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ABIM Questions ­ ACP Conference September 23, 2010 Question 1 Which of the following is the most specific diagnostic test for latent 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 The CDC recommends using the Tuberculosis Skin Test OR the Interferon-gamma assay be used to diagnosis latent tuberculosis in the setting of a negative CXR and symptoms or findings. There is a good article at the CDC related to Interferon tests for TB (http://www.cdc.gov/tb/publications/factsheets/testing/IGRA.htm). In particular, the QuantiFERON®-TB Gold test maybe what clinicians are used to hearing. White blood cells from most persons that have been infected with M. tuberculosis will release interferon-gamma (IFN-g) when mixed with antigens (substances that can produce an immune response) derived from M. tuberculosis. Patients treated with BCG-vaccination in the past do NOT cross-react with this test, which is a boon for many immigrants. The specificity of this test is around 79% in pooled data (Eur Respir J. 2010 Sep 16.) Specificity = 79% of all those WITHOUT the disease will have a negative test. The PPD test has a low specificity, meaning that the vast majority of positive reactions in low-risk individuals are false-positive results.(Chest 1998;113;1175-1177)

Question 2 A 62-year-old woman who has chronic exertional dyspnea is hospitalized with an exacerbation of chronic obstructive pulmonary disease (COPD). She smoked cigarettes for many years but recently quit. She does not have a history of asthma, cystic fibrosis, or alpha1-antitrypsin deficiency. Current medications are an inhaled combination corticosteroid­long-acting beta-adrenergic blocking agent, inhaled ipratropium bromide, and oral mucolytics (only in the winter). 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. Which of the following interventions has been shown to reduce the rate of decline in pulmonary function in patients who have COPD? (A) Smoking cessation (B) Oral mucolytics (C) Inhaled ipratropium (D) Inhaled combination corticosteroid­long-acting beta-adrenergic blocking agent The question, by the way, has little to do with the patient case. Long term use of ICS (> six months) did not significantly reduce the rate of decline in FEV1 in COPD patients. (Cochrane Database Syst Rev. 2007 Apr 18;(2):CD002991.) Smoking cessation is the single most effective--and cost effective--intervention in most people to reduce the risk

of developing COPD and stop its progression (Evidence A).(Global Initiative for Chronic Obstructive Lung Disease (GOLD); 2009. 93 p.) Question 3 A 74-year-old man who is hospitalized with stage IV non­small cell lung cancer has had progressively worsening shortness of breath for three weeks. You perform a therapeutic thoracentesis of a large right-sided pleural effusion. In addition to verbally confirming the patient's identity and the site of the procedure, which of the following elements has the Joint 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 Joint Commission Universal Protocol: During the time-out, the team members agree, at a minimum, on the following: correct patient identity correct site procedure to be done http://www.jointcommission.org/NR/rdonlyres/F8046F2C-A8A2-412F-88D4E1762BCC5C26/0/UP_Poster.pdf Question 4 A 44-year-old woman comes to the emergency department because of nonexertional syncope of several seconds duration during her child's birthday party at home. Before this episode, the patient was pale, felt warm, and had nausea. She had no headache, palpitations, dyspnea, or chest pain. She was lucid on waking, and experienced no bowel or bladder incontinence. Medical history is significant for hypertension. Family history is unremarkable. Her only current medication is chlorthalidone (25 mg daily). 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 are complete 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 This patient's syncope episode is most likely from mild dehydration--but orthostatic pressure here is only a 14 point drop--the Guidelines report a definite diagnosis with > 20 point drop. It also suggests that syncope occurring in the following settings are clinically relevant to this diagnosis: After standing up

Temporal relationship with start of medication leading to hypotension or changes of dosage Prolonged standing especially in crowded, hot places Presence of autonomic neuropathy or Parkinsonism After exertion While we are almost definite that this is orthostatic related, it is a single episode in a low risk patient, and the guidelines do not recommend further workup or admission. Carotid artery US is NOT a normal part of the syncopal workup, as carotid distribution TIA/Stroke do NOT cause syncope. A CT of the head is NOT a recommended initial workup in syncope without other symptoms. (Guidelines on management (diagnosis and treatment) of syncope-update 2004. Executive Summary. Eur Heart J. 2004 Nov;25(22):2054-72.) Question 5 A 72-year-old man who has severe chronic obstructive pulmonary disease was intubated by the paramedics and brought to the emergency department because of respiratory distress. Both his advance directive and hospital records indicate that the patient did not want to be intubated. The patient's son, who quit his job and moved in with his father to be his sole caregiver, states that his father recently changed his mind and would want the use of a ventilator, 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 This is a question that in my mind may have differences between the legal responsibility and the responsibility of conscience. The Advance Directive is not a mandate, but a guide for clinicians as to what the patient's wishes are, and those wishes can be verified when the patient is alert and oriented. When the family disagrees with what is written, particularly claiming that the patient has disavowed the document recently, in a setting where the patient is unconscious and can not provide input, clinicians often choose to continue active care rather than withdrawing it. The American College of PhysiciansAmerican Society of Internal Medicine End-of-Life Care Consensus Panel wrote, If there are differences in family opinion about how to proceed, the wishes of a family member advocating a more aggressive medical approach are likely to be given greater weight, even if not based on evidence about patient preferences. This is because of the perceived belief that the legal risks of continuing treatment are less than those of stopping it. The default in favor of aggressive treatment is probably stronger if the patient lacks capacity but is not permanently unconscious and has been unclear about his/her wishes. (JAMA. 2000;284(19):2495-2501) In this case, when the patient becomes alert and oriented, he may verify that he wishes care to be withdrawn. Question 6 A ten-year-old hospital medicine service with increased patient volume demand must implement new electronic health records, computerized physician order entry, medication

reconciliation compliance, and JCAHO-mandated institutional adjustments. Additionally, the emergency department has introduced a "no divert" policy. A new well-trained manager provided by the hospital is trying to apply industrial engineering techniques. Several physicians have left the group, and the hospital is having difficulty attracting high-quality new staff. Hospital margins hover at 1%, and the finance department has introduced a total hiring freeze. End of text Which of the following is the best management strategy for this 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 Physician engagement in Quality Improvement has become a core competency taught in residency, and found in many CME programs, including MKSAP 15. MKSAP recommends a Plan-Do-Study-Act cycle. Planning commonly begins with flow-charting the current processes in order to understand where inefficiencies occur and what their root causes are. Question 7 A previously healthy 61-year-old man comes to the emergency department because of chest pain that began four hours ago. Electrocardiogram reveals 2-cm ST-segment depressions in the anterior leads. In this patient, early coronary intervention (within 24 hrs) versus delayed coronary intervention (longer than 36 hrs) is associated with prevention of which of the following at six months? (A) Recurrent ischemia (B) Myocardial infarction (C) Stroke (D) Death Interesting that there has been a widely publicized article in the last month or so addressing this, stating that cardiologists know that it only prevents recurrent ischemia, but that the general public believes it decreases future heart attacks and death. This has not been shown in studies so far. Ann Intern Med, 2010;153(5):307-313 Question 8 A patient who has type 2 diabetes mellitus and hyperlipidemia is admitted to the intensive care unit with septic shock due to pyelonephritis. After adequate fluid resuscitation with Ringer's lactate, temperature is 35.7 C (96.2 F), pulse rate is 118 per minute, respirations are 22 per minute, and blood pressure is 73/42 mm Hg. Plasma glucose is 162 mg/dL. Which of the following is most likely to improve mortality in patients who have septic shock? (A) Fluid resuscitation with colloid

(B) Intensive insulin therapy to maintain euglycemia (C) Vasopressor therapy The Shock Bundle from the 100,000 Lives Campaign recommend Vasopressors for hypotension not responding to initial fluid resuscitation. (http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/) Colloid can be used for fluid resuscitation instead of, or in addition to, crystalloid, but not as the next step in treatment. The current recommendation is only to keep the glucose less than 180--not euglycemia.

Question 9 A 32-year-old homeless man who was hospitalized with syncope and confusion is transferred to the telemetry unit because of hypotension. The patient has a history of substance abuse and intravenous opiate dependence. Current medications are 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 reveals wide complex, variable-focus ventricular tachycardia. Toxicology screen is positive for tetrahydrocannabinol, alcohol, opiates, and acetaminophen. End of text Which of the following medications is the most likely cause of this patient's arrhythmia? (A) Alcohol (B) Benzodiazepines (C) Cannabis (D) Methadone (E) Oxycodone While heavy alcohol use is associated with Atrial Fibrillation (Holiday Heart Syndrome), high dose methadone is associated with Torsade de pointes, as described in a case series in Annals from 2002. (Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, Robertson AD, Mehler PS. Torsade de pointes associated with very-high-dose methadone. Ann Intern Med. 2002 Sep 17;137(6):501-4.) Question 10 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. Current medications are aspirin, clopidogrel, lisinopril, metoprolol, and simvastatin. End of text After placement of drug-eluting stents, how long should elective noncardiac surgery be delayed? (A) One month (B) Two months

(C) Six months (D) One year For knee arthroplasty, anticoagulants are routinely discontinued preoperatively. The most recent guidelines on this issue of a drug-eluting stent and noncardiac surgery recommend waiting a year after stent placement before surgery is performed. The pertinent guidelines and their level of evidence are quoted below. It is a IIIB recommendation: ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2007 Oct 23;50(17):e159-241. "Class IIa 1. In patients in whom coronary revascularization with percutaneous coronary intervention (PCI) is appropriate for mitigation of cardiac symptoms and who need elective noncardiac surgery in the subsequent 12 months, a strategy of balloon angioplasty or bare-metal stent placement followed by 4 to 6 weeks of dual-antiplatelet therapy is probably indicated. (Level of Evidence: B) 2. In patients who have received drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and restart the thienopyridine as soon as possible. (Level of Evidence: C) "Class III 1. It is not recommended that routine prophylactic coronary revascularization be performed in patients with stable CAD before noncardiac surgery. (Level of Evidence: B) 2. Elective noncardiac surgery is not recommended within 4 to 6 weeks of baremetal coronary stent implantation or within 12 months of drug-eluting coronary stent implantation in patients in whom thienopyridine therapy or aspirin and thienopyridine therapy will need to be discontinued perioperatively. (Level of Evidence: B) 3. Elective noncardiac surgery is not recommended within 4 weeks of coronary revascularization with balloon angioplasty. (Level of Evidence: B) Contraindications If there is a contraindication to 12 months of dual-antiplatelet therapy, such as planned noncardiac surgery, then drug-eluting stents (DES) should not be implanted. However, a few recent articles are showing that there are fewer complications than expected from surgery within a year of DES placement, so we may see changes in these recommendations in the future: Berger PB, Kleiman NS, Pencina MJ, Hsieh WH, Steinhubl SR, Jeremias A, Sonel A, Browne K, Barseness G, Cohen DJ; EVENT Investigators. Frequency of major noncardiac surgery and subsequent adverse events in the year after drugeluting stent placement results from the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry. JACC Cardiovasc Interv. 2010 Sep;3(9):920-7.

CONCLUSIONS: The frequency of major noncardiac surgery in the year after DESplacement is >4%. Although the overall risk of adverse outcomes was less than previously reported when surgery is performed months after DES placement, it is significantly increased in the week after major noncardiac surgery. Gandhi NK, Abdel-Karim Md AR, Banerjee S, Brilakis ES. Frequency and risk of noncardiac surgery after drug-eluting stent implantation. Catheter Cardiovasc Interv. 2010 Sep 7. CONCLUSION: Noncardiac surgery is frequently needed in the years after drugeluting stent implantation and appears to carry a low risk of stent thrombosis and perioperative complications.

Question 11 A 53-year-old man is admitted to the hospital for an exacerbation of heart failure. At baseline, he becomes mildly dyspneic with activities of daily living but he is currently dyspneic even at rest. He also has ischemic cardiomyopathy, with a left ventricular ejection fraction of 25%. Current medications are lisinopril, carvedilol, spironolactone, simvastatin, and aspirin. Estimated central venous pressure is 12 cm H2O. Bibasilar crackles 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 the anterior leads. Left bundle branch block is also seen, with QRS duration of 160 msec. End of text Which of the following therapeutic interventions is most likely to improve mortality in this patient? (A) Digoxin (B) Furosemide (C) Isosorbide mononitrate (D) Cardiac resynchronization therapy A number of papers in the first half of the decade demonstrated that CRT decreases mortality in CHF. A metanalysis in 2004: Systematic review: cardiac resynchronization in patients with symptomatic heart failure. Ann Intern Med. 2004 Sep 7;141(5):381-90. Epub 2004 Aug 16. CONCLUSIONS: In selected patients with heart failure, cardiac resynchronization therapy improves functional and hemodynamic status, reduces heart failure hospitalizations, and reduces all-cause mortality. Upon studies such as these, the ACC/AHA recommended a Class IA recommendation for CRT in pts with severe systolic CHF: ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the

ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Recommendations for Cardiac Resynchronization Therapy in Patients With Severe Systolic Heart Failure CLASS I 1. For patients who have left ventricular ejection fraction (LVEF) less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, cardiac resynchronization therapy (CRT) with or without an ICD is indicated for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms with optimal recommended medical therapy. (Level of Evidence: A) (Abraham et al., 2002; Bristow et al., 2004; Cleland et al., 2005; Hunt, 2005) Interestingly, a more recent article is looking at patients with more mild NYHA I or II and did NOT find a significant difference in mortality (3% annual). They did have decreased heart-failure events in patients with a wide QRS. So, this field is pushing the boundaries to define if other subsets of CHF patients will benefit from CRT. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med. 2009 Oct 1;361(14):1329-38. Epub 2009 Sep 1. Digoxin can help decrease hospitalizations, but not mortality. Also, the QRS of 160 is a relative contraindication to digoxin, which could increase the risk of torsade. Nitrates in combination with hydralazine were found to decrease death in Africanamerican patients. While conventional wisdom suggests that Furosemide has not been demonstrated to improve mortality, I was able to find a Cochran Database study showing that a metanalysis of diuretic studies demonstrated a decrease in mortality. The most recent guidelines on CHF from 2005 do not seem to take that into account. I assume that more recent Randomized Controlled Trials will need to address this question. Hmmm. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003838. Diuretics for heart failure. AUTHORS' CONCLUSIONS: The available data from several small trials show that in patients with chronic heart failure, conventional diuretics appear to reduce the risk of death and worsening heart failure compared to placebo. Question 12 A 40-year-old man who has a history of alcohol dependence comes to the emergency department because of heart failure. Echocardiography shows a left ventricular ejection fraction of 30%. End of text Which of the following should you do to satisfy the Joint Commission's hospital core measures for heart failure for this patient? (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

The Joint Commission's Core Measures can be reviewed here: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/C urrent+NHQM+Manual.htm Question 13 A 65-year-old woman is admitted to the intensive care unit because of communityacquired pneumonia. Gram stain of the blood shows gram-positive cocci in pairs. Despite aggressive fluid resuscitation, blood pressure remains 82/40 mm Hg; mean arterial pressure is 54 mm Hg. Which of the following vasopressor drugs should you order next? (A) Epinephrine (B) Norepinephrine (C) Phenylephrine (D) Vasopressin From the surviving sepsis guidelines, the recommendation is to use Norepinephrine as first choice. In review: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008 Jan;34(1):17-60 Vasopressors 1. The guideline committee recommends mean arterial pressure (MAP) be maintained >65 mm Hg. (Grade 1C) The guideline committee recommends either norepinephrine or dopamine as the first choice vasopressor agent to correct hypotension in septic shock (administered through a central catheter as soon as one is available). (Grade 1C) 3a. The guideline committee suggests that epinephrine, phenylephrine, or vasopressin should not be administered as the initial vasopressor in septic shock. (Grade 2C) Vasopressin .03 units/min may be subsequently added to norepinephrine with anticipation of an effect equivalent to norepinephrine alone. 3b. The guideline committee suggests that epinephrine be the first chosen alternative agent in septic shock that is poorly responsive to norepinephrine or dopamine. (Grade 2B) 5. The guideline committee recommends that low dose dopamine not be used for renal protection. (Grade 1A) 6. The guideline committee recommends that all patients requiring vasopressors have an arterial line placed as soon as practical if resources are available. (Grade 1D)

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