Hematology, Oncology, Endocrinology & Infectious Disease – Full Test

Shawn Egers is 60-year-old male admitted to critical care with decreased level of consciousness from intracranial hemorrhage.  Family believes he took an anticoagulant this morning but they do not know which one.  Complete the following table. (4 marks)

You admit Rick Lefebvre, a 56-year-old patient with bleeding due to warfarin-induced coagulopathy. You are going to give Vitamin K.

a) State the onset of action of orally administered Vitamin K compared to intravenous administration. (1 mark)

b) Explain why Vitamin K must be given over at least 30 minutes when given intravenously. (1 mark)

A 61-year-old man, Ferdinand Oliviero, with streptococcal toxic shock syndrome and refractory septic shock is being considered for adjunctive intravenous immunoglobulin (IVIG) therapy. The team is reviewing the potential harms of this treatment prior to administration.

a) List TWO potential toxicities associated with IVIG use. (2 marks)

Yeva Dagmar is a 38-year-old woman admitted to the ICU with fever, thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. The team is considering thrombotic thrombocytopenic purpura (TTP) versus disseminated intravascular coagulation (DIC) as competing diagnoses. Using the terms high, low, normal, many, or some, complete the following comparison for each laboratory parameter.

a) Compare TTP versus DIC for: platelets, LDH, INR, schistocytes, and bilirubin. (5 marks)

Selena Estevan is a 28-year-old graduate student admitted to the ICU with high work of breathing, worsening acute liver injury, and hypotension. She is maintained on high-flow nasal cannula at FiO2 0.4 and 60 L/min with SpO2 99% and RR 26 breaths per minute. Peak temperature is 39.2°C. Investigations reveal leukocytosis of 22,000, ferritin 45,000 µg/L, and negative blood and urine cultures at 72 hours. There is no rash, sputum production, urinary symptoms, or rigors. Bone marrow biopsy is pending.

a) State the most likely diagnosis. (1 mark)

b) State EXACTLY TWO treatments for the most likely diagnosis. (2 marks)

c) State ONE specific complication of initiating empiric treatment from b) before bone marrow biopsy results are available, and state whether you would initiate treatment now. (2 marks)

d) List EXACTLY TWO diagnoses on the differential if the most likely diagnosis is ruled out by bone marrow biopsy. (1 mark)

Heather O’Leary is a 61-year-old woman with relapsed multiple myeloma who received her first full dose of teclistamab after completing ramp-up dosing. She was discharged following ramp-up with no cytokine release syndrome (CRS) events. On day 10 she is brought to the ICU by her family with progressive confusion, word-finding difficulty, and difficulty following commands. She has no fever. Neuroimaging shows diffuse cerebral edema.

a) State the diagnosis and describe its typical temporal relationship to CRS. (2 marks)

b) State the FIRST-LINE treatment for ICANS and the treatment for severe or refractory ICANS. (2 marks)

c) State ONE pre-existing patient factor this guideline identifies as increasing the risk for ICANS. (1 mark)

Pernilla Bhatt is a 58-year-old woman on day 4 following severe TBI with a small subdural hemorrhage on repeat CT with equivocal extension managed conservatively. She develops sudden hypoxemia and tachycardia. CT pulmonary angiogram confirms bilateral pulmonary emboli with RV/LV ratio 1.3 and echo shows RV dilatation with preserved systolic blood pressure at 101/59 mmHg. A lower limb Doppler confirms an extensive proximal DVT. Troponin is mildly elevated. Neurosurgery recommends against anti-coagulation pending follow up CT head in 72 hours

a) State the classification of this PE based on the findings described. (1 mark)

b) State the MOST APPROPRIATE management option for the pulmonary embolism at this moment (1 mark)

c) Describe your mitigation strategy to prevent future hemodynamic collapse in light of the DVT and echocardiographic findings (1 mark)

d) Pernilla develops worsening hypotension and lactate rises to 5mmol/L. List THREE management strategies and identify the preferred option with a star (3 marks)

Soraya Lindqvist is a 44-year-old woman in the ICU for 10 days with presumed sepsis from pneumonia, on broad-spectrum antibiotics with no growth on repeat cultures. She has persistent fever 39.2°C, worsening pancytopenia (Hgb 76, WBC 1.8, platelets 32), ferritin 18,400 µg/L, triglycerides 4.8 mmol/L, fibrinogen 1.1 g/L, and splenomegaly on imaging. AST/ALT are elevated.

a) State the diagnosis most consistent with this combination of findings. (1 mark)

b) List three diagnostic criteria from the data provided that support this diagnosis. (3 marks)

c) State the single test that would help identify a triggering infection specific to this syndrome. (1 mark)

d) State the first-line treatment for this syndrome. (1 mark)

Brett Fraser is a 66-year-old male admitted post cardiac surgery, complicated by post-operative bleeding and mediastinal dehiscence.  An intra-aortic balloon pump had been in place for the first five days postoperatively.  The patient is currently anuric and on continuous renal replacement therapy with heparin pre-filter at 600 units/hour. A pulmonary artery catheter is in place and the patient is receiving milrinone at 0.5 mcg/kg/min.  The patient is also on dalteparin 5000 units daily. Platelet counts are shown below.

There are two major tests available for the diagnosis of HIT.  Describe the two tests including which has the highest specificity, which has the highest sensitivity and which test you would order as an initial screening test (4 marks)

A scoring system for pretest probability of HIT has been developed, known as 4Ts.  List four components of this scoring system (4 marks)

Assume very high clinical suspicion for HIT. List two alternative anticoagulation strategies for continuous renal replacement system (2 marks)

Indicate what monitoring, if any, is required for your chosen anticoagulation strategies (2 marks)

In addition to the heparin that was being given intravenously for PRISMA anticoagulation, List all other heparin sources that this patient has that must be discontinued (2 marks)

Hugh Quincy is 64-year-old man admitted to ICU with septic shock from pneumonia. Over the first 48 hours he receives 5 L crystalloid and is on norepinephrine 0.18 µg/kg/min with MAP 67 mmHg, HR 112 bpm. Lactate has improved from 5.2 to 2.1 mmol/L and urine output is 0.6 mL/kg/hr. He is mechanically ventilated on VC mode (Vt 420 mL, RR 22, PEEP 8 cmH₂O, FiO₂ 0.4, plateau pressure 24 cmH₂O). ABG shows pH 7.36, PaCO₂ 41 mmHg, PaO₂ 92 mmHg. He is receiving piperacillin–tazobactam, vancomycin, and prophylactic heparin 5000 units SC BID. There is no active bleeding.

His platelet count has fallen from 210 ×10⁹/L on admission to 58 ×10⁹/L on day 3. Hb is 92 g/L (down from 108), WBC 18 ×10⁹/L, creatinine 165 µmol/L. INR is 1.6 and fibrinogen 1.4 g/L. Peripheral smear shows occasional schistocytes (<1%). Over the past 24 hours, vasopressor requirements have been stable.

Rank the following etiologies of thrombocytopenia in terms of likelihood: Heparin-Induced Thrombocytopenia, Idiopathic/immune thrombocytopenia purpura, disseminated intravascular coagulopathy, thrombotic thrombocytopenia purpura (4 marks)

List TWO features of the clinical story that reduce the probability of HIT (2 marks)

List TWO situations where platelet transfusion would be indicated at a count of 58 x 10⁹/L (2 marks)

You suspect Desire Michaels, a 46-year-old female patient has developed TRALI because they have developed acute lung injury within 6 hours of completion of transfusion. There are no other risk factors for ALI and there is no evidence of volume overload.

Describe your principles of management (3 marks)

State whether steroids are indicated (Yes or No) (1 mark)

Fumi Mireille is a 34-year-old woman with no significant medical history is admitted to the ICU for altered mental status, seizures, and hypoxemia requiring intubation (ventilator settings: FiO2 60%, PEEP 8 cm H2O, tidal volume 6 mL/kg, respiratory rate 18/min). She has petechiae on her arms and legs and a history of fatigue over the past week. Labs reveal hemoglobin of 65, platelet count of 12, LDH 900 U/L, creatinine 180 mmol/L, Peripheral smear shows schistocytes. Vitals are BP 95/60 mmHg (on norepinephrine 0.05 µg/kg/min), HR 110 bpm, and SpO2 95%.

Provide the most likely diagnosis (1 mark)

List THREE alternative etiologies where schistocytes are commonly noted (3 marks)

Provide the TWO most important therapies required immediately (2 marks)

Given Fumi has a fever and platelet count <20, articulate if you would transfuse platelets (yes/no) with a brief explanation (2 marks)

Rebecca Young is a 58-year-old woman with diabetes and chronic kidney disease (GFR 30 mL/min) is admitted to the ICU for septic shock secondary to pyelonephritis. She is treated with broad-spectrum antibiotics, including piperacillin-tazobactam. On day 5, she develops massive hemoptysis requiring intubation (ventilator settings: FiO2 100%, PEEP 10 cm H2O, tidal volume 6 mL/kg, respiratory rate 20/min). Her platelet count decreases from 180 on admission to 8. Vitals include BP 85/55 mmHg (on norepinephrine 0.2 µg/kg/min and vasopressin 0.03 units/min), HR 120 bpm, and SpO2 90%. Coagulation studies show normal PT/INR and fibrinogen, and a peripheral smear reveals no schistocytes.

Provide the MOST LIKELY cause of thrombocytopenia (1 mark)

Provide TWO immediate management priorities (2 marks)

Describe the impact of chronic kidney disease on platelets (1 mark)

Louis Marconi is a 62-year-old man recently diagnosed diffuse large B-cell lymphoma admitted to the ICU for worsening confusion, fever, and hypotension. He began R-CHOP chemotherapy two days ago. His medical history includes hypertension, gout, and chronic kidney disease (GFR 40 mL/min). On admission, his vitals are BP 85/50 mmHg (on norepinephrine 0.1 µg/kg/min), HR 120 bpm, RR 25/min, SpO2 96% on FiO2 50%, and temperature 38.8°C. He is intubated for airway protection and placed on ventilator settings: FiO2 50%, PEEP 5 cm H2O, tidal volume 6 mL/kg, respiratory rate 18/min. Lab results are as follows:

1. Hematology WBC 12 Hb 100 Plt 150
2. Chemistry Na 137 K 6.5 TCO2 18 Mg 0.88 P 7.2 Ca 4.2 Cr 220 Lactate 2.8

Blood cultures are pending, and a chest X-ray shows mild pulmonary edema without consolidations. Despite initial fluid resuscitation, the patient remains hypotensive and oliguric with a urine output of 10 mL/hour. No overt source of infection is identified on exam.

Provide the MOST LIKELY diagnosis (1 mark)

Provide TWO immediate management priorities (2 marks)

List ONE additional laboratory investigation you would order to confirm the diagnosis (1 mark)

Jhamak Koirala is a 58-year-old male with a history of cirrhosis secondary to non-alcoholic steatohepatitis (NASH) undergoes an orthotopic liver transplant. Pre-transplant health status was notable for RSVP estimated at 24mm Hg by transthoracic echocardiography, portal hypertension with ascites and splenomegaly.  On postoperative day 1, he develops worsening hypotension and increasing abdominal distension. Jackson-Pratt abdominal drain output increases from 20mL/h of serous drainage to 150mL in one hour of sanguinous output. His vitals are BP 85/55 mmHg (on norepinephrine 0.2 µg/kg/min and vasopressin 0.04 units/min), HR 115 bpm, RR 20/min, and SpO2 94% on FiO2 40%. He remains intubated on ventilator settings: FiO2 40%, PEEP 8 cm H2O, tidal volume 6 mL/kg, respiratory rate 16/min. Labs reveal the following abnormalities:

1. Hematology Hb: 70 g/dL (baseline 10 g/dL) Plt 45 INR: 2.5 Fibrinogen: 0.9
2. Chemistry Lactate: 6.0 mmol/L Cr: 130 AST: 1200 U/L ALT: 800 U/L

The patient receives 4 units of packed red blood cells (PRBCs) and develops new hypoxemia and a fever (39.0°C). Repeat chest X-ray shows diffuse bilateral infiltrates, and his oxygenation worsens despite increased ventilator support. His urine output has also decreased to 10 mL/hour.

In addition to the packed red blood cells, list THREE blood products indicated for transfusion (2 marks)

Identify the MOST LIKELY transfusion reaction (1 mark)

Describe THREE management priorities for the transfusion reaction (3 marks)

Indicate whether diuresis and corticosteroids are indicated with Yes or No (2 mark)

Justin Marks is a 38-year-old male with sickle cell anemia presenting with mesenteric ischemia and shock to the intensive care unit.  You cover a community ICU with 7 ventilated beds. The nearest referral centre is 2 hours away. A pulmonary artery catheter is inserted through a 7Fr introducer in the right internal jugular vein and a left femoral triple lumen central venous catheter was also placed. Admission hemoglobin was 67g/L.

Describe the shape of the oxy-hemoglobin dissociation curve (1 mark)

Provide the pO₂ corresponding to the following: SpO₂ 75% SpO₂ 90% p50 (3 marks)

You are in discussion with a tertiary care centre with a sickle cell unit. Describe whether a difference in tissue oxygenation would be expected if blood were transfused from your smaller rural site with a smaller blood bank, as compared to the tertiary centre with justification (2 marks).

Simultaneous blood gas sampling from the internal jugular introducer and femoral venous lines are drawn with SpO₂ of 65% and 80% respectively. The bedside nurse recommends addition of cardiac inotrope given low SvO2. Provide your response with justification (2 marks)

Anna Luiz is a 20-year-old female with severe aplastic anemia receives a 10/10 matched unrelated donor (MUD) allogeneic stem cell transplant with intent to cure. She develops progressive respiratory failure and requires intubation despite treatment with broad spectrum antibiotics. She is day +56 post MUD.

a) List EXACTLY THREE of the most common complications post allo-SCT. (3 marks)

b) Name the most common class of infectious organisms post allo-SCT. (1 mark)

c) List EXACTLY TWO specific potential pathogens in each of THREE organism classes. (3 marks total: bacteria, viral, fungal – 1 mark per class)

You are assessing Samuel de Vos, a 56 year-old male with acute lymphocytic leukemia who began chemotherapy induction two days ago. The nurse called CCOT because she witnessed a brief seizure that was self-limited.   He is complaining of fatigue and muscle cramps.  He is tachycardic (sinus rate 126) with a normal blood pressure.  Urine output has decreased over the previous 24 hours to < 20 mL/hour.

Acute laboratory investigations are as follows:
Hb 148 WBC 68.5 Platelets 23
Na⁺ 146 K⁺ 7.2 Cl^– 108 HCO₃^– 23 Lactate 3.2
Urea 17 Creatinine 289 Mg⁺⁺  1.9 Ca⁺⁺  1.38 (Albumin 24) P  3.9
Urate 246,383 (normal < 420)

Provide the most likely diagnosis (1 mark)

Describe the pathophysiology of the increased urate level (2 marks)

List four principles of therapy over the next 6 hours (4 marks)

Provide one pharmacologic prophylaxis indicated for this diagnosis.  Justify your answer (2 marks)

Taylor Greene is a 50-year-old female who presented to the emergency department two days ago with several days of confusion and decreased level of consciousness.  One week prior she developed rhinorrhea and cough with temperature of 38.2^oC. She has become increasingly lethargic over the past three days. Medical history is significant for diabetes mellitus type II and giant cell arteritis treated with empagliflozin, insulin and prednisone.  Initial vitals were:  BP 80/40 HR 130 SpO₂ 94% on room air RR 22 T 38.1^oC.

Ms. Greene received 4L of Ringer’s Lactate, is being treated with norepinephrine 0.4mcg/kg/m, vasopressin 2.4u/h and epinephrine 0.3mcg/kg/m. Urine output is 500mL/24h.  She was treated with imipenem and vancomycin. Chest is clear to auscultation, heart sounds are clear.  Extremities are warm and well perfused.  Neurologic examination reveals symmetric and reactive pupils bilaterally with globally reduced tone.  GCS is 5T. She is not cooperative for a detailed neurologic examination. POCUS reveals hyperdynamic left ventricle with no evidence of right ventricular overload or dysfunction.  There is no pericardial effusion.  Blood, urine, sputum and cerebrospinal fluid cultures were all negative.  Urine legionella antigen was negative.  WBC is 10 Hb 125 Plt 453.  Lactate is 12.

Outline the MOST LIKELY diagnosis (1 mark)

Provide FOUR alternative diagnoses for refractory hypotension and shock (4 marks)

Describe five laboratory abnormalities associated with your most likely diagnosis (5 marks)

Provide one management strategy for the most likely diagnosis (1 mark)

Olive Ewart is a 70-year-old female with hypothyroidism treated intermittently with levothyroxine and paroxysmal atrial fibrillation treated with digoxin admitted to the Cardiac Surgical Intensive Care Unit following Type A aortic dissection repair with total arch replacement under circulatory arrest. Surgery was three days ago. Extubation was delayed due to depressed level of consciousness. She is currently drowsy. Vital reveal temperature of 31°C, heart rate paced at 70bpm with underlying junctional bradycardia at 40bpm), BP 80/50 on norepinephrine 0.2 mcg/kg/min. Labs reveal TSH >100 mIU/L, free T4 <0.3 ng/dL, Na+ 120 mmol/L, and glucose 3.6.

List THREE immediate steps in management and provide a BRIEF justification (6 marks)

List THREE etiologies of hypothermia, excluding myxedema coma and accidental/environmental (3 marks)

Cathy Galda is a 65-year-old female with type 1 diabetes on canagliflozin and congestive heart failure with preserved ejection fraction presenting with nausea, abdominal pain, and dyspnea. She is afebrile, BP 110/70, HR 100, RR 30, SpO2 98%. Labs: glucose 12 mmol/L, Na+ 134 mmol/L, K+ 5.2 mmol/L, bicarbonate 14 mmol/L, pH 7.25, troponin 200 and serum ketones positive.

List THREE unique features of euglycemic diabetic ketoacidosis (3 marks)

Provide TWO management strategies for Cathy (2 marks)

List THREE precipitating factors for euglycemic DKA and star the MOST LIKELY in this scenario (4 marks)

Andre Burress is a 48-year-old male presenting with fatigue, unintentional weight loss and seizure. He is intubated in the Emergency Department and transferred to your intensive care unit. Medical history is insignificant. Current vitals: BP 90/55 (phenylephrine 200mcg/m, vasopressin 0.04IU/kg/h), HR 130 sinus tachycardia, VCV 400mL PEEP 8cm H2O FiO2 0.5 f 20, T 38.5. POCUS reveals a hyperdynamic heart with LVOT gradient 30mm Hg, A-line pattern in lungs, IVC 1.8cm with respiratory variability of 5%. CT head is normal. Labs show the following:

1. WBC 12 Hb 130 Plt 230
2. Chemistry: Na 118 K 4 Cl 95 TCO2 20. Serum osmolality 270mOsm/kg. Lactate 4
3. Endocrine: Free T4 15. Urine serum metanephrines pending.

Provide the MOST likely diagnosis (1 mark)

Provide TWO initial steps in management (2 marks)

List TWO etiologies for seizure in this patient (2 marks)

Jill Carmichael is a 27-year-old female with insulin-dependent diabetes presents with a 48-hour illness characterized by nausea, vomiting and shortness of breath. She has been unable to eat or drink and has not been taking her insulin. On examination: heart rate 137 beats/min, respiratory rate 36 breaths/min, O2 saturation 99% on room air, blood pressure 92/34 mmHg. She weighs 80 kg, her blood sugar level is 42 mmol/L and potassium is 3.4mmol/L.

a) State the diagnosis. (1 mark)

b) List EXACTLY TWO diagnostic criteria for this illness. (2 marks)

c) Describe the pathogenesis of this illness in EXACTLY THREE points. (3 marks)

d) List the THREE MOST ESSENTIAL initial management orders. (3 marks)

Sofia Romano is a 44-year-old woman admitted to the ICU following subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm, treated by surgical clipping via craniotomy. On day 2 her plasma sodium falls to 126 mmol/L with urine sodium 85 mmol/L, urine osmolality 480 mOsm/kg, and a euvolaemic clinical examination. On day 7, while receiving fluid restriction for presumed SIADH, she develops acute confusion and clinical signs of volume depletion with worsening cerebral vasospasm. On day 10, following re-exploration of the clip site with hypothalamic retraction, she develops polyuria at 450 mL/hr with plasma sodium rising to 155 mmol/L and urine osmolality 88 mOsm/kg.

a) State the diagnosis on day 2 and the initial management. (2 marks)

b) Explain the diagnostic error by day 7 and state the correct diagnosis. (2 marks)

c) State the diagnosis on day 10 given the urine findings, identify the area of the brain injured during surgery, and state the treatment. (2 marks)

d) List TWO other common causes of polyuria in critically ill patients aside from the diagnosis in c). (1 mark)

Rebecca Amalie is a 45-year-old woman presenting with hypertensive crisis (BP 220/140 mmHg), acute cardiogenic pulmonary edema, LVEF of 20% with apical ballooning on transthoracic echocardiography, and a CT-confirmed adrenal mass consistent with pheochromocytoma. Two litres of Ringer’s Lactate have been administered cautiously given the pulmonary edema. The team is discussing pharmacologic management of her hypertensive crisis.

a) Briefly explain the risk of administering IV labetalol as first-line therapy in this patient. (1 mark)

b) Phenoxybenzamine is administered and the patient develops cardiovascular collapse and cardiac arrest. List EXACTLY THREE physiologic mechanisms that explain this collapse. (3 marks)

Thandiwe Moyo is a 58-year-old woman with type 2 diabetes who presents obtunded after several days of vomiting and poor oral intake. She is hypotensive at 78/45 mmHg with glucose 62 mmol/L, sodium 148 mmol/L, and effective osmolality 358 mOsm/kg; CT head shows a 2cm left thalamic hemorrhage and an incidental lacunar infarct. Resuscitation begins with Ringer’s lactate per standard HHS volume-replacement protocol. By 5h on the same infusion, glucose is 22 mmol/L, sodium 132 mmol/L, and GCS has fallen from 13 to 10 with a new dilated left pupil.

a) Identify the principal risk of using Ringer’s lactate as the initial resuscitation fluid in this patient. (2 marks)

b) Calculate her effective osmolality at 5h given sodium 132 mmol/L and glucose 22 mmol/L. (2 marks)

c) State the single most appropriate immediate change to her fluid management. (2 marks)

Randolph Lahey is a 56-year-old gentleman admitted to your intensive care unit with confusion, lethargy and depressed level of consciousness followed by seizure. Medical history is significantly for renal transplantation 15 years ago managed initially with cyclosporine then transitioned to tacrolimus. Tacrolimus level is 22ng/mL (normal 5-15). CT head is pending.

Describe THREE neurologic complications of calcineurin inhibitors (3 marks)

Describe TWO other complications of calcineurin inhibitor therapy (2 marks)

3SITES was a trial investigating central line placement. This study complemented CDC and local guidelines around techniques, placement and monitoring for vascular access devices.

Identify the recommended site for a central venous catheter (untunneled) in adults to minimize risk of infection (1 mark)

Explain the optimal management for replacement of central venous catheters in situ for over five days (1 mark)

Ontario Ministry of Health and Long-term Care monitors incidence of catheter related bloodstream infections in hospitals across Ontario and posts this information on the MOH LTC website.  List six other hospital quality assurance/patient safety indicators that are monitored and publicly reported in Ontario (6 marks)

Karl Pullman is a 38-year-old man transferred to the ICU three weeks post heart transplant.  His initial postoperative course was complicated by a urinary tract infection, treated successfully with ciprofloxacin.  He is also known to be MRSA positive. 72 hours ago he developed edema of the legs, along with worsening renal function.  In addition, he has had excruciating unexplained pain in his right leg, which has been worsening.  Doppler/ultrasound studies of the legs have been normal.  Mild erythema was present diffusely in the right leg 12 hours ago, however now the erythema has darkened to a reddish-purple color, and blisters and bullae are present.  On examination his vitals reveal: mild confusion; temperature 39.0°C; blood pressure 85/55 mmHg; heart rate 125 beats/minute; respiratory rate 30 breaths/minute.

Laboratory studies reveal: hemoglobin 85 g/L; WBC 1.2 x109/L; platelets 35 x109/L; BUN 20 mmol/L; creatinine 350 μmol/L; serum sodium 118 mmol/L; serum potassium 6.0 mmol/L; bicarbonate 12 mmol/L.  A leg radiograph is done.  The image is seen below.

Septic shock is suspected. Provide the MOST likely specific diagnosis (1 mark)

Outline the MOST appropriate initial empiric antibiotic regimen following cultures in this patient Justify your answer with a description of the classification of this type of infection and the most likely pathogens involved (4 marks)

Resuscitation is started with intravascular fluids, vasopressor support, ventilatory support and empiric antibiotics.  List one other essential intervention at this time (1 mark)

List THREE causes of blistering or bullous cutaneous lesions aside from the diagnosis presented here (3 marks)

Florence Burridge is a 23-year-old female with sickle cell disease admitted with fever, leukocytosis and hypotension.  Blood cultures are positive for gram positive cocci in pairs.

Provide the most likely diagnosis (1 mark)

You support the patient with intravenous fluids and vasopressors to manage her shock.  List three static physiologic parameters to monitor the adequacy of your resuscitation (3 marks).

Compare vasopressin and norepinephrine based on medication class, half-life and endogenous production location (3 marks)

Victor Bohl is a 24-year-old male admitted with febrile neutropenia and septic shock to the intensive care unit.  Medical history is significant for diffuse large B-cell lymphoma treated with allogeneic stem cell transplant 33 days ago.  He developed hypotension and lactic acidosis refractory to volume optimization prompting admission to critical care.  He endorsed cough productive of dark sputum and facial pain.  Victor was intubated and sedated for shock, treated with empiric imipenem, vancomycin and anidulafungin.  Blood cultures were positive for staphyloccus epidermidis. Examination of the pharynx demonstrates black eschar overlying the palate. Absolute neutrophil count is 0.2.

Identify the most likely pathogen responsible for the upper airway findings (1 mark)

Outline your antimicrobial strategy for this patient (1 mark)

In addition to antibiotics, describe one management strategy for this condition (1 mark)

Liam Callaghan is a post-allogeneic stem cell transplant patient (day +56) worsens and is intubated. Bronchoalveolar lavage reveals Pneumocystis jirovecii pneumonia (PJP).

a) List EXACTLY TWO components of management for this PJP infection. (2 marks)

b) State EXACTLY TWO options for PJP prophylaxis when trimethoprim-sulfamethoxazole (Septra) is not an option. (1 mark)

A 23-year-old man from Syria named Ari Tiphanie is admitted to the ICU with increased work of breathing, a right pleural effusion, and suspected active pulmonary tuberculosis. The team is planning isolation precautions and management.

a) Outline your approach to isolation for this patient including room type, ventilation requirements, and personal protective equipment for ICU personnel. (2 marks)

b) State the criteria for removal of airborne isolation. (1 mark)

c) State the minimum number of air exchanges per hour required in a newly constructed airborne infection isolation room. (1 mark)

Sergei Rosario is a 58-year-old man who uses intravenous drugs presenting with septic shock, GCS 10, SpO2 88% on room air, fever, and bilateral crackles with right lower lobe consolidation. He was treated two weeks prior for left arm cellulitis with cephalexin and has now returned with worsening cellulitis and pneumonia. You suspect hematogenous spread from the skin infection.

a) List the pathogens most likely responsible for the pneumonia in this host. (2 marks)

b) State the antibiotic(s) you would use empirically for MRSA pneumonia and identify the preferred agent. (1 mark)

Sneha Loman is a 63-year-old woman who undergoes elective hemicolectomy for adenocarcinoma and receives antibiotics two months prior for a urinary tract infection. On postoperative day 3 she develops fever, purulent sputum, and a new pulmonary infiltrate on chest X-ray. She has no organ dysfunction and does not require intubation.

a) List SIX specific bacterial pathogens most likely responsible for this hospital-acquired pneumonia. (6 marks)

A 44-year-old woman, Brittany Macdonald, with acute leukemia and prolonged neutropenia develops progressive pulmonary infiltrates and skin nodules with central necrosis. Tissue biopsy is sent and the team is considering empiric antifungal therapy while awaiting results. Potential pathogens include Aspergillus, Mucor/Rhizopus, and Fusarium species.

a) State the first-line antifungal agent for invasive Aspergillus infection. (1 mark)

b) State the first-line antifungal agent for invasive Mucor/Rhizopus infection and ONE alternative agent. (2 marks)

c) State ONE common class of anti-fungal medication without activity against non-aspergillus mold species (1 mark)

Lemuel Sharma is a 61-year-old man with prosthetic valve endocarditis caused by methicillin-resistant Staphylococcus epidermidis. The ID team adds rifampin to his regimen. He is on warfarin for atrial fibrillation, midazolam infusion for sedation, and tacrolimus following a kidney transplant 2 years ago.

a) State the expected change in tacrolimus levels after starting rifampin and the monitoring action required. (2 marks)

b) State the expected effect on warfarin’s anticoagulant activity and the monitoring action required. (2 marks)

c) State one reason rifampin is used despite these interactions in this indication. (1 mark)

Mee Phaophanit is a 60-year-old female post operative day 22 from liver transplantation who remains invasively ventilated due to delirium and aggressive behaviours. Transcranial doppler pulsatility index suggests normal intracranial pressure. MRI shows cortical and subcortical edema without focal lesions. There are minimal changes to temporal lobes. HSV PCR from cerebrospinal fluid is negative.  With sedation liberation, the patient develops unmanageable hiccupping, coughing and vomiting. One episode of opisthotonus was noticed.

Provide the MOST LIKELY microbiologic etiology for the clinical state and the MOST IMPORTANT diagnostic test for confirmation (2 marks)

Tahir Joubert is a 67-year-old man 3 weeks following emergency repair of a ruptured abdominal aortic aneurysm with synthetic graft placement. He has persistent low-grade fever, rising inflammatory markers, and vague back pain. Blood cultures are negative. CT shows fluid and gas adjacent to the graft attributed to normal post-operative changes by the surgical team. He has a history of poorly controlled diabetes and was on pip-tazo and vancomycin for 10 days postoperatively followed by 5 days of fluconazole empirically.

a) State your INVESTIGATIONAL strategy to diagnose an infectious etiology for fever (1 mark)

b) Your investigation in a) demonstrates candida albicans. State the first-line antifungal agent and the minimum duration of therapy for this diagnosis. (2 marks)

c) State why antifungal therapy alone is insufficient for this diagnosis. (1 mark)

d) State one reason prolonged prior antibiotic use is relevant to this presentation. (1 mark)

Franklin Reynolds is a 58-year-old man with septic shock from a community-acquired pneumonia. He is on norepinephrine 0.15 mcg/kg/min with MAP 68 mmHg. PA catheter shows CO 8.4 L/min, CI 4.6 L/min/m², SVR 520 dynes·sec·cm⁻⁵, and ScvO2 82%. Despite this, his lactate is 5.1 mmol/L, he has mottled knees and elbows, and his urine output is 10 mL/hr.

a) State the most accurate characterization of the hemodynamic phenotype present. (1 mark)

b) State two mechanisms at the microvascular or cellular level that account for the discordance between adequate global oxygen delivery and evidence of tissue dysoxia in this patient. (2 marks)

c) State the SSC 2026-recommended lactate target during initial resuscitation and identify one intervention beyond vasopressor titration that addresses the underlying mechanism in (b). (2 marks)

Takoda Mombourquette is a 67-year-old man with ischemic cardiomyopathy on a HeartMate 3 LVAD as bridge-to-transplant who presents with septic shock. He has a history of a hospitalization 4 months ago for a Pseudomonas aeruginosa wound infection treated with meropenem, with documented susceptibility. He now has purulent discharge at his LVAD driveline exit site, fever of 39.6°C, WBC 22 × 10⁹/L, lactate 3.8 mmol/L, creatinine 298 µmol/L (baseline 120), and ALT 340 U/L. He has a documented severe penicillin allergy (anaphylaxis) and a previous history of Candida albicans fungemia during his index LVAD implant hospitalization.

a) State why piperacillin-tazobactam is an inadequate empiric regimen for this patient, providing two specific reasons. (2 marks)

b) State your empiric antibiotic choice (2 marks)

c) State the indication for empiric antifungal therapy in this patient and name the preferred agent class, given his renal and hepatic dysfunction. (2 marks)

d) State the primary reason definitive source control is not immediately achievable in this patient, and name one local infection control measure that should be initiated. (2 marks)

Domingo Fuertes is a 41-year-old male admitted with necrotizing pancreatitis from an infected pancreatic pseudocyst.  Describe four microvascular effects from sepsis (4 marks)

Antonio Montalcino is a 62-year-old gentleman post-admission day eleven to the critical care unit. He was admitted for necrotizing pancreatitis and respiratory failure from ARDS. He developed anuric acute kidney injury and was placed on continuous renal replacement therapy. He develops increased right middle lung field opacity on chest x-ray with new purulent secretions.

List TWO risk factors for multi-drug resistance ventilator associated pneumonia in THIS patient (2 marks)

Pseudomonas aeruginosa is isolated with resistance to ceftazidime, piperacillin-tazobactam, imipenem-cilastin, meropenem, fluroquinolones, and gentamicin. List TWO antibiotic options available in Canada that could be used for treatment (2 marks)

Antonio improves clinically within seventy-two hours of antimicrobial initiation. Provide the duration of treatment you would order (1 mark)

You are caring for Caleb Evonne, a 35-year-old male with traumatic brain injury admitted to the intensive care unit fourteen days ago.  He remains ventilator dependent with subclavian central venous catheter, left radial arterial catheter and urinary catheter.  Over the past day his clinical status has worsened with fever, tachycardia, increased vasopressor doses to maintain mean arterial blood pressure and lactate elevation to 4 despite optimal fluid management.  Central line associated blood stream infection is suspected.  Your unit antibiogram is significant for elevated prevalence of methicillin-resistant Staphylococcus aureus.

List THREE agents to cover for MRSA line infection (3 marks)

List THREE risk factors for multidrug resistant gram-negative bacilli infection (3 marks)

List ONE risk factor for suspected catheter-related candidemia (1 mark)

Mathieu Sherley is a 56-year-old male is admitted to critical care with Covid-19 pneumonia.  After developing acute respiratory distress syndrome he was treated with prone positioning, dexamethasone and continuous renal replacement therapy for oliguric acute kidney injury.  10 days after admission he worsens clinically with increasing minute ventilation, fraction of inspired oxygen and purulent secretions with left lower lobe consolidation on chest x-ray and point of care ultrasound.  Blood pressure is maintained with norepinephrine 0.05mcg/kg/m and lactate if 0.7.

DEFINE ventilator associated pneumonia (2 marks)

List THREE potential organisms responsible for causing VAP (3 marks)

List TWO strategies shown to decrease the risk of ventilator associated pneumonia (2 marks)

Kyler Snow is a 30-year-old male who injects drugs is prescribed linezolid for multiorgan dysfunction and invasive life support. Describe the mechanism of action (1 mark)

List two bacteria for which this medication is indicated (2 marks)

Identify one drug with severe complications resulting from interaction with linezolid.  Identify the medication and complication (2 marks)

Kinsley Gilbert is a 22-year-old university student who presents with two days of fever and feeling unwell.  There is no nuchal rigidity, headache, photophobia or neck stiffness.  Abdomen is soft and nontender. There are find crackles at both lung bases.  The rash is pictured below.

Provide the most likely diagnosis (1 mark)

Describe the most likely gram stain result, if positive blood cultures are found (1 mark)

Provide the causative organism (1 mark)

Danielle Easton is a 48-year-old female admitted with fever, hypotension and necrotizing soft tissue infection.  Define septic shock (2 marks)

Define organ dysfunction in the context of sepsis (2 marks)

Provide three criteria for qSOFA (3 marks)