Quizz 1

A 33-year-old woman with sickle cell disease reports several days of bilateral upper- and lower-extremity pain. She denies recent fevers,

chills, chest pain, or shortness of breath. She has a temperature of 37.2°C, a blood pressure of 135/80 mm Hg, a heart rate of 110 beats

per minute, and a respiratory rate of 20 breaths per minute. Initial laboratory studies and a chest radiograph are unremarkable.

The patient is hospitalized for pain control. Shortly after admission, she develops increasing shortness of breath and a cough. Her

temperature rises to 38.9°C, and she now requires 4 liters of supplemental oxygen to maintain an oxygen saturation above 90%.

A repeat chest radiograph reveals bilateral, patchy, lower-lobe predominant pulmonary opacities.

In addition to administering intravenous fluids, which one of the following management approaches is most appropriate for this patient?

• Administer hydroxyurea

• Initiate ketamine

• Initiate a heparin infusion

• Initiate antibiotic treatment

Answer explanation

The primary areas of focus in treating acute chest syndrome in a patient with sickle cell disease should be adequate pain control, fluid management to prevent hypovolemia, blood transfusion, oxygen supplementation, and antibiotic therapy.

An 85-year-old woman is diagnosed with influenza A infection and treated with a

course of oseltamivir. One week after her initial onset of influenza symptoms, she

is hospitalized with worsening symptoms. She reports that her viral symptoms

never completely abated and that during the past 2 days, she has had a

recurrence of fever as well as increasing sputum production and dyspnea. Before

the influenza, she was healthy with no recent hospitalizations.

She currently has a temperature of 38.4°C, a heart rate of 96 beats per minute, a

respiratory rate of 24 breaths per minute, and an oxygen saturation of 92% on

2 liters of oxygen via nasal cannula. She has bilateral wheezes that are worse in

the right lung fields. She has bronchial breath sounds in the posterior mid-lung zone on the right.

Which one of the following initial intravenous antibiotic regimens is most

appropriate for this patient?

• Vancomycin

• Daptomycin, ceftriaxone, and azithromycin

• Vancomycin, ceftriaxone, and azithromycin

• Ceftriaxone and azithromycin

• Vancomycin, piperacillin-tazobactam, and levofloxacin

Answer explanation

The addition of vancomycin to cover methicillin-resistant S. aureus (MRSA) is not recommended unless the patient has relevant risk factors, such as prior respiratory isolation of MRSA, recent hospitalization with parenteral antibiotics, or other locally validated risk factors for MRSA. Although a history of recent influenza infection was previously considered reason enough to initiate empiric MRSA treatment, current data suggest that it is not by itself a strong enough risk factor to warrant empiric MRSA treatment in most cases.

However, given that S. aureus pneumonia — including MRSA — is more common after influenza, empiric coverage may be reasonable to

consider if the patient is extremely ill or has other MRSA risk factors, neither of which is the case here

A 57-year-old man with a history of hyperlipidemia presents with progressive bilateral edema that he first noticed 6 weeks ago. Initially,

the edema would improve in the mornings, but now it persists throughout the day. The patient reports that he was previously able to

walk a mile without stopping but can now walk only one block because of shortness of breath, which subsides with rest. He also

describes shortness of breath at night, which improves when he sits up. He is a current smoker with a 25-pack-year history who binge

drinks on the weekends. He currently takes simvastatin 20 mg daily.

On physical examination, he is afebrile and has a blood pressure of 138/73 mm Hg, a heart rate of 73 beats per minute, a respiratory

rate of 18 breaths per minute, and an oxygen saturation of 97% while he breathes ambient air. His BMI is 31.

Cardiac examination reveals a regular rhythm without rub or gallop. The point of maximal impulse is laterally displaced. Jugular venous

pressure is mildly elevated. Breath sounds are diminished with bibasilar crackles and an occasional expiratory wheeze. The abdomen is

soft but mildly distended. There is no hepatosplenomegaly and no fluid wave. There is 2+ peripheral pitting edema to both calves.

An electrocardiogram reveals sinus rhythm with nonspecific ST/T-wave changes.

Which one of the following diagnostic tests is most appropriate for this patient?

• Ultrasound of the right upper quadrant

• Pulmonary function tests

• Lower-extremity venous duplex ultrasound

• Echocardiogram

• Exercise tolerance test

Answer explanation

This patient presents with new-onset heart failure; several of his physical examination findings (bibasilar crackles, elevated jugular venous pressure, bilateral edema) are consistent with volume overload. Coronary artery disease (CAD) is the underlying cause of heart

failure in roughly two-thirds of patients with reduced systolic function; this patient’s alcohol consumption also places him at increased risk for alcohol-induced cardiomyopathy. The 2022 American College of Cardiology/American Heart Association guidelines for the management of heart failure include a class I recommendation for echocardiography in patients suspected of having heart failure.

A 25-year-old otherwise healthy man is hospitalized for acute pancreatitis. He says he does not use tobacco but reports occasional alcohol use (no more than two drinks per week). He is married and has two children.

CT of the abdomen and pelvis confirms uncomplicated acute pancreatitis, but no gallstones, with mild dilation of the pancreatic duct (5 mm). He improves during the next 2 days with intravenous hydration and no longer requires opioids for pain control.

Which one of the following short-term nutritional recommendations is most appropriate for this patient?

• Bland diet

• Parenteral nutrition

• Low-fat diet

• Enteral nutrition via nasojejunal tube

• Nil Per Mouth

Answer explanation

The early introduction of a low-fat diet is the optimal approach for patients recovering from mild acute pancreatitis. Early introduction of a full diet has been associated with recurrence of pain.

Key learning point: The most appropriate nutritional management recommendation for patients recovering from mild acute pancreatitis is a low-fat diet.

A 47-year-old man is evaluated in the emergency department for severe epistaxis and oral mucosal bleeding. He has developmental

delay but no significant medical history and is taking no medications except for a daily multivitamin.

His international normalized ratio (INR) is 10.2, and his partial-thromboplastin time is >300 seconds (reference range, 22.1–35.1). His

liver function test results are normal. He is given 4 units of fresh frozen plasma and 10 mg of vitamin K liquid by mouth.

The following day, his INR is 1.9. However, 2 days later while still in the hospital, he develops gross hematuria and his INR is 4.8. At that

time, additional laboratory evaluation shows decreased levels of factors II, VII, IX, and X. His D-dimer, thrombin time, and levels of

factors V, VIII, XI, and XII are normal. Mixing studies are negative for a prothrombin time inhibitor, a partial-thromboplastin time

inhibitor, and lupus anticoagulant. He is managed with further fresh frozen plasma transfusions and daily vitamin K. His coagulopathy improves over several months with ongoing tapering of vitamin K therapy.

Which one of the following diagnoses is the most likely cause of this patient’s coagulopathy?

• Hemophilia A

• Superwarfarin (rat poison) intoxication

• Hemophilia B

• Acquired von Willebrand syndrome

• Warfarin overdose

Answer explanation

Superwarfarins are high-potency vitamin K antagonists that are used as rat poisons. They are more potent and longer acting than warfarin. Superwarfarin intoxication leads to a life-threatening coagulopathy characterized by increases in the international normalized ratio (INR), prothrombin time, and partial-thromboplastin time, and corresponding decreases in the vitamin K-dependent coagulation factors II, VII, IX, and X. Patients with superwarfarin intoxication can be managed with fresh frozen plasma and vitamin K, followed by a

several months of tapering vitamin K therapy until the agent is eliminated from the body.

Key learning point: The cause of a prolonged, reversible coagulopathy characterized by a high international normalized ratio and deficiencies of factors II, VII, IX, and X should raise suspicion for superwarfarin (rat poison) intoxication.

A 25-year-old woman presents to the emergency department with sudden-onset pleuritic chest pain and dyspnea. She has noticed pain

and swelling in her left lower leg during the past several days. She has no preexisting medical conditions, and her only medication is an

oral contraceptive.

On examination, the patient is afebrile. She has a blood pressure of 105/70 mm Hg, a heart rate of 115 beats per minute, a respiratory

rate of 22 breaths per minute, and an oxygen saturation of 93% while she is breathing ambient air. She appears mildly uncomfortable

but otherwise not acutely ill. Her lungs are clear on auscultation. On cardiac examination, her rhythm is regular, and she has no murmurs, rubs, or gallops. She has 2+ lower-extremity edema on the left. She is up to date with COVID-19 vaccinations, and testing for SARS-CoV-2 is negative. An electrocardiogram documents sinus tachycardia without any other abnormalities. A urine pregnancy test is negative.

Which one of the following diagnostic tests is most appropriate for this patient?

• Myocardial perfusion stress testing

• Serum D-dimer testing

• CT pulmonary angiography

• Transthoracic echocardiogram

• Magnetic resonance angiography of the chest

Answer explanation

This patient presents with signs and symptoms that are consistent with pulmonary embolism (PE). Her pretest probability of PE is high, as indicated by a Wells score of 7.5. The criteria for calculating a Wells score are listed below. This patient meets the first three criteria.

• Signs and symptoms of deep-vein thrombosis (3 points)

• Likelihood of an alternative diagnosis that is less than or equal to that of PE (3 points)

• Heart rate >100 beats per minute (1.5 points)

• Immobilization for ≥3 days or surgery in the past 4 weeks (1.5 points)

• Previous deep-vein thrombosis or PE (1.5 points)

• Hemoptysis (1 point)

• Malignancy treated in the past 6 months (1 point)

A cumulative Wells score >6 is associated with high risk for PE. The most appropriate diagnostic test in high-risk cases is CT pulmonary angiography.

Key learning point: In a patient with a high pretest probability of pulmonary embolism, the diagnostic test of choice is CT pulmonary angiography.

A 70-year-old man reports a one-week history of dyspnea and cough that is productive of yellow-brown sputum but no blood. The

patient reports that he has also had fevers during the past week but no chills or weight loss. He was born in the United States and has

not recently traveled. He had a stroke 3 years ago. He does not smoke or use illicit drugs. His temperature is 41°C. His heart rate is 115 beats per minute, and his blood pressure is 110/54 mm Hg. His peripheral oxygen saturation is 88% while he is breathing ambient air and 93% while he is receiving supplemental oxygen (2 liters per minute via nasal cannula).

On examination, the patient is mildly confused, oriented to person and place but not to time. Chest examination shows tachycardia and

increased tactile fremitus with associated diminished breath sounds and egophony in the lower portion of the right posterior lung field. Chest radiography reveals a right lower lobe consolidation and a small right-sided pleural effusion.

Which of the following is the most appropriate next step in this patient’s care?

• Hospitalization and treatment with intravenous vancomycin

• Administration of one dose of intravenous ceftriaxone in the emergency department followed by discharge to home

  with oral azithromycin

• Discharge to home with doxycycline

• Hospitalization and treatment with intravenous cefazolin

• Hospitalization and treatment with intravenous azithromycin and intravenous ceftriaxone

Answer explanation

The use of validated clinical prediction tools, such as the Pneumonia Severity Index (PSI), can be useful in risk stratifying ambulatory patients presenting with community-acquired pneumonia. Of the variables included in the PSI, age has the highest contribution, equal to the patient’s age in years for men and equal to the patient's age in years minus 10 for women. Coexisting neoplasm and arterial pH

<7.35 have the greatest weight besides age; each is allocated 30 points. All of the other variables in the index (including a history of stroke, temperature >40°C, and the presence of pleural effusion) are assigned a score between 10 and 20. The presence of egophony on examination is not included in the PSI.

This 70-year-old man with community-acquired pneumonia (CAP), fever, altered mental status, pleural effusion, and a history of cerebrovascular disease has a high PSI score (i.e., >90), which is associated with a mortality risk of >9% within 30 days after presentation. At this level of risk, he should be hospitalized and started on appropriate intravenous antibiotic therapy.

For patients with severe CAP who are not in the intensive care unit and are not at high risk for drug-resistant or gram-negative infection, guidelines continue to recommend either a respiratory fluoroquinolone alone or the combination of a beta-lactam (e.g., ceftriaxone) with a macrolide (e.g., azithromycin) or doxycycline. A large randomized controlled trial showed that treatment with a beta-lactam alone is

noninferior to combined treatment with a macrolide, but a subsequent systematic review continued to support the use of combination therapy.

Key learning point: A useful tool for stratifying the risk of death in ambulatory patients presenting with community-acquired pneumonia

is the pneumonia severity index.

A 30-year-old woman who has been taking an oral contraceptive presents with swelling and tenderness in her left calf. An ultrasound reveals an acute thrombus involving the left popliteal vein. She has normal renal function, is taking no other medications, and weighs 67kg. In addition to stopping the oral contraceptive and recommending alternative forms of contraception, which one of the following treatments is most appropriate for this patient?

• Admit for intravenous unfractionated heparin

• Start dabigatran 150 mg twice daily

• Start rivaroxaban 15 mg twice daily for 3 weeks and then decrease the dose to 20 mg once daily

• Admit for catheter-directed thrombolysis

• Start warfarin 5 mg once daily in the evening

Answer explanation

In contrast to older oral anticoagulants such as warfarin that act as vitamin K antagonists, direct oral anticoagulants (DOAC) directly inhibit specific coagulation factors. DOACs are now considered standard of care for the treatment of uncomplicated acute venous thromboembolism (VTE) in appropriate patients. Clinicians should assess a patient’s renal function, other medication use, and body weight before prescribing a DOAC. The appropriate dosing of DOACs depends on the specific DOAC used, the timing relative to VTE diagnosis, the indication for the DOAC (VTE vs. stroke prevention in atrial fibrillation), and the presence of comorbidities such as renal impairment. Apixaban and rivaroxaban can each be started at the time of VTE diagnosis, but they must be dosed higher in the initial treatment period than later; in addition, rivaroxaban should be taken with food.

Key learning point: In most patients with uncomplicated venous thromboembolism, the recommended initial anticoagulant is a direct (non-vitamin K) oral anticoagulant, such as rivaroxaban.

A 65-year-old man presents for evaluation of left-sided abdominal pain that began 24 hours ago, accompanied by nausea and persistent vomiting. He recalls no prior episodes. On examination, his temperature is 40°C, and his heart rate is 105 beats per minute. He is tender to abdominal palpation in the lower left quadrant, with some guarding and rebound.

CT of the abdomen shows the presence of diverticula and inflammation of the pericolic fat surrounding the sigmoid colon.

What is the most appropriate next step in managing this patient’s care?

• Sigmoid colectomy

• Colonoscopy

• Intravenous antibiotic therapy

• CT-guided drain placement

• Oral antibiotic therapy

Answer explanation

Antibiotics are no longer recommended routinely for all patients with acute diverticulitis. Controlled trials in patients with uncomplicated diverticulitis (no abscess) showed no difference in outcomes between patients who received antibiotics and those who did not.

However, antibiotics are recommended in cases of severe infection, sepsis, or complications. In this case, antibiotics are indicated because of the patient’s severe symptoms (persistent vomiting) and would need to be given intravenously to ensure adequate effect.

Broad-spectrum antibiotics with gram-negative and anaerobic coverage are recommended as first-line therapy.

Key learning point: A patient with acute diverticulitis who has signs of severe infection or sepsis and who cannot tolerate oral intake of medication is best managed with intravenous antibiotic therapy

A 47-year-old woman reports a 3-day history of nonbloody diarrhea 45 days after undergoing allogeneic bone marrow transplantation for acute myeloid leukemia. She also reports symptoms of nausea and vomiting. On examination, she is afebrile, and her abdomen is slightly tender throughout. Her leukocyte count is normal. Stool cultures, stool examination for ova and parasites, Gram stain, Clostridioides difficile testing, fecal occult-blood testing, and stains for Cryptosporidium are negative.

Which one of the following diagnoses is most likely in this case?

• Campylobacter

• Enterohemorrhagic Escherichia coli

• Typhlitis

• Graft-versus-host disease

• Giardia

Answer explanation

The most typical causes of diarrhea after bone marrow transplantation are graft-versus-host disease (GVHD) and infection. Acute GVHD traditionally occurs within 100 days after bone marrow transplantation. The gastrointestinal tract is the second most commonly involved organ system in GVHD. Symptoms include nausea, vomiting, pain, and diarrhea. The diagnosis of GVHD is made with endoscopic gastrointestinal biopsies.

Any transplant recipient undergoing evaluation for diarrhea should first have infectious causes ruled out. Biopsies for cytomegalovirus infection should be performed, followed by rectosigmoid biopsies, as they have the highest sensitivity, specificity, positive predictive value, and negative predictive value for diagnosing GVHD.

Key learning point: The most likely cause of nausea, vomiting, and nonbloody diarrhea in a patient who recently received an allogeneic bone marrow transplant and has negative stool studies, a negative stool examination for ova and parasites, and a normal leukocyte count is acute graft-versus-host disease.