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  #1  
Old 09-07-2012
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Default A 75-year-old woman with COPD

A 75-year-old woman with a history of chronic obstructive pulmonary disease is evaluated in the intensive care unit for delirium. She had a median sternotomy and repair of an aortic dissection and was extubated uneventfully on postoperative day 4. Two days later she developed fluctuations in her mental status and inattention. While still in the intensive care unit, she became agitated, pulling at her lines, attempting to climb out of bed, and asking to leave the hospital. The patient has no history of alcohol abuse or other substance abuse. The use of frequent orientation cues, calm reassurance, and presence of family members has done little to reduce the patient's agitated behavior. Medical evaluation identifies no focal neurologic deficits .

Hematology


Activated partial thromboplastin time — 25-35 s

Bleeding time — less than 10 min

Erythrocyte count — 4.2-5.9 106/μL

Erythrocyte sedimentation rate 20 mm/h

Erythropoietin — less than 30 mU/mL


D-Dimer — less than 0.5 μg/mL


Ferritin, serum — 100 ng/mL


Haptoglobin, serum — 100 mg/dL


Hematocrit 38%

Hemoglobin— 12 g/dL

Leukocyte alkaline phosphatase — 15-40 mg of phosphorus liberated/h per 1010 cells; score = 13-130/100 polymorphonuclear neutrophils and band forms

Leukocyte count — 4000/μL

Mean corpuscular hemoglobin — 28 pg

Mean corpuscular hemoglobin concentration — 32 g/dL

Mean corpuscular volume — 80 fL

Platelet count — 150,000/μL

Prothrombin time — 11 s

Reticulocyte count — 0.5% of erythrocytes;

Blood, Plasma, and Serum Chemistry Studies


Albumin, serum — 3.5 g/dL


Alkaline phosphatase, serum — 36 U/L

α-Fetoprotein, serum — 10 ng/mL

Aminotransferase, alanine (ALT) — 35 U/L

Aminotransferase, aspartate (AST) — 35 U/L

Ammonia, plasma — 40 μg/dL


Amylase, serum — 13 U/L

Bilirubin, serum

Total — 0.3 mg/dL



Direct — 0.3 mg/dL



Blood gases, arterial (ambient air)

pH — 7.38


PCO2 — 35 mm Hg



PO2 — 80 mm Hg



Oxygen saturation — 95%



Blood urea nitrogen — 20 mg/dL


C-reactive protein — 0.0-0.8 mg/dL


Carbon dioxide content, serum — 28 meq/L


Chloride, serum — 98 meq/L


Cholesterol, plasma

Total — 199 mg/dL



Low-density lipoprotein (LDL) — 130 mg/dL


High-density lipoprotein (HDL) — 40 mg/dL



Complement, serum

C3 —120 mg/dL


Total (CH50) — 55 U/mL



Creatine kinase, serum — 170 U/L

Creatinine, serum — 1.3 mg/dL


Electrolytes, serum

Sodium — 136 meq/L



Potassium — 3.5 meq/L



Chloride — 98 meq/L



Carbon dioxide — 28 meq/L



Fibrinogen, plasma — 150 mg/dL


Folate, red cell — 160 ng/mL


Folate, serum — 20 ng/mL


Glucose, plasma — fasting, 100 mg/dL


γ-Glutamyltransferase, serum — 0-30 U/L

Homocysteine, plasma 1.89 mg/L


Immunoglobulins

Globulins, total — 3.5 g/dL


IgG — 640 mg/dL




IgA — 70 mg/dL




IgM — 20 mg/dL



IgE — 0.01 mg/dL




Iron studies

Ferritin, serum — 100 ng/mL



Iron, serum — 160 μg/dL



Iron-binding capacity, total, serum — 460 μg/dL



Transferrin saturation — 50%


Lactate dehydrogenase, serum — 100 U/L

Lactic acid, venous blood — 16 mg/dL


Lipase, serum — 95 U/L

Magnesium, serum — 2.4 mg/dL


Methylmalonic acid, serum — 150 nmol/L

Osmolality, plasma — 275 mosm/kg H2O

Phosphatase, alkaline, serum — 36 U/L

Phosphorus, serum — 4.5 mg/dL


Potassium, serum — 3.5 meq/L


Protein, serum

Total — 6.0 g/dL



Albumin — 3.5 g/dL



Globulins, total — 2.5 g/dL



Rheumatoid factor — 40 U/mL

Sodium, serum — 136 meq/L


Transferrin saturation —50%

Triglycerides — 150 mg/dL


Troponins, serum

Troponin I — 0.5 ng/mL



Troponin T — 0.10 ng/mL



Urea nitrogen, blood — 20 mg/dL

Uric acid, serum — 2.5mg/dL

Vitamin B12, serum — 200 pg/mL


Endocrine


Adrenocorticotropic hormone (ACTH), serum — 9-52 pg/mL


Aldosterone, serum

Supine — 5 ng/dL



Standing — 7 ng/dL



Aldosterone, urine — 5 μg/24 h

Catecholamines

Epinephrine, plasma (supine) — 75 ng/L



Norepinephrine, plasma (supine) — 50 ng/L



Catecholamines, 24-hour, urine — less than 100 μg/m2 per 24 h


Cortisol, free, urine - less than 50 μg/24 h


Dehydroepiandrosterone sulfate (DHEA), plasma 3.3 μg/mL


Epinephrine, plasma (supine) — less than 75 ng/L

Estradiol, serum day 1-10, 14-27 pg/mL (50-100 pmol/L); day 11-20, 14-54 pg/mL (50-200 pmol/L); day 21-30, 19-41 pg/mL (70-150 pmol/L)


Growth hormone, plasma — after oral glucose: less than 2 ng/mL (2 μg/L); response to provocative stimuli: greater than 7 ng/mL



Metanephrine, urine — less than 1.2 mg/24 h (6.1 mmol/24 h)

Norepinephrine, plasma (supine) — 50-440 ng/L (296-2600 pmol/L)

Parathyroid hormone, serum — 10-65 pg/mL (10-65 ng/L)

Thyroid function tests

Thyroid iodine (131I) uptake — 20% of administered dose at 24 h


Thyroid-stimulating hormone (TSH) — 3.0 μU/mL (0.5-5.0 mU/L)


Thyroxine (T4), serum


Total — 12 μg/dL (64-155 nmol/L)



Free — 2.4 ng/dL (12-31 pmol/L)



Free T4 index — 4



Triiodothyronine, free (T3) — 3.6 ng/L



Triiodothyronine, resin (T3) — 25%


Triiodothyronine, serum (T3) — 70 ng/dL



Vanillylmandelic acid, urine — less than 8 mg/24 h


Vitamin D

1,25-dihydroxy, serum — 65 pg/mL



25-hydroxy, serum — 80 ng/mL



Urine


Albumin-creatinine ratio — less than 30 mg/g

Calcium — 200 mg/24 h


Creatinine — 25 mg/kg per 24 h


Glomerular filtration rate (GFR) 120 mL/min/1.73 m2

5-Hydroxyindoleacetic acid (5-HIAA) — 2mg/24 h


Protein-creatinine ratio - 0.2 mg/mg

Sodium — 200 meq/24 h

Uric acid — 250 mg/24 h


Gastrointestinal


Gastrin, serum — 18 pg/mL


Stool fat — less than 5 g/d on a 100-g fat diet

Stool weight — less than 200 g/d

Pulmonary


Forced expiratory volume in 1 second (FEV1) — greater than 80% of predicted

Forced vital capacity (FVC) — greater than 80% of predicted

FEV1/FVC — greater than 75%

Cerebrospinal Fluid


Cell count — 5/μL

Glucose — 80 mg/dL


Pressure (opening) — 200 mm H2O

Protein — 60 mg/dL (150-600 mg/L)

Hemodynamic Measurements


Cardiac index — 2.5 L/min/m2

Left ventricular ejection fraction — 55%
Pulmonary capillary wedge — 12 mm Hg



Which of the following is the most appropriate therapy?


(A) Diphenhydramine
(B) Haloperidol
(C) Lorazepam
(D) Propofol

Last edited by Novobiocin; 09-07-2012 at 10:15 AM.
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  #2  
Old 09-07-2012
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Holly mother of god Novo are you serious? hahaha :S

I would say haloperidol but i sense a trap in that much information...
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Old 09-07-2012
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would go with A ......
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  #4  
Old 09-07-2012
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B.) haloperidol
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  #5  
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From what i can gather, she is OLD and delirius...

The drug of choice in old patients are antipsychotics

The drug of choice in the acute setting is Haloperidol

BZD's are relatively contraindicated in the elderly because of slow elimination rate and because they can worsen confusion... and also because this lady has already a respiratory condition that could be worsen by respiratory depression that BZD's cause.. the same goes for Propofol...

And maybe im stupid but I dont know if Diphenhydramine which is a strong anticholinergic and antihistaminic drug used most often for nausea would have any indication on this patient.
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Old 09-07-2012
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I would go with B

I skipped most of the endless findings

I just attempted the longest Q of usmle
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  #7  
Old 09-07-2012
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this is like the largest question ever
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Old 09-07-2012
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i have read the whole question including the investigations and m like

but i will go for B
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Old 09-07-2012
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I think A. But I want answer and explanation

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  #10  
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This was a very straightforward question of a patient with delirium and you treat it with Haloperidol.

Quote:
The appropriate treatment for this patient is haloperidol. When supportive care is insufficient for prevention or treatment of delirium, symptom control with medication is occasionally necessary to prevent harm or to allow evaluation and treatment in the intensive care unit. The recommended therapy for delirium is antipsychotic agents.
Haloperidol does not cause respiratory suppression, which is one reason that it is often used in patients with hypoventilatory respiratory failure who require sedation.

Diphenhydramine and other antihistamines are a major risk factor for delirium, especially in older patients. Lorazepam is actually deliriogenic. There is no evidence that propofol has any role in treating delirium.
But the point of posting this question was to address the issue of "time management" on the real exam which has become a major issue with new format. I put in all those investigations (which are all normal) to make it a bit longer just to see how many of us can solve it in one minute. And if not what would be your approach in the real test.

So, how much time did you spend on this question?
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  #11  
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Less than 2 minutes, i read the case and quickly scrolled and saw the first laboratory findings, saw normal and then went for the options saw haloperidol and prayed XD
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