Transcript 2010 ABIM - American College of Physicians

Self-Evaluation Process
2010 Update in Hospital-Based
Internal Medicine
Module A0-K Version 10-1
Confidential
Only for use at the ACP SWAN Learning Session held October 14-15, 2010.
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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
© 2010 ABIM
Question 1
 Correct Answer: (A) Interferon-gamma Assay
Question 1
 Interferon-gamma Assay:
• Measurement of interferon-γ release by T
lymphocytes specific for M. tuberculosis.
• Can only occur in patients exposed to MTb.
• No false positives in those who have received BCG
vaccine.
Question 1
 Mantoux test (PPD)
• Higher possibility of both false positives and false
negatives.
Question 1




5 mm or more is positive in
•
HIV-positive person
•
Recent contacts of TB case
•
Persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB
•
Patients with organ transplants and other immunosuppressed patients
10 mm or more is positive in
•
Recent arrivals (less than 5 years) from high-prevalence countries
•
Injection drug users
•
Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes,
hospitals, homeless shelters, etc.)
•
Mycobacteriology lab personnel
•
Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged
corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes,
low body weight, etc.)
•
Children less than 4 years of age, or children and adolescents exposed to adults in high-risk
categories
15 mm or more is positive in
•
Persons with no known risk factors for TB
•
(Note: Targeted skin testing programs should only be conducted among high-risk groups)
A tuberculin test conversion is defined as an increase of 10 mm or more within a 2-year period,
regardless of age.
Question 1
Rapid Molecular Detection of Tuberculosis and Rifampin Resistance
N Engl J Med 2010; 363:1005-1015September 9, 2010
• Samples from patients with suspected TB were
assayed for TB and drug resistance with several
different techniques.
• An automated molecular test showed a sensitivity of
98% in smear-positive, culture-positive samples and
a sensitivity of 72–90% in smear-negative, culturepositive samples, and it identified rifampin
resistance >97% of the time.
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
corticosteroid–long-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.
© 2010 ABIM
Question 2 - continued
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 corticosteroid–long-acting
beta-adrenergic blocking agent
© 2010 ABIM
Question 2
 Correct answer: (A) Smoking Cessation
Question 2
 The Lung Health Study
• Participants were followed up to 14.5 years and data
for mortality rates were analyzed in terms of smoking
habits.
• Smoking cessation reduced not only deaths from
COPD but also all-cause mortality.
 Reduced rate of decline of lung function has
been demonstrated with smoking cessation in a
number of studies.
Question 2
 No medication has been shown to reduce the
progressive decline in lung function in COPD.
 Oral mucolytics may be beneficial in patients
with viscous sputum, but have no long term
benefit.
 Bronchodilators do reduce symptoms and
hospitalizations, as well as overall health status.
 Inhaled corticosteroids have a limited role in the
management of COPD and particularly in the
elderly come with undesirable side effects.
Question 3
A 74-year-old man who is hospitalized with stage IV non–small
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
© 2010 ABIM
Question 3
 Correct Answer: (D) The type of procedure.
Question 3
 The Joint Commission’s 2009 National
Patient Safety Goals for Hospitals

Improve the accuracy of patient identification

Improve the effectiveness of communication among caregivers

Improve the safety of using medications

Reduce the risk of health care–associated infections

Accurately and completely reconcile medications across the continuum of
care

Reduce the risk of patient harm resulting from falls

Encourage patients’ active involvement in their own care as a patient safety
strategy

Identify safety risks inherent in the organization’s patient population

Improve recognition and response to changes in a patient’s condition

Universal Protocol: Conducting a pre-procedure verification process,
marking the procedure site, performing a time-out
Question 3
 Pre-procedure “time out”
 The Joint Commission Board of Commissioners
originally approved the Universal Protocol for
Preventing Wrong Site, Wrong Procedure and
Wrong Person Surgery™ in July 2003, and it
became effective July 1, 2004 for all accredited
hospitals, ambulatory care and office-based
surgery facilities.
Question 4
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).
© 2010 ABIM
Question 4 - continued
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
© 2010 ABIM
Question 4
 Correct Answer: (A) Discharge the patient
without further testing.
Question 4
 Attempt to stratify risk for arrhythmia or sudden
death.
 Several recent studies have tried and failed to
define prediction rules with sufficient sensitivity
to detect life-threatening causes. While no rule
has been validated for widespread use, the
literature has identified several factors
associated with a significantly increased risk of
adverse events.
Question 4
 Risk Factors for Short-Term Adverse Outcomes from Syncope
(American College of Emergency Physicians)
• Abnormal ECG
• Acute ischemia
• New changes on ECG
• Any rhythm other than sinus
• Significant conduction abnormalities
• Hematocrit <30%
• History of heart failure, coronary artery disease, or structural
heart disease
• Older age
Question 4
 Other options were…
• Carotid Duplex
• CT Head
• Admit for OBS and tele overnight.
Question 5
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
© 2010 ABIM
Question 5
 Correct Answer: (C) Request an ethics
consultation.
Question 5
 DNR/DNI
• To be honored as per the patient record.
• Open communication with patients and family about
the decision.
• Must be wary of conflict of interest in family members
who may stand to benefit when the patient’s best
interest or expressed wishes are not followed.
Question 6
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.
© 2010 ABIM
Question 6 - continued
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
© 2010 ABIM
Question 6
 Correct Answer: (C) Flow chart the current
process and redesign the work to eliminate
rework, defects, and other waste.
Question 6
 Martin LA, Neumann CW, Mountford J,
Bisognano M, Nolan TW. Increasing Efficiency
and Enhancing Value in Health Care: Ways to
Achieve Savings in Operating Costs per Year.
IHI Innovation Series white paper. Cambridge,
Massachusetts: Institute for Healthcare
Improvement; 2009. (Available on www.IHI.org)
Question 6
 Fundamental workflow design can be a positive,
sustainable, cost-effective strategy to manage
physician workload. Attention must be paid to
preserving or enhancing patient, staff, and
physician satisfaction as waste is removed in the
health care processes.
Question 7
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
© 2010 ABIM
Question 7
 Correct Answer: (A) Recurrent Ischemia.
Question 7
 N Engl J Med. 2009 May 21;360(21):2165-75.
Early versus delayed invasive intervention in acute
coronary syndromes.
Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP,
Faxon DP, Afzal R, Chrolavicius S, Jolly SS, Widimsky
P, Avezum A, Rupprecht HJ, Zhu J, Col J, Natarajan MK,
Horsman C, Fox KA, Yusuf S; TIMACS Investigators.
Question 7
 ACS without ST elevation.
 Early invasive strategy (within 24 hours)
• No benefit in preventing death, MI, or stroke over
delayed intervention (median time 50 hours).
• Modest benefit in decreasing occurrence of recurrent
ischemia.
Question 8
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
© 2010 ABIM
Question 8
 Correct Answer: (C) Vasopressor Therapy
Question 8
 Lessest of Three Evils
• Fluid Resuscitation with Colloid
• Increased risk for renal replacement therapy.
Question 8
 Lessest of Three Evils
• Intensive Insulin Therapy to Maintain Euglycemia
• Initially favored in the peri-op and ICU setting
• Numerous studies have failed to show benefit.
Question 8
 Lessest of Three Evils
• Vasopressor Therapy.
• As a general concept, on occasion simply is
required when volume expansion with crystalloid is
ineffective in improving tissue perfusion.
Question 9
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.
© 2010 ABIM
Question 9 - continued
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
© 2010 ABIM
Question 9
 Correct Answer: (D) Methadone
Question 9
 J Interv Card Electrophysiol. 2010 Jun;28(1):1922. Epub 2010 Feb 23.
 Ventricular arrhythmias in patients treated
with methadone for opioid dependence.
 Hanon S, Seewald RM, Yang F, Schweitzer P,
Rosman J.
 Division of Cardiology, Beth Israel Medical
Center, University Hospital and Manhattan
Campus for the Albert Einstein College of
Medicine, New York, NY, USA.
[email protected]
Question 9
 Case report of 12 cases of apparently
methadone-induced TDP
 Related to Q-T prolongation
Question 9
 Other options:
•
•
•
•
Alcohol
Benzos
Cannabis
Oxycodone
Question 10
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.
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
© 2010 ABIM
Question 10
 Correct Answer: (D) One year
Question 10
 Dual anti-platelet therapy post-stent: minimum of one month for
bare metal stent and minimum of one year for drug-eluting stent.
 Elective noncardiac surgery should be delayed for at least 6
weeks following placement of a bare metal stent and for at least
1 year following a drug-eluting stent to allow for completion of the
patient’s dual antiplatelet regimen.
 No role for routine stress testing or even ECGs post-stent
placement, unless change in symptoms, physical exam, or
medications.
 The risk of stent thrombosis is approximately 0.7% and is
increased with the premature discontinuation of dual antiplatelet
therapy (aspirin and clopidogrel). Stent
 thrombosis is associated with a short-term mortality rate of 40%.
Question 11
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.
© 2010 ABIM
Question 11 - continued
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
© 2010 ABIM
Question 11
 Correct Answer: (D) Cardiac Resynchronization
Therapy
Question 11
 A meta-analysis found a 37% reduction in
hospitalizations and a 22% reduction in all-cause
mortality in patients with left ventricular systolic
dysfunction, prolonged QRS duration, and NYHA class
III or IV symptoms who received CRT.
 Interventricular conduction delay is common in patients
with heart failure and results in poor coordination of
ventricular contraction, which contributes to the
hemodynamic consequences of chronic left ventricular
systolic dysfunction.
Question 11
Question 11
 Other morbidity decreasing modalities.
Question 12
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%.
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
© 2010 ABIM
Question 12
 Correct Answer: (A) Document the use of or
contraindication to ACE inhibitors.
Question 12
 Four Core Measures in HF Admissions:
•
•
•
•
Measuring and documenting LVEF
ACE/ARB for impaired LVEF
Adult smoking cessation counseling and advice
Discharge instructions
Question 13
A 65-year-old woman is admitted to the intensive care unit
because of community-acquired 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
© 2010 ABIM
Question 13
 Correct Answer: (B) Norepinephrine
Question 13
 N Engl J Med. 2010 Mar 4;362(9):779-89.
Comparison of dopamine and norepinephrine in the treatment
of shock.
De Backer D, Biston P, Devriendt J, Madl C, Chochrad D, Aldecoa
C, Brasseur A, Defrance P, Gottignies P, Vincent JL; SOAP II
Investigators.
Although there was no significant difference in the rate of death between
patients with shock who were treated with dopamine as the first-line
vasopressor agent and those who were treated with norepinephrine, the
use of dopamine was associated with a greater number of adverse
events.
Question 13
 Vasopressor therapy with norepinephrine,
vasopressin, or dopamine may be necessary
when appropriate fluid challenge fails to restore
adequate tissue perfusion or during lifethreatening hypotension, but no trials have
established a single superior approach to
handling initial vasopressor choice.
Question 14
An 85-year-old woman who has osteoporosis is admitted to
the hospital because of midscapular back pain. Neurologic
examination is otherwise normal. Computed tomography
reveals a thoracic vertebral compression fracture in one
vertebra, without cord compression.
Compared with placebo, which of the following is the most
likely outcome of treatment with vertebroplasty for
osteoporotic compression fractures?
 (A) No better pain control
 (B) Decreased disability
 (C) Improved physical functioning
 (D) Improved quality of life
 (E) Prevention of future osteoporotic fractures
© 2010 ABIM
Question 14
 Correct answer: (A) No better pain control
Question 14
 N Engl J Med 2009; 361:569-579
 A Randomized Trial of Vertebroplasty for
Osteoporotic Spinal Fractures
 Kallmes DF et al.
 Improvements in pain and pain-related
disability associated with osteoporotic
compression fractures in patients treated with
vertebroplasty were similar to the
improvements in a control group
Question 15
A previously healthy 65-year-old man was in a motor vehicle
collision and underwent surgical repair of a hip fracture 24
hours ago. After the procedure, the patient receives
acetaminophen and morphine.
The patient is oriented to person but not the situation.
Temperature is 38.4 C (101.2 F), pulse rate is 110 per minute,
respirations are 18 per minute, and blood pressure is
150/90 mm Hg. The lungs are clear; no signs of infection are
present. The patient has a mild resting tremor. Physical
examination is otherwise normal.
© 2010 ABIM
Question 15 - continued
Which of the following is the most important factor to consider
in the differential diagnosis?




(A) Alcohol withdrawal
(B) Drug-induced delirium from morphine
(C) Pneumonia
(D) Wound infection
© 2010 ABIM
Question 15
 Correct answer: (A) Alcohol withdrawal
Question 15
 Timing and spectrum of abnormalities is
best explained by alcohol withdrawal
 8% of the general hospital population at
risk for alcohol withdrawal (Drug Alcohol
Rev 1995;14:49–54. The incidence of
alcohol-related problems and the risk
of alcohol withdrawal in a general
hospital population. Foy A, Kay J.)
Question 16
A 28-year-old woman who has a history of cocaine use comes
to the emergency department because of chest pain. She is
otherwise healthy and has no history of tobacco or alcohol use.
Serum creatine kinase and cardiac troponin are normal, as is
electrocardiogram.
Which of the following is most appropriate for this patient?
 (A) Treat with aspirin and a benzodiazepine and observe
until chest pain resolves
 (B) Treat with aspirin and a beta-adrenergic blocking agent
and order complete cardiac enzyme studies, then
discharge after pain resolves
 (C) Treat with aspirin alone and order complete cardiac
enzyme studies, then order a stress test
before discharge
© 2010 ABIM
Question 16
 Correct answer: (A) Treat with aspirin and a
benzodiazepine and observe until chest pain
resolves
 Beta-blockade is contraindicated due to risk for
unbalanced alpha-adrenergic activity
 Stress testing would be very unlikely to add
useful clinical information
 Morgan, JP. Cardiovascular complications of
cocaine abuse. In: UpToDate, Basow, DS (Ed),
UpToDate, Waltham, MA, 2010.
Question 17
A correlation exists between the use of proton pump inhibitors
(PPIs) and which of the following?
Clostridium difficile Hospital-acquired Osteoporosiscolitis
pneumonia
related fracture
(A)
No
No
No
(B)
Yes
Yes
No
(C)
No
Yes
Yes
(D)
Yes
Yes
Yes
© 2010 ABIM
Question 17
 Correct answer: (D) All three diagnoses
Question 17
 PPI correlation to C. difficile colitis is
least clear
 JAMA. 2005;294:2989-2995.
 Use of Gastric Acid–Suppressive
Agents and the Risk of CommunityAcquired Clostridium difficile–
Associated Disease
 Dial S, Delaney JAC, Barkun AN,
Suissa S.
Question 17
 PPIs moreso than histamine-2
receptor antagonists are correlated
with pneumonia
 JAMA. 2009;301(20):2120-2128.
 Acid-Suppressive Medication Use
and the Risk for Hospital-Acquired
Pneumonia
 Herzig SJ, Howell MD, Ngo LH,
Marcantonio ER.
Question 17
 Use of PPIs was not associated with hip fractures
but was modestly associated with clinical spine,
forearm or wrist, and total fractures
 Arch Intern Med. 2010;170(9):765-771.
 Proton Pump Inhibitor Use, Hip Fracture, and
Change in Bone Mineral Density in
Postmenopausal Women: Results From the
Women's Health Initiative
 Gray SL, LaCroix AZ, Larson J, Robbins J,
Cauley JA, Manson JE, Chen Z.
Question 17
 Increased risk of adverse events after acute coronary syndrome is
thought to be due to attenuation of clopidogrel effect

Unclear if choice of PPI matters
 JAMA. 2009;301(9):937-944.
 Risk of Adverse Outcomes Associated With Concomitant Use of
Clopidogrel and Proton Pump Inhibitors Following Acute
Coronary Syndrome

Maddox TM, Wang L, Fihn SD, Jesse RL, Peterson ED,
Ho PM,
Rumsfeld JS.
Question 18
A 38-year-old man who works at a beef processing plant has
fever, headache, and swollen erythematous hands, which
have small painless papules. The papules progress to central
vesicles, then turn necrotic with a painless black eschar.
Which of the following is the most likely diagnosis?




(A) Bullous pemphigoid
(B) Cutaneous anthrax
(C) Methicillin-sensitive Staphylococcus aureus infection
(D) Pasteurella infection
© 2010 ABIM
Question 18
 Correct answer: (B) Cutaneous anthrax
Question 18
 Anthrax classically presents after exposure to
certain animal tissues as lesions of face, neck or
hands progressing to vesicles and then painless
eschar
 Wilson KH. Clinical manifestations and
diagnosis of anthrax. In: UpToDate, Basow,
DS (Ed), UpToDate, Waltham, MA, 2010.
Question 18
 Pasteurella causes soft tissue infections, septic
arthrits, osteomyelitis, meningitis, pneumonia,
endocarditis, ocular infection, and
intraabdominal infection.
 Cat bite or scratch
 Weber DJ, Rutala WA, Kaplan SL. Pasteurella
infections. In: UpToDate, Basow, DS (Ed),
UpToDate, Waltham, MA, 2010.
 MRSA presents as cellulitis, folliculitis, etcetera
 Risk for Bullous pemphigoid is advancing age
Question 19
A 44-year-old male hospital medicine physician does not use full
barrier precautions when inserting central lines and does not wear
gloves or isolation gowns consistently when visiting patients who
are in isolation. He is aware of standard infection control
procedures and has been counseled repeatedly by the nursing
and medical staff.
Which of the following is the best course of action?





(A) Support the physician's decision
(B) Practice informal counseling
(C) Invite the physician to a seminar on blood stream infections
(D) Redesign isolation setups
(E) Inform the physician that you are required to report his
actions
© 2010 ABIM
Question 19
 Correct answer: (E) Inform the physician that
you are required to report his actions
Question 19
 AMA Code of Medical Ethics Opinion
9.031 - Reporting Impaired,
Incompetent, or Unethical Colleagues
 “When the inappropriate conduct of a
physician continues despite the initial
report(s), the reporting physician
should report to a higher or additional
authority”
Question 20
A 68-year-old man had a myocardial infarction three months ago
and underwent implantation of a cardioverter–defibrillator (ICD) one
month ago. Today, he comes to the emergency department after an
ICD shock.
Pulse rate is 88 per minute, respirations are 20 per minute, and
blood pressure is 102/54 mm Hg. Cardiac impulse is displaced
laterally; S1 and S2 are normal. The lungs are clear.
Which of the following is the prognosis for patients such as this who
have heart failure and an ICD in place for primary prevention and
have had a shock delivered by the ICD compared with similar
patients who do not receive such shocks?
 (A) Comparable risk of death
 (B) Significantly decreased risk of death
 (C) Significantly increased risk of death
© 2010 ABIM
Question 20
 Correct answer: (C) Significantly increased risk
of death
Question 20
 Risk of death is about 4 times higher in 4 years
of followup
 N Engl J Med 2008; 359:1009-1017
 Prognostic Importance of Defibrillator
Shocks in Patients with Heart Failure
 Poole JE, Johnson GW, Hellkamp AS, Anderson
J, Callans DJ, Raitt MH, Reddy RK, Marchlinski
FE, Yee R, Guarnieri T, Talajic M, Wilber DJ,
Fishbein DP, Packer DL, Mark DB, Lee KL,
Bardy GH.
Question 21
A 72-year-old woman is evaluated for complicated cellulitis.
History is remarkable for an allergy to vancomycin.
Temperature is 39.0 C (102.2 F), pulse rate is 100 per minute,
respirations are 16 per minute, and blood pressure is
100/68 mm Hg. Daptomycin is begun.
The pharmaceutical manufacturer specifically advises that
which of the following tests be performed weekly for patients
who are treated with daptomycin for cellulitis complicated by
methicillin-resistant Staphylococcus aureus?
 (A) Complete blood count
 (B) Serum ALT
 (C) Serum calcium
 (D) Serum creatine kinase
 (E) Serum creatinine
© 2010 ABIM
Question 21
 Correct answer: (D) Serum creatine kinase
Question 21
 Weekly CPK recommended by the
manufacturer and other authorities
 J Antimicrob Chemotherapy 55(4), 599600.
 Severe myopathy and possible
hepatotoxicity related to daptomycin
 Echevarria K, Datta P, Cadena J, Lewis
JS.
Question 22
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
© 2010 ABIM
Question 22
 Correct answer: (D) Lymphoma
Question 22
 World Health Organization (WHO),
Centers for Disease Control (CDC)
list conditions with “impaired cellular
immunity” as contraindications to live
vaccines
Question 23
An asymptomatic 27-year-old man who emigrated from India
three years ago undergoes tuberculin skin testing as part of a
pre-employment physical examination. He will be working as
an aide in the emergency department of a hospital. He thinks
that he received the Bacillus Calmette-Guérin vaccination as a
child. He has never been hospitalized, takes no medications,
smokes one pack of cigarettes daily, and drinks alcoholic
beverages occasionally. He is HIV negative.
Physical examination is normal. Tuberculin skin test
(PPD, 5 TU) shows 11 mm of induration at 48 hours, and a
follow-up chest radiograph is normal. Serologic test for HIV is
negative.
© 2010 ABIM
Question 23 - continued
Based on the patient's results from the tuberculin skin test,
which of the following should you recommend now?




(A) No further testing
(B) Repeat tuberculin skin test
(C) Sputum stain and culture for acid-fast bacilli
(D) Treatment for latent tuberculosis
© 2010 ABIM
Question 23
 Correct answer: (D) Treatment for latent tuberculosis
Question 23
 Disregard BCG status
 Recipients are usually from high-incidence areas
 If x-ray positive or symptoms present, perform sputum
analysis & consider treatment for active TB
 MMWR Recomm Rep, 2005, 30; 54(17):1-141.
 Centers for Disease Control and Prevention,
Guidelines for Preventing the Transmission
of Mycobacterium tuberculosis in HealthCare Settings, 2005
Question 23
 Blood assay for M. tuberculosis (BAMT) is a
specific method of diagnosis, but not currently
listed as a recommendation
 Pai M, Menzies R. Diagnosis of latent tuberculosis
infection in adults. In: UpToDate, Basow, DS (Ed),
UpToDate, Waltham, MA, 2010
 >20% of BCG recipients after age 1 have
positive PPD >10 year later
 Int J Tuber Lung Dis 2006; 10:1. False positive
tuberculin skin tests: What is the absolute effect of
BCG and non-tuberculous mycobacteria? Farhat, M,
Greenaway, C, Pai, M, Menzies, D.
Question 24
A healthy 32-year-old woman is admitted to the hospital after
briefly losing consciousness and suffering a closed head injury
during a fall at a party. Current medications are loratadine and
an oral contraceptive.
The patient is oriented and cooperative but moderately
intoxicated. Pulse rate is 78 per minute, respirations are
16 per minute, and blood pressure is 112/70 mm Hg.
A laceration and a right temporal hematoma are noted.
Neurologic examination is negative for motor, sensory reflex,
and cranial nerve abnormalities. Computed tomography of the
head is normal.
© 2010 ABIM
Question 24 - continued
Laboratory studies:
Serum electrolytes
INR
Serum aminotransferase
ALT
AST
Blood ethanol
Normal
Normal
60 U/L
47 U/L
205 mg/dL
Which of the following interventions is the most feasible and
effective strategy for addressing alcohol abuse?
 (A) Court-mandated attendance at Alcoholics Anonymous (AA)
 (B) Family intervention
 (C) Disulfiram
 (D) Screening, brief interventions, and referral to treatment
(SBIRT)
 (E) Referral to a social worker
© 2010 ABIM
Question 24
 Correct answer: (D) Screening, brief
interventions, and referral to treatment (SBIRT)
Question 24
 No support in literature for the other foils
 Lancet 2004; 364: 1334–39
 Screening and referral for brief intervention
of alcohol-misusing patients in an
emergency department: a pragmatic
randomised controlled trial
 Crawford MJ, Patton R, Touquet R, Drummond
C, Byford S, Barrett B, Reece B, Brown A,No
JAH.
Question 25
A 78-year-old woman came to your office last week because
she had had fever for one week, cough for two days, and
dyspnea for one day. Blood cultures taken at the time have
grown methicillin-resistant Staphylococcus aureus (MRSA).
Today, temperature is 39.0 C (102.2 F), pulse rate is
130 per minute, respirations are 30 per minute, and blood
pressure is 90/52 mm Hg. Tubular breath sounds and crackles
are audible in the left lower lobe. Cardiac examination reveals
tachycardia and a grade 3/6 systolic murmur at the left sternal
border and apex; S1 and S2 are normal.
© 2010 ABIM
Question 25 - continued
For which of the following reasons is daptomycin
contraindicated for the treatment of this patient's MRSA
pneumonia?
 (A) MRSA has a high level of resistance to daptomycin
 (B) Daptomycin triggers parenchymal hemorrhage in lung
tissue
 (C) Daptomycin diffuses poorly into the blood supply of the
lungs
 (D) Daptomycin interacts with pulmonary surfactant,
resulting in inhibition of antibacterial activity
© 2010 ABIM
Question 25
 Correct answer: (D) Daptomycin interacts with
pulmonary surfactant, resulting in inhibition of
antibacterial activity
Question 25
 J Infect Dis. 2005 Jun
15;191(12):2149-52. Epub 2005 May
5.
 Inhibition of daptomycin by pulmonary
surfactant: in vitro modeling and clinical
impact.
 Silverman JA, Mortin LI, Vanpraagh AD, Li T,
Alder J.