Medical Case Studies
ACNP Boot Camp 2013
Case Study #1
Mr. Allen is a 62 y/o male, PMH HTN and DM2,
admitted to MICU with hypoxia related to newly
diagnosed community acquired pneumonia. He was
given azithromycin by his PCP 2 days ago, however this
morning awoke short of breath and feeling worse. He
has an allergy to sulfa drugs.
In the ED, SpO2 was 89% on RA. Vitals on arrival to
MICU: HR 115, BP 101/58, RR 38, SpO2 92% on 50%
venti-mask. His CXR is as follows:
ABG on admission:
7.49 / 25 / 65 / 24
Na 138, K 4.2, Cl 102, C02 24, BUN 12 , Cr 0.8 ,
AG 12
What is the acid-base disturbance?
A. Mixed metabolic
acidosis and respiratory
alkalosis
B. Respiratory alkalosis
with compensation
C. Respiratory alkalosis
without compensation
D. Respiratory acidosis
What antibiotic changes should be made?
A. Discontinue Azithro
then start Vancomycin
and Zosyn
B. Add Bactrim to
regimen
C. Start Clindamycin and
discontinue Azithro
D. None of the above
After 24 hours of antibiotics and bipap, Mr. Allen
worsens and requires intubation. Repeat CXR :
ABG prior to intubation
7.2 / 50 / 53 / 20
Na 136, K 4.5, Cl 100, C02 21, BUN _ , Cr _ ,
AG 15
Lactate 3.9
What is the acid-base disturbance?
A. Metabolic acidosis
B. Respiratory acidosis
C. Respiratory acidosis
with metabolic
acidosis
D. None of the above
With a pH of 7.2, what can you do to correct
the acidosis?
A. Increase minute
ventilation (RR up
to 35)
B. Start a paralytic
infusion
C. Give crystalloid
fluids
D. Do nothing
He now has ARDS and is now requiring 70%
FiO2. For maximizing alveolar recruitment, what
should his PEEP setting be?
A.
B.
C.
D.
5 mmHg
18 mmHg
22 mmHg
12 mmHg
Mr. Allen is 73 inches in height and weighs 105kg.
Calculate his set tidal volume (predicted body
weight x 6)
A.
B.
C.
D.
480 ml
340 ml
920 ml
220 ml
After 3 days of supportive care, Mr. Allen continues to
decompensate and a bronchoscopy is performed.
Preliminary results reveal a gram positive organism.
What changes should be made to the antibiotic
regimen?
A. Discontinue vancomycin
and start linezolid
B. Discontinue vancomycin
and start daptomycin
C. Add coverage for atypical
organisms
D. Both A and C
Unfortunately, the next day, Mr. Allen starts having
melena stools. His PCV has been downtrending from
3833 27. After further review of his medication
list, he was never started on stress ulcer prevention.
Which is the best treatment option?
A.
B.
C.
D.
IV H2 Blocker
PO H2 Blocker
High dose IV PPI
PO PPI
Aggressive red blood cell transfusion would be
the next best course of action.
A. True
B. False
Mr. Allen’s condition is improving. Which factor
is not required to start vent weaning:
A. Make unassisted
breathing efforts
B. No pressors required
C. FiO2 <.40 and PEEP <8
D. Awake and following
all commands
Questions?
Case Study #2
Mr. Commodore is a 43 yo M with a hx of alcoholic
cirrhosis and CAD on daily ASA who presents to the
MICU with c/o melena, fatigue, and weakness.
Pertinent labs on admission include WBC 15, PCV 26,
and platelets 100K. His initial VS are: BP 120/80, HR
110, RR 18, afebrile.
Physical exam is negative except for abdominal
distention with positive fluid wave.
What would you do next?
A.Begin Pepcid 20 mg
IVP BID
B.Transfuse 1 unit of
PRBC
C.Begin esomeprazole
40 mg IVP BID
D.Prep for colonoscopy
You should begin an octreotide drip at
50 mcg/hr after a 50 mcg bolus dose.
A. True
B. False
SBP prophylaxis should be initiated.
A. True
B. False
Which antibiotic would you start for SBP
prophylaxis?
A.
B.
C.
D.
Vancomycin
Ceftriaxone
Metronidazole
Caspofungin
Within 1 hour of arrival, the patient develops
large volume hematemesis and becomes
hemodynamically unstable. His vital signs are as
follows: HR 135, BP 80/44, RR 26, O2 sat 89% on
2L NC.
Which of the following is the most important
next step:
A. Intubate the patient and
obtain 2 large bore PIVs
B. Insert CVC and begin
levophed drip
C. Order STAT PT/INR
D. Consult EGS
Once the patient is intubated and the airway is
stabilized, you consult the GI team STAT for endoscopy
and intervention.
While waiting for the team to arrive, how can you
optimize the patient for endoscopy and attempt to
stabilize him?
A. Transfuse 1 pack of
platelets
B. Give 10 mg Reglan IVP
now
C. Transfuse 1 unit of PRBC
D. All of the above
The patient undergoes endoscopy and is noted
to have large esophageal varices. Five bands are
placed and hemostasis is achieved. Incidentally,
the patient is noted to also have esophageal
candidiasis.
Which antibiotic should be initiated in this
patient?
A. Fluconazole
B. Micafungin
C. Amphotericin B
D. None of the above;
pt is asymptomatic
The patient remains in the MICU overnight for
close observation. He remains hemodynamically
stable and has no further bleeding. However,
this morning’s labs reveal a PCV of 20 and
platelet count of 92K.
Which of the following is the next best course of
action?
A. Nothing. The patient is
stable without evidence
of recurrent bleeding.
B. Transfuse 1 unit of PRBC
C. Discharge the patient
home
D. Transfuse FFP
Questions?
Case Study #3
Mr. Smith is a 67 yo male who resides in a SNF, with a
history of CVA, COPD on 2L 02 who was treated 6
weeks ago for CAP. He is admitted to the MICU with
SOB, AMS, and a 5 day history of diarrhea.
VS: BP 88/52, HR 116, RR 22, 02 sat 92% on 6L 02
ABG: 7.22 / 30 / 65 / 10
What acid base disturbance is present?
A. Metabolic acidosis
B. Acute Respiratory
acidosis
C. Chronic Respiratory
acidosis
D. Respiratory alkalosis
Winter’s formula
1.5 x 10 + 8 = 23
What does this tell us?
A. Respiratory
compensation is
incomplete
B. Pt. has a secondary
respiratory acidosis
C. Both 1 and 2
D. Neither 1 or 2
Delta / Delta ratio is 7/14
This indicates the following:
A. There is an additional
non-gap metabolic
acidosis
B. There is an additional
metabolic alkalosis
C. Neither of the above
D. Not sure
Mr. Smith’s diarrhea becomes severe and he
tests positive for clostridium difficile.
What is the best antibiotic treatment for this
patient?
A.
B.
C.
D.
Metronidazole PO
Vancomycin IV
Fluconazole IV
Vancomycin PO
Questions?
Case Study #4
55 y/o male presented to ED with 3 day hx of malaise,
fever, and poor PO intake. PMH significant for HTN,
DM, and ESRD s/p renal transplant March 2013.
Admitted to MICU for septic shock. Admission labs
showed WBC 0.4, creatinine 5.0, increased from
baseline of 1.8, and lactate 6. Patient received 1500mg
IV Vancomycin, Zosyn, and 2L IVF in the emergency
department.
When should the Vancomycin level be checked
and what type of level should it be (peak,
trough, random)?
A. Trough level 30 min before
5th dose
B. Peak level 12 hours after
initial dose
C. Peak level after the 5th dose
D. Random level 12-24 hours
after the initial dose
Patient arrived in MICU hypotensive. An
additional 3L IVF given with no improvement
and vasopressors started. Patient rapidly
became hypoxic (SpO2 in the 70’s) and required
intubation.
Vent settings: Volume control, 100% FiO2, 12
PEEP, rate 15. Fentanyl drip started.
Patient remains hypoxic on the current vent
settings. Peak pressure is 23.
This patient’s peak pressure is within
acceptable range.
A. True
B. False
ABG: pH 7.22 / 30 / 65 / 10
Na 136, Cl 102, C02 10
What is the acid-base disturbance?
A. Respiratory acidosis
B. Non-anion gap
metabolic acidosis
C. Anion gap metabolic
acidosis
D. Compensated
metabolic acidosis
What are the next steps to improve
oxygenation?
A.
B.
C.
D.
Paralyze the patient
Increase PEEP
Prone positioning
Inhaled Flolan
Hospital day #2: Patient without improvement.
Remains ventilated and on vasopressors.
Creatinine up to 5.5 and WBC holding at 0.4.
Current antibiotics include Vancomycin, Zosyn,
and Levaquin.
Blood cultures pending. Urine culture pending.
What additional organisms should be
considered as a source of infection?
A.
B.
C.
D.
MRSA
ESBLs
Candida
Candida and ESBLs
Which is the best antibiotic to treat an ESBL in
this patient?
A.
B.
C.
D.
Zosyn
Aztreonam
Clindamycin
Meropenem
Which antibiotic would best treat Candida in
this patient?
A. Fluconazole
B. Caspofungin
C. Fluconazole and
Caspofungin
D. None of the above
Patient’s shock is resolved and he is no longer
requiring pressors. What should your next
action be?
A. Continue fluid
infusions
B. Daily CPAP breathing
trials
C. Attempt diuresis
D. Both B and C
Questions?
References
Acute Respiratory Distress Syndrome Network: Ventilation with Tidal Volumes as compared
with traditional tidal volumes for acute lung injury and the acute respiratory distress
syndrome. New Engl J Med. 2000; 342: 1302-1308.
ARDSNet: Higher versus lower Positive End-Expiratory Pressures in patients with the acute
respiratory distress syndrome. New Engl J Med. 2004; 351: 327-336.
CDC website
Garcia-Pagan et al, NEJM 2010; 362:2370-9
Halperin, Mitchell L., Kamel, Kamel S. and Goldstein, Marc B. (2010) Fluid, Electrolyte and AcidBase Physiology: A Problem Based Approach, Fourth Edition. Philadelphia, PA. Saunders
Elsevier.
Infectious Disease Society of America website
Lau JY, Sung JJ, Lee KKC, et al, NEJM 2000; 343: 310–316
Marini, J.J., Wheeler, A.W. (2010). Critical care medicine: The essentials (4th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.
Rivkins, K., Lyakhovetskiy, A AJHP 2005; 62: 1164-1165
Sucher, A.J., Chahine, E.B., Balcer, H.E. Echinocandins: The Newest Class of Antifungals. The
Annals of Pharmacotherapy. 2009, (43), pp. 1647 - 1657.
Villaneuva, C et al NEJM 2013; 368:11-21