Answer and Explanation 21

21.  The correct answer is D.  This is a notorious side effect of ACE inhibitors and should be classified as a class effect.  Switching a patient to a different ACE inhibitor will not fix this.  It is because of the elevated levels of the bradykinnin produced.  Diovan is an angiotensin receptor blocker and would produce  a similar effect but not raise bradykinnin levels.  Metoprolol may induce bronchospasm but should not be ruled out.  It the patient is not wheezing, it would be prudent to start removing the ACE inhibitor.

Question 21

21.  Your are evaluating a a patient in your office that come to you complaining of a dry cough.  You have recently started him on many medicines and suspect that may be the cause.  Which of the following medicines would likely be the culprit?

A.  Diovan

B. Cardizem

C. Metoprolol

D. Lisinopril

Answer and Explanation 20

20.  The correct answer is B.  This rhythm is torsades which is caused by low magnesium.  It is important not only to obtain a magnesium level but to treat it in a timely manner.  Potassium should also be checked.  Remember hypokalemia cannot be  effectively treated if the magnesium level is low.  Abnormal phosphorus and sodium levels will not produce rhythms such as this.

Question 20

20.  You have just successfully treated a patient who was just in this rhythm listed below in this EKG strip.  Which of the following is the most important lab value to check on this patient immediately and correct?

A.  Potassium

B.  Magnesium

C.  Phosphorus

D. Sodium

Answer and Explanation 19

19.  The correct answer is A.  Vancomycin is the drug of choice for patients with infective endocarditis, especially for IV drug users.  The causative organism is usually staph.

Question 19

19.  Once the diagnosis is confirmed in question 18, what is the most appropriate antibiotic to give the patient intravenously?

A.  Vancomycin 1 gram IV
 
B.  Avelox 400 mg IV piggy back

C.  Zosyn 3.375 grams IV

D.  Cipro 400 mg IV piggy back

Answer and Explanation 18

18.  The correct answer is D.  This patient has infective endocarditis.  Blood cultures times 5 can rule out endocarditis but does not confirm the diagnosis.  The patient needs an echo.  A cardiac cath may be dangerous to perform.  A VQ scan would not be helpful because the patient really is not presenting like a pulmonary embolus.  

Question 18

18.   Your patient is a 29 year old male who comes in complaining of chest pain and a fever or 102.4 F.  He relates he is an IV drug user.  He also has noted to have splinter hemorrhages under his nails.  Which of the following is the best test to evaluate this patient to diagnose his condition immediately?

A.   Blood Cultures times 5.

B.   Cardiac Catheterization

C.  VQ scan.

D.  Echocardiogram

Answer 17

17.  The correct answer is C.  While management of this patient may involve getting a follow up CT scan at some point, this patient is actively bleeding in his brain and it is life threatening and needs to be reversed.  So giving the patient Vitamin K and FFP is the most important.  Protamine is the antidote for heparin and would not be helpful.  Intubating the patient unnecessarily may raise ICP and hyperventilation has not been shown to lower ICP for a prolonged period of time.

Question 17

17.  You are evaluating a  45 year old patient with a history of recurrent DVT, last was 6 years ago and has a greenfield filter.  He is on warfarin.  He was just involved in a motor vehicle collision and has a large subdural hematoma with a  3 mm midline shift.  His INR is 5.5.  Which of the following is the best immediate intervention.

A.   Order a follow up head CT for 12 hours from now to see if it has progressed.

B.  Intubate the patient and hyperventilate the patient.  This has been shown to decrease intracranial pressure.

C.  Give the patient 10 mg of Vitamin K and 2 units of Fresh Frozen Plasma

D.  Give the patient Protamine right away.