Systemic Organ Function and the Nervous System
Questions
1. A 50-year-old male patient with a left ventricular assist device is admitted to the emergency department with a 30 mL right temporal intracerebral hemorrhage with intraventricular hemorrhage. His home medications include coumadin and aspirin daily. He has a left hemiparesis but is awake, and following commands. His blood pressure is 174/74 and his INR is 3.4. What is the best initial management consideration?
A. Administration of protamine sulfate
B. Administration of prothrombin complex concentrate (PCC)
C. Intubation and mechanical ventilation
D. Platelet transfusion
E. Systolic blood pressure reduction
View Answer
1. Answer B. (MN-119) Timely reversal of anticoagulation to prevent hematoma expansion is considered an essential component of the initial management of intracerebral hemorrhage. The specific reversal agent for vitamin-k antagonist anticoagulants is 4-factor PCC.
2. You are consulted to see a 45-year-old female patient with a left ventricular assist device who had an acute ischemic stroke with hemorrhagic conversion 4 days ago. The ICU team wants to know when it is safe to initiate a heparin infusion. What is the most appropriate response?
A. 3 days
B. 1 week
C. 2 weeks
D. 2 months
E. An individualized approach that balances the risks of thromboembolism with the risks of hemorrhagic complications
View Answer
2. Answer E. (MN-119) There are currently insufficient high-quality data to recommend a specific timeline to initiate antithrombotic medications. Factors that may be considered include: the size of the acute ischemic stroke, evidence of device or cardiac thromboses, ongoing evidence of cerebral embolization as demonstrated via transcranial Doppler, extent of hemorrhagic conversion, and presence of mycotic aneurysms or septic embolization.
3. A 34-year-old female patient with no prior medical history is admitted with a poor-grade subarachnoid hemorrhage with obstructive hydrocephalus due to a ruptured posterior communicating artery. She is noted to be in shock, which stabilizes after fluid resuscitation and initiation of two vasopressors. An electrocardiogram shows diffuse symmetrical T-wave inversions with a prolonged QTc interval. An emergent echocardiogram demonstrates a diminished ejection fraction with apical akinesis. Which of the following most accurately describes the cause of her shock?
A. Distributive shock
B. Myocardial infarction
C. Neurogenic stunned myocardium
D. Pulmonary embolism
E. Septic shock
View Answer
3. Answer C. (MN-119) The most likely etiology of shock in this young patient with no significant history of coronary artery disease is neurogenic stunned myocardium. The echocardiogram findings are consistent with neurogenic stunned myocardium, which classically demonstrates globally reduced systolic function, and apical ballooning (Takotsubo sign) with hypokinesis.
4. Which group of objective findings is most consistent with neurogenic stunned myocardium?
A. Anterior ST segment elevations on EKG, troponin-I level of 35.60 ng/mL (normal <0.04 ng/mL), echocardiogram showing segmental anterior wall hypokinesis
B. Global ST segment depressions on ECG, troponin-I level of 0.01 ng/mL, echocardiogram showing right ventricular hypokinesis
C. Global T-wave inversions on ECG, troponin-I level of 0.90 ng/mL, echocardiogram showing global hypokinesis
D. Inferior ST segment depressions on ECG, troponin-I level of 12.45 ng/mL, echocardiogram showing basal hypokinesis
E. Nonspecific ST-T wave changes, troponin-I level of 0.01 ng/mL, echocardiogram showing left ventricular hyper-contractility
View Answer
4. Answer C. (MN-119) Neurogenic stunned myocardium typically presents with low to moderately elevated troponin levels (0.04-10.0 ng/mL), T-wave inversions on ECG, and apical ballooning or global hypokinesis on echocardiogram. Although there is often overlap, this contrasts with ischemic myocardial infarction which typically presents with highly elevated troponin levels, focal ST segment elevations on ECG, and segmental wall motion abnormalities on echocardiogram.
5. What of the following conditions can be associated with the development of neurogenic myocardial stunning?
A. Aneurysmal subarachnoid hemorrhage
B. Guillain-Barré syndrome
C. Severe traumatic brain injury
D. All of the above
View Answer
5. Answer D. (MN-119) All of these conditions can trigger the development of neurogenic stunned myocardium.
6. A 24-year-old male patient is admitted to the neurocritical care unit after suffering a severe traumatic brain injury. After 4 days, he develops transient 45-minute episodes of concurrent hypertension, tachycardia, fever, and extensor posturing which are severe enough to interfere with adequate mechanical ventilation. Electroencephalogram is obtained which shows no evidence of cortical seizures. What is the most likely diagnosis?
A. Acute dystonic reaction
B. Cortical spreading depression
C. Electroencephalogram-negative seizures
D. Paroxysmal sympathetic hyperactivity
E. Transtentorial herniation
View Answer
6. Answer D. (MN-119) After excluding seizures, the constellation of these transient symptoms after severe traumatic brain injury is most consistent with paroxysmal sympathetic hyperactivity, also known as autonomic storming (see Chapter 117: Paroxysmal Sympathetic Hyperactivity After Acute Brain Injury in Merritt’s, 14th edition).
7. The above patient develops episodes of concurrent hypertension, tachycardia, fever, and extensor posturing which are severe enough to interrupt adequate mechanical ventilation and cause significant oxygen desaturation. Electroencephalogram is obtained which shows no evidence of cortical seizures. Which of the following is the best first-line treatment for the management of this condition?
A. IV β-blockers
B. IV propofol
C. PO bromocriptine
D. PO gabapentin
E. Transdermal clonidine
View Answer
7. Answer B. (MN-119) While all of these medications play a role in the management of paroxysmal sympathetic hyperactivity, this patient requires immediate and definitive control to facilitate adequate oxygenation. IV propofol is a powerful sedative-hypnotic anesthetic that can produce a quiet, motionless state within minutes. IV beta-blockers will only lower the heart rate and blood pressure, but will not stop the extensor posturing which is causing ventilator desynchrony. The other choices will not produce the immediate control that is needed.
8. An early triggering event in the sequence of sepsis-associated encephalopathy (SAE) pathophysiology is:
A. Global cerebral ischemia
B. Increased blood-brain-barrier (BBB) permeability
C. Neuroinflammation manifesting initially as microglial glial cell activation
D. Nonconvulsive seizure activity
E. Programmed neuron cell death (apoptosis)
View Answer
8. Answer C. (MN-120) Microglial activation resulting from exposure to circulating inflammatory mediators (cytokines) and blood-brain barrier disruption is thought to be a uniform early pathophysiologic event in SAE. Increased BBB permeability and neurons triggered to suffer programmed cell death are late manifestations of SAE. Global ischemic injury occurs prior to death as a consequence of refractory hypotension. Non-convulsive seizures occur in a subset of SAE patients and are not a uniform early pathophysiologic event.
9. “Sickness behavior” in the early stages of sepsis refers to:
A. A coordinated set of adaptive behaviors that help individuals cope with infection, such as sleepiness, malaise, and loss of appetite
B. Fever, chills, and sweats
C. Psychological changes that occur weeks to months after an acute illness
D. Severe states of agitated delirium
E. Somatization disorder and hypochondria
View Answer
9. Answer A. (MN-120) Sickness behavior occurs early in the course of infection as an active behavioral response that preserves energy, minimizes fever, and minimizes gastro-enteric bacterial translocation. It is triggered by activation of specific centers in the brainstem and amygdala. Delirium is one of many behavioral manifestations of SAE. Somatization disorder is a tendency to manifest psychological stress as physical symptoms. Fever, chills, and sweats are part of the autonomic response to infection.
10. Which of the following is true about EEG monitoring during SAE?
A. Electroencephalographic seizures occur in about 10% to 15% of patients with SAE
B. Lack of EEG reactivity to physical stimuli implies a good prognosis
C. Periodic epileptic discharges (PED) have no prognostic significance in SAE
D. Seizures in SAE are typically convulsive
E. Sepsis does not induce long-term epilepsy among survivors
View Answer
10. Answer A. (MN-120) Electroencephalographic seizures occur in about 10% to 15% of patients with SAE. The seizures are almost always electrographic and non-convulsive. PEDs imply a worse long-term neurological outcome and overall prognosis. SAE increases the risk of subsequent epilepsy. Lack of EEG background reactivity to physical stimuli in comatose patients implies a poor prognosis.
11. Which of the following is true of SAE management?
A. SAE requires liberal use of benzodiazepines and neuroleptics to treat agitation
B. SAE is entirely preventable if sleep promotion and early mobilization are employed
C. Statins have been shown to reduce the risk of SAE
D. The early use of dexmedetomidine for sedation results in less delirium compared to benzodiazepines
View Answer
11. Answer D. (MN-120) A clinical trial has shown that in critically-ill patients, many with sepsis, dexmedetomidine results in less delirium compared to benzodiazepines. Non-pharmacologic interventions can reduce the risk and severity of delirium but do not impact SAE itself. An association has been found between benzodiazepine use and delirium, so these agents should be minimized or avoided. Trials have failed to find any effect of statins on SAE incidence or severity.
12. Regarding SAE epidemiology and clinical manifestations, which of the following is true?
A. Although SAE may be related to long-term cognitive dysfunction, affected patients do not develop psychological or emotional issues after their ICU stay
B. Common risk factors for SAE are older age, previous neurological impairment, and benzodiazepine use
C. SAE does not induce any long-term sequelae in the brain
D. SAE is a rare event in the ICU, and it is usually self-limited
E. SAE is clinically manifested only by delirium
View Answer
12. Answer B. (MN-120) SAE is a common problem in the ICU, particularly in elderly, those with pre-existing dementia, or those exposed to benzodiazepines. It is associated with long-term cognitive and psychological problems such as depression and PTSD after ICU discharge. SAE may be manifested by a spectrum of manifestations, ranging from delirium to coma.
13. Regarding the diagnosis of SAE, which of the following is true?
A. Delirium, one of the principle manifestations of SAE, can be diagnosed by the use of appropriate scales in responsive patients
B. EEG alone can also be used to establish the diagnosis of delirium
C. Head CT is often abnormal in SAE, showing global cerebral edema in 50% of patients
D. Some biomarkers, like neuron-specific enolase and S100-B, can confirm the diagnosis of SAE
View Answer
13. Answer A. (MN-120) Validated scales can be used to diagnose delirium in ICU patients, but only if they are responsive and exhibit some degree of cooperation. Although SAE is associated with many EEG alterations, EEG alone cannot be used for SAE diagnosis. Blood biomarkers are not validated for SAE diagnosis, either, although elevations have been associated with SAE occurrence. Head CT is usually normal in patients diagnosed with SAE.
14. When intubating acute ischemic stroke patients, which of the following is the most important to avoid?
A. Hypotension
B. Hypothermia
C. Normocarbia
D. Transient hyperoxia
E. Use of nondepolarizing neuromuscular blockers
View Answer
14. Answer A. (MN-121) Hypotension must be avoided during intubation of stroke patients due to the risk of reducing blood flow to the ischemic penumbra and increasing infarction volume. Intubation may require paralytic use; use of nondepolarizing paralytics is preferred in patients with any type of neuromuscular weakness (instead of depolarizing agents such as succinylcholine). Normocarbia during intubation is acceptable. Hypothermia is not a typical complication of intubation. Preoxygenation hyperoxia prior to intubation is a valuable method to reduce the risk of peri-intubation hypoxia.
15. Respiratory failure due to respiratory muscle weakness should be suspected when:
A. Normal respiratory rate and effort and pH is 7.31
B. pH is 7.38, serum HCO3 is 12 mEq/L, and PCO2 is 27 mm Hg
C. Respiratory rate is 32, vital capacity of 0.7 Liters, and, and pH is 7.31
D. Work of breathing is increased, and pH is 7.49
E. Work of breathing is normal, but pH is 7.49 and the patient is difficult to arouse
View Answer
15. Answer C. (MN-121) A patient with rapid shallow breathing (rapid RR and low vital capacity) and a low pH is demonstrating intact respiratory drive but ineffective ventilation due to neuromuscular weakness. A patient with decreased work of breathing and low pH has respiratory failure due to impaired central respiratory drive – either due to medications, chronic hypercarbia, or brainstem pathology. A patient with increased work of breathing and high pH has hyperventilation, not respiratory failure. An alkalotic patient who is difficult to arouse does not have respiratory failure could be breathing slowly due to metabolic alkalosis. The blood gas reported in answer B shows appropriate respiratory compensation for metabolic acidosis, and is not suggestive of respiratory failure.
16. When weaning patients from mechanical ventilation, which of the following would be considered a contraindication to performing a spontaneous breathing trial (SBT)?
A. DNR order
B. Glasgow coma scale score <8
C. Increased work of breathing
D. pH 7.50
E. Unstable symptomatic vasospasm
View Answer
16. Answer E. (MN-121) Patients with active brain or coronary ischemia should not undergo spontaneous breathing trials due to the potential for diverting blood flow to the respiratory muscles and away from the regions of ischemia. Increased work of breathing is not a contraindication, though it may sometimes be wise to limit SBTs in patients that are becoming fatigued. It is advisable to do pressure support ventilation trials despite low GCS to provide respiratory muscle exercise, even if extubation is not likely to occur. DNR orders and alkalosis are not reasons to avoid an SBT, though alkalosis may lead to apnea until the pH corrects.
17. Physiologic effects of hyperventilation may include:
A. Decreased cerebral blood flow and decreased intracranial pressure (ICP)
B. Decreased cerebral blood flow and increased ICP
C. Decreased risk of cortical ischemia
D. Increased cerebral blood flow and decreased ICP
E. Increased cerebral blood flow and increased ICP
View Answer
17. Answer A. (MN-121) Hyperventilation induces a respiratory alkalosis, which in turn causes cerebral vasoconstriction, decreased cerebral blood flow, and decreased ICP. As such hyperventilation is effective at rapidly reducing ICP. This effect, however, is at the potential cost of causing cortical ischemia. It is, therefore, suitable as an interim measure to decrease ICP in an emergency but is rarely used on a prolonged basis unless a prolonged state of cerebral hyperemia is being treated.
18. A 45-year-old woman is in the ICU after transsphenoidal resection of a nonfunctional pituitary adenoma. Immediately postoperatively, the first hourly urine output measurement is 250 mL, with a specific gravity of 1.001. Serum sodium is pending. The patient is awake and feels thirsty. What is the next best option?
A. Directly give desmopressin (DDAVP) 1 μg IV
B. Give intravenous normal saline to match input volumes to the urine output volume
C. Let her drink as much as she wants and closely monitor urine output, urine specific gravity, and sodium every hour
D. Start oral free water fluid restriction
View Answer
18. Answer C. (MN-122) The initial management of central diabetes insipidus (DI) in awake, cooperative patients consists of free water intake to thirst. In case of failure to keep up with fluid losses or in case of rising serum sodium levels, desmopressin (DDAVP) administration will be the next step. Fluid restriction and normal saline given to match urine output volumes can rapidly worsen DI if it should develop.
19. A 35-year-old woman with known Graves disease was scheduled for elective breast surgery. The procedure was uneventful and the patient was transferred to the recovery room. Three hours later she is found agitated and vomiting, with a high-grade fever (40 °C) and a heart rate of 150 beats per minute. What is the more appropriate next step?
A. Admit to ICU, treat with methimazole and beta-blockers, and continue supportive management
B. Obtain MRI scan of the head, and if negative obtain a lumbar puncture
C. Perform ECG, troponins, and call for cardiology consultation
D. Start broad-spectrum antibiotics empirically, and send blood and urine cultures
E. Start levetiracetam and order a continuous video EEG
View Answer
19. Answer A. (MN-122) The patient is probably suffering from thyroid storm, as she likely did not receive her regular antithyroid medications before her surgery and also underwent a surgical procedure. When suspected, the patient should be treated emergently to prevent mortality. Methimazole is an antithyroid medication used to treat hyperthyroidism and is categorized within the thioamide drug class. Methimazole primarily functions by inhibiting thyroid hormone production in the thyroid gland. While tachycardia and ischemic ECG changes may occur, treating these will not correct the underlying acute endocrine disorder. Her syndrome is unlikely to be due to seizures or a structural disorder.
20. A 50-year-old man presents to your office with progressive horizontal diplopia, worse on left gaze. His past medical history is significant for DM type II on insulin (recent HbA1c of 10.5%), hypertension, and hyperlipidemia. His blood glucose level in 222 mg/dL. Neurological examination is consistent with partial right third nerve palsy without pupillary dilatation. No other focal neurological signs are present.
What is the best next step?
A. Hospitalize immediately and obtain STAT neurosurgery consult
B. Obtain CT angiogram in the ED to assess for possible posterior communicating artery aneurysm
C. Observe overnight in the Emergency Department
D. Refer for outpatient MRI and to primary care physician for improved HbA1c and cardiovascular risk factor management
View Answer
20. Answer D. (MN-122) The patient is suffering from a diabetic third nerve neuropathy due to poor glycemic control, resulting in ischemic injury to the vaso-vasorum. For patients with uncontrolled diabetes or other clearly-causative disease process, in the absence of pupillary dilatation or any other neurological deficits, there is no indication for immediate brain imaging; it may be considered if symptoms worsen or do not improve in a few months. Any third nerve palsy with pupillary involvement suggests an external compression of the nerve and is an indication for structural and vessel imaging; the classic lesion causing this syndrome is an aneurysm of the posterior communicating artery.
21. A 24-year-old man with known adrenoleukodystrophy (ALD) was found confused and with worsening vomiting and diarrhea 2 days after developing gastroenteritis. His mother states that he did not increase his regular hydrocortisone dose over the past few days. What is the best next step?
A. Admit to a medicine floor, administer intravenous fluids, and keep N.P.O
B. Administer hydrocortisone 100 mg IV and then continue 200 to 300 mg daily for the next 48 hours, obtain an endocrinology consultation and admit to the ICU
C. Discharge home with a recommendation to take double his home dose of hydrocortisone
D. Endocrinology consultation, administer intravenous fluids, keep N.P.O
E. Start aggressive IV hydration, and check AM cortisol level
View Answer
21. Answer B. (MN-122) ALD is the cause for up to 20% of male cases of idiopathic Addison disease. The patient is at high risk for adrenal crisis, which if untreated has very high mortality. Immediate administration of stress dose hydrocortisone is recommended with hospitalization in an ICU setting and close hemodynamic monitoring.
22. A 54-year-old woman is admitted to the neurologic intensive care unit with subarachnoid hemorrhage due to a ruptured posterior communicating artery aneurysm. The aneurysm is treated with endovascular coil embolization. On the 6th day postadmission, her level of consciousness declines slightly and she is noted to have diffuse cerebral vasospasm on a CT angiogram. There is some improvement with hemodynamic augmentation with norepinephrine. On morning rounds, the bedside nurse notes that the hemoglobin concentration is 7.8 g/dL and wonders whether the patient should receive a red blood cell transfusion. The correct response is:
A. Clinical trials have demonstrated that targeting a hemoglobin concentration above 7.0 g/dL does not modify outcomes in critically ill patients, therefore she does not need a blood transfusion
B. Red blood cell transfusions increase oxygen delivery to the brain in patients with subarachnoid hemorrhage, therefore transfusion can be considered as a treatment option, although it is unclear whether the benefits outweigh the risks
C. Red blood cell transfusions increase the blood viscosity and may therefore impair blood flow and oxygen delivery to the brain
D. Red blood cell transfusion should be administered as there are no associated risks and may provide some benefit
E. The hemoglobin concentration should be kept above 10.0 g/dL at all times in all patients with subarachnoid hemorrhage
View Answer
22. Answer B. (MN-123) Although it is correct that a transfusion is not required for most critically ill patients unless the hemoglobin concentration falls below 7.0 g/dL, patients with brain injury were under-represented in these clinical trials, and remains unclear that such a low hemoglobin concentration is safe, especially in the setting of cerebral ischemia. The optimal hemoglobin concentration in this situation remains unclear, but a level above 10.0 g/dL is not routinely required. Transfusion does raise viscosity and reduce cerebral blood flow, but it increases oxygen delivery. Risks of transfusion are relatively low, but are associated with volume overload, transfusion-associated lung injury, and allergic transfusion reactions.
23. Sickle cell anemia is a major cause of stroke and cognitive decline in young people. Which treatment is proven to prevent development of stroke in patients with sickle cell disease?
A. Lipid-lowering therapy
B. Maintaining oxygen saturation above 96%
C. Red blood cell transfusion aimed at keeping the fraction of Hemoglobin S below 30%
D. Use of anti-platelet drugs
E. Use of hydroxyurea
View Answer
23. Answer C. (MN-123) The Stroke Prevention Trial in Sickle Cell Anemia found that keeping the Hemoglobin S concentration below 30% and the hemoglobin concentration above 9.0 g/dL reduces stroke risk. Anti-platelet drugs and lipid-lowering therapy have not been shown to be beneficial in sickle cell anemia. Hydroxyurea has a therapeutic role but has not been demonstrated to reduce the risk of ischemic stroke.
24. Posttransplant lymphoproliferative disorders are associated with which of the following viruses?
A. Cytomegalovirus
B. Epstein-Barr virus
C. Herpes simplex virus
D. Human T-lymphotropic virus
E. Varicella zoster virus
View Answer
24. Answer B. (MN-123) EBV remains dormant in B-cells are may trigger reactivation in immunocompromised patients. Post-transplant lymphoproliferative disorders are a group of conditions involving proliferation of lymphoid or plasmacytic cells; in this setting they typically harbor EBV.
25. A 49-year-old man presents to the emergency department with a history of profound fatigue, malaise, and generalized weakness. This morning, his family was concerned because he also developed depressed level of consciousness. Blood work demonstrates that his white blood cell count is profoundly elevated at 230,000 cells/µL, with a hemoglobin concentration of 9.0 g/dL, platelets 69,000/µL, and blast cells observed on the blood smear. The hematology service makes a diagnosis of acute myelogenous leukemia and wants him to receive chemotherapy as soon as possible. You are asked to assess his depressed level of consciousness. He opens his eyes to voice, intermittently follow one-step commands, moves all four limbs with equal strength, and makes only incomprehensive sounds. Apart from chemotherapy, urgent treatment of this patient requires:
A. Antibiotics
B. Intrathecal chemotherapy
C. Leukapheresis
D. None of the above
E. All of the above
View Answer
25. Answer C. (MN-123) This patient has hyperviscosity syndrome. This is a medical emergency that necessitates emergent reduction of the blood viscosity. There is no role for intrathecal chemotherapy at this stage, without evidence of central nervous system leukemia. While the patient is immunocompromised, and could conceivably be septic, there is not enough information provided to conclude that this is the case.
26. A 67-year-old man is admitted to the neuro-hospitalist service because of worsening myasthenia gravis. After treatment with intravenous immunoglobulin, he is improving. On post-admission day 6, he becomes acutely dyspneic with chest discomfort. His oxygen saturation on 5 L of oxygen is 90%. His chest radiographic is unremarkable. His laboratory tests are unremarkable, with the exception that his platelet count is 51,000 per µL. At admission, the value was 212,000 per µL. Which of the following would be appropriate initial therapy for suspected pulmonary thromboembolic disease in this situation?
A. Argatroban
B. Aspirin
C. Clopidogrel
D. Enoxaparin
E. Unfractionated heparin drip titrated to a PTT between 80 and 110 seconds
View Answer
26. Answer A. (MN-123) This patient has heparin-induced thrombocytopenia (HIT). Although not explicitly stated, it would have been standard for this patient to have received prophylactic pharmacologic venous thromboembolism prophylaxis. Enoxaparin is not appropriate therapy for a pulmonary embolism in the context of HIT. Fondaparinux or a direct thrombin inhibitor, such as argatroban or bivalirudin, should be considered.
27. A 73-year-old man with a history of atrial fibrillation, treated with beta-blockade for rate control and dabigatran for stroke prophylaxis presents acutely with aphasia and right hemiparesis. A CT scan demonstrates intracerebral hemorrhage, approximately 35 mL in volume, arising in the left putamen. A CT angiogram reveals a positive spot sign. The most effective treatment aimed at limiting further hematoma expansion is:
A. 4-factor prothrombin complex concentrate
B. Andexanet alfa
C. Cryoprecipitate
D. Fresh frozen plasma
E. Idarucizumab
View Answer
27. Answer E. (MN-123) Idarucizumab is a monoclonal antibody that binds and neutralizes dabigatran. Prothrombin complex concentrate and fresh frozen plasma have some efficacy but are less effective at reversal of novel oral anticoagulants. Andexanet alfa is designed to reverse the effects of factor Xa inhibitor drugs such as apixaban and rivaroxaban. Cryoprecipitate is a fibrinogen concentrate that is used to restore fibrinogen levels.
28. Which of the following elements are used to calculate the Child-Pugh score?
A. Albumin level, ascites, encephalopathy, serum sodium level
B. Ammonia level, ascites, fibrinogen, serum sodium, international normalized ratio (INR)
C. Bilirubin, albumin level, INR, hematocrit
D. INR, albumin level, bilirubin, ascites, encephalopathy
E. INR, serum creatinine, bilirubin
View Answer
28. Answer D. (MN-124) The Child–Turcotte–Pugh score was designed 30 years ago to predict outcome after surgery for portal hypertension. It is now used to risk stratify disease severity in patients with cirrhotic hepatic encephalopathy. Sodium (A), hematocrit (C), ammonia (B), and creatinine (E) abnormalities are not consistently involved or correlated with disease severity in cirrhosis and are not components of the score. The MELD score (Model for End-Stage Liver Disease), utilizes serum creatinine and serum bilirubin to predict 3-month mortality.
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