A 42-year-old man admitted with a high fever and leukocytosis is transferred to the intensive care unit in shock. Which of the following is a common finding in the early stages of septic shock?Which of the following is an appropriate initial therapy for both septic shock and cardiogenic shock?
Answer(s): C
The usual early hemodynamic response to sepsis is a hyperdynamic circulation. This includes tachycardia, elevated cardiac output, and decreased systemic resistance. Septic shock may then progress with intractable hypotension, metabolic acidosis, reduced cardiac output, oliguria, and death. The initial resuscitation of patients with all forms of shock requires rapid expansion of circulating blood volume to help maintain BP and tissue perfusion. This is usually achieved with the infusion of crystalloid fluids. When septic shock is suspected, cultures of blood, urine, and other sources along with antibiotic therapy targeted toward the most likely source is critical. Mechanical ventilation may be required when altered mental status, acidosis, and hypoxia are present. Beta-blockers and diuretics may have specific indications that cardiac ischemia and pulmonary edema are present
Which of the following patterns is most consistent with the physiologic profile of cardiogenic shock?
Answer(s): B
Patients with cardiogenic shock B. demonstrate a pattern with increased CVP, low CO, increased SVR, and decreased SVO2. Those with hypovolemic shock A. demonstrate low CVP, low CO, increased SVR, and decreased SVO2. The distinguishing feature of early septic shock C. is an increased cardiac output.Patients with neurogenic shock D. have severe loss of vasomotor tone leading to the unusual combination of low SVR and low CO. CVP = central venous pressure, CO = cardiac output, SVR = systemic vascular resistance,SVO2 = venous O2 saturation
A 35-year-old man presents with acute low back pain after lifting a couch in his home. Pain is in the lumbosacral area and increases with walking and bending. Examination reveals paraspinal muscle spasm and tenderness and negative straight leg raise bilaterally. Lower extremity strength is intact. Which of the following is the best next step in managing this patient?
Answer(s): D
In younger patients, low back pain tends to be mild and self-limited, typically resolving in 46 weeks.Patients should be encouraged to remain active and symptom control can be achieved with pain medications. Low back pain is the leading cause of work-related disability in the United States. The absence of alarm symptoms such as unilateral or bilateral leg weakness and bladder, bowel or sexual dysfunction makes a cauda equine syndrome or other spinal cord injury unlikely. Age >50, constant pain at night, history of cancer, unexplained weight loss, and lack of response to conservative therapy make further investigation including radiologic evaluation appropriate.
A54-year-old woman is brought to the ER with palpitations and dizziness. She has a history of arrhythmia. Adenosine is given and the patient converts to a sinus rhythm. With which of the following rhythms did this patient most likely present to the ER?
The majority of paroxysmal supraventricular tachycardias respond to adenosine, because they involve a re- entrant circuit including the atrioventricular node. Adenosine is ineffective in the termination of the majority of other atrial or ventricular tachycardias that do not involve the AV node, although it may slow the ventricular response to an atrial tachycardia
A 48-year-old man complains of fatigue and shortness of breath. His hematocrit is 32% and hemoglobin is 10.3 g/100 mL. Peripheral blood smear reveals macrocytosis. His serum vitamin B12 level is 90 pg/mL (normal, 170940); serum folate level is 6 ng/mL (normal, 214). Which of the following is the most likely cause of this patient's symptoms?
The most common causes of megaloblastic anemia are folate and vitamin B12 deficiencies. Vitamin B12 deficiency rarely results from inadequate intake, but has been associated with strict vegetarianism.Decreased absorption may be due to insufficient intrinsic factor (as in pernicious anemia and after gastrectomy), malabsorption of the intrinsic factor-vitamin B12 complex in the terminal ileum (as in regional enteritis, sprue, pancreatitis, and after ileectomy), or competition for vitamin B12 by gut bacteria (as in the blind loop syndrome and Diphyllobothrium latum infections). Because diverticulosis and constipation do not interfere with stomach or small-bowel functioning, they are not causes of vitamin B12 deficiency.
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