Self-Evaluation Process2010 Update in Hospital-Based

Internal MedicineModule A0-K Version 10-

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ConfidentialOnly for use at the ACP SWAN Learning Session held October 14-15, 2010.

Question 1

© 2010 ABIM

Which of the following is the most specific diagnostic test forlatent tuberculosis?

(A) Interferon-gamma assay (B) Mantoux test (PPD, 5 TU) with specific cutoffs for

different populations (C) Radiograph of the chest (D) Sputum stain and culture for acid-fast bacilli (E) Tine test

Question 1

Correct Answer: (A) Interferon-gamma Assay

Question 1

Interferon-gamma Assay:• Measurement of interferon-γ release by T

lymphocytes specific for M. tuberculosis. • Can only occur in patients exposed to MTb.• No false positives in those who have received BCG

vaccine.

Question 1

Mantoux test (PPD)• Higher possibility of both false positives and false

negatives.

Question 1 5 mm or more is positive in

• HIV-positive person

• Recent contacts of TB case

• Persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB

• Patients with organ transplants and other immunosuppressed patients

10 mm or more is positive in

• Recent arrivals (less than 5 years) from high-prevalence countries

• Injection drug users

• Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.)

• Mycobacteriology lab personnel

• Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc.)

• Children less than 4 years of age, or children and adolescents exposed to adults in high-risk categories

15 mm or more is positive in

• Persons with no known risk factors for TB

• (Note: Targeted skin testing programs should only be conducted among high-risk groups)

A tuberculin test conversion is defined as an increase of 10 mm or more within a 2-year period, regardless of age.

Question 1

Rapid Molecular Detection of Tuberculosis and Rifampin Resistance

N Engl J Med 2010; 363:1005-1015September 9, 2010

• Samples from patients with suspected TB were assayed for TB and drug resistance with several different techniques.

• An automated molecular test showed a sensitivity of 98% in smear-positive, culture-positive samples and a sensitivity of 72–90% in smear-negative, culture-positive samples, and it identified rifampin resistance >97% of the time.

Question 2

© 2010 ABIM

A 62-year-old woman who has chronic exertional dyspneais hospitalized with an exacerbation of chronic obstructivepulmonary disease (COPD). She smoked cigarettes for manyyears but recently quit. She does not have a history of asthma,

cystic fibrosis, or alpha1-antitrypsin deficiency. Currentmedications are an inhaled combination corticosteroid–long-acting beta-adrenergic blocking agent,inhaled ipratropium bromide, and oral mucolytics (only in thewinter).

BMI is 22. Temperature is normal, respirations are 20 per

minute, and blood pressure is 124/70 mm Hg. FEV1 is 60% of

predicted. Arterial blood PO2 is 40 mm Hg, PCO2 is 60 mm Hg,and pH is 7.42.

Question 2 - continued

© 2010 ABIM

Which of the following interventions has been shown to reducethe rate of decline in pulmonary function in patients who haveCOPD?

(A) Smoking cessation (B) Oral mucolytics (C) Inhaled ipratropium (D) Inhaled combination corticosteroid–long-acting

beta-adrenergic blocking agent

Question 2

Correct answer: (A) Smoking Cessation

Question 2

The Lung Health Study• Participants were followed up to 14.5 years and data

for mortality rates were analyzed in terms of smoking habits.

• Smoking cessation reduced not only deaths from COPD but also all-cause mortality.

Reduced rate of decline of lung function has been demonstrated with smoking cessation in a number of studies.

Question 2

No medication has been shown to reduce the progressive decline in lung function in COPD.

Oral mucolytics may be beneficial in patients with viscous sputum, but have no long term benefit.

Bronchodilators do reduce symptoms and hospitalizations, as well as overall health status.

Inhaled corticosteroids have a limited role in the management of COPD and particularly in the elderly come with undesirable side effects.

Question 3

© 2010 ABIM

A 74-year-old man who is hospitalized with stage IV non–smallcell lung cancer has had progressively worsening shortness ofbreath for three weeks. You perform a therapeutic thoracentesisof a large right-sided pleural effusion.

In addition to verbally confirming the patient's identity and thesite of the procedure, which of the following elements has theJoint Commission identified as being a critical component of"time out" in the Universal Protocol for invasive procedures?

(A) The patient's blood pressure (B) The patient's blood type (C) The patient's oxygen saturation level (D) The type of procedure (E) The follow-up plan after the procedure

Question 3

Correct Answer: (D) The type of procedure.

Question 3

The Joint Commission’s 2009 National Patient Safety Goals for Hospitals

Improve the accuracy of patient identification

Improve the effectiveness of communication among caregivers

Improve the safety of using medications

Reduce the risk of health care–associated infections

Accurately and completely reconcile medications across the continuum of care

Reduce the risk of patient harm resulting from falls

Encourage patients’ active involvement in their own care as a patient safety strategy

Identify safety risks inherent in the organization’s patient population

Improve recognition and response to changes in a patient’s condition

Universal Protocol: Conducting a pre-procedure verification process, marking the procedure site, performing a time-out

Question 3

Pre-procedure “time out” The Joint Commission Board of Commissioners

originally approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ in July 2003, and it became effective July 1, 2004 for all accredited hospitals, ambulatory care and office-based surgery facilities.

Question 4

© 2010 ABIM

A 44-year-old woman comes to the emergency departmentbecause of nonexertional syncope of several seconds durationduring her child's birthday party at home. Before this episode,the patient was pale, felt warm, and had nausea. She had noheadache, palpitations, dyspnea, or chest pain. She was lucidon waking, and experienced no bowel or bladder incontinence.Medical history is significant for hypertension. Family history isunremarkable. Her only current medication is chlorthalidone(25 mg daily).

Question 4 - continued

© 2010 ABIM

Temperature is 35.8 C (98.3 F), pulse rate is 72 per minute, respirations are 14 per minute, and blood pressure is 132/74 mm Hg while supine and 118/70 mm Hg while standing.Cardiopulmonary and neurologic examinations are normal, as arecomplete blood count, serum electrolytes, and electrocardiogram.

Which of the following should you do next?

(A) Discharge the patient without further testing (B) Order Duplex ultrasonography of the carotid arteries (C) Order contrast-enhanced computed tomography of the

head (D) Admit for observation and overnight telemetry monitoring

Question 4

Correct Answer: (A) Discharge the patient without further testing.

Question 4

Attempt to stratify risk for arrhythmia or sudden death.

Several recent studies have tried and failed to define prediction rules with sufficient sensitivity to detect life-threatening causes. While no rule has been validated for widespread use, the literature has identified several factors associated with a significantly increased risk of adverse events.

Question 4

Risk Factors for Short-Term Adverse Outcomes from Syncope (American College of Emergency Physicians)

• Abnormal ECG

• Acute ischemia

• New changes on ECG

• Any rhythm other than sinus

• Significant conduction abnormalities

• Hematocrit <30%

• History of heart failure, coronary artery disease, or structural heart disease

• Older age

Question 4

Other options were…• Carotid Duplex• CT Head• Admit for OBS and tele overnight.

Question 5

© 2010 ABIM

A 72-year-old man who has severe chronic obstructive pulmonarydisease was intubated by the paramedics and brought to theemergency department because of respiratory distress. Both hisadvance directive and hospital records indicate that the patientdid not want to be intubated. The patient's son, who quit his joband moved in with his father to be his sole caregiver, states thathis father recently changed his mind and would want the use of aventilator, even if that treatment were to become permanent.

Which of the following should you do?

(A) Follow the written documents and extubate the patient and provide comfort care measures

(B) Follow the son's verbal updates of his father's wishes and continue with mechanical ventilation

(C) Request an ethics consultation

Question 5

Correct Answer: (C) Request an ethics consultation.

Question 5

DNR/DNI• To be honored as per the patient record.• Open communication with patients and family about

the decision.• Must be wary of conflict of interest in family members

who may stand to benefit when the patient’s best interest or expressed wishes are not followed.

Question 6

© 2010 ABIM

A ten-year-old hospital medicine service with increased patientvolume demand must implement new electronic health records,computerized physician order entry, medication reconciliationcompliance, and JCAHO-mandated institutional adjustments.Additionally, the emergency department has introduced a "no divert" policy. A new well-trained manager provided by thehospital is trying to apply industrial engineering techniques.Several physicians have left the group, and the hospital ishaving difficulty attracting high-quality new staff. Hospitalmargins hover at 1%, and the finance department has introduced a total hiring freeze.

Question 6 - continued

© 2010 ABIM

Which of the following is the best management strategy forthis hospital?

(A) Add residents to the workforce (B) Eliminate conference times (C) Flow chart the current process and redesign the work to

eliminate rework, defects, and other waste (D) Schedule morning transfers of care earlier (E) Schedule evening transfers of care later

Question 6

Correct Answer: (C) Flow chart the current process and redesign the work to eliminate rework, defects, and other waste.

Question 6

Martin LA, Neumann CW, Mountford J, Bisognano M, Nolan TW. Increasing Efficiency and Enhancing Value in Health Care: Ways to Achieve Savings in Operating Costs per Year. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2009. (Available on www.IHI.org)

Question 6

Fundamental workflow design can be a positive, sustainable, cost-effective strategy to manage physician workload. Attention must be paid to preserving or enhancing patient, staff, and physician satisfaction as waste is removed in the health care processes.

Question 7

© 2010 ABIM

A previously healthy 61-year-old man comes to the emergencydepartment because of chest pain that began four hours ago.Electrocardiogram reveals 2-cm ST-segment depressions inthe anterior leads.

In this patient, early coronary intervention (within 24 hrs) versusdelayed coronary intervention (longer than 36 hrs) is associatedwith prevention of which of the following at six months?

(A) Recurrent ischemia (B) Myocardial infarction (C) Stroke (D) Death

Question 7

Correct Answer: (A) Recurrent Ischemia.

Question 7

N Engl J Med. 2009 May 21;360(21):2165-75.

Early versus delayed invasive intervention in acute coronary syndromes.

Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP, Faxon DP, Afzal R, Chrolavicius S, Jolly SS, Widimsky P, Avezum A, Rupprecht HJ, Zhu J, Col J, Natarajan MK, Horsman C, Fox KA, Yusuf S; TIMACS Investigators.

Question 7

ACS without ST elevation. Early invasive strategy (within 24 hours)

• No benefit in preventing death, MI, or stroke over delayed intervention (median time 50 hours).

• Modest benefit in decreasing occurrence of recurrent ischemia.

Question 8

© 2010 ABIM

A patient who has type 2 diabetes mellitus and hyperlipidemiais admitted to the intensive care unit with septic shock due topyelonephritis. After adequate fluid resuscitation with Ringer'slactate, temperature is 35.7 C (96.2 F), pulse rate is 118 per minute, respirations are 22 per minute, and bloodpressure is 73/42 mm Hg. Plasma glucose is 162 mg/dL.

Which of the following is most likely to improve mortality inpatients who have septic shock?

(A) Fluid resuscitation with colloid (B) Intensive insulin therapy to maintain euglycemia (C) Vasopressor therapy

Question 8

Correct Answer: (C) Vasopressor Therapy

Question 8

Lessest of Three Evils• Fluid Resuscitation with Colloid

• Increased risk for renal replacement therapy.

Question 8

Lessest of Three Evils• Intensive Insulin Therapy to Maintain Euglycemia

• Initially favored in the peri-op and ICU setting• Numerous studies have failed to show benefit.

Question 8

Lessest of Three Evils• Vasopressor Therapy.

• As a general concept, on occasion simply is required when volume expansion with crystalloid is ineffective in improving tissue perfusion.

Question 9

© 2010 ABIM

A 32-year-old homeless man who was hospitalized with syncope and confusion is transferred to the telemetry unitbecause of hypotension. The patient has a history of substanceabuse and intravenous opiate dependence. Current medicationsare lorazepam, disulfiram, and methadone.

Temperature is 35.8 C (96.4 F), respirations are 10 per minute,and blood pressure is 92/50 mm Hg. Electrocardiogram revealswide complex, variable-focus ventricular tachycardia. Toxicologyscreen is positive for tetrahydrocannabinol, alcohol, opiates, andacetaminophen.

Question 9 - continued

© 2010 ABIM

Which of the following medications is the most likely causeof this patient's arrhythmia?

(A) Alcohol (B) Benzodiazepines (C) Cannabis (D) Methadone (E) Oxycodone

Question 9

Correct Answer: (D) Methadone

Question 9

J Interv Card Electrophysiol. 2010 Jun;28(1):19-22. Epub 2010 Feb 23.

Ventricular arrhythmias in patients treated with methadone for opioid dependence.

Hanon S, Seewald RM, Yang F, Schweitzer P, Rosman J.

Division of Cardiology, Beth Israel Medical Center, University Hospital and Manhattan Campus for the Albert Einstein College of Medicine, New York, NY, USA. shanon@chpnet.org

Question 9

Case report of 12 cases of apparently methadone-induced TDP

Related to Q-T prolongation

Question 9

Other options:• Alcohol• Benzos• Cannabis• Oxycodone

Question 10

© 2010 ABIM

A 64-year-old man is evaluated for worsening knee pain. He has had severe, progressive osteoarthritis for many years and is considering total knee arthroplasty. He has high cholesterol,hypertension, and coronary artery disease. Seven months ago, he underwent drug-eluting stent placement for worsening angina,and he has been asymptomatic since the surgery. Currentmedications are aspirin, clopidogrel, lisinopril, metoprolol, andsimvastatin.

After placement of drug-eluting stents, how long should electivenoncardiac surgery be delayed?

(A) One month (B) Two months (C) Six months (D) One year

Question 10

Correct Answer: (D) One year

Question 10

Dual anti-platelet therapy post-stent: minimum of one month for bare metal stent and minimum of one year for drug-eluting stent.

Elective noncardiac surgery should be delayed for at least 6 weeks following placement of a bare metal stent and for at least 1 year following a drug-eluting stent to allow for completion of the patient’s dual antiplatelet regimen.

No role for routine stress testing or even ECGs post-stent placement, unless change in symptoms, physical exam, or medications.

The risk of stent thrombosis is approximately 0.7% and is increased with the premature discontinuation of dual antiplatelet therapy (aspirin and clopidogrel). Stent

thrombosis is associated with a short-term mortality rate of 40%.

Question 11

© 2010 ABIM

A 53-year-old man is admitted to the hospital for anexacerbation of heart failure. At baseline, he becomes mildlydyspneic with activities of daily living but he is currentlydyspneic even at rest. He also has ischemic cardiomyopathy,with a left ventricular ejection fraction of 25%. Currentmedications are lisinopril, carvedilol, spironolactone,simvastatin, and aspirin.

Estimated central venous pressure is 12 cm H2O. Bibasilarcrackles are audible. Cardiac examination is normal except for

an S3. Bilateral edema (3+) is noted in the lower extremities.Electrocardiogram reveals sinus rhythm and Q waves in theanterior leads. Left bundle branch block is also seen, with QRSduration of 160 msec.

Question 11 - continued

© 2010 ABIM

Which of the following therapeutic interventions is most likelyto improve mortality in this patient?

(A) Digoxin (B) Furosemide (C) Isosorbide mononitrate (D) Cardiac resynchronization therapy

Question 11

Correct Answer: (D) Cardiac Resynchronization Therapy

Question 11

A meta-analysis found a 37% reduction in hospitalizations and a 22% reduction in all-cause mortality in patients with left ventricular systolic dysfunction, prolonged QRS duration, and NYHA class III or IV symptoms who received CRT.

Interventricular conduction delay is common in patients with heart failure and results in poor coordination of ventricular contraction, which contributes to the hemodynamic consequences of chronic left ventricular systolic dysfunction.

Question 11

Question 11

Other morbidity decreasing modalities.

Question 12

© 2010 ABIM

A 40-year-old man who has a history of alcohol dependencecomes to the emergency department because of heart failure.Echocardiography shows a left ventricular ejection fraction of30%.

Which of the following should you do to satisfy the JointCommission's hospital core measures for heart failure for thispatient?

(A) Document the use of or contraindication to ACE inhibitors

(B) Document your discussion of alcohol cessation before discharge

(C) Select an adequate dose of diuretics at discharge (D) Start digoxin to prevent readmission

Question 12

Correct Answer: (A) Document the use of or contraindication to ACE inhibitors.

Question 12

Four Core Measures in HF Admissions:• Measuring and documenting LVEF• ACE/ARB for impaired LVEF• Adult smoking cessation counseling and advice• Discharge instructions

Question 13

© 2010 ABIM

A 65-year-old woman is admitted to the intensive care unitbecause of community-acquired pneumonia. Gram stain of theblood shows gram-positive cocci in pairs. Despite aggressivefluid resuscitation, blood pressure remains 82/40 mm Hg;mean arterial pressure is 54 mm Hg.

Which of the following vasopressor drugs should you ordernext?

(A) Epinephrine (B) Norepinephrine (C) Phenylephrine (D) Vasopressin

Question 13

Correct Answer: (B) Norepinephrine

Question 13

N Engl J Med. 2010 Mar 4;362(9):779-89.

Comparison of dopamine and norepinephrine in the treatment of shock.

De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa C, Brasseur A, Defrance P, Gottignies P, Vincent JL; SOAP II Investigators.

Although there was no significant difference in the rate of death between patients with shock who were treated with dopamine as the first-line vasopressor agent and those who were treated with norepinephrine, the use of dopamine was associated with a greater number of adverse events.

Question 13

Vasopressor therapy with norepinephrine, vasopressin, or dopamine may be necessary when appropriate fluid challenge fails to restore adequate tissue perfusion or during life-threatening hypotension, but no trials have established a single superior approach to handling initial vasopressor choice.

Question 14

© 2010 ABIM

An 85-year-old woman who has osteoporosis is admitted tothe hospital because of midscapular back pain. Neurologicexamination is otherwise normal. Computed tomographyreveals a thoracic vertebral compression fracture in onevertebra, without cord compression.

Compared with placebo, which of the following is the mostlikely outcome of treatment with vertebroplasty forosteoporotic compression fractures? (A) No better pain control (B) Decreased disability (C) Improved physical functioning (D) Improved quality of life (E) Prevention of future osteoporotic fractures

Question 14

Correct answer: (A) No better pain control

Question 14

N Engl J Med 2009; 361:569-579 A Randomized Trial of Vertebroplasty for

Osteoporotic Spinal Fractures Kallmes DF et al. Improvements in pain and pain-related

disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in a control group

Question 15

© 2010 ABIM

A previously healthy 65-year-old man was in a motor vehiclecollision and underwent surgical repair of a hip fracture 24hours ago. After the procedure, the patient receivesacetaminophen and morphine.

The patient is oriented to person but not the situation.Temperature is 38.4 C (101.2 F), pulse rate is 110 per minute,respirations are 18 per minute, and blood pressure is 150/90 mm Hg. The lungs are clear; no signs of infection arepresent. The patient has a mild resting tremor. Physicalexamination is otherwise normal.

Question 15 - continued

© 2010 ABIM

Which of the following is the most important factor to considerin the differential diagnosis?

(A) Alcohol withdrawal (B) Drug-induced delirium from morphine (C) Pneumonia (D) Wound infection

Question 15

Correct answer: (A) Alcohol withdrawal

Question 15

Timing and spectrum of abnormalities is best explained by alcohol withdrawal

8% of the general hospital population at risk for alcohol withdrawal (Drug Alcohol Rev 1995;14:49–54. The incidence of alcohol-related problems and the risk of alcohol withdrawal in a general hospital population. Foy A, Kay J.)

Question 16

© 2010 ABIM

A 28-year-old woman who has a history of cocaine use comesto the emergency department because of chest pain. She isotherwise healthy and has no history of tobacco or alcohol use.Serum creatine kinase and cardiac troponin are normal, as iselectrocardiogram.

Which of the following is most appropriate for this patient?

(A) Treat with aspirin and a benzodiazepine and observe until chest pain resolves

(B) Treat with aspirin and a beta-adrenergic blocking agent and order complete cardiac enzyme studies, then discharge after pain resolves

(C) Treat with aspirin alone and order complete cardiac enzyme studies, then order a stress test

before discharge

Question 16

Correct answer: (A) Treat with aspirin and a benzodiazepine and observe until chest pain resolves

Beta-blockade is contraindicated due to risk for unbalanced alpha-adrenergic activity

Stress testing would be very unlikely to add useful clinical information

Morgan, JP. Cardiovascular complications of cocaine abuse. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.

Question 17

© 2010 ABIM

A correlation exists between the use of proton pump inhibitors (PPIs) and which of the following? 

Clostridium difficile colitis

Hospital-acquired pneumonia

Osteoporosis-related fracture

(A) No No No

(B) Yes Yes No

(C) No Yes Yes

(D) Yes Yes Yes

Question 17

Correct answer: (D) All three diagnoses

Question 17

PPI correlation to C. difficile colitis is least clear

JAMA. 2005;294:2989-2995. Use of Gastric Acid–Suppressive

Agents and the Risk of Community-Acquired Clostridium difficile–Associated Disease

Dial S, Delaney JAC, Barkun AN, Suissa S.

Question 17

PPIs moreso than histamine-2 receptor antagonists are correlated with pneumonia

JAMA. 2009;301(20):2120-2128. Acid-Suppressive Medication Use

and the Risk for Hospital-Acquired Pneumonia

Herzig SJ, Howell MD, Ngo LH, Marcantonio ER.

Question 17

Use of PPIs was not associated with hip fractures but was modestly associated with clinical spine, forearm or wrist, and total fractures

Arch Intern Med. 2010;170(9):765-771. Proton Pump Inhibitor Use, Hip Fracture, and

Change in Bone Mineral Density in Postmenopausal Women: Results From the Women's Health Initiative

Gray SL, LaCroix AZ, Larson J, Robbins J, Cauley JA, Manson JE, Chen Z.

Question 17

Increased risk of adverse events after acute coronary syndrome is thought to be due to attenuation of clopidogrel effect

Unclear if choice of PPI matters

JAMA. 2009;301(9):937-944. Risk of Adverse Outcomes Associated With Concomitant Use of

Clopidogrel and Proton Pump Inhibitors Following Acute Coronary Syndrome

Ho PM, Maddox TM, Wang L, Fihn SD, Jesse RL, Peterson ED,

Rumsfeld JS.

Question 18

© 2010 ABIM

A 38-year-old man who works at a beef processing plant hasfever, headache, and swollen erythematous hands, whichhave small painless papules. The papules progress to centralvesicles, then turn necrotic with a painless black eschar.

Which of the following is the most likely diagnosis?

(A) Bullous pemphigoid (B) Cutaneous anthrax (C) Methicillin-sensitive Staphylococcus aureus infection (D) Pasteurella infection

Question 18

Correct answer: (B) Cutaneous anthrax

Question 18

Anthrax classically presents after exposure to certain animal tissues as lesions of face, neck or hands progressing to vesicles and then painless eschar

Wilson KH. Clinical manifestations and diagnosis of anthrax. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.

Question 18

Pasteurella causes soft tissue infections, septic arthrits, osteomyelitis, meningitis, pneumonia, endocarditis, ocular infection, and intraabdominal infection.

Cat bite or scratch Weber DJ, Rutala WA, Kaplan SL. Pasteurella

infections. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010.

MRSA presents as cellulitis, folliculitis, etcetera Risk for Bullous pemphigoid is advancing age

Question 19

© 2010 ABIM

A 44-year-old male hospital medicine physician does not use fullbarrier precautions when inserting central lines and does not weargloves or isolation gowns consistently when visiting patients whoare in isolation. He is aware of standard infection controlprocedures and has been counseled repeatedly by the nursingand medical staff.

Which of the following is the best course of action?

(A) Support the physician's decision (B) Practice informal counseling (C) Invite the physician to a seminar on blood stream infections (D) Redesign isolation setups (E) Inform the physician that you are required to report his

actions

Question 19

Correct answer: (E) Inform the physician that you are required to report his actions

Question 19

AMA Code of Medical Ethics Opinion 9.031 - Reporting Impaired, Incompetent, or Unethical Colleagues

“When the inappropriate conduct of a physician continues despite the initial report(s), the reporting physician should report to a higher or additional authority”

Question 20

© 2010 ABIM

A 68-year-old man had a myocardial infarction three months agoand underwent implantation of a cardioverter–defibrillator (ICD) onemonth ago. Today, he comes to the emergency department after anICD shock.

Pulse rate is 88 per minute, respirations are 20 per minute, and blood pressure is 102/54 mm Hg. Cardiac impulse is displaced

laterally; S1 and S2 are normal. The lungs are clear.

Which of the following is the prognosis for patients such as this whohave heart failure and an ICD in place for primary prevention andhave had a shock delivered by the ICD compared with similarpatients who do not receive such shocks? (A) Comparable risk of death (B) Significantly decreased risk of death (C) Significantly increased risk of death

Question 20

Correct answer: (C) Significantly increased risk of death

Question 20

Risk of death is about 4 times higher in 4 years of followup

N Engl J Med 2008; 359:1009-1017 Prognostic Importance of Defibrillator

Shocks in Patients with Heart Failure Poole JE, Johnson GW, Hellkamp AS, Anderson

J, Callans DJ, Raitt MH, Reddy RK, Marchlinski FE, Yee R, Guarnieri T, Talajic M, Wilber DJ, Fishbein DP, Packer DL, Mark DB, Lee KL, Bardy GH.

Question 21

© 2010 ABIM

A 72-year-old woman is evaluated for complicated cellulitis.History is remarkable for an allergy to vancomycin.Temperature is 39.0 C (102.2 F), pulse rate is 100 per minute,respirations are 16 per minute, and blood pressure is 100/68 mm Hg. Daptomycin is begun.

The pharmaceutical manufacturer specifically advises thatwhich of the following tests be performed weekly for patientswho are treated with daptomycin for cellulitis complicated bymethicillin-resistant Staphylococcus aureus? (A) Complete blood count (B) Serum ALT (C) Serum calcium (D) Serum creatine kinase (E) Serum creatinine

Question 21

Correct answer: (D) Serum creatine kinase

Question 21

Weekly CPK recommended by the manufacturer and other authorities

J Antimicrob Chemotherapy 55(4), 599-600.

Severe myopathy and possible hepatotoxicity related to daptomycin

Echevarria K, Datta P, Cadena J, Lewis JS.

Question 22

© 2010 ABIM

Which of the following is a contraindication to the herpes zostervaccine?

(A) Age younger than 60 years (B) Chronic post-herpetic neuralgia (C) History of shingles (D) Lymphoma (E) No history of varicella infection

Question 22

Correct answer: (D) Lymphoma

Question 22

World Health Organization (WHO), Centers for Disease Control (CDC) list conditions with “impaired cellular immunity” as contraindications to live vaccines

Question 23

© 2010 ABIM

An asymptomatic 27-year-old man who emigrated from Indiathree years ago undergoes tuberculin skin testing as part of apre-employment physical examination. He will be working asan aide in the emergency department of a hospital. He thinksthat he received the Bacillus Calmette-Guérin vaccination as achild. He has never been hospitalized, takes no medications,smokes one pack of cigarettes daily, and drinks alcoholicbeverages occasionally. He is HIV negative.

Physical examination is normal. Tuberculin skin test (PPD, 5 TU) shows 11 mm of induration at 48 hours, and a follow-up chest radiograph is normal. Serologic test for HIV isnegative.

Question 23 - continued

© 2010 ABIM

Based on the patient's results from the tuberculin skin test,which of the following should you recommend now?

(A) No further testing (B) Repeat tuberculin skin test (C) Sputum stain and culture for acid-fast bacilli (D) Treatment for latent tuberculosis

Question 23

Correct answer: (D) Treatment for latent tuberculosis

Question 23

Disregard BCG status Recipients are usually from high-incidence areas If x-ray positive or symptoms present, perform sputum

analysis & consider treatment for active TB MMWR Recomm Rep, 2005, 30; 54(17):1-141.

Centers for Disease Control and Prevention, Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005

Question 23

Blood assay for M. tuberculosis (BAMT) is a specific method of diagnosis, but not currently listed as a recommendation

Pai M, Menzies R. Diagnosis of latent tuberculosis infection in adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2010

>20% of BCG recipients after age 1 have positive PPD >10 year later

Int J Tuber Lung Dis 2006; 10:1. False positive tuberculin skin tests: What is the absolute effect of BCG and non-tuberculous mycobacteria? Farhat, M, Greenaway, C, Pai, M, Menzies, D.

Question 24

© 2010 ABIM

A healthy 32-year-old woman is admitted to the hospital afterbriefly losing consciousness and suffering a closed head injuryduring a fall at a party. Current medications are loratadine andan oral contraceptive.

The patient is oriented and cooperative but moderately intoxicated. Pulse rate is 78 per minute, respirations are 16 per minute, and blood pressure is 112/70 mm Hg. A laceration and a right temporal hematoma are noted. Neurologic examination is negative for motor, sensory reflex,and cranial nerve abnormalities. Computed tomography of thehead is normal.

Question 24 - continued

© 2010 ABIM

Laboratory studies: Serum electrolytes NormalINR NormalSerum aminotransferase   

ALT 60 U/L   AST 47 U/L

Blood ethanol 205 mg/dL

Which of the following interventions is the most feasible andeffective strategy for addressing alcohol abuse? (A) Court-mandated attendance at Alcoholics Anonymous (AA) (B) Family intervention (C) Disulfiram (D) Screening, brief interventions, and referral to treatment

(SBIRT) (E) Referral to a social worker

Question 24

Correct answer: (D) Screening, brief interventions, and referral to treatment (SBIRT)

Question 24

No support in literature for the other foils Lancet 2004; 364: 1334–39 Screening and referral for brief intervention

of alcohol-misusing patients in an emergency department: a pragmatic randomised controlled trial

Crawford MJ, Patton R, Touquet R, Drummond C, Byford S, Barrett B, Reece B, Brown A,No JAH.

Question 25

© 2010 ABIM

A 78-year-old woman came to your office last week becauseshe had had fever for one week, cough for two days, anddyspnea for one day. Blood cultures taken at the time havegrown methicillin-resistant Staphylococcus aureus (MRSA).

Today, temperature is 39.0 C (102.2 F), pulse rate is 130 per minute, respirations are 30 per minute, and bloodpressure is 90/52 mm Hg. Tubular breath sounds and cracklesare audible in the left lower lobe. Cardiac examination revealstachycardia and a grade 3/6 systolic murmur at the left sternal

border and apex; S1 and S2 are normal.

Question 25 - continued

© 2010 ABIM

For which of the following reasons is daptomycincontraindicated for the treatment of this patient's MRSApneumonia?

(A) MRSA has a high level of resistance to daptomycin (B) Daptomycin triggers parenchymal hemorrhage in lung

tissue (C) Daptomycin diffuses poorly into the blood supply of the

lungs (D) Daptomycin interacts with pulmonary surfactant,

resulting in inhibition of antibacterial activity

Question 25

Correct answer: (D) Daptomycin interacts with pulmonary surfactant, resulting in inhibition of antibacterial activity

Question 25

J Infect Dis. 2005 Jun 15;191(12):2149-52. Epub 2005 May 5.

Inhibition of daptomycin by pulmonary surfactant: in vitro modeling and clinical impact.

Silverman JA, Mortin LI, Vanpraagh AD, Li T, Alder J.