© Springer International Publishing Switzerland 2016
Kevin Conrad (ed.)Absolute Hospital Medicine Review10.1007/978-3-319-23748-0_3Hospital Systems Management
(1)
Department of Hospital Medicine, Ochsner Health Systems, 1521 Jefferson Highway, New Orleans, LA 70121, USA
(2)
Tulane University School of Medicine, New Orleans, LA, USA
(3)
University of Queensland School of Medicine, New Orleans, LA, USA
365.
As the unit medical director, you are asked by hospital administration to recommend and lead a process that will limit practice variability and better align hospital resuscitation practices with evidence-based guidelines. During codes there is great deal of variability dependent upon the time of day, staff present, and location.
Which of the following would you suggest?
A)
Increasing the frequency of advanced cardiovascular life support (ACLS) training to become an annual requirement for all clinical practitioners
B)
Interviewing hospital staff using a Delphi method process to enumerate optimal resuscitation practices
C)
Implementation of the American Heart Association (AHA) Get with the Guidelines – Resuscitation program
D)
Developing resuscitation-specific privileges that are required for all hospital- credentialed
Answer: C
Often the first step in a performance improvement project is to research currently validated programs. According to the American Heart Association (AHA), the Get with the Guidelines program was developed to identify improvement opportunities, allow performance comparison among hospitals, and reduce medical errors through data-driven peer review. The program includes specific up-to-date consensus statements and guidelines for resuscitation, atrial fibrillation, heart failure, and stroke.
Reference
366.
A 55-year-old male with type 2 diabetes mellitus, hypertension, and hyperlipidemia presents with fever, hypotension, and decreased urine output. He is admitted to the intensive care unit with sepsis due to pyelonephritis. In addition to broad-spectrum antibiotics, the patient has received one liter of fluid resuscitation with 0.9 % saline. Two hours after presentation, the blood pressure is currently 73/42 mmHg. Temperature is 36.8 °C (98.2 °F), pulse rate is 120 beats/minute, and respiratory rate is 24 breaths/minute. Hematocrit is 29 %, blood sugar is 257 mg/dL, and serum lactate is 3.0 mg/dL.
Which of the following is the most likely to improve mortality in this particular patient?
A)
Continued fluid resuscitation with colloid added
B)
Intensive insulin therapy to maintain euglycemia
C)
Vasopressor therapy
D)
Bicarbonate infusion
E)
Transfusion with PRBC
Answer: C
This patient has not responded to aggressive fluid resuscitation per sepsis guidelines. At this point within 6 h of attempted fluid resuscitation, vasopressor therapy is indicated and has been shown to improve mortality. Intensive insulin therapy and fluid resuscitation with colloid have been recommended for critical illnesses in the past. However, recent trials have failed to show a definitive benefit of these therapies in severe sepsis. Intensive insulin therapy increases risk of hypoglycemia and has not been shown to improve mortality in an acute setting of sepsis.
Reference
Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36:296–327.
367.
Which clinical outcome is reduced with the use of chlorhexidine bathing compared to soap and water bathing in ICU patients?
A)
Global infection rates
B)
Ventilator-associated pneumonia (VAP) rates
C)
Catheter-associated urinary tract infection (CAUTI) rates
D)
All of the above
Answer: D
All of the answers are correct. Bathing with chlorhexidine-impregnated wipes was associated with both global and specific infection rate reduction in a study of >1000 ICU patients when compared to soap and water bathing.
Reference
Michael W. Climo, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368:533–42.
368.
What is true concerning postoperative cognitive dysfunction (POCD)?
A)
POCD is less likely to occur after operations under regional anesthesia as under general anesthesia.
B)
More likely after major, than minor, operations.
C)
More likely after cardiac surgery than other types of surgery.
D)
More likely in aged than in younger patients.
E)
All of the above.
Answer: E
The risk of POCD increases with age, type, and duration of surgery. There is a very low incidence among all age groups associated with minor surgery. POCD is common in adult patients of all ages at hospital discharge after major noncardiac surgery. The elderly (aged 60 years or older) are at significant risk for long-term cognitive problems, which may last as long as 6 months or become permanent.
Reference
Rasmussen LS. Postoperative cognitive dysfunction: incidence and prevention best practice & research. Clin Anaesthesiol. 2006;20(2):315–30.
369.
A 35-year-old female with AIDS is admitted for failure to thrive. She is experiencing chronic diarrhea and anorexia. The family has struggled to get her to eat more than a few bites per day. She has no obvious opportunistic infections. Her family is distressed that the cause of her continued decline appears to be lack of oral intake. They request that home IV nutrition be established.
On physical exam the temperature is 36.2 °C (97.2 °F), heart rate 55 bpm, blood pressure 100/62 mmHg, respiratory rate 12 breaths/min, height 74 in, and weight 45 kg. She appears chronically ill. There is bitemporal wasting, and her hair is thinning.
Which of the following statements regarding home total parenteral nutrition (TPN) is true?
A)
Survival and quality of life are improved in patients with metastatic cancer who are receiving home TPN.
B)
Survival and quality of life are improved in patients with AIDS who are receiving home TPN.
C)
Survival and quality of life are improved in patients with short bowel from Crohn’s disease who are receiving home TPN.
D)
No evidence supports the use of home TPN.
Answer: C
Mean survival in AIDS patients or those with metastatic cancer who received home TPN for failure to thrive is about 3 months. There is no evidence that home TPN prolongs life or improves quality of life in these patients. Home TPN is expensive and is indicated in select circumstances. Patients with short bowel resulting from the treatment of Crohn’s disease or pseudo-obstruction have a good response to home TPN. In these patients, TPN increases quality-adjusted years of life patients and is cost-effective. There is little evidence to support the use of home TPN, in most chronic diseases resulting in malnutrition.
References
Hoda D, Jatoi A, Burnes J, Loprinzi C, Kelly D. Should patients with advanced, incurable cancers ever be sent home with total parenteral nutrition? Cancer. 2005;103:863–8.
Mullady DK, O’Keefe SJ. Treatment of intestinal failure: home parenteral nutrition. Nat Clin Pract Gastroenterol Hepatol. 2006;3:492–504.
370.
A 78-year-old man who has ischemic heart failure, New York Heart Association (NYHA) functional class IV, and severe chronic obstructive pulmonary disease is admitted to the ICU for cardiac decompensation. This is his third admission in the past 2 months, and he is now having difficulty with his activities of daily living. The patient’s current medications are carvedilol, lisinopril, spironolactone, furosemide, and beta agonist inhalers. He had previously taken warfarin and aspirin, but had significant bleeding from a gastric ulcer 3 weeks prior to admission, which prompted discontinuation.
Two years ago, an automatic implantable cardioverter defibrillator (AICD) was placed with a transvenous approach for persistent ventricular arrhythmias. In the past 2 weeks, the AICD has fired six times. The patient’s daughter reports that since his last hospital discharge, the patient has spent most of his time sleeping in a recliner or in bed and has a poor appetite.
On physical examination, the patient is dyspneic and poorly communicative, but denies current chest pain.
Which of the following is the correct treatment?
A)
Initiation of a milrinone infusion
B)
Angiography for possi(ble percutaneous intervention
C)
Insertion of an intra-aortic balloon pump
D)
Deactivation of the AICD
E)
AICD recalibration
Answer: D
This patient has multiple indicators for the definition of advanced chronic heart failure, including symptom-based high New York Heart Association (NYHA) classification, severe chronic obstructive pulmonary disease, and left ventricular ejection fraction below 30 %. Palliative care is appropriate and should be offered. The most reasonable intervention at this time is deactivation of the automatic implantable cardioverter defibrillator (AICD). Failure to deactivate the AICD leaves many patients vulnerable to inappropriate device discharge, unnecessary discomfort, and intense anxiety. Other measures, such as infusion of positive inotropes, are used on a temporary basis with a plan for more definitive therapies. The use of intermittent infusions to control symptoms is not recommended by the AHA/ACC guidelines unless the patient is awaiting definitive therapy, such as transplantation.
371.
A 64-year-old man has been admitted for a large subarachnoid hemorrhage (SAH) from a ruptured cerebral aneurysm. He has no spontaneous movement for the past week. He remains intubated. There is concern that the patient has brain death.
What test is most commonly used to diagnose brain death in this situation?
A)
Cerebral angiography
B)
Apnea testing
C)
Demonstration of absent cranial nerve reflexes
D)
Demonstration of fixed and dilated pupils
E)
Performance of transcranial Doppler ultrasonography
Answer: B
Brain death is defined as lack of cerebral function with continued cardiac activity. This state requires support by artificial means. If an individual is determined to have brain death, life-sustaining therapies may be withdrawn. This can occur without the consent of the family. It is important to have ongoing communication with the family to allow the withdrawal of care without conflict. Most hospitals have developed specific protocols in line with state law to diagnose a patient with brain death.
Three elements should be demonstrated for the diagnosis of brain death. The patient should have widespread cortical damage with the complete absence of response to all external stimuli. Second, the patient should have no evidence of medullary function demonstrated by a lack of oculovestibular and corneal reflexes. A common test is to assess pupillary reaction to light. Finally, there should be no evidence of medullary activity. This is manifested by apnea. Specific protocols have been developed to perform the apnea test.
References
Allen LA, Stevenson LW, Grady KL, et al. AHA scientific statement: decision making in advanced heart failure. Circulation. 2012;125:1928–52.
Wijdicks EFM. The diagnosis of brain death. N Engl J Med. 2001;344:1215–21.
372.
A 56-year-old woman is admitted for severe nausea and diarrhea. She complains of nausea and diarrhea that began early that afternoon. She reports that she ate a sandwich from a street vendor for lunch, and she began experiencing symptoms several hours later. She reports no similar experiences in the past; she has no recent travel history, nor has she had any contacts with sick persons. She was treated with a 5-day course of ciprofloxacin for a urinary tract infection 2 months ago and is otherwise healthy.
On physical exam she is heme negative. Abdomen is mildly tender. She is afebrile. Which organism is the most likely cause of this patient’s acute diarrheal illness?
A)
Campylobacter jejuni
B)
Salmonella enteritidis
C)
Staphylococcus aureus
D)
C. difficile
E)
E. coli
Answer: C
Most acute diarrheas are caused by viral infections, such as adeno, norwalk, and rotavirus. They and are self-limited. Some are caused by bacteria. The most common agents in urban areas are Campylobacter, Salmonella, Shigella, and Escherichia coli. Protozoa such as Giardia lamblia and Entamoeba histolytica account for other common causes.
One mechanism for acute diarrhea is ingestion of a preformed toxin. Several species of bacteria, such as S. aureus, C. perfringens, and Bacillus cereus, can produce toxins that produce syndrome commonly designated as food poisoning. This occurs within 4 h of ingestion. In such cases, the bacteria do not need to establish an intraluminal infection; ingestion of the toxin alone can produce the disease. Symptoms subside after the toxin is cleared, usually by the next day. Symptoms are usually localized and fever is minimal.
Reference
Loir YL, Baron F,Gautier M. Review Staphylococcus aureus and food poisoning. Genet Mol Res. 2003;2(1):63–76.
373.
A 52-year-old female with a history of renal transplant 5 years prior presents with headache, fever, and purulent rhinorrhea. This has occurred over the past 5 days. She has been on steroids intermittently over the past 6 months for episodes of acute rejection.
On physical exam, she is lethargic but able to respond to questions appropriately. Her lungs are cleared to auscultation. She has diffuse maxillary tenderness and is noted to have a black nasal discharge.
Which of the following is the likely cause of her illness?
A)
Coccidioides immitis
B)
Rhizopus (mucormycosis)
C)
Histoplasmosis capsulatum
D)
Blastomyces dermatitidis
E)
Cryptococcus neoformans
Answer: B
This patient’s symptoms are consistent with mucormycosis which is an invasive fungal infection caused by a variety of fungi most commonly rhizopus. This is a rapid opportunistic infection that invades the vascular system. It is a life-threatening condition and urgent consultation with otolaryngology and infectious disease is warranted. Mucormycosis is acquired by inhalation of the spores that are found ubiquitously in soil, decaying fruit, and old bread. Although a black eschar is the classic finding of mucormycosis, it is present in less than half of the patients. The presence of a black eschar indicates vascular invasion and predicts a poor prognosis.
The prognosis of mucormycosis is poor and has varied mortality rates depending on its form and severity. Patients who are immunocompromised have a significantly higher mortality rate from 60 to 80 %. In the rhinocerebral form, the mortality rate is between 30 and 70 %. Disseminated mucormycosis has a very poor prognosis with a mortality rate of up to 90 %
Reference
Roden MM, Zaoutis TE, Buchanan WL, et al. Epidemiology and outcome of Mucormycosis: a review of 929 reported cases. Clin Infect Dis. 2005;41(5):634–53.
374.
A 68-year-old male with a past medical history of diabetes mellitus II, hypertension, hypothyroidism, and ESRD on hemodialysis 3 days per week presents with right leg swelling and leg pain.
Imaging confirms lower extremity deep vein thrombosis (DVT). The patient wants to know if there are any other treatment options besides warfarin because he states that grandma “bled too much on that drug.”
As the attending physician, you explain to him that his choices are:
A)
Rivaroxaban
B)
Dabigatran
C)
Warfarin (heparin bridge for minimum 5 days)
D)
All of the above
Answer: C
There are several alternatives to coumadin in the treatment of DVTs. It is important to know the advantages and disadvantages of each. This patient is on hemodialysis, which limits his medication options for DVT treatment. Rivaroxaban should be avoided once the CrCl <30 mL/min. Dabigatran was not studied in HD patients or in patients with a CrCl <30 mL/min. These populations were excluded from the DVT/PE trials. However, warfarin requires no renal adjustment and is safe to use in HD patients with appropriate monitoring of the INR.
References
Dabigatran Package Insert. http://bidocs.boehringer-ingelheim.com/BIWebAccess/ViewServlet.ser?docBase=renetnt&folderPath=/Prescribing%20Information/PIs/Pradaxa/Pradaxa.pdf. Accessed 6/24/2014. Accessed 25 May 2014.
Rivaroxaban Package Insert. http://www.xareltohcp.com. Accessed 24 May 2014.
375.
A 65-year-old female presents with new-onset right hemiplegia. A CT scan is performed and she is found to have had a large left-sided middle cerebral artery stroke. Her past medical history is significant for hypertension and diabetes. Her hospital course is uneventful.
Prior to her transfer to a skilled nursing facility, the patient has initiated physical therapy and is making good progress. She has good family support, and it is anticipated that after her admission to a skilled nursing facility, she will live at home with medical assistance. She has no history of depression or other psychiatric disorder. The patient’s family states that she had an extremely active lifestyle before this event and is concerned about the development of depression. They have noticed that she seems a bit down at times and they request that an antidepressant be started for the treatment and prevention of depression.
Which of the following is the most appropriate advice to the family?
A)
The incidence of depression is 7 %, and therefore, no therapy is recommended.
B)
The incidence of depression poststroke is 29 %, and no therapy is recommended.
C)
The incidence of depression is 42 %, and a low-dose selective serotonin reuptake inhibitor would be a reasonable choice.
D)
The incidence of depression poststroke is 29 %, and a low-dose selective serotonin reuptake inhibitor would be a reasonable choice.
Answer: B
The incidence of a mild dysthymic state is common after the incidence of stroke. This is due not only to the loss of prior function, but possibly due to chemical changes seen in the cerebral cortex. The duration of this condition may last several weeks.
The lifetime prevalence of depression after stroke is 29 %. The cumulative incidence within 5 years of stroke appears to be 39–52 %. A meta-analysis performed in 2008 revealed no definitive benefit with pharmacological therapy for the prevention of depression after stroke. There was a small but statistically significant benefit of psychotherapy. The most appropriate approach would be to advise the patient and the family to follow for signs of depression and consider treatment when the diagnosis becomes apparent. This patient currently has no signs of depression and has appropriate signs of grieving from the loss of function.
Reference
Mosnik D, Williams LS, Kroenke K, Callahan C. Symptoms of post-stroke depression: a distinct syndrome compared to geriatric depression. Neurology. 2000;54(Suppl 3):A378–9.
376.
A 44-year-old female is admitted for community-acquired pneumonia. Her past medical history includes diabetes, hypothyroidism, and vitamin D deficiency. Her clinical course improves with antibiotic therapy and is ready for discharge. She asks you to review her need for lipid-lowering therapy. A lipid panel is not drawn during this admission, and she is currently not taking any lipid-lowering therapy.
Would she benefit from starting a statin and if so, why?
A)
Yes, she is diabetic.
B)
Yes, she is 44 years old.
C)
No, her LDL is unknown.
D)
No, need to assess her hemoglobin A1C before deciding to initiate therapy.
Answer: A
Diabetes is one of the four statin benefit groups according to the new lipid guidelines by the American College of Cardiology. Evidence shows that each 39 mg/dL reduction in LDL by statins reduces atherosclerotic cardiovascular disease (ASCVD) risk by about 20 %. The four major statin benefit groups are as follows: clinical ASCVD, LDL ≥190, age 40–75 years with diabetes and LDL 70–189 without clinical ASCVD, and age 40–75 years with LDL 70–189 and estimated 10-year ASCVD risk >7.5 % without clinical ASCVD or diabetes. Diabetics (ages 40–75) are further classified according to the patient’s 10-year ASCVD risk (<7.5 % = moderate intensity statin or ≥7.5 % = high-intensity statin). Initial LDL values are not needed in order to initiate statin therapy in a diabetic patient. In addition, age alone is not a factor, but it helps calculate the 10-year risk. Lastly, hemoglobin A1C does not influence the initiation of statin therapy.
Reference
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;S0735–1097(13):06028–2.
377.
Linezolid has the following characteristics as compared to vancomycin:
A)
Decreased nephrotoxicity at higher doses
B)
Increased intrapulmonary penetration
C)
Increased incidence of thrombocytopenia
D)
All of the above
E)
None of the above
Answer: D
All of the answers are correct. Vancomycin is the current main stay for methicillin-resistant Staphylococcus aureus (MRSA) infections, but newer agents will see an increase in use due to better side effect profiles and tissue penetration. Linezolid may be more preferable for treating nosocomial pneumonia due to MRSA.
Reference
Chastre J, et al. European perspective and update on the management of nosocomial pneumonia due to methicillin-resistant Staphylococcus aureus after more than 10 years of experience with linezolid. Clin Microbiol Infect. 2014;20 Suppl 4:19–36.
378.
Increasing the dosage of benzodiazepines in cardiac patients admitted to the hospital is associated with:
A)
Increased risk of sudden death.
B)
Increased heart failure hospitalization.
C)
Increased risk of myocardial infarction.
D)
Increased risk of dementia.
E)
None of the answers is correct.
Answer: A
The adjusted incidence of sudden death was significantly associated with increased benzodiazepine dosage during 4.8 years of follow-up in a 2014 study.
Reference
Wu CK, et al. Anti-anxiety drugs use and cardiovascular outcomes in patients with myocardial infarction: a national wide assessment. Atherosclerosis. 2014;235(2):496–502.
379.
A 72- year-old female is admitted with community-acquired pneumonia. On chest X-ray, she is noted to have a marked pleural effusion. You plan to perform a therapeutic thoracentesis of a large right-sided pleural effusion.
In addition to confirming the patient’s identity verbally and noting the site of the procedure, which of the following has the Joint Commission identified as being a critical component of the time-out in the Universal Protocol for invasive procedures?
A)
The patient’s admitting diagnosis
B)
The patient’s date of birth
C)
The type of procedure
D)
The patient’s age and date of admission
E)
The follow-up plan after the procedure
Answer: C
The Joint Commission has defined several critical components of the “time-out” in an effort to improve patient safety and reduce medical errors. All components must be performed prior to the procedure. This includes confirming the patient’s identity, the site of the procedure, and the type of the procedure.
Reference
A follow-up review of wrong site surgery. Sentinel Event Alert. 2001;24:3.
380.
Which of the following statements is false in reference to urinary tract infections?
A)
Asymptomatic bacteriuria should be treated when patients are pregnant.
B)
Candiduria may represent vaginal flora or colonization.
C)
Urine cultures are usually positive in the presence of a Foley catheter and should be treated in the absence of symptoms.
D)
A colony count of greater than 100,000 is required to diagnose a UTI.
Answer: C
A common dilemma is the necessity to treat asymptomatic bacteriuria. There are several situations where first-line antibiotics can be avoided in patients who are non-immunocompromised. Positive urine cultures do not necessitate antibiotics in all circumstances. Urine cultures are usually positive in the presence of a Foley catheter and, with the absence of symptoms, should not be treated. If treatment is deemed necessary, remove the Foley catheter and treat for a total of 7 days. Treatment of either bacteriuria or candiduria with a Foley catheter in place is usually ineffective and does nothing more than to increase the resistance for microbes.
Reference
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections. Infect Control Hosp Epidemiol. 2010;31(4):319–26.
381.
You are preparing to discharge a 77-year-old, retired nurse from your inpatient service after a 4-day hospitalization for heart failure. She has had two admissions this year. The patient has a long history of hypertension and heart failure. Prior to admission, she reported weight gain, peripheral edema, and decreased exercise tolerance for 3 days. While hospitalized, the patient was given intravenous furosemide 40 mg IV BID with a good response. Her admission medications are amlodipine, 5 mg daily; carvedilol, 12.5 mg twice daily; furosemide, 40 mg once daily; and aspirin, 81 mg daily. You suspect that she is compliant with her medications and diet.
On day of her discharge, her blood pressure is 125/60 mmHg and heart rate is 60 bpm. Her serum sodium is 134 mEq/L, and serum creatinine is 1.6 mg/dL. A 12-lead electrocardiogram demonstrates normal sinus rhythm, with increased voltages in the precordial leads and left-axis deviation. A transthoracic echocardiogram shows a left ventricular ejection fraction of 60 %, with a mildly thickened left ventricle and an enlarged left atrium.
Which of the following should you do next?
A)
Increase the amlodipine dosage to 10 mg once daily.
B)
Increase the furosemide dosage to 40 mg twice daily.
C)
Add digoxin, 0.125 mg daily.
D)
Add lisinopril, 2.5 mg daily.
E)
Increase carvedilol to 25 mg twice daily.
Answer: D
This patient has responded to diuresis but now may need some intervention to prevent further exacerbations of congestive heart failure. Heart failure with normal left ventricle ejection fraction (HFNEF) is prevalent among older women with a history of hypertension. The mainstays of treatment include blood pressure management, rate control, low-salt diet, weight loss, and exercise that has been attempted here and should be reinforced.
A pair of observational studies demonstrated an association of discharge prescriptions for angiotensin-converting enzyme (ACE) inhibitors and lower overall mortality among patients with HFNEF. In this patient, it would seem reasonable to cautiously add an ACE inhibitor. Increasing her furosemide dosage might further exacerbate her possible volume depletion.
References
Ahmed A, Rich MW, Zile M, et al. Renin-angiotensin inhibition in diastolic heart failure and chronic kidney disease. Am J Med. 2013;126:150–61.
Mujib M, Patel K, Fonarow GC, et al. Angiotensin-converting enzyme inhibitors and outcomes in heart failure and preserved ejection fraction. Am J Med. 2013;126:401–10.
382.
A 65-year-old male presents with progressive shortness of breath over the past month. He has a 40 pack-year history of smoking. CT scan of the chest reveals a right middle lobe mass for which he subsequently undergoes biopsy, which reveals adenocarcinoma. Magnetic resonance imaging of the brain reveals a 1 cm tumor in the left cerebral cortex, which is consistent with metastatic disease. The patient has no history of seizures or syncope. The patient is referred to outpatient therapy in the hematology/oncology service as well as follow-up with radiation oncology. The patient is ready for discharge.
Which of the following would be the most appropriate therapy for primary seizure prevention?
A)
Seizure prophylaxis is not indicated.
B)
Valproate.
C)
Phenytoin.
D)
Phenobarbital.
E)
Oral prednisone 40 mg daily.
Answer: A
There is no indication for antiepileptic therapy for primary prevention in patients who have brain metastasis who have not undergone resection. Past studies have revealed no difference in seizure rates between placebo and antiepileptic therapy in patients who have brain tumors. Antiepileptic therapy has high rates of adverse reactions and caution should be exercised in their use.
Reference
Sirven JI, Wingerchuk DM, Drazkowski JF, Lyons MK, Zimmerman RS. Seizure prophylaxis in patients with brain tumors: a meta-analysis. Mayo Clin Proc. 2004;79(12):1489–94.
383.
An 86-year-old man is admitted to a dedicated geriatric acute care unit from home for treatment of nausea and vomiting related to a urinary tract infection. The unit is staffed by a limited group of trained providers. Outcomes for geriatric patients are assumed to be better on this unit.
Which of the following statements does not accurately characterize the benefits of a geriatric acute care unit over a general inpatient ward?
A)
The geriatric acute care unit reduces inhospital functional decline.
B)
Patients who receive care in a geriatric acute care unit have improved functional status 3 months after discharge.
C)
The geriatric acute care unit provides patient-centered care that emphasizes independence.
D)
There is an increased likelihood that patients receiving care in a geriatric acute care unit will be able to return home upon discharge.
E)
The geriatric acute care unit provides intensive review of medical care to minimize the adverse effects of medications.
Answer: A
By 90 days after discharge, functional capacity is the same on geriatric units as it is on nonspecialized acute care units.
Geriatric units have specially prepared environments, specific protocols for enhanced discharge planning, and medical care that is designed to minimize the adverse effects of procedures and medications. The geriatric unit is one of several models of comprehensive inpatient geriatric care that have been developed by geriatrician researchers to address the adverse events and functional decline that often accompany hospitalization.
Despite the assumed benefits, studies so far have been mixed. Several short-term favorable outcomes have been recorded. These include reductions in decline of short-term functionality and readmission. Other long-term endpoints have not yet been demonstrated.
Reference
Landefeld CS, Palmer RM, Kresevic DM, Fortinski RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332:1338–44.
384.
Which of the following bacteria or virus is the most likely etiology of ventilator-associated pneumonia (VAP) in an 82-year-old nursing home patient who is in the medical ICU for congestive heart failure?
A)
Legionella pneumonia
B)
E. Coli
C)
Mycoplasma pneumonia
D)
Respiratory syncytial virus
E)
Staphylococcus aureus
Answer: E
Despite geographical variations, Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species (ESKAPE) pathogens constitute more than 80 % of ventilator-associated pneumonia (VAP) episodes. The organisms “escape” the biocidal actions of many antibiotics and have developed increasing resistance. As antibiotic development declines and resistance rises, healthcare-associated infections remain a constant threat to patient welfare. The ESKAPE pathogens will be of increasing relevance to antimicrobial chemotherapy in the coming years.
References
Park DR. The microbiology of ventilator-associated pneumonia. Respir Care. 2005;50:742–63.
Sandiumenge A, Rello J. Ventilator-associated pneumonia caused by ESKAPE organisms: cause, clinical features, and management. Curr Opin Pulm Med. 2012;18(3):187–93.
385.
Polymerase chain reaction (PCR) bacterial testing has been proven to assist in the diagnosis of what conditions?
A)
Community-acquired pneumonia
B)
Cellulitis
C)
Endocarditis
D)
A and B
E)
A and C
Answer: E
PCR bacterial testing represents a major advance in the rapid diagnosis of infectious diseases. They may be used for blood as well as tissue samples. In a recent study, a broad-range PCR assay diagnosed infective endocarditis with a specificity of 91 %. Sensitivity was 67 %, positive predictive value was 96 %, and negative predictive value was 46 %. In situations where early diagnosis is beneficial or where antibiotics may be given for a long period, it may be cost-effective. So far PCR has shown promise in diagnosing community-acquired pneumonia and endocarditis tissue samples. As costs of PCR testing decrease, further use is anticipated.
References
Barken KB, Haagensen JA, Tolker-Nielsen T. Advances in nucleic acid-based diagnostics of bacterial infections. Clin Chim Acta. 2007;384(1–2):1–11.
Edwards K, Logan J, Langham S, Swift C, Gharbia S. Utility of Real-time amplification of selected 16S rDNA sequences as a tool for detection and identification of microbial signatures directly from clinical samples. J Med Microbiol. 2012;61(5):645–52.
386.
Factors not named in the literature as contributing to higher rates of readmission include:
A)
Differences in patient health status
B)
Discharge planning and care coordination
C)
The availability and effectiveness of local primary care
D)
Threshold for admission in the area
E)
Lack of advance directive
Answer: E
Although implementing increased use of advance directives is thought to be an effective tool in decreasing readmissions, so far they have not been demonstrated to be a significant factor in reducing readmissions. Socioeconomic status, comorbidities, and care coordination remain significant factors in determining whether patients are readmitted to the hospital.
Care transitions on discharge should include coordinated with follow-up care and communication as patients transfer between locations of levels of care. This is a time when medical errors and patient harm are known to be more likely.
Due to increasing financial incentives, many studies are currently looking at readmission prevention strategies. As of yet no single factor has been identified as a primary factor in readmission prevention.
Reference
Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults, J Palliat Med. 2012;15(12):1356–61. Leonard Davis School of Gerontology. Los Angeles: University of Southern California.
387.
Which of the following is a contraindication to the herpes zoster vaccine?
A)
Age younger than 60 years
B)
Chronic post-herpetic neuralgia
C)
History of shingles
D)
Lymphoma
E)
No history of varicella infection
Answer: D
As of 2013 the Advisory Committee on Immunization Practices (ACIP) recommends that herpes zoster vaccine be routinely recommended for adults aged ≥60. The ACIP states that people with primary or acquired immunodeficiency should not receive the vaccine. Immunodeficient states such as lymphoma, AIDS, and leukemia constitute an absolute contraindication to receiving the herpes zoster vaccine.
Both the Centers for Disease Control and Prevention and the ACIP recommend that adults be vaccinated whether or not they report a previous episode of herpes zoster.
There remains a large population of mildly to moderately immunocompromised patients in whom the risk-benefit ratio of vaccination is not well understood.
Reference
Brisson M, Pellissier JM, Camden S, Quach C, De Wals P. The potential cost-effectiveness of vaccination against herpes zoster and post-herpetic neuralgia. Hum Vaccin. 2008;4(3):238–45. Epub 2010 May 25.
388.
A 52-year-old man is evaluated in the hospital. The patient was admitted yesterday for treatment of acute pancreatitis secondary to alcohol abuse. He has remained symptomatic for 24 h.
On physical examination, he is lying on his side with his knees drawn to his chest. Vital signs include a temperature of 38.1 °C (100.6 °F), blood pressure is 145/80 mmHg, pulse rate is 106 beats/min, and respiratory rate is 14 breaths/min. Oxygen saturation on ambient air is 94 %. The oral mucosa is dry. Abdominal examination discloses decreased bowel sounds and epigastric tenderness. The remainder of the examination is normal.
Leukocyte count is 12,000/μL, hematocrit is 39 %, blood urea nitrogen is 68 mg/dL, creatinine is 3.4 mg/dL, and amylase is 657 U/L.
Abdominal ultrasonography shows no gallstones or dilatation of the common bile duct.
Which of the following is most predictive of a poor outcome in this patient?
A)
Amylase level
B)
Anemia
C)
Blood urea nitrogen level
D)
Leukocytosis
E)
Age
Answer: C
Hemoconcentration measurements are the best predictors of higher morbidity and mortality in patients with acute pancreatitis. This includes elevated blood urea nitrogen, serum creatinine, or hematocrit levels. Multiple scoring systems have been devised to measure outcomes in patients with acute pancreatitis. Traditionally utilized, the Ranson criteria rely on parameters that are measured at admission and at 48 h. The Acute Physiology and Chronic Health Evaluation II score is more accurate than the Ranson criteria.
Hemoconcentration may serve as a marker of a capillary leak in acute pancreatitis. This may explain its correlation with mortality. Patients with severe disease tend to have elevated levels of blood urea nitrogen, serum creatinine, and hematocrit. Of these factors, the blood urea nitrogen level is the most accurate for predicting severity. Other factors that predispose patients to a poor prognosis are medical comorbidities, age greater than 70 years, and an increased body-mass index.
There is no correlation between the degree of elevation of the serum amylase level and severity or prognosis of illness in patients with acute pancreatitis. Mild to moderate leukocytosis is common in patients with acute pancreatitis and has no prognostic significance.
Reference
Tenner S, Baillie J, Dewitt J, et al. American College of Gastroenterology guidelines: management of acute pancreatitis. Am J Gastroenterol. 2013;108(9):1400–15.
389.
Which of the following therapies for severe acute respiratory distress syndrome (ARDS) has the strongest evidence for improving survival in large randomized studies?
A)
Steroids
B)
High-frequency oscillation ventilation
C)
Prone positioning
D)
Nebulized beta-adrenergic agonist therapy
E)
Antibiotics
Prone positioning may improve oxygenation in patients who have acute respiratory distress syndrome (ARDS). Several studies have examined strategies to improve outcomes in ARDS with limited positive results. A recent large study of 466 patients found a marked reduction in patients treated with prone positioning. Complications were not different between the two treatments, except for a higher incidence of cardiac arrest in the supine patient group. Another large randomized trial showed potential harm with increased mortality from early use of high-frequency oscillation in ARDS patients. The ARDS network trial of nebulized beta-adrenergic agonist therapy failed to show benefit.
References
Ferguson ND, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med. 2013;3368:795–805.
Matthay MA, et al. (ARDSNet). Randomized, placebo-controlled clinical trial of an aerosolized B2-agonist for treatment of acute lung injury. Am J Respir Crit Care Med. 2011;184:561–8.
Soo Hoo GW. In prone ventilation, one good turn deserves another. N Engl J Med. 2013;368(23):2227–8.
390.
A 62-year-old white male with a past medical history of diabetes presents to the emergency room for chest pain and is admitted. He rules out for a myocardial infarction and will be scheduled for an outpatient stress test.
His labs are remarkable for increased lipid values, particularly an LDL of 213. On discharge, you inform him that he will be starting a high-intensity statin. Which of the following statins, with corresponding dosage regimen, is considered high intensity?
A)
Rosuvastatin 10 mg PO QHS
B)
Pravastatin 20 mg PO QHS
C)
Simvastatin 80 mg PO QHS
D)
Atorvastatin 80 mg PO QHS
Answer: D
Atorvastatin 80 mg daily is considered a high-intensity statin according to current guidelines. Rosuvastatin is considered high intensity in doses 20–40 mg daily. Pravastatin 20 mg is considered low intensity. Simvastatin 80 mg daily is not recommended by the FDA due to increased risk of myopathy, including rhabdomyolysis.
Reference
Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;S0735–1097(13):06028–2.
391.
A 65-year-old male has been admitted with cellulitis which has developed within the past 2 days. He develops the sudden onset of chest pain 2 h ago. Inspiration and movement exacerbate the pain. The patient has not had hemoptysis. He has no history of recent surgery, prolonged periods of immobility, venous thromboembolism, or cancer.
Pulse rate is 102 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 185/96 mmHg. Oxygen saturation is 94 % on room air. The patient is anxious; he is alert and oriented to person, place, and time. Physical examination shows no abnormalities of the heart and lungs.
On laboratory studies, cardiac enzyme levels are within normal limits. Electrocardiography and chest x-ray study show no abnormalities.
Based on the Wells criteria, which of the following best represents the probability of pulmonary embolism in this patient?
A)
Low
B)
Intermediate
C)
High
D)
None
Answer: A
This patient has a low Wells criteria probability for pulmonary embolism. The Wells criteria are used to determine the pretest probability of pulmonary embolism in patients based on history and physical examination. The Wells criteria allow clinicians to determine which patients need further diagnostic or invasive testing.
The Wells criteria assign points for presence of signs, symptoms, and historical factors. This includes tachycardia, hemoptysis, and deep venous thrombosis. Additional points are assigned for a history of venous thromboembolism, active malignancy, and recent immobilization and surgery. The Wells criteria assign points if no other alternative diagnosis is likely. This patient has no historical factors or clinical findings suggestive of pulmonary embolism; his Wells score is 1.5/12.5. His symptoms could be related to musculoskeletal pain, pleurisy, or anxiety.
Reference
Wells PS, Anderson DR, Bormanis J, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795–8.
392.
Brain natriuretic factor (BNP) use in the emergency room has resulted in what endpoints?
A)
Decreased admission rates
B)
Decreased all-cause mortality
C)
Decreased length of stay
D)
Decreased readmissions
E)
A and C
Answer: E
Although widely measured, the benefits of BNP measurements on clinical and quality endpoints remain uncertain. A meta-analysis measuring the effects of BNP testing on clinical outcomes of patients presenting to the emergency department with shortness of breath revealed that BNP testing led to a decrease in admission rates and decrease in mean length of stay. No effect on all-cause hospital mortality was seen.
The BNP test is used as an aid in the diagnosis and assessment of severity of heart failure. The BNP test is also used for the risk stratification of patients with acute coronary syndromes. BNP values may fluctuate due to factors other than heart failure. Lower than predicted levels are often seen in obese patients. Higher levels are seen in those with renal disease, in the absence of heart failure.
It has been suggested that one of the most important use of natriuretic peptides is in helping to establish the diagnosis of heart failure (HF) when the diagnosis is uncertain. In these patients a value less than 100 makes HF unlikely and a value greater than 400 makes HF likely.
References
Lam LL, Cameron PA, Schneider HG, Abramson MJ, Müller C, Krum H. Meta-analysis: effect of B-type natriuretic peptide testing on clinical outcomes in patients with acute dyspnea in the emergency setting. Ann Intern Med. 2010;153(11):728–35.
Maisel A, Mueller C, Adams K Jr, et al. State of the art: using natriuretic peptide levels in clinical practice. Eur J Heart Fail. 2008;10(9):824–39.
393.
An 86-year-old female is admitted from the nursing home with a diagnosis of urinary tract infection and sepsis. She has a history of progressive dementia. She has no known implantable devices or orthopedic, internal hardware.
Blood cultures are drawn which reveal gram-positive rods. Otherwise, no other source of infection is isolated. Urine cultures are negative. In the first 48 h she clinically improves and is back to her baseline mental status.
Which of the following explains the positive blood cultures?
A)
Urinary tract infection
B)
Endocarditis
C)
Skin contamination
D)
Chronic wound infection
Answer: C
There are four bacteria that are common contaminants when blood cultures are positive. They are coagulase-negative staph (gram-positive cocci), Corynebacterium (gram-positive rods), Propionibacterium acnes (anaerobic gram-positive rods), and Bacillus species (anaerobic gram-positive rods). These may be considered to be true pathogens when multiple sites are positive, or the patient has prosthetic implants.
Staphylococcus aureus, Streptococcus species, Enterococcus, Candida, Pseudomonas, and other gram-negative rods-positive bacillus are usually not a contaminant from the skin. In this particular case, without signs of overwhelming sepsis, the gram-positive rod is almost certainly a contaminant.
Reference
Madeo M, Barlow G. Reducing blood-culture contamination rates by the use of a 2 % chlorhexidine solution applicator in acute admission units. J Hosp Infect. 2008;69(3):307–9.
394.
A 62-year-old Caucasian female with a past medical history of diabetes and osteoarthritis was admitted for right hip total arthroplasty. Perioperatively, she received subcutaneous enoxaparin for anticoagulant therapy. She is on the hip fracture service managed by hospital medicine. You are called to see her on day three for the sudden-onset substernal chest pain. She has minimal response to two doses of sublingual nitroglycerin. Initial 12-lead EKG demonstrates inferior lead ST elevation. Stat labs are drawn and reveal elevated troponins at 45 ng/mL. Complete blood count shows a platelet count of 20,000 cells/mcl which were 238,000 cells/mcl at the time of admission.
Which drug is FDA approved and is indicated for management of acute coronary syndrome of this patient?
A)
Oral lepirudin
B)
Oral rivaroxaban
C)
Intravenous enoxaparin
D)
Bivalirudin
E)
Fondaparinux
Answer: D
This patient developed heparin-induced thrombocytopenia (HIT) and an acute STEMI. Bivalirudin is a direct thrombin inhibitor that is FDA approved for the management of patients with acute STEMI secondary to or at risk for HIT. Enoxaparin should be avoided in patients with HIT. Although fondaparinux and lepirudin are used in acute coronary syndromes (ACS), they are not indicated in patients who developed ACS with HIT.
Reference
Bittl JA, Chaitman BR, Feit F, et al. Bivalirudin versus heparin during coronary angioplasty for unstable or postinfarction angina: final report reanalysis of the bivalirudin angioplasty study. Am Heart J. 2001;142:952–9.
395.
Beta-blockers will provide which of the following benefits in elderly patients with congestive heart failure and preserved ejection fractions?
A)
Decreased all-cause mortality
B)
Decreased heart failure re-hospitalization
C)
All of the above
D)
None of the above
Answer: D
Beta-blockers are essential in the treatment of CHF with reduced ejection fraction. However, in patients with CHF with preserved ejection fraction, benefits have not been demonstrated. In a study over 6 years in patients over the age of 65, there was no association with individual endpoints of all-cause mortality or heart failure re-hospitalization, with the use of beta-blockers on discharge.
Reference
Patel K, et al. Beta-blockers in older patients with heart failure and preserved ejection fraction: Class, dosage, and outcomes. Int J Cardiol. 2014;173(3):393–401.
396.
Which of the following is the most common type of preventable adverse event in hospitalized patients?
A)
Adverse drug events
B)
Diagnostic failures
C)
Falls
D)
Technical complications of procedures
E)
Wound infections
Answer: A
The most common adverse event in the hospitalized patient is an adverse drug event (ADE). This occurs in approximately 19 % of hospitalizations. An adverse event is defined as an injury caused by medical management rather than the underlying disease of the patient.
In recent years, there has been increasing focus on the safety of health care provided throughout the world. An Institute of Medicine report identified safety as an essential component of quality in health care. One of the largest studies that has attempted to quantify adverse events in hospitalized patients was the Harvard Medical Practice Study. In that study adverse events included ADE (19 %), wound infections (14 %), technical complications of a procedure (13 %), diagnostic mishaps (15 %), and falls (5 %).
Rounding pharmacists have been shown to greatly reduce preventable adverse drug events. In one study 78 % fewer preventable adverse drug events (ADEs) occurred among patients when a pharmacist participated in weekday medical rounds.
References
Krahenbuhl-Melcher A, Schlienger R, Lampert M, et al. Drug-related problems in hospitals: a review of the recent literature. Drug Saf. 2007;30:397–407.
Kucukarslan SN, Peters M, Mlynarek M, et al. Pharmacists on rounding teams reduce preventable adverse drug events in hospital general medicine units. Arch Intern Med. 2003;163:2014–8.
397.
The most common precipitating trigger for type 1 hepatorenal syndrome is:
A)
Sepsis
B)
Large-volume paracentesis
C)
Renal toxic drugs
D)
Increased diuretic dose
E)
Spontaneous bacterial peritonitis
F)
Urinary tract infection
Answer: E
The hepatorenal syndrome (HRS) can develop spontaneously, or it can be triggered by a precipitating event. Type 1 HRS is characterized by rapidly progressive kidney failure, with a doubling of serum creatinine to a level greater than 2.5 mg/dL or a halving of the creatinine clearance to less than 20 mL/min over a period of less than 2 weeks. The most common precipitating trigger for the type 1 hepatorenal (HRS) syndrome is spontaneous bacterial peritonitis, and this should be considered in any end-stage liver disease (ESLD) patient with hepatorenal syndrome. It is important that this is considered even in the absence of symptoms.
Type 1 HRS occurs in approximately 25 % of patients with SBP, despite rapid resolution of the infection with antibiotics.
Hepatorenal syndrome is primarily induced by renal arterial vasoconstriction. Several conditions that decrease renal blood flow can also induce type 1 hepatorenal syndrome. This includes sepsis, volume depletion, and volume shifts. This may occur when a large-volume paracentesis is undertaken. Adequate plasma expansion should be undertaken when a large-volume paracentesis occurs.
Reference
Betrosian AP, Agarwal B, Douzinas EE. Acute renal dysfunction in liver diseases. World J Gastroenterol. 2007;13(42):5552–9.
398.
A 47-year-old female is admitted to the hospital medicine service for possible osteomyelitis. Past medical history includes hypertension, diabetes mellitus type 2, depression, and hyperlipidemia.
Labs are within normal limits except for an elevated WBC count. As her medication admission orders are being completed, the emergency room physician orders pantoprazole 40 mg PO daily for stress ulcer prophylaxis.
Is the pantoprazole indicated in this patient?
A)
Yes
B)
No
Answer: B
Prophylactic proton pump inhibitor therapy is recommended for any of the following major risk factors: respiratory failure requiring mechanical ventilation (likely for greater than 48 h) or coagulopathy defined as platelet count <50,000, INR >1.5, or a PTT >2× the control (prophylactic or treatment doses of anticoagulants do not constitute a coagulopathy). Additional risk factors warranting stress ulcer prophylaxis are as follows: head or spinal cord injury, severe burn (more than 35 % BSA), acute organ dysfunction, history of GI ulcer/bleeding within 1 year, high doses of corticosteroids, liver failure with associated coagulopathy, postoperative transplantation, acute kidney injury, major surgery, and multiple trauma.
Suppressing the acid production of the stomach may lead to adverse side effects, such as an increased risk of aspiration pneumonia.
References
ASHP Commission on Therapeutics. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. Am J Health Syst Pharm. 1999;56:347–79.
Sessler JM. Stress-related mucosal disease in the intensive care unit: an update on prophylaxis. AACN. Adv Crit Care. 2007;18:199–206.
399.
As the unit medical director, you are asked by the hospital administration to align the current cardiac code policies with evidence-based guidelines. In particular you are asked to reduce the variability that currently occurs.
Which of the following would you suggest?
A)
Increasing the frequency of advanced cardiovascular life support (ACLS) training to become an annual requirement for all clinical practitioners
B)
Interviewing hospital staff using a Delphi method process to enumerate optimal resuscitation practices
C)
Developing resuscitation-specific privileges that are required for all hospital credentialed
D)
Implementation of the American Heart Association (AHA) Get with the Guidelines – Resuscitation program
Answer: D
The American Heart Association (AHA) has put a great deal of effort and expertise into developing evidence-based guidelines for cardiac resuscitation.
The AHA “Get with the Guidelines” program was developed to identify improvement opportunities, allow performance comparison among hospitals, and reduce medical errors through data-driven peer review. The AHA has reviewed the most up-to-date research and scientific publications in developing this program. The program includes guidelines for resuscitation, atrial fibrillation, heart failure, and stroke.
Reference
American Heart Association (AHA) Get with the Guidelines – Resuscitation program 2012. http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/GetWithTheGuidelinesStrokeHomePage/Get-With-Guidelines-Stroke-Overview. Accessed 12 Dec 2014.
400.
The US government’s National Quality Forum-approved methodology for calculating excess 30-day readmission rates includes all of the following except:
A)
Adjustment for clinically relevant patient comorbidities
B)
The patient’s socioeconomic status, specifically federally defined income level below the poverty line
C)
Established 3-year period for which discharges are calculated
D)
Readmissions from all causes to the same or another hospital for patients with specified diagnoses
E)
Minimum number of cases (25) annually for the hospital for each listed
Answer: B
Thirty-day hospital readmissions are common and costly and because they may signal an unnecessary use of resources have been the focus of US health policy interventions to reduce cost.
In March 2010, the comprehensive health reform act, the Patient Protection and Affordable Care Act, went into law. The law established a program to encourage reduction in hospital readmissions, which requires the US Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions.
Thirty-day hospital readmission calculations do not consider socioeconomic status, race or ethnicity, or English language proficiency in the risk adjustments. These are strong risk factors for readmission. Some hospital advocates feel these are factors that clinicians have no control over and should not be considered in penalty determinations.
Reference
CMS.gov. Readmissions reduction program 2013. www.cms.gov/Medicare/Medicare-Feefor- Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed 14 Nov 2014.
401.
Which of the following statements is true comparing dopamine with norepinephrine as a first-line vasotherapy for septic shock?
A)
Increased 28-day overall death rate
B)
Increased death rate among the septic shock group
C)
Increased arrhythmias
D)
Increased use of additional vasopressors
Answer: C
Although there has been a long-standing debate, no single vasopressor has been definitively shown to have a mortality benefit over another in patients with septic shock. To help better answer the question of whether there is a mortality benefit from the initial vasopressor used, the Sepsis Occurrence in Acutely Ill Patients II (SOAP II) study randomized 1679 patients with shock to norepinephrine or dopamine as the initial vasopressor. The study found no difference between the two groups in 28-day mortality, although there were significantly more cardiac arrhythmias in the dopamine group.
References
Havel C, Arrich J, Losert H, Gamper G, Müllner M, Herkner H. Vasopressors for hypotensive shock. Cochrane Database Syst Rev. 2011;5:CD003709.
Marik PE, Mohedin M. The contrasting effects of dopamine and norepinephrine on systemic and splanchnic oxygen utilization in hyperdynamic sepsis. JAMA. 1994;272(17):1354–57.
402.
A 92-year-old female presents with confusion, diaphoresis, and mild shortness of breath. A rapidly performed EKG reveals possible ischemia.
The most common symptom of acute myocardial infarction in patients older than 85 years old is:
A)
Chest pain
B)
Altered mental status
C)
Syncope
D)
Dyspnea
E)
Fever
Answer: D
In patients older than 85 years of age, shortness of breath is the most common symptom during a myocardial infarction. This may be due acute congestive heart failure or anxiety. Elderly, diabetic, and female patients often have atypical anginal symptoms. The initial evaluation of an elderly patient with suspected myocardial ischemia should begin with a high index of suspicion for atypical symptoms.
References
Aronow WS, Epstein S. Usefulness of silent ischemia, ventricular tachycardia, and complex ventricular arrhythmias in predicting new coronary events in elderly patients with coronary artery disease or systemic hypertension. Am J Cardiol. 1990;65:511–2.
Siegel R, Clements T, Wingo M, et al. Acute heart failure in elderly: another manifestation of unstable “angina.” J Am Coll Cardiol. 1991;17:149A.
403.
Which antibiotic may be associated with the greatest odds for ventricular arrhythmia and cardiovascular death in adult patients?
A)
Levofloxacin
B)
Azithromycin
C)
Moxifloxacin
D)
Clarithromycin
E)
Clindamycin
Answer: B
There has been concern that azithromycin may increase the risk of ventricular arrhythmias in susceptible adults. A database analysis found increased arrhythmias and cardiovascular events in patients treated with azithromycin and found no association between clarithromycin or ciprofloxacin and adverse cardiac outcomes.
Many authorities suggest that older individuals and those at high risk for cardiovascular disease may be more vulnerable to adverse effects and should use extra caution when taking this antibiotic.
It has also been suggested that inappropriate use has led to widespread antibiotic resistance and is contributing to the emergence of resistant bacteria.
Azithromycin was developed in 1980 and has been marketed in the United States since 1991. As of 2011, it was the most commonly prescribed antibiotic.
References
Bril F, Gonzalez CD, Di Girolamo G. Antimicrobial agents-associated with QT interval prolongation. Curr Drug Saf. 2010;5(1):85–92.
Ray WA, Murray KT, Hall K, Arbogast PG, Stein CM. Azithromycin and the risk of cardiovascular death. N Engl J Med. 2012;366(20):1881–90.
404.
A 45-year-old male was admitted the prior morning with suspected meningitis. Blood cultures done in the emergency room now reveal Neisseria meningitidis. The patient was started 12 h ago with vancomycin and ceftriaxone. The patient is currently afebrile. Neck stiffness and photophobia have decreased.
When is the appropriate time to remove the patient from isolation?
A)
Discontinuation now
B)
48 h following admission
C)
24 h after antibiotics have been started
D)
Upon complete resolution of clinical symptoms
E)
Upon discharge
Answer: C
For most cases of bacterial meningitis, isolation can be discontinued 24 h after the initiation of antibiotics. It is important to remove isolation when it can be safely done to reduce the psychological stress placed on the patient, improve patient care, and facilitate discharge planning.
Reference
Chaudhuri A, Martinez–Martin P, Martin PM et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008;15(7):649–59.
405.
A pharmaceutical company does not publish inconclusive results of new drug that it is marketing. This is an example of:
A)
Reporting bias
B)
Underestimation
C)
Cofounding
D)
None of the above
Answer: A
Reporting bias continues to be a major problem in the assessment of health-care interventions. Several prominent cases of reporting or publication bias have been described in the literature. These have included trials reporting the effectiveness of antidepressants, class I anti-arrhythmic drugs, and selective COX-2 inhibitors. Studies in which drugs are shown to be ineffective are often not published, delayed, or modified to emphasize the positive results suggested.
In addition, trials with statistically significant findings were generally published in academic journals with higher circulation more often than trials with nonsignificant findings. In general, published evidence tends to overestimate efficacy and underestimate safety risks. The extent of this is often unknown.
References
MacAuley D. READER: an acronym to aid critical reading by general practitioners. Br J Gen Pract. 1994;44:83–5.
Sterne J, Egger M, Moher D. Addressing reporting biases. In: Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions. Chichester: Wiley; 2008. p. 297–334.
406.
Compared with central venous catheters (CVCs), peripherally inserted central catheters (PICCs) are associated with which of the following?
A)
Lower patient satisfaction
B)
Lower cost-effectiveness
C)
Greater risk of bloodstream infection
D)
Greater risk of deep vein thrombosis
Answer: D
PICCs have many advantages over central venous catheters. PICCs are a reliable alternative to short-term central venous catheters, with a lower risk of complications. PICCs have higher patient satisfaction and lower infection rates and are more cost-effective than other CVCs.
However, PICCs are associated with a higher risk of deep vein thrombosis than are central venous catheters (CVCs). This risk is increased in patients who are critically ill or those with a malignancy. Also, to meet the definition of a PICC, the distal tip of the catheter must terminate in the superior vena cava, the inferior vena cava, or the proximal right atrium. Thrombosis may be a result of PICCs being inserted into peripheral veins that are narrower and more likely to occlude in the presence of a catheter than the large veins used for CVCs.
Reference
Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382:311–25.
407.
What is the 30-day hospital readmission rate for patients in the United States?
A)
20 % of all Medicare discharges
B)
10 % of all Medicare discharges
C)
12 % of hospitalized patients covered by commercial payers
D)
20 % of Medicare and commercial payers
E)
None of the above
Answer: A
19.6 % of 11,855,702 Medicare beneficiaries who had been discharged from a hospital in 2003 and 2004 were rehospitalized within 30 days, and 34 % were rehospitalized within 90 days. Since that time small reductions in readmissions have occurred.
Reducing readmission rates is a major priority for hospitals given that the Affordable Care Act (ACA) established a Hospital Readmissions Reduction Program that requires the Centers for Medicare and Medicaid Services (CMS) to reduce payments to hospitals with excessive readmissions.
Not all readmissions are avoidable. But unplanned readmissions frequently suggest breakdowns in continuity of care and unsuccessful transitions of care between settings. Studies suggest that readmissions are not usually tied to medical errors committed during the hospital stay, but rather to social issues, poor follow-up, or the patient’s lack of understanding of post-hospital care.
Reducing readmissions has proven to be difficult. No simple fix has been found. Most gains are seen in institutions that employed a multifactorial approach.
Reference
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–28.
408.
A 27-year-old man presents painful swelling of the right knee and swelling of several fingers. He is otherwise healthy but does recall a severe bout of diarrheal illness about 3–4 weeks prior that spontaneously resolved. He takes no medications and reports rare marijuana use.
On physical exam he has limited motion and swelling of the right knee. You suspect reactive arthritis due to a diarrheal illness.
Which of the following is the most likely etiologic agent of his diarrhea?
A)
Campylobacter jejuni
B)
Clostridium difficile
C)
Escherichia coli
D)
Helicobacter pylori
E)
Shigella flexneri
Answer: E
The most common organism associated with reactive arthritis in diarrheal illness is the Shigella species. Reactive arthritis refers to an acute, nonpurulent arthritis that occurs after an infection elsewhere in the body. In shigella infections, it often presents with lower joint inflammatory arthritis occurring 1–4 weeks after a diarrheal episode. Reactive arthritis may also include uveitis or conjunctivitis, dactylitis, and urogenital lesions. It can occur with yersinia, chlamydia, and, to a much lesser extent, salmonella and campylobacter.
Reference
Hannu T, Mattila L, Siitonen A, Leirisalo-Repo M. Reactive arthritis attributable to Shigella infection: a clinical and epidemiological nationwide study. Ann Rheum Dis. 2005;64(4):594–8.
409.
An 82-year-old nursing home resident has been admitted for melena. You are called to see him the first night because he was found unresponsive in his bed immersed in black stool. His past medical history is remarkable for Alzheimer’s dementia.
On physical his pressure is 85/50 mmHg and heart rate is 130 beats/min. He is transferred to the ICU and a central venous catheter is placed that reveals CVP less than 5 mmHg. Catheterization of the bladder yields no urine. Anesthesiology has been called to the bedside and is assessing the patient’s airway.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
