2002 Self-Assessment Exercise

XXIX. Critical care

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Questions

Question 6. Answer.e

A 2-week-old infant presents with tachypnea, poor perfusion, gallop

rhythm, diminished pulses, and hepatomegaly. Arterial blood gas shows
metabolic acidosis. Echocardiography reveals critical aortic stenosis.

Of the following, the intervention MOST likely to stabilize the infant's

condition is:

A. dobutamine

B. epinephrine

C. nitric oxide

D. 100% oxygen

E. prostaglandin E1 [ductal dependent]

Question 25. Answer.c

A 4-year-old child is brought by ambulance to the emergency department.

He is unconscious and has deep, regular, and rapid respirations.

A clinical finding that BEST distinguishes this respiratory pattern as central

hyperventilation rather than tachypnea is:

A. arterial carbon dioxide pressure (Paco2) of 26 mm Hg

B. decreased mental status

C. nonreactive pupils

D. oxygen saturation of 95% by pulse oximetry

E. sternal retractions

Question 46. Answer.c

The most likely finding in the initial stages of septic shock is:

A. abnormally low blood pressure

B. absent femoral pulses

C. delayed capillary refill

D. hyperpnea

E. tachypnea

Question 66. Answer.b

A 5-year-old boy is given general anesthesia with halothane for a

tonsillectomy and adenoidectomy. Shortly after initiating the procedure, he
develops tachycardia, a temperature of 103F (39.4C), and muscle
rigidity.

Of the following, the MOST appropriate definitive treatment includes

discontinuation of anesthetic and treatment with:

A. acetaminophen

B. dantrolene 3mglkg [malignant hyperthermia]

C. dapsone

D. hydrocortisone

E. succinylcholine

Question 110. Answer.a

A 7-year-old child presents after a motor vehicle accident. He was not

wearing a seatbelt, and he was sitting at the point of impact in the left
rear passenger seat. There was intrusion into the vehicle. He complains of
left upper quadrant abdominal pain and left shoulder pain. Physical
examination shows diffuse abdominal tenderness, but no obvious
tenderness or trauma to the shoulder. Blood pressure is 120/80 mm Hg
and heart rate is 120 beats/ min. You have sent blood for a complete blood
count.

Of the following, the MOST appropriate next diagnostic study is:

A. abdominal computed tomography

B. abdominal ultrasonography

C. barium contrast enema

D. diagnostic peritoneal lavage

E. upright plain abdominal film

Question 132. Answer.a

A 2-day-old boy has biphasic stridor that worsens with agitation. He has
intermittent desaturations with bradycardia and a weak cry. Blood
pressure is 80/60 mm Hg, and pulse rate is 112 beats/min.

Of the following, the MOST likely etiology of this child's condition is:
A. congenital subglottic stenosis [laryngomalesia]

B. cystic fibrosis

C. hypoplastic left heart

D. innominate artery compression

E. tracheoesophageal fistula

Question 154. Answer.e

An adolescent who has systemic lupus erythematosus develops pericardial

tamponade.

In addition to muffled heart tones, the MOST likely finding would be

decreased:

A. heart rate during expiration

B. heart rate during inspiration

C. jugular venous pulsation during expiration

D. systolic blood pressure during expiration

E. systolic blood pressure during inspiration [p.paradoxus]

Question 177. Answer.d

A 6-year-old boy presents with a 24-hour history of fever, malaise, and

bruising. Physical examination reveals an ill-appearing child whose
temperature is 103.1F (39.5C). He has widespread petechiae and areas
of palpable purpura, especially on the buttocks and lower extremities. The
hemoglobin is 10.5 g/dL (105 g/L), white blood cell count is 18,500/cu mm
(18.5 x 109/L), and platelet count is 25,000/cu mm (25 x 109/L).

Of the following, the MOST likely diagnosis is:

A. Henoch-Schnlein purpura

B. idiopathic thrombocytopenic purpura

C. Lyme disease

D. meningococcemia

E. Rocky Mountain spotted fever

Question 200. Answer.b

A 16-year-old driver who was not wearing a seatbelt was involved in a

high-speed head-on collision. He has suffered extensive trauma to the
chest. In the emergency department, he is alert but tachypneic, with
markedly diminished breath sounds on the right. Chest radiography
reveals several anterior rib fractures on the right and fluid in the right
pleural space.

Of the following, the MOST appropriate next step in the management of

this boy is:

A. administration of intravenous furosemide

B. chest tube placement [p.thorax]

C. elevation of the head of the bed

D. emergent thoracotomy

E. endotracheal intubation

Question 221. Answer.d

A 6-month-old previously healthy child presents in January with fever of 3

days' duration and wheezing that has increased in severity for 2 days. On
physical examination, the child is awake and interactive. Respiratory rate
is 60 breaths/min, and there are marked wheezes bilaterally and
intercostal retractions. Because there is no improvement after two
treatments with nebulized albuterol, you admit the child to the hospital.
Upon re-evaluation 4 hours later, the child is agitated and has a
respiratory rate of 80 breaths/min. Arterial blood gas while receiving 35%
oxygen reveals pH of 7.24, Po2 of 65 mm Hg, and Pco2 of 60 mm Hg.

Of the following, the MOST appropriate next step in management is:

A. administration of intramuscular dexamethasone

B. administration of racemic epinephrine

C. continuous albuterol nebulization

D. immediate endotracheal intubation[ resp. Failure]

E. increase of inspired oxygen to 50%

Question 243. Answer.c

The mother of a 3-year-old girl finds the girl submerged in a backyard pool.

Of the following, the finding that is MOST compatible with a favorable

neurologic prognosis for this child is:

A. apnea at the time of admission to the emergency department

B. coma at the time of admission to the emergency department

C. first spontaneous respirations within 10 minutes of resuscitation

D. initial arterial pH <7.0

E. submersion of more than 25 minutes

Question 263. Answer.c

A 14-year-old girl presents with sustained palpitations and a heart rate of

210 beats/min. Electrocardiography shows narrow complex
supraventricular tachycardia (SVT). Administration of an intravenous bolus
of adenosine results in normal sinus rhythm for 30 seconds, followed by a
return of sustained SVT.

Of the following, the MOST appropriate intervention for this girl is:

A. intravenous amiodarone

B. intravenous digoxin

C. intravenous diltiazem

D. intravenous quinidine

E. synchronized electrical cardioversion

Question 21. Answer.a

A 10-year-old boy is brought to the emergency department after being

struck by a car while riding his bicycle. He was not wearing a helmet.
Physical examination immediately upon arrival reveals that he is
responsive to painful stimuli only by moaning. His pupils are equal, small,
and reactive.

Of the following, the sign MOST LIKELY to be associated with increasing

intracranial pressure in this patient is

A. hyperventilation

B. hypotension

C. hypothermia

D. nystagmus

E. tachycardia

Question 102. Answer.b

You are evaluating a 15-year-old girl for muscular weakness, weight loss,
and dizziness of 3 months' duration. She has no history of recent infection.
Findings on physical examination include: blood pressure, 85/40 mm Hg;
pulse, 120 beats/min; respiratory rate, 30 breaths/min; and oral thrush.
Laboratory evaluation reveals: creatinine, 106 mcmol/L (1.2 mg/dL); blood
urea nitrogen, 15 mmol/L of urea (42 mg/dL); sodium, 125 mmol/L (125
mEq/L); potassium, 6.5 mmol/L (6.5 mEq/L); chloride, 98 mmol/L (98
mEq/L); bicarbonate, 16 mmol/L (16 mEq/L); glucose 3.33 mmol/L (60
mg/dL); urine sodium, 80 mmol/L (80 mEq/L); urine potassium, 2 mmol/L
(2 mEq/L); and urine specific gravity, 1.035.

Of the following, the MOST likely diagnosis is

A. acute tubular necrosis

B. adrenal insufficiency

C. diuretic abuse

D. ipecac abuse

E. syndrome of inappropriate secretion of antidiuretic hormone

Question 149. Answer.d

The mother of a 3-year-old reports that her son has begun to cough and
have difficulty breathing. She was keeping him home from preschool today
because he had a cough and upper respiratory tract infection without
fever.

The MOST likely cause of this child's symptoms is

A. aspiration pneumonia

B. bacterial pneumonia

C. foreign body aspiration

D. reactive airway disease

E. vascular ring

Question 236. Answer.d

You are examining a 10-year-old girl who sank to the bottom of the pool
after a dive. Rescuers could detect no pulse, but she awakened before
they initiated cardiopulmonary resuscitation. The girl's mother had been
treated for epilepsy for 15 years and died at age 28 during a seizure.

Of the following, the parameter MOST likely to be abnormal in this girl is

A. coronary artery anatomy on angiography

B. epileptiform activity on electroencephalography

C. ionized calcium level on serum chemistry profile

D. QT measurement on electrocardiography [cong.long q-t syndrome]

E. septal thickness on echocardiography

Questions [Print Directions]

Question 21. Answer.a

A 4-month-old girl has failed to thrive, feeds poorly, and is tachypneic.

Findings on physical examination include a third heart sound, faint
expiratory rales, and hepatomegaly.

Of the following, the MOST likely explanation for these findings is

A. anomalous origin of the left coronary artery from the pulmonary

artery [with ccf]

B. atrial septal defect with partial anomalous drainage of the right

upper pulmonary vein

C. tetralogy of Fallot with severe pulmonic stenosis

D. transposition of the great arteries with intact ventricular septum

E. truncus arteriosus with severe truncal valve incompetence

Question 59. Answer.b

A healthy-appearing 6-month-old infant has a resting heart rate of 55

beats/min that increases to 70 beats/min while crying. When quiet, he has
a soft, vibratory ejection murmur. Careful inspection of the extended neck
reveals an intermittent brisk jugular venous pulse wave.

Of the following, the MOST likely explanation for these findings is

A. carditis due to Lyme disease

B. congenital complete heart block

C. congenital long QT syndrome

D. familial dysautonomia

E. sick sinus syndrome

Question 115. Answer.a

A 4-year-old child is struck by a car when crossing the street. At the

emergency department, examination of the child's abdomen reveals
distention, diffuse tenderness, and absent bowel sounds.

Of the following, the best INITIAL radiologic study to evaluate this

abdominal injury is

A. computed tomography
B. intravenous pyelography

C. magnetic resonance imaging

D. plain radiography

E. ultrasonography

Question 164. Answer.d

An 11-month-old girl is brought to the emergency department because

she is having a generalized seizure. She had been playing all day in an
above-ground pool when she began to jerk. There is no history of recent
fever or trauma, and her development has been normal. Intravenous
administration of appropriate doses of anticonvulsants results in partial
cessation of the seizure activity.

Of the following, the test that is MOST likely to explain these findings is

A. a culture of the cerebrospinal fluid

B. magnetic resonance imaging of the brain

C. measurement of the tympanic membrane temperature

D. serum electrolyte concentrations [hyponatremia]

E. skull radiography

Question 217. Answer.d

A 4-year-old girl presented 18 hours ago to the emergency department in

severe respiratory distress and septic shock. A diagnosis of severe viral
pneumonia was made, and she now is in the pediatric intensive care unit,
intubated and on assisted ventilation. Over the past few hours, she has
become more hypoxemic on current ventilator settings.

Of the following, the BEST way to increase her oxygenation is to

A. decrease the inspiratory time

B. decrease the peak inspiratory pressure

C. increase the expiratory time

D. increase the positive end-expiratory pressure [ards]

E. increase the rate (breaths/min)

Question 103. Answer.d

You are treating a 12-year-old boy who has purpura. His blood pressure is
68/43 mm Hg. Arterial blood gas analysis on 100% FIO2 reveals: pH, 7.20;
PO2, 160 torr; PCO2, 21 torr. Following intubation and the administration
of intravenous antibiotics, saline (20 mL/kg), and dopamine (10.0 mcg/kg
per minute), the blood pressure is 72/56 mm Hg and pulses are easily felt,
but acidosis persists.

The most appropriate NEXT step is to

A. administer a bolus of 5% albumin (20 mL/kg)

B. administer another bolus of saline (30 mL/kg)

C. begin dobutamine infusion at 5.0 mcg/kg per minute

D. begin norepinephrine infusion at 0.5 mcg/kg per minute [septic

shock]

E. increase dopamine infusion to 15.0 mcg/kg per minute

Question 28. Answer.e

A 2-week-old infant has tachycardia, tachypnea, and poor weight gain.

Findings include: chest radiography, cardiomegaly; echocardiography, a
structurally normal heart, left ventricular dilatation, ejection fraction of
20% (normal, >55%), a small pericardial effusion, and mild mitral and
tricuspid regurgitation. Arterial blood gases: pH, 7.30; PO2, 72 torr; PCO2,
41 torr.

The most appropriate INITIAL step in management is intravenous

administration of

A. angiotensin-converting enzyme inhibitor

B. corticosteroid

C. digoxin

D. epinephrine

E. furosemide

Question 131. Answer.b

Of the following, the MOST likely finding in a child who has impending liver
failure is

A. acute onset of ascites

B. hyperammonemia and mental status changes

C. polyuria

D. severe epistaxis

E. significant hepatomegaly