Self-Evaluation Process 2015 Update in

Hospital MedicineModule 83-R

Version 15-1April 23, 2015

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Common Abbreviations

The following abbreviations may be used in this examination:

ACE Angiotensin-converting enzyme

ALT Alanine aminotransferase

AST Aspartate aminotransferase

BMI Body mass index

eGFR Estimated glomerular filtration rate

FDA Food and Drug Administration

HIV Human immunodeficiency virusINR International normalized ratioLDL Low-density lipoproteinRBC Red blood cellS3 Third heart sound (ventricular gallop)S4 Fourth heart sound (atrial gallop)WBC White blood cell

Introduction

CopyrightCopyright ©American Board of Internal Medicine. All rights reserved. Do not copy withoutpermission.

Please read the following information carefully.

On successful completion of this module, you will receive 10 points of self-evaluation of medicalknowledge credit in the Maintenance of Certification Program; credit remains valid for 10 years.

InstructionsRead each one-best-answer question in the module and indicate your answer by clicking in theappropriate box. You should use educational resources (e.g., online medical references, textbooks,journal articles) to assist in answering the questions. Suggested resources are listed in the EducationResources section of the CME information.

On each question screen, the Help button will provide you with technical information andinstructions on how to navigate through the module, including submitting your completed module. For common abbreviations that may appear in this module, click the "Resources" button on the rightside of the screen.

CME information for this module, including CME expiration date, may be reviewed by clicking the“CME Credit for the ABIM Maintenance of Certification Program” link in the left-hand column.

Laboratory Studies and Reference RangesReference ranges for laboratory test reports are included in the text of the ABIM exam questions. As is true in practice, interpretation of a particular patient’s test result in relation to thereference range depends on the clinical context. For example, reference ranges for tests assessinglipid or glucose metabolism may not be applicable in certain clinical settings; ABIM referenceranges should not be confused with patient-specific targets for such tests. Information on specific studiesThe National Cancer Institute advises that there is no specific normal or abnormal level of prostate-specific antigen (PSA) in the blood. Therefore, ABIM is reporting “no specific normal or abnormallevel” in place of the reference range for PSA.

The comprehensive metabolic panel contains the following assays: Albumin, alanine and aspartateaminotransferases (ALT and AST), alkaline phosphatase, total bilirubin, blood urea nitrogen,calcium, creatinine, electrolytes (sodium, potassium, chloride, and bicarbonate), glucose, and totalprotein.

Unless noted otherwise in examination questions:• Arterial blood gas studies are done at sea level with the patient breathing room air• Reticulocyte counts are uncorrected• Tuberculin skin tests are done with purified protein derivative (PPD) at intermediate

strength (5 TU)• Electrocardiograms are recorded at normal standard and speed• Lung volumes are determined by body plethysmography

Illustrations and Multimedia (if applicable)Some questions are accompanied by illustrations, such as radiographs, electrocardiograms,photographs of physical or histologic findings, videos, and charts. All electrocardiograms arerecorded at normal standard and speed unless otherwise specified.

Criteria for successful completionIn order to successfully complete this module and receive Maintenance of Certification credit, youmust answer every question. Submission of this module will not be accepted until answers havebeen provided for every question.

Page 1

1An 18-year-old man who has a history of depression is brought to the emergency department after anintentional overdose on his father's antihypertensive medications. He took an unknown quantity ofextended-release metoprolol and was found unresponsive at home.

The patient is somnolent and arouses only to painful stimuli. Pulse rate is 46 per minute, and blood pressureis 72/40 mm Hg. Cardiac examination is bradycardic but without murmurs. Pulmonary examination isnormal. Electrocardiogram shows sinus bradycardia with slightly prolonged PR interval but no otherabnormalities.

The patient receives atropine and intravenous fluids. Pulse rate increases to 70 per minute, but bloodpressure remains low at 80/42 mm Hg after 15 minutes; he is still not alert. Atropine dosing is repeated withno improvement in vital signs or overall clinical status.

Which of the following should you recommend now?

(A) Hemodialysis(B) Temporary transvenous pacemaker placement(C) Intravenous magnesium sulfate(D) Intravenous glucagon

Page 2

2A 69-year-old man is admitted to the hospital after sustaining an acute humeral fracture after a fall. Thepatient has stage III chronic kidney disease (serum creatinine of 1.4 [0.7–1.5 mg/dL] and eGFR of 48mL/min/1.73 m2). Blood pressure on admission is 210/110 mm Hg.

After pain control and continuation of his home medications of candesartan and hydrochlorothiazide, bloodpressure is lowered to 165/95 mm Hg, which is consistent with his prior level of control. Duplex renalultrasonography reveals severe left renal artery stenosis of 80%.

Which of the following is the most appropriate management of renal artery stenosis in this patient?

(A) Balloon angioplasty of the left renal artery stenosis and addition of amlodipine andatorvastatin

(B) Stenting of left renal artery stenosis and addition of amlodipine and atorvastatin(C) Addition of amlodipine and atorvastatin only(D) No change in therapy; follow-up duplex renal ultrasonography in six months

Page 3

3Patients who have an intermediate-risk pulmonary embolism are defined as those who are hemodynamicallystable but have right ventricular dysfunction as measured by echocardiography or biomarkers, such aselevations in serum cardiac troponin or cardiac B-type natriuretic peptide. Rescue therapy is defined as theneed for further thrombolytic therapy, surgical intervention, or vasopressor support.

In patients who have an intermediate-risk pulmonary embolism, which of the following are the expectedoutcomes of using thrombolytic therapy as compared to standard anticoagulation therapy?

(A) Lower overall mortality, higher rates of major bleeding, lower rates of rescue therapy(B) Higher overall mortality, higher rates of major bleeding, lower rates of rescue therapy(C) No difference in mortality, higher rates of major bleeding, lower rates of rescue therapy(D) No difference in mortality, higher rates of major bleeding, no difference in rescue therapy

Page 4

4Which of the following is most likely to produce a major risk of an adverse medication effect when added toallopurinol?

(A) Azathioprine(B) Phenytoin(C) Trimethoprim–sulfamethoxazole(D) Nitrofurantoin

Page 5

5A 55-year-old man is admitted to the hospital because of gross hematuria with urinary obstruction. Medicalhistory is significant for hypertension and bladder cancer. Seventy-two hours after admission, he undergoesresection of a bladder neoplasm. The procedure goes well with expected blood loss and no intraoperativecomplications. The patient is extubated postoperatively; he has emesis and observed aspiration immediatelyfollowing endotracheal tube removal. The patient develops hypoxemia and requires 2 L of oxygen by nasalcannula to increase oxygen saturation to 90%. The patient is in mild respiratory distress; crackles, egophony,and dullness to percussion are heard in the right lower lung fields. Chest radiograph reveals a right middlelobe opacity. Two hours later temperature is 38.0 C (100.4 F), and leukocyte count is 14,000/:L[4000–11,000]. You are consulted by the surgical team.

Which of the following is the most appropriate initial recommendation?

(A) Ceftriaxone and azithromycin(B) Levofloxacin and metronidazole(C) Methylprednisolone(D) Vancomycin and piperacillin–tazobactam(E) Supportive care only; start antibiotics if no improvement in 48 hours

Page 6

6A 76-year-old woman is found to have small bowel obstruction after evaluation of abdominal pain. She isadmitted to the surgery service and scheduled to undergo exploratory laparotomy with lysis of adhesions inthe next few days. The patient has chronic atrial fibrillation and hypertension; home medications arewarfarin, amlodipine, and metoprolol. She has no history of heart failure, diabetes, transient ischemic attack,stroke, or renal insufficiency. Warfarin is discontinued upon admission to the hospital; you are consulted onhospital day 3 to guide her anticoagulation therapy.

Temperature is normal, pulse rate is 82 per minute and irregular, and blood pressure is 146/84 mm Hg. Anasogastric tube has been placed. Abdominal examination reveals high-pitched bowel sounds. INR is 1.5(2.7 on admission). Complete blood count (including platelet count) and kidney function studies are normal.

Which of the following is the most appropriate anticoagulation therapy for this patient duringhospitalization?

(A) Aspirin, 325 mg daily(B) Prophylactic dosing of enoxaparin or heparin(C) Subcutaneous enoxaparin, 1 mg/kg twice daily; hold perioperatively(D) Intravenous heparin at full therapeutic dose; hold perioperatively

Page 7

7A 54-year-old man who has chronic spinal stenosis is brought to the emergency department (ED) byambulance after his family found him at home with confusion and lethargy. Current home medications aresustained-release morphine (60 mg three times daily) and oxycodone (10 mg every four hours as needed). He has had significant depression, and his family is concerned he may have taken an overdose of his painmedication.

The patient is deeply somnolent but responds to painful stimuli and moves all extremities with purpose. Temperature is 36.9 C (98.4 F), respirations are 8 per minute, and blood pressure is 104/62 mm Hg. Thepupils measure 2 mm bilaterally. Breath sounds are clear, and cardiac examination is normal. Urinetoxicology screen is positive for opiates but no other substances. Electrocardiogram is normal with no QTprolongation.

The patient receives 0.5 mg of naloxone in the ED, and his mental status and vital signs normalize. One hourlater, confusion and reduced respiratory rate recurs.

In addition to supporting ventilation, which of the following is the most appropriate therapy for this patient?

(A) Initiation of intravenous naloxone drip(B) Initiation of flumazenil and naloxone(C) Administration of activated charcoal by nasogastric tube(D) Consultation with nephrology for initiation of hemodialysis

Page 8

8A 60-year-old woman is brought to the emergency department after sudden-onset substernal chest pain withradiation to her back, acute dyspnea, and right-arm tingling. She has hypertension, for which she takeshydrochlorothiazide.

Pulse rate is 104 per minute, respirations are 22 per minute, and blood pressure is 170/90 mm Hg. Cardiacexamination reveals a soft systolic murmur at the left upper sternal border. Pulmonary examination isnormal. Neurological exam reveals normal sensation in the extremities and normal strength. Plasma D-dimer is 1.7 :g/mL [less than 0.5], and serum cardiac troponin is 0.12 ng/mL [0–0.1]. Electrocardiogramshows sinus tachycardia. Chest radiograph is normal.

Which of the following should be done next in the evaluation and management of this patient?

(A) Transthoracic echocardiography and initiation of a beta-adrenergic blocking agent(B) Cardiac stress test and initiation of a beta-adrenergic blocking agent(C) Aortic protocol computed tomography and initiation of a beta-adrenergic blocking agent(D) Pulmonary embolism protocol computed tomography and initiation of intravenous heparin

Page 9

9Your hospital is testing a new Rapid Response Team as a quality improvement initiative to reduce mortality. The team is piloted in one of multiple similar general medicine-surgery units with the highest mortality forthe last quarter. The pilot program demonstrates a 28% reduction in mortality over the next nine months; thehospital rolls out the same Rapid Response Team to all medicine-surgery units in the hospital. Analysisreveals equivalent rates of call to the Rapid Response Team on the pilot unit as on the other units after theprogram is expanded, but analysis two years later reveals no change in hospital-wide mortality.

Which of the following best explains why mortality fell for the pilot unit but not for the entire hospital?

(A) Sampling bias(B) Hawthorne effect(C) Regression to the mean(D) Manipulation (“gaming”) of the data(E) Lack of stakeholder buy-in

Page 10

10A 79-year-old man is transferred from an outside hospital after being evaluated for melena andlightheadedness. He was found to be hypotensive and severely anemic (hemoglobin 6.2 g/dL [14–18]). Inaddition to the gastrointestinal bleeding, he was found to have a large hematoma in the right thigh. Thepatient was stabilized, transfused, and transferred for a higher level of care. Medical history is remarkablefor diverticulosis and hypothyroidism. He underwent cholecystectomy at age 22 without complications. Hehas no personal or family history of bleeding problems. Current medications are a daily multivitamin and L-thyroxine. The patient is a retired psychiatrist and has been receiving counseling for depression.

The patient is pleasant and in no acute distress. Pulse rate is 78 per minute, respirations are 12 per minute,and blood pressure is 112/64 mm Hg. No conjunctival hemorrhage or conjunctival or oral petechiae arenoted. Cardiopulmonary examination is normal. The abdomen is soft and nontender. The diameter of theright thigh is greater than the left. Large ecchymoses are noted on the inferior, lateral, and superior aspectsof the right thigh.

Laboratory studies:

Hemoglobin 7.6 g/dL [14–18]Leukocyte count 9200/:L [4000–11,000]Platelet count 184,000/:L [150,000–300,000]Plasma prothrombin time 12.5 seconds [11–13]Activated partial thromboplastin

time 65.2 seconds [25–35]Comprehensive metabolic panel Normal

Which of the following is the most likely cause of this patient’s bleeding diathesis?

(A) Factor VIII deficiency(B) Antiphospholipid antibody syndrome(C) Henoch-Schönlein purpura(D) Bernard-Soulier syndrome(E) Factitious disorder involving warfarin abuse

Page 11

11A 57-year-old man is admitted to the hospital after a transient ischemic attack. Spontaneous left armweakness developed within 60 minutes of dinner with his wife. Symptoms resolved by the time he wasevaluated in the emergency department; diffusion magnetic resonance imaging was negative for infarction. Medical history is significant for atrial fibrillation, hyperlipidemia, and placement of a bi-leaflet aorticmechanical heart valve. The patient has no risk factors for increased bleeding risk. Current medications aredabigatran (for three years), atorvastatin, and diltiazem.

Which of the following is the most appropriate management of his antithrombotic regimen?

(A) Continue dabigatran without change(B) Add aspirin to dabigatran(C) Add clopidogrel to dabigatran(D) Discontinue dabigatran and transition to warfarin with aspirin(E) Discontinue dabigatran and transition to clopidogrel with aspirin

Page 12

12A 58-year-old man who has chronic bronchitis is hospitalized because he has had worsening dyspnea,wheezing, and cough productive of brownish sputum for three days. He reports subjective fevers, but he hasnot had chills, night sweats, or recent weight loss. He has smoked two and one-half packs of cigarettes dailyfor 35 years. He receives supplemental oxygen (1 L by nasal cannula) at home chronically.

Temperature is 37.8 C (100.0 F), pulse rate is 98 per minute, and respirations are 22 per minute. Oxygensaturation is 88% on room air and 91% with the patient breathing oxygen (1 L by nasal cannula). He iscoughing and tachypneic and in moderate respiratory distress, using his accessory muscles. Scatteredrhonchi and faint expiratory wheezes are heard throughout the lung fields. Chest radiograph shows no acuteopacities. Most recent pulmonary function testing showed an FEV1 of 28% of predicted and FEV1/FVC of52%, consistent with stage IV chronic obstructive pulmonary disease (COPD).

Compared to a 14-day course, a five-day course of corticosteroids is associated with which of the following?

(A) A similar rate of repeat exacerbations for COPD stages I and II, but a higher rate of repeatexacerbations for COPD stages III and IV

(B) A similar rate of repeat exacerbations for COPD stages III and IV(C) A higher rate of repeat exacerbations across all stages of COPD(D) A lower rate of repeat exacerbations across all stages of COPD

Page 13

13A 55-year-old man is evaluated in the emergency department (ED) for dull, non-radiating, right-sided chestdiscomfort. Symptoms are not associated with exertion. He has generalized anxiety disorder andhypertension; his only medication is hydrochlorothiazide.

Chest radiograph and electrocardiogram are normal. Serum cardiac troponins every six hours are negative(x3).

Which of the following is the most accurate description of the effect of ordering an inpatient stress test?

(A) Decrease in subsequent ED visits by the patient for chest pain but increase in overall cost ofcare

(B) Decrease in the probability of admission if the patient returns to the ED with chest pain(C) Decrease in overall cost of care(D) Decrease in the patient’s anxiety

Page 14

14A 72-year-old man is admitted to the hospital because of a fall that resulted in left nondisplaced hip fracture. He is incidentally found to have anemia on laboratory studies. Hemoglobin is 11 g/dL [14–18], meancorpuscular volume is 100 fL [80–98], and reticulocyte production index is normal. Two years agocolonoscopy was normal. The patient has diet-controlled type 2 diabetes mellitus. His only medication is anoccasional nonsteroidal anti-inflammatory drug. He has no history of alcohol use or dietary restrictions.

Pain and discomfort are elicited with movement of the left hip; the remainder of the physical examination isnormal.

Which of the following laboratory studies represent an appropriate, cost-effective initial evaluation of thispatient's anemia?

(A) Serum ferritin, serum iron/total iron-binding capacity ratio, and serum vitamin B12 (B) Serum ferritin, serum iron/total iron-binding capacity ratio, serum folate, and serum vitamin

B12 (C) Serum ferritin, serum iron/total iron-binding capacity ratio, red cell folate, and serum

vitamin B12 (D) Serum ferritin, serum iron/total iron-binding capacity ratio, red cell folate, serum vitamin

B12, and serum methylmalonic acid

Page 15

15A 52-year-old man is evaluated because of lower abdominal pain, vomiting, and fever to 39.2 C (102.6 F) forone day. Leukocyte count on admission is 14,000/:L [4000–11,000]. Computed tomography of theabdomen reveals sigmoid inflammation, consistent with diverticulitis without perforation or abscess. Thepatient had a similar episode of diverticulitis two years ago. Family history is negative for diverticulitis ormalignancy. The patient last underwent screening colonoscopy at age 50, which only demonstrateddiverticulosis.

After three days of hospitalization, he is afebrile and clinically improved. Blood cultures are negative. Ashort course of antibiotics is planned.

Which of the following is the most appropriate recommendation?

(A) Unrestricted high-fiber diet and repeat colonoscopy at age 60(B) Sigmoid colon resection prior to discharge(C) Elective outpatient sigmoid colon resection after the acute flare has resolved(D) Colonoscopy in six weeks and avoidance of nuts, popcorn, and whole seeds in the future

Page 16

16A 45-year-old woman who has severe sepsis and acute respiratory distress syndrome has been in theintensive care unit receiving tube feedings for five days. Nursing staff reports no distension, pain, or emesisin the past 24 hours. The patient has achieved goal tube feeding rate, but the last gastric residual volume wasmeasured at 400 mL; a nurse raises concern about the potential for aspiration and subsequentventilator-acquired pneumonia.

Which of the following is the most appropriate response to this patient’s gastric residual volume?

(A) No change in tube feeding rate(B) Discontinue tube feeding for one hour, then resume at the prior rate(C) Discontinue tube feeding for two hours, then resume at 80% of the prior rate(D) Discontinue tube feeding for four hours, then resume at 50% of prior rate

Page 17

17A 58-year-old man is admitted to the hospital because of fever and left lower abdominal pain and tenderness. The patient has hypertension, benign prostatic hypertrophy, and asthma. Current medications areamlodipine, doxazosin, hydrochlorothiazide, and albuterol by metered-dose inhaler.

Laboratory studies reveal leukocytosis. Computed tomography (CT) of the abdomen shows sigmoiddiverticulitis and an incidental right-sided homogeneous adrenal nodule that measures 8 mm in size and 1Hounsfield unit.

Which of the following is the most appropriate recommendation for evaluation of the adrenal nodule?

(A) No further evaluation(B) Serum biochemical testing for functioning adenoma; repeat CT in six to 12 months (C) Right adrenal vein sampling to assess for functioning adenoma(D) Repeat CT in six to 12 months without biochemical testing(E) Interventional radiology–guided percutaneous biopsy

Page 18

18A 38-year-old female nurse is admitted to the hospital because of fever and severe arthralgias for three daysand headache and diffuse rash for one day. She returned eight days ago from a one-week mission trip to theDominican Republic. Today, she recorded a temperature at home of 39.6 C (103.2 F). The joint pains arebilateral and primarily involve her hands, feet, and hips. She also has diffuse myalgias and has had difficultylifting objects above her head and climbing stairs. Yesterday, she developed a pruritic rash over her arms,legs, chest, back, and neck. She has not had shortness of breath, nausea, vomiting, abdominal pain, ordiarrhea. Medical history is otherwise unremarkable. Her only medication is ibuprofen (400 mg three timesdaily as needed for fever and arthralgias). Prior to travel, the patient received typhoid vaccination and tookprimaquine for malaria prophylaxis.

Temperature is 39.3 C (102.8 F), pulse rate is 98 per minute, respirations are 14 per minute, and bloodpressure is 128/64 mm Hg. She has no icterus, and the lymph nodes are not enlarged. Cardiopulmonaryexamination is normal. The abdomen is soft, nontender, and nondistended; bowel sounds are hyperactive,and no organ enlargement is detected. A fine macular rash covering the majority of the neck, chest, back,upper arms, and upper legs is noted without involvement of the palms and soles. The joints are painful withactive or passive movement and are somewhat tender; no joint effusion or redness is noted.

Laboratory studies:

Hemoglobin 14.7 g/dL [12–16]Leukocyte count 1800/:L [4000–11,000]Platelet count 154,000/:L [150,000–300,000]Plasma glucose 88 mg/dL [70–99]Blood urea nitrogen 12 mg/dL [8–20]Serum creatinine 1.0 mg/dL [0.7–1.5]Serum electrolytes:

Sodium 139 mEq/L [136–145]Potassium 4.5 mEq/L [3.5–5.0]Chloride 108 mEq/L [98–106]Bicarbonate 22 mEq/L [23–28]

Serum total bilirubin 0.5 mg/dL [0.3–1.0]Serum alkaline phosphatase 72 U/L [30–120]Serum aminotransferases:

ALT 123 U/L [10–40]AST 92 U/L [10–40]

Serum calcium 8.9 mg/dL [8.6–10.2]

Which of the following is the most likely diagnosis?

(A) Chikungunya infection(B) Dengue hemorrhagic fever(C) Ehrlichiosis(D) Malaria(E) Typhoid fever

Page 19

19You are asked to evaluate a 94-year-old woman who was brought to the emergency department because ofsuprapubic discomfort and increased frequency of urine incontinence in the past five days. She has dementiaand lives in a nursing home.

On physical examination, the patient is pleasant but confused. She denies having any symptoms. Temperature is 37.8 C (100.0 F), pulse rate is 70 per minute, respirations are 14 per minute, and bloodpressure is 145/70 mm Hg. Oxygen saturation is 94% on room air. Mild suprapubic tenderness on palpationis noted without tenderness at the costovertebral angle. Urine dipstick test shows positive nitrates andmoderate leukocyte esterase. Urine microscopy reveals greater than 75 WBCs and many bacteria. Urineculture is pending.

Which of the following is the most appropriate management plan for this patient?

(A) Discharge the patient; no antibiotics are indicated(B) Discharge with a three-to-six–day course of oral antibiotics(C) Discharge with a seven-to-14–day course of oral antibiotics(D) Admit the patient for observation and intravenous antibiotics; after she is afebrile for 24

hours, discharge her on a three-to-six–day course of oral antibiotics(E) Admit for one day of observation and intravenous antibiotics, and then discharge with a

seven-day course of oral antibiotics

Page 20

20A 52-year-old man is evaluated for an episode of syncope that occurred after a prolonged period of standing. He said that he had one to two minutes of lightheadedness and nausea immediately before the episode andwas nauseated and sweating afterward. He did not have chest pain, palpitations, or dyspnea prior to theepisode. Witnesses said that there was no head injury, seizure activity, or incontinence. The patient wasunconscious for 30 seconds, and his mental status returned to normal immediately upon arousing. He doesnot have any headache, numbness, or symptoms of focal weakness. In the emergency department (ED), he isback to his normal state of health. The patient has hypothyroidism. He is physically active and runs three tofive miles four times weekly. Family history is negative for blood clots or sudden cardiac death.

The patient is alert and oriented to person, place, time, and situation. Temperature is 36.6 C (97.7 F), pulserate is 64 per minute, respirations are 12 per minute, and blood pressure is 118/76 mm Hg. No evidence ofhead trauma is noted, and cardiopulmonary and abdominal examinations are normal. Cranial nerves arenormal. Strength and sensation are intact in all extremities. Reflexes are 2+ and symmetric. Romberg test,tandem gait, and cerebellar examination are normal.

Electrocardiogram shows sinus rhythm with no ischemic changes and no evidence of left ventricularhypertrophy or old infarct. Complete blood count, basic metabolic panel, and serum thyroid-stimulatinghormone are normal.

You are called to consult in the ED and determine if admission is required for further evaluation.

Which of the following should you recommend regarding brain imaging and admission of this patient?

(A) Brain imaging is not recommended; discharge from the ED(B) Brain imaging is not recommended; admit for observation(C) Order computed tomography of the head; discharge if negative(D) Order computed tomography of the head; admit for observation

Page 21

21An 82-year-old man who has an extended history of alcohol and tobacco abuse is brought to the hospital by afriend because of hemoptysis and confusion. His friend first noted the confusion one week ago. The patienthas lost 18 kg (40 lb) in the past year.

On initial evaluation, the patient is cachectic and profoundly disoriented. He appears to be euvolemic. Chestradiograph reveals multiple pulmonary nodules, suggestive of metastatic cancer. Serum sodium is 112mEq/L [136–145], and serum potassium is 2.0 mEq/L [3.5–5.0]. Serum osmolality is low. Blood ethanoland plasma glucose are normal. Urinalysis suggests syndrome of inappropriate antidiuretic hormonesecretion.

Which of the following is the most appropriate target increase of this patient’s serum sodium level?

(A) 118 mEq/L over 24 hours(B) 124 mEq/L over 24 hours(C) 116 mEq/L over the first four hours and to 135 mEq/L by 48 hours(D) 120 mEq/L over the first 24 hours and to 134 mEq/L by 48 hours

Page 22

22A 53-year-old man who has type 2 diabetes mellitus is admitted because he has had fatigue, fevers, chills,and diaphoresis for one week.

The patient appears diaphoretic. Temperature is 38.4 C (101.2 F), pulse rate is 92 per minute, respirationsare 18 per minute, and blood pressure is 138/58 mm Hg. Oxygen saturation by pulse oximetry is 92%. Scattered petechiae are visible on the bilateral conjunctivae. Cardiovascular examination shows regularrhythm, a soft decrescendo diastolic murmur at the left lower sternal border, and a soft S3 gallop. Bibasilarcrackles are heard on pulmonary examination. Abdominal examination is normal without tenderness orevidence of enlarged organs. He has 1+ pitting edema in the legs. Leukocyte count is 15,200/:L[4000–11,000], and kidney function studies are normal. Blood cultures grow Staphylococcus aureus in fourof four bottles within one day of admission; urine culture shows no growth. Chest radiograph shows mildpulmonary vascular congestion. Transesophageal echocardiogram shows a hyperdynamic left ventricle withsevere aortic regurgitation. A 0.7-cm, mobile vegetation is visible on the aortic valve leaflet. Noperivalvular abscess is seen. Electrocardiogram (EKG) shows normal conduction.

Which of the following describes the correct course of action and rationale regarding surgical consultation inthis patient?

(A) Surgical consultation is warranted to prevent embolization(B) Surgical consultation is warranted due to signs of heart failure(C) Surgical consultation is not needed at this time because there is no perivalvular abscess(D) Surgical consultation is not needed at this time because there is no conduction abnormality

on the EKG(E) Surgical consultation is not needed at this time because there is no evidence of septic emboli

Page 23

23A 26-year-old woman is evaluated because of epistaxis. She has had bloating and diarrhea for three years,occurring mostly on weekends. Although her stools are foul smelling, she reports no blood in her stools. Herdiarrhea does not occur at night and is not associated with abdominal pain. She has also had diffusemyalgias and an associated rash with pruritic inflammatory papules and vesicles on her left lower abdomen. She has unintentionally gained 9.1 kg (20 lb) in the past two to three years. Vaccination status is unknownby the patient.

BMI is 23. Vital signs are normal. The right nares is packed and still oozing blood around the packing. The abdomen is not tender to palpation, and digital rectal examination is normal. The remainder of thephysical examination is normal.

Laboratory studies:

Hemoglobin 11.5 g/dL [12–16]Platelet count 258,000/:L [150,000–300,000]Prothrombin time 20.5 seconds [11–13]Serum albumin 2.9 g/dL [3.5–5.5]Plasma fibrinogen 400 mg/dL [200–400]Serum creatinine 1.0 mg/dL [0.7–1.5]Serum electrolytes:

Sodium 143 mEq/L [136–145]Potassium 3.4 mEq/L [3.5–5.0]

Serum 25-hydroxyvitamin D 24 ng/mL [30–60]Anti–tissue transglutaminase

Ig antibody PositiveAntinuclear antibodies NegativeAnti–smooth muscle antibodies Negative

Vitamin K replacement is administered, and her epistaxis resolves.

Which of the following should be performed prior to discharge?

(A) Oral bisphosphonate therapy(B) Vaccination against encapsulated organisms(C) Antigliadin antibody testing(D) Colonoscopy with biopsies

Page 24

24A 32-year-old man is evaluated because of worsening jaundice and abdominal pain. Severe alcoholichepatitis is diagnosed by liver biopsy; Maddrey’s (discriminant function) score is 34. The patient does nothave diabetes mellitus and does not have evidence of a current infection.

Which of the following should you prescribe for the treatment of alcoholic hepatitis in this patient?

(A) No therapy is effective(B) Prednisolone, 40 mg daily(C) Pentoxifylline, 400 mg three times daily(D) Prednisolone, 40 mg daily and pentoxifylline, 400 mg three times daily

Page 25

25A 52-year-old man is admitted to the trauma service for repair of a humeral fracture he sustained in a motorvehicle collision in which he was the driver. You are consulted for medical management and sleep apneaassessment. The patient said that the accident occurred while driving home from his job as an accountant. He does not remember details of the collision but thinks he may have nodded off. He admits to being tired inthe day, especially during the past few weeks. He says that his diet is poor, he does not exercise regularly,and he has been gaining weight. His wife reports that he snores frequently at night, which has beenaccompanied by nocturnal choking and gasping in the past year. She has also noted episodes of apnea atnight. He has hypertension, type 2 diabetes mellitus, and osteoarthritis of knees; he has had a kidney stone.

BMI is 32. The tonsillar pillars and throat are not visible; the base of the uvula is visible, as is the soft palate(Mallampati class 3). The lungs are clear. The right humerus shows evidence of repair. Based on thispatient’s history, you suspect obstructive sleep apnea.

Which of the following clinical features is most predictive of obstructive sleep apnea?

(A) Daytime somnolence(B) Nocturnal choking and gasping(C) Episodes of apnea(D) Snoring

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26A 53-year-old African-American man is admitted to the psychiatry service for an exacerbation of bipolaraffective disorder. You are consulted to assist in the management of a diffuse and intensively pruritic rashthat the patient has had over his legs, chest, and back for several months. He also has chronic hepatitis Cinfection and hypertension; hepatitis C infection is not yet treated due to the fragility of his psychiatricdisease.

The patient is well developed and mildly obese; he is in slight distress because of the pruritus. Hundreds ofcircular- to oval-shaped papules measuring 4 to 10 mm across cover the abdomen, back, thighs, and lowerlegs, as shown. Scattered lesions are present on his chest and upper arms. Most lesions have a slightadherent scale and are reddish purple, flat across the top, and without either vesicular or pustular features. The palms and soles appear to be spared.

Laboratory studies:

Complete blood count NormalSerum alkaline phosphatase 192 U/L [30–120]Serum aminotransferases:

ALT 87 U/L [10–40]AST 64 U/L [10–40]

Hepatitis C antibodies Positive with detectable viremiaHIV NegativeRapid plasma reagin Negative

Which of the following is the most likely diagnosis?

(A) Cryoglobulinemia-associated vasculitis(B) Lichen planus(C) Porphyria cutanea tarda(D) Secondary syphilis

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27Your hospitalist group is re-evaluating its staffing due to increasing workload. There are currently threehospitalists that work in parallel during the day. Each hospitalist is accustomed to seeing an average of 15patients daily, and this has increased to an average of 19 patients daily. Members of the group have askedabout adding a fourth hospitalist to reduce the average daily encounters. As you evaluate this, you considerthe effect of workload on patient care.

Which of the following best describes the effect of a workload of 19 daily encounters as compared to aworkload of 15 daily encounters?

(A) Increase in length of stay and costs(B) Decrease in patient satisfaction(C) Increase in calls made to the Rapid Response Team(D) Increase in in-hospital mortality(E) Increase in seven-day readmission rate, but no change in 30-day readmission rate

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28A 34-year-old man is admitted to the hospital with pancreatitis. He develops acute respiratory distresssyndrome (ARDS) and requires intubation and mechanical ventilation. After intubation, he requires 100%FIO2 to maintain oxygen saturations at 90%–94%.

Which of the following is the optimal type of ventilation for this patient?

(A) Volume-cycled ventilation with a goal of 6 mL/kg tidal volume(B) Volume-cycled ventilation with a goal of 12 mL/kg tidal volume(C) Pressure support ventilation without positive end-expiratory pressure(D) Pressure-cycled ventilation with permissive hypoxemia

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29A 75-year-old man is evaluated in the emergency department for suspected pulmonary embolism. He isdetermined to have low clinical probability. Your laboratory uses a high-sensitivity D-dimer assay with astated upper limit of normal of 500 :g/L.

Which of the following represents the upper limit of D-dimer value (:g/L) that could be used to effectivelyrule out pulmonary embolism in this patient?

(A) 250(B) 350(C) 500(D) 750(E) 950

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30Your hospital has been asked to create a program to reduce all-cause hospital readmissions because of high30-day readmission rates.

When designing readmission risk reduction programs, focusing on which of the following has been found tobe associated with the greatest likelihood of success?

(A) Medication reconciliation at discharge(B) Remote telemonitoring of vital signs after discharge(C) Post-discharge follow-up by telephone(D) Support for the patient’s capacity for self-care