Self-Evaluation Process 2011 Update in Hospital-Based

Internal MedicineModule 83-L Version 2011-1

WARNING: This Self-Evaluation Process (SEP) is copyrighted work under the Federal Copyright Act. It is a federal criminal offense to copy or reproduce this work in any manner or to make adaptations of this work. It is also a crime to knowingly assist someone else in the infringement of a copyrighted work. No part of this work may be reproduced by any means or transmitted in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise) without the prior written permission of the American Board of Internal Medicine. The making of adaptations from this work also is strictly forbidden. In addition to criminal penalties, the Copyright Act, 17 U.S.C.§§101, et seq., provides a number of remedies for the infringement of a copyright, including injunctive relief, the award of statutory and actual damages, the award of attorney fees and costs, and confiscation and destruction of infringing works and materials. It is the policy of the Board to strictly enforce its rights to this copyrighted work.

ConfidentialOnly for use at the Scott & White Learning Sessions held July 16th 2012.

Stephen Sibbitt, MD, FACPCMO Scott & White Memorial Hospital

Curtis Mirkes, DO, FACPProgram Director

IM Residency

31st Annual Internal Medicine Review

July 16th 2011

Toxidrome Examples Vital signs Pupils Other findings

Sympatho-mimetic

Cocaine, Amphetamine

Pseudo-ephedrine

Hyperthermia Tachycardia

HypertensionTachypnea

Mydriasis PiloerectionHyperreflexiaDiaphoresis

Tremors

Anticholinergic

AtropineTCA

Antihistamine

Hyperthermia Tachycardia

Hypertension

Mydriasis Hot, dry, red, blind

Seizures

Sedative- hypnotic

BZDBarbiturates

AlcoholAnticonvulsa

nt

HypothermiaBradycardiaHypotensionHypopnea

Miosis(usually)

HyporeflexiaConfusion

Stuporcoma

OpioidOpiatesHeroin

HypothermiaBradycardiaHypotension

Miosis CNS depression,

Coma

Question 1

Question 1Psychoactive: Club Drugs &

Inhalants

3, 4-Methylenedioxy-methamphetamine (“ecstasy”)

Question 1

Duration of action Methamphetamine (approximately 20

hours) Cocaine (duration of action 30 minutes) PCP (duration of action less than 8

hours)

Question 1

Question 1

Oral burns

Meth-mouth

A. Hallucinogenic mushroomsB. Phencyclidine (PCP)C. MDMA (Ecstasy)D. Methamphetamine

Question 1

Question 2

A working definition of ACS1. Presence of a new pulmonary infiltrate, not due to

atelectasis, involving at least one complete lung segment

2. Chest pain 3. Temperature >38.5ºC 4. Tachypnea, wheezing, or cough

Question 2

Question 2

Transfusions Hypoxemia PaO2 < 70

mmHg

Question 2

A. Ceftriaxone and azithromycinB. HydroxyureaC. Packed red blood cellsD. Hydromorphone via patient-

controlled analgesiaE. Exchange transfusion

Question 2

Question 3

Question 3

Question 3

It is unclear what to do with aspirin in patients who have transient ischemic attacks or cerebrovascular accidents. However, this patient is asymptomatic, so she likely would not benefit from intervention.

A. AspirinB. WarfarinC. ResectionD. No further intervention

Question 3

Question 4

A. Discontinuation nowB. For 48 hours following admissionC. Until follow-up blood cultures are

negativeD. Until skin lesions have resolvedE. Until completion of therapy

Question 4

Question 5

Question 5

Question 5

A. EndocarditisB. Wound infection, possibly osteomyelitisC. Central venous catheter infectionD. Skin contamination when culture was

drawn

Question 5

Question 6

Question 6

Need to start antibiotics

Question 6

Question 6

Question 6

A. Noninvasive ventilationB. AmoxicillinC. LevofloxacinD. Low-molecular-weight

heparinE. Prednisone

Question 6

Question 7

Question 7

Question 7

Question 7

A. Repeat lumbar punctureB. Discontinue current medications and

dischargeC. Discontinue current medications and

observeD. Discontinue current medications, initiate

oral valacyclovir, and dischargeE. Discontinue current medications, initiate

oral cefpodoxime and valacyclovir, and discharge

Question 7

Question 8 I- Nonblanchable erythema

caused by extravasation of erythrocytes into the interstitium, without damage to deeper layers.

II- Ulceration that involves the epidermis and dermis; depth is no more than several millimeters; underlying tissue should appear normal.

III- Full-thickness ulcerations through the dermis; ulcerations can be extensive and deep and may involve subcutaneous fat; underlying tissue should appear normal.

IV- Ulcerations exposing muscle, tendon, or bone; stage IV heel ulcers can be only 4 to 5 mm deep; stage IV sacral ulcers in obese patients can be many centimeters deep.

Question 8

Question 8

Stage 2 pressure ulcers on the lower sacrum do not require Foley catheterization to heal. Foley catheters in ulcer scenarios are only indicated for stage 4 sacral or perineal ulcers.

A. Continue the indwelling urinary catheter while the patient remains hospitalized

B. Remove the indwelling urinary catheter while the patient remains hospitalized but replace before discharge

C. Remove the indwelling urinary catheter and replace with a condom catheter

D. Remove the indwelling urinary catheter

Question 8

Question 9

A. Oral metronidazoleB. Oral vancomycin aloneC. Intravenous metronidazole

aloneD. Oral vancomycin and

intravenous metronidazole

Question 9

Question 10

Question 10

Question 10

The patient has responded clinically and is known to have gram-negative rods in her urine. That the blood culture took three days to become positive suggests this is a low-grade bacteremia, and her clinical response suggests that the drugs she has received are working. The other options are excessive for this scenario and would unnecessarily prolong her hospitalization.

A. Order immediate echocardiographyB. Begin amoxicillin–clavulanate and order

abdominal computed tomographyC. Begin amoxicillin–clavulanate and continue

discharge planningD. Continue ticarcillin–clavulanate and postpone

discharge

Question 10

Question 9

Question 9

A. Metronidazole orallyB. Metronidazole intravenouslyC. Vancomycin orallyD. Vancomycin intravenously

Question 11

Question 12

Haloperidol

Lorazepam

Olanzapine

Risperidone Atypical Antipsychotics-2nd and 3rd generation

Antipsychotic - Typical Non Phenothiazines

Atypical Antipsychotics-2nd and 3rd generation

Benzodiazepine

Haldol

Ativan

Zyprexa

Risperdal

Question 12

Antipsychotic medications Cause high rates of extrapyramidal side

effects Rigidity Bradykinesia Tremor Akathisia

Tardive dyskinesia—hyperkinetic, involuntary movements most readily observed in the face and extremities.

A. HaloperidolB. LorazepamC. OlanzapineD. Risperidone

Question 12

Question 13

A. Hepatitis C viral loadB. Hepatitis C genotypeC. Serum albumin levelD. Serum ALT and AST levelsE. Prothrombin time

Question 13

Question 14Treatment of Ascites

Question 14Treatment of Refractory Ascites

Question 14

A. AmilorideB. BumetanideC. EplerenoneD. IndapamideE. Midodrine

Question 14

Question 15

Question 15

A. 180/100B. 160/95C. 140/90D. 130/80

Question 15

Question 16

A. BacteremiaB. EndocarditisC. OsteomyelitisD. Pneumonia

Question 16

Question 17

A. CalcitoninB. Hip protectorsC. AlendronateD. Teriparatide

Question 17

Question 18

Question 18

A. The cause of the error is not yet known but will be fully investigated

B. Occasional errors are unavoidable because of human factors

C. The administering nurse failed to check the patient's allergies and will be disciplined

D. An error most likely occurred due to an oversight on the part of the administering nurse and dispensing pharmacist, and system changes will be implemented to ensure the error does not happen again

Question 18

Question 19

A. Confirm the diagnosis of coronary artery disease in low-risk patients

B. Confirm the diagnosis of coronary artery disease in high-risk patients

C. Exclude the diagnosis of coronary artery disease in low-risk patients

D. Exclude the diagnosis of coronary artery disease in high-risk patients

Question 19

Question 20

Question 20

A. Aspirin, 325 mg dailyB. Clopidogrel, 75 mg dailyC. Warfarin adjusted to achieve an

INR of 2-3D. Unfractionated heparin bolus

followed by infusionE. Enoxaparin, 1 mg/kg

subcutaneously every 12 hours

Question 20

Question 21

Question 21

Question 21

With chronic kidney disease and heart failure, the patient will require diuretics at discharge. It would be futile to discharge her on less than she came in on (e.g., no diuretics, hydrochlorothiazide, or lower-dose furosemide), because she will get volume overloaded again. Sending her out on the same dose of furosemide she came in with carries some risk of recurrent volume overload, but it may be the safest option pending follow-up evaluation. She will eventually need a higher furosemide dose, but it is prudent not to raise the dose until her renal function has stabilized.

A. Decrease home furosemide dosage

B. Continue home furosemide dosage

C. Switch to metolazoneD. Withhold diuretics until follow-up

with primary care physician

Question 21

Question 22

What is her condition?

Question 22

Question 22

A. Discharge with prescription for metoclopramide, 10 mg before every meal

B. Obtain barium swallowC. Obtain esophagogastroduodenoscopyD. Obtain gastric emptying studyE. Change insulin therapy to insulin glargine at

bedtime and insulin aspart with meals; discharge

Question 22

Question 23

Question 23

Question 24

Question 24

A. Measurement of plasma D-dimerB. Computed tomographic

angiography of the pulmonary vasculature

C. Venous duplex compression ultrasonography of the lower extremities

D. Ventilation–perfusion lung scan

Question 24

Question 25

A. 400 IU dailyB. 1000 IU dailyC. 2000 IU dailyD. 50,000 IU

weekly

Question 25

Questions