Multiple Choice Questions (MCQ)

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Category: Critical Care Medicine-Pulmonary Disorders--->Pulmonary Infections
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Question 1# Print Question

A 68-year-old woman with a history of hypertension and poorly controlled diabetes mellitus presents to the emergency department (ED) with fevers and 5 days of progressive shortness of breath and cough. She presented to her primary care physician 3 days ago and was prescribed amoxicillin. Despite this treatment, her symptoms worsened; she has no other associated symptoms. On arrival to the ED, her vital signs are notable for :

  • T 38.4°C
  • blood pressure (BP) 118/75 mm Hg
  • heart rate (HR) 90 beats per minute
  • respiratory rate 14 breaths per minute
  • SpO2 83% breathing ambient air

She is placed on high-flow nasal cannula at 60 L/min and FiO2 0.6 in the ED, and vancomycin and cefepime administered. She is subsequently admitted to the intensive care unit (ICU) for severe community-acquired pneumonia (CAP).

Which of the following is the BEST next step in her management?

A. Perform flexible bronchoscopy and bronchoalveolar lavage to obtain bacterial culture
B. Add levofloxacin to her antibiotic regimen
C. Send quantitative respiratory cultures and blood cultures
D. Change her antibiotic regimen to ceftriaxone and azithromycin
E. Change vancomycin to linezolid

Question 2# Print Question

A 45-year-old man was diagnosed 1 month ago with a squamous cell lung cancer involving his left hilum and has been receiving chemotherapy. He is now admitted to the ICU with hypoxemia and fever. He reports about 10 days of low-grade fevers and loss of appetite, which has progressed to worsening shortness of breath and a cough productive of foul-smelling, purulent sputum. His chest radiograph demonstrates dense consolidation of his left lower lobe with evidence of an abscess. A computed tomography (CT) scan is ordered and he is started on vancomycin, cefepime, and metronidazole. Sputum cultures are pending.

Which of the following is the most accurate regarding his diagnosis?

A. His current antibiotic regimen is appropriate
B. He should receive a standard 7 to 10 day course of antibiotics
C. His pneumonia is unlikely to recur if appropriately treated
D. If his sputum cultures do not show anaerobic species, then his coverage can be narrowed

Question 3# Print Question

A 65-year-old man with congestive heart failure is intubated and mechanically ventilated in the ICU for acute decompensated heart failure complicated by pulmonary edema. His extubation is delayed by ongoing delirium. On day 5 of his ICU stay, he is noted to have a new fever, with a temperature of 38.5°C. He is on pressure support ventilation, with an inspiratory pressure of 5 cm H2O, positive endexpiratory pressure (PEEP) of 5 cm H2O, and FiO2 0.4. The remainder of his vital signs are:

  • BP 130/75 mm Hg
  • HR 75 beats per minute
  • respiratory rate 12 breath per minute
  • SpO2 98%

His examination reveals clear lung fields with auscultation and no other notable findings. A diagnostic workup, including blood cultures, urinalysis, and chest radiograph, are performed. Chest radiograph reveals clear lung fields. His urinalysis and blood cultures are unrevealing. Over the next 48 hours, he has one additional fever, and the respiratory therapist notes increased thick secretions suctioned from his endotracheal tube that are sent for sputum culture. His vent settings, chest radiograph, and vital signs remain unchanged.

Which of the following is the MOST appropriate management at this time?

A. Initiate treatment with vancomycin and cefepime
B. Perform flexible bronchoscopy with bronchoalveolar lavage
C. Initiate treatment with vancomycin, cefepime, and azithromycin
D. Close observation
E. Initiate treatment with cefepime

Question 4# Print Question

A 25-year-old man with a history of mild intermittent asthma is admitted to the ICU with rapidly progressive hypoxemic respiratory failure following 4 days of fevers, myalgias, and cough at home. He is intubated and mechanically ventilated on volume assist-control with a tidal volume of 6 mL/kg, respiratory rate 14 breaths per minute, FiO2 0.8, and PEEP of 10 cm H2O. His arterial blood gas on these settings is:

  • pH 7.30
  • PaCO2 50
  • PaO2 85

His chest radiograph demonstrates diffuse bilateral patchy opacities, and his rapid influenza testing is positive for influenza A.

Which of the following statements is MOST accurate regarding diagnosis and treatment for this patient?

A. With his history of asthma, he should receive methylprednisolone at 1 mg/kg daily
B. Antibacterial coverage can be discontinued as he is positive for influenza A
C. Treatment with oseltamivir 75 mg twice daily is not indicated as he is 4 days into his illness
D. If a sputum culture cannot be obtained, a diagnostic bronchoscopy with bronchioalveolar lavage is indicated
E. This patient does not meet criteria for acute respiratory distress syndrome (ARDS) and does not need low tidal volume ventilation

Question 5# Print Question

A 65-year-old man with acute myeloid leukemia is admitted to the ICU with worsening hypoxemia while receiving induction chemotherapy on the oncology ward. His chest radiograph reveals bibasilar opacities, and he is started on treatment with vancomycin and cefepime. His hypoxemia improves by day 3 of treatment, however his fevers continue. On day 5 of treatment, chest radiograph reveals opacification of the right lower lung fields with loss of visualization of the right hemidiaphragm and costophrenic angle. A thoracic ultrasound demonstrates a pleural effusion, and diagnostic thoracentesis is performed with removal of 60 mL of fluid. Pleural fluid analysis demonstrates:

cloudy tan fluid

  • pH 7.1
  • glucose 30 mg/dL
  • lactate dehydrogenase (LDH) 2000 U/L
  • cholesterol 85 mg/dL
  • protein 4.5 g/dL

Gram stain and cultures are pending.

What is the next best step in management?

A. Broaden antibiotic coverage and await results of gram stain and culture
B. Perform tube thoracostomy and continue antibiotic therapy
C. Continue antibiotic therapy with serial imaging, drainage if no response
D. Repeat thoracentesis to drain pleural space
E. Perform video-assisted thoracoscopic surgery to clear pleural space

Category: Critical Care Medicine-Pulmonary Disorders--->Pulmonary Infections
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