measures should be taken to prevent the patient from developing subtherapeutic phenytoin levels? A. Change to 18 h tube feeds, and only administer phenytoin at night. B. Change to 18 h tube feeds, and only administer phenytoin twice daily. C. Switch from standard to hydrolyzed tube feeds. D. Switch from standard to glycemic control tube feeds. E. Hold tube feeds for 2 h before and after phenytoin administration. 28. A 37-year-old female presents to the emergency department with approximately 2 weeks of progressively worsening clumsiness and drastic mood swings. Her past medical history is significant only for Crohn’s disease, for which she takes both natalizumab and infliximab. A contrast-enhanced CT scan of her head is performed, revealing hypodense, non-enhancing lesions in the cortical white matter of the frontal and parietal lobes. Despite treatment, the patient expires 1 month later. Which of the following is true regarding the most likely diagnosis? A. The diagnosis may be confirmed via CSF analysis. B. The pathologic process spares oligodendrocytes. C. It is a prion-based disease. D. The condition is universally fatal despite treatment. E. All of the above. 29. A 58-year-old female presents to the emergency department with dry cough, fever and rapidly progressive dyspnea over 1 week. She has a history of rheumatoid arthritis (RA) and is maintained on weekly methotrexate and daily prednisone (which was increased to 30 mg starting 1 month ago for an acute flare). She takes no other medications. Her vital signs are as follows: blood pressure 100/70 mmHg, heart rate 110 beats/min, respiratory rate 20 breaths/min, and temperature 38.0 °C. In the ED she develops progressive hypoxemia with oxygen saturation 92% on 100% nonrebreather, and is increasingly diaphoretic. She is emergently intubated, and a chest x-ray post intubation shows extensive bilateral lung opacities. Which of the following should be administered at this time? A. Ceftriaxone and azithromycin. B. Vancomycin and piperacillin-tazobactam. C. Vancomycin, cefepime, and fluconzole. D. Ceftriaxone, levofloxacin, and trimethoprim-sulfamethoxazole. E. Tigecycline only 30. A 45-year-old woman undergoes uncomplicated transsphenoidal resection of a pituitary macroadenoma. She appears well hydrated and is not complaining of excessive thirst. Post-operatively, she is noted to have increased urine output. Serum sodium is 137 mEq/L, and serum osmolarity is 275 mOsm/kg. What is the most likely cause of her polyuria? A. Syndrome of inappropriate antidiuretic hormone. B. Diabetes insipidus. C. Cerebral salt wasting. D. Fluid mobilization. E. All of the above are equally likely. 31. A 36-year-old female with a recent lumbar puncture to rule out subarachnoid hemorrhage is now complaining of a severe headache unlike anything she has experienced previously. She reports her headache is worse when standing, and better upon lying flat. She is otherwise neurologically intact. All of the following medications may be beneficial in this scenario except: A. Acetaminophen. B. Ibuprofen. C. Caffeine. D. Aminophylline. E. Methylprednisolone. 32. Which of the following is the most common overall cause of acute myocardial infarction? A. Coronary dissection. B. Plaque rupture. C. Imbalance between oxygen demand and supply across a fixed obstruction. D. Coronary vasospasm. E. Ischemia related to hypotension and decreased perfusion. 33. A 78-year-old male is in the ICU recovering from sepsis and pneumonia. He was just recently extubated after 2 days of mechanical ventilation and sedation with a fentanyl infusion. Over the ensuing days, he develops worsening abdominal distention, poor bowel sounds, and no stool output. CT scan reveals significant colonic distention, but no mass or obstruction. Records demonstrate a normal routine colonoscopy performed 6 weeks ago. You have appropriately hydrated the patient, corrected any electrolyte abnormalities, placed a rectal tube, withheld all opiates, and given intravenous erythromycin, but to no avail. Abdominal x-rays continue to demonstrate marked cecal dilatation greater than 12 cm in diameter. What is the next best appropriate therapy for this patient? A. Neostigmine. B. Naloxone. C. Metoclopromide. D. Surgical consultation for hemicolectomy. E. Endoscopic percutaneous cecostomy tube placement. 34. Which of the following is the most common cerebral vascular malformation in the general population? A. AV malformation. B. Dural AV fistula. C. Developmental venous anomaly. D. Cavernous malformation. E. Vein of Galen malformation. 35. A 49-year-old female with a history of acute lymphoblastic leukemia and recent subcutaneous cerebrospinal fluid (CSF) reservoir placement presents to the emergency department with fever, chills, and increased confusion for the past 3 days. Her CSF reservoir was last accessed 1 week ago. A thorough work-up reveals no other obvious infectious source, and there is concern for CSF reservoir-associated meningitis. Which of the following is the most likely causative organism? A. Coagulase-negative staphylococci. B. Propionobacterium acnes. C. Methicillin-resistant Staphylococcus aureus. D. Klebsiella pneumoniae. E. Neisseria meningitidis. 36. A 47-year-old woman presents to the emergency department with headache, nausea, and vomiting. Non-contrast head CT is performed, revealing subarachnoid blood in the right Sylvian fissure, and conventional angiography reveals the presents of a large right-sided MCA aneurysm. The patient undergoes successful surgical clipping of her aneurysm, and is being observed in the ICU. On admission, the patient’s serum sodium was 142 mEq/L and the hematocrit was 37%; by the seventh post-operative day, the serum sodium is 127 mEq/L and the hematocrit is 44%. Bedside ultrasonography demonstrates an IVC diameter of approximately 0.9 cm. Which of the following interventions would be least reasonable at this time? A. Fludrocortisone, 0.2 mg twice a day. B. 2% hypertonic saline, infused peripherally. C. 3% hypertonic saline, infused centrally. D. Sodium chloride oral tablets. E. 1500 mL daily fluid restriction. 37. Which of the following is true regarding central (non-infectious) fever? A. Less common in subarachnoid hemorrhage. B. More common versus infectious fever. C. Earlier onset versus infectious fever. D. Easier to confirm versus infectious fever. E. All of the above. 38. Flaccid paralysis is most commonly associated with which of the following forms of encephalitis? A. West Nile. B. Varicella zoster. C. Rabies. D. Herpes simplex. E. Epstein-Barr. 39. Which of the following would not be considered appropriate therapy for heparin-induced thrombocytopenia (HIT)? A. Discontinuation of heparin products alone. B. Danaparoid. C. Fondaparinux. D. Argatroban. E. All of the above are acceptable treatment options. 40. A 45-year-old male with severe blunt traumatic brain injury (TBI) from a motor vehicle collision suffered a ventricular fibrillation cardiac arrest at the time of injury with return of spontaneous circulation (ROSC) in the field after endotracheal intubation and one dose of epinephrine. On arrival to the emergency department, no regional wall motion abnormalities were noted on surface echocardiography and no ST segment changes were seen on the presenting EKG. Head CT revealed cerebral contusions but no extra-axial mass lesions. The patient is now in the ICU and found to be comatose without sedation. Mild therapeutic hypothermia to 33° is being considered in the management of this post-arrest patient. Which of the following statements is true? A. Mild therapeutic hypothermia is contraindicated due to the risk of induced epilepsy. B. Mild therapeutic hypothermia is contraindicated with any intracranial pathology on CT imaging. C. Mild therapeutic hypothermia does not induce a clinically significant coagulopathy. D. Patients who have sustained ROSC after an arrest associated with TBI do not benefit from therapeutic hypothermia. E. Endovascular cooling is superior to surface cooling in young patients with ROSC. 41. A 35-year-old male is in the intensive care unit following resection of a large right-sided meningioma. He is currently intubated and sedated on a continuous fentanyl infusion. The nurse calls you to the bedside due to concerns over “unusual ventilator waveforms”. Upon arrival, you note the following (see Image 1). What is the best way to describe this phenomenon? A. Reverse triggering. B. Double triggering. C. Breath stacking. D. Missed triggering. E. None of the above; normal ventilator waveforms are present;
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