will try my best
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20. A 67-year-old woman has been intubated for 1 week after undergoing a left lobectomy for lung
cancer. She has chronic obstructive pulmonary disease. Her preoperative functional vital capacity
was 40% of predicted. She is awake and alert. Her blood pressure is 130/75 mm Hg, and pulse is
72/min. The ventilator settings are a synchronized intermittent mandatory ventilation of 8/min,
FIO2 of 40%, and positive-end expiratory pressure of 5 cm H2O. Arterial blood gas analysis shows:
pH 7.42
PCO2 47 mm Hg
PO2 90 mm Hg
O2 saturation 96%
Which of the following is the most appropriate next step in management?
A
) Antibiotic therapy
B
) Bronchodilator therapy
C
) Chest physiotherapy
D
) Decrease inotropes
E
) Diuretic therapy
F
) Fiberoptic bronchoscopy
G
) Heparin therapy
H
) Incentive spirometry
I
) Increase FIO2
J
) Increase inotropes
K
) Increase respiratory rate
L
) Placement of thoracostomy tube
M
) Tracheostomy
N
)Wean from ventilator
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| will try my best
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Please explain the answer
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| will try my best
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NBME form 1 sec 2 qs 26:
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| will try my best
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26. A 19-year-old man comes to the physician because of frequent nosebleeds over the past 3
weeks. He has bipolar disorder currently well controlled with lithium carbonate, bupropion, and
valproic acid. Physical examination shows no abnormalities except for dried blood in the nares.
Mental status examination shows an anxious mood and slight motor restlessness. Serum studies
show a lithium carbonate level of 1.3 mEq/L (therapeutic range=0.6–1.2), and valproic acid level of
77 μg/mL (therapeutic range=40–100). Which of the following is the most appropriate next step in
management?
A
) Measurement of serum aspartate aminotransferase (AST, GOT) activity
B
) Measurement of serum bupropion level
C
) Platelet count
D
) Discontinuation of lithium carbonate therapy
E
)Discontinuation of Valproic acid
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| will try my best
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Is' nt A the answer?
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| will try my best
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NBME form 1 sec 2 qs 26:
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| will try my best
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29. A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of
290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril
for hypertension and glyburide for type 2 diabetes mellitus. She also has intermittent episodes of
gout. Fasting serum studies show:
Total cholesterol 252 mg/dL
HDL-cholesterol 80 mg/dL
Triglycerides 300 mg/dL
Glucose 118 mg/dL
Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step in management?
A
) Alcohol cessation
B
) Better control of diabetes
C
) Switch from captopril to calcium-channel blocking agent therapy
D
) Gemfibrozil therapy
E
)Thyroid replacement therapy
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| will try my best
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I thought D....
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| hero
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29 - gemfibrosil - for HDL - incr HDL by 10-20 %, she doesn't need.
I would say A. Pint of vodka is just too much 
28 - pt has platelet kind of bleeding, probably plat count (C). Li level high, but Li toxicity - thyroid and nephro, not liver
20- respi rate incr (K), she retains CO2, acidotic, and has good saturation and pO2
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| will try my best
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29. I agree the vodka is too much but TG is too high.And fibrates are good for lowering TG.That is why I thought so.
26. Though Li is high I was worried about valproate causing the bleeding either by direct liver toxicity or thrombocytopenia.And I guess Hero you are right that since the bleeding is platelet type,platelet count comes first.
20. I thought ABG was fine for person with lobectomy. I was wondering about choosing between heparin(which I thought that any ICU pt will be on anyways),chest physiotherapy(since COPD pt and now on ventialator) and weaning (since the ABG is good and it has to be started some day). I would disagree with incr resp rate since ABG is not acidotic and she is on intermittent mandatory meaning that she takes some of her breaths on her own and the machine is giving her some incase she does not take , so compulsory rate of 8 is good enough and she must be definately having more breaths.
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| hero
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yes, not acidotic. And probably needs bit higher pCO2 for resp drive. Wean from ventilator?
Found this criteria
Criteria for starting weaning
Adequate oxygenation
PaO2≥60 mm Hg on FiO2≤0.4
(PaO2/FiO2= 150–300) with positive
end-expiratory pressure ≤5 cm H2O
Hemodynamic stability
No myocardial ischemia
or significant hypotension
Temperature < 38˚C
Hemoglobin ≥8–10 g/dL
Adequate mental status
Patient awake or easily aroused
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So I guess she does fit into the criteria for weaning.
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| GOGETA
I'm Dr. GOGETA
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The first question is N, how I know I ask the ICU/PULMONOLOGIST Doc 
For the cholesterol lady her HDL is 80!!!
I go with A stop drinking lady, get therapy is better.
for the bleeding guy that seems a platelet problem so first check the platelet
___________________
As a general rule, the better it felt when you said it, the more trouble it's going to get you into.
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| will try my best
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Thanks Gogeta, I think I am convinced of the answers thanks to you and Hero.
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