When should intensive insulin therapy should be initiated in critically ill?
(A) when the blood glucose level exceeds 110 mg/dl regardless of caloric intake
(B) when the blood glucose level exceeds 215 mg/dl regardless of caloric intake
(C) when the blood glucose level exceeds 110 mg/dl and t...
When should intensive insulin therapy should be initiated in critically ill?
(A) when the blood glucose level exceeds 110 mg/dl regardless of caloric intake
(B) when the blood glucose level exceeds 215 mg/dl regardless of caloric intake
(C) when the blood glucose level exceeds 110 mg/dl and the patient is receiving IV glucose (200 to
300 gm per 24 hours), total parenteral, parenteral and enteral, or total enteral feedings
(D) when the blood glucose level exceeds 215 mg/dl and the patient is receiving IV glucose (200 to
300 gm per 24 hours), total parenteral, parenteral and enteral, or total enteral feedings -
ANSWERAnswer: C.
Intensive insulin therapy (maintaining serum glucose between 80-110 mg/dl) has been found to
decrease morbidity and mortality in critically ill patients. Most institutions have developed insulin
protocols to help achieve these serum glucose goals, and consider serum glucose levels of < 150
mg/dl as clinically acceptable. When using intensive insulin therapy, hypoglycemia can occur if a
continuous supply of glucose substrate is not maintained. Therefore, a continuous glucose supply
should be initiated in patients who are not profoundly hyperglycemic to minimize hypoglycemic
episodes.
TB is a 34-year-old, sexually active man who admits an encounter tens days ago with a woman whom
he met in a nightclub. He participated in oral and vaginal sex without a condom. He did not notice
any discharge from his partner but began experiencing dysuria three days ago with a mucopurulent
discharge that stained his underwear. PMH: genital herpes simplex two years ago. FH unremarkable.
He smokes one pack per day; alcohol 3-4 x week; sexually active with multiple partners. Meds: none.
Allergies: none. Discharge culture is positive for gonorrhea. What should be recommended to treat
TB?
(A) ceftriaxone 125 mg IM
(B) azithromycin 1 g in a single dose
(C) ceftriaxone 125 mg IM + azithromycin 1 g in a single dose
(D) benzathine penicillin G 2.4 million units IM in a single dose - ANSWERAnswer: C.
, Ceftriaxone 125 mg IM or ciprofloxacin 500 mg or ofloxacin 400 mg or levofloxacin 250 mg or
gatifloxacin 400 mg—all as a single dose, would be the correct answer. Since the incidence of
coinfection with Chlamydia is high, azithromycin or doxycycline should be added presumptively to
the above therapy; in areas where coinfection is low, patients should be tested and not treated
presumptively. Benzathine penicillin G 2.4 million units IM in a single dose is the treatment for
syphilis.
The beneficial effects of activated protein C in severe sepsis are thought to be due to its anti-
inflammatory, antithrombotic and profibrinolytic activity.
DF is a 45-year-old man who suffered a non-ST segment elevation myocardial infarction one month
ago, and had a stent placed in his distal left anterior descending artery. He has a history of
hypertension and diabetes, and an echocardiogram after the myocardial infarction revealed no wall
motion abnormalities, and a normal ejection fraction. Prior to this hospitalization, he was on glipizide
10 mg BID, metformin 500 mg BID, aspirin 81 mg every day, vitamin E 400 IU every day,
hydrochlorothiazide 25 mg every day, and atorvastatin 10 mg every day His discharge medications
consisted of the above medications, plus metoprolol 50 mg BID and clopidogrel 75 mg every day (for
stent patency), and the atorvastatin was increased to 40 mg every day. You see DF one month after
his hospital discharge when he presents for routine follow-up. Pertinent labs include serum
creatinine = 1.0 mg/dl, potassium = 4.3 mEq/L, HbA1c = 6.8%, LDL- - ANSWERAnswer: B.
DF is not at his goal blood pressure, which is < 130/80 mm Hg due to his diabetes. Also due to his
diabetes and high-risk of another myocardial infarction, he has a compelling indication for an
angiotensin-converting enzyme inhibitor (ACEI). Adding an ACEI to his existing therapy makes sense
to try to reach his goal blood pressure. Increasing the beta-blocker is less attractive, because his
heart rate is not elevated, and it does not allow the addition of the mandatory ACEI. His LDL is
already well below the minimum goal of 100 mg/dl. Increasing to 80 mg/day will not decrease it
much more, perhaps another 5%. While not absolutely wrong to increase atorvastatin, this is less
important than to get his BP to goal. Aspirin at 75-325 mg/day are equally effective cardioprotective
dosages. No additional benefit is derived with increasing the dose from 81-325 mg.
True or false: a patient who develops a rash on one anti-epileptic drug has an increased risk of
developing a rash with other anti-seizure medications. - ANSWERTrue. 58% of patients who develop
a rash with phenytoin will also get a rash with carbamazepine. 40% of patients who get a rash with
carbamazepine will also get one with phenytoin, while 20-30% will get one with oxcarbazepine. 80%
of patients who experience a rash with phenobarbital will get a rash with carbamazepine or
phenytoin. Patients with a history of developing a rash with other AEDs are more likely to get one
with lamotrigine as well.
RN is a 42-year-old man who has been HIV positive since 1995. His current viral load is 200,000
copies/ml and his CD4 count is 210/mm3. Which one of the following is the best treatment for RN?
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