ABFM KSA- CARE OF HOSPITALIZED
PATIENTS EXAM | NEWEST ACTUAL
ACCURATE EXAM COMPLETE
QUESTIONS AND DETAILED VERIFIED
ANSWERS GRADED A+ | 100% VERIFIED
| 2024 UPDATE!!!
A 42-year-old construction worker with a 3-day history of cough, fever,
chills, dyspnea, and right posterolateral chest pain with inspiration is
brought to the emergency department by his wife. He has been in good
health until this illness and has never been hospitalized. He does not
take any routine medications, does not smoke, and drinks alcohol only
occasionally.On examination he appears ill and in mild respiratory
distress. His temperature is 40.3°C (104.5°F), pulse rate 126 beats/min,
respiratory rate 32/min, blood pressure 136/70 mm Hg, and oxygen
saturation 88% on room air. He has diminished breath sounds in the
right posterolateral chest. His Pneumonia Severity Index is 97. Based on
the severity of his illness you recommend hospital admission.Antibiotic
choices recommended for empiric treatment in this patient include
which of the following?
Ceftriaxone plus azithromycin (Zithromax)
Cefuroxime
Ciprofloxacin (Cipro) intravenously
,Piperacillin/tazobactam (Zosyn) plus vancomycin (Vancocin)
A
Relative risk stratification should be performed for patients with
community-acquired pneumonia (CAP), using a clinical prediction tool
such as the Pneumonia Severity Index (PSI) or the CURB-65 (SOR A).
These tools can be used along with the judgment of the physician to
decide whether or not a patient can be treated as an outpatient or
should be admitted to the hospital. This patient is moderately ill and
has a PSI score of 97 based on his age, heart rate, respiratory rate,
temperature, and oxygenation. This score indicates that he should
initially be treated in the hospital.A macrolide plus a β-lactam is
recommended for combination therapy in patients hospitalized with
CAP who are at low risk (PSI score of 71–130) (SOR A). A respiratory
fluoroquinolone (levofloxacin or moxifloxacin) can also be used as
monotherapy (SOR A). Because of concerns about increasing levels of
resistance, macrolides are not recommended as monotherapy for a
moderately ill patient (SOR C). Ciprofloxacin, a first-generation
quinolone, has poor potency against Streptococcus pneumoniae and
is therefore not appropriate treatment for CAP (SOR C). Treatment
with piperacillin/tazobactam is not indicated since there are no risk
factors for Pseudomonas. Vancomycin is likewise not indicated since
there are no MRSA risk factors.Adults hospitalized with non-severe
CAP who do not have risk factors for MRSA can be treated by either of
the following regimens:(1) combination therapy with a β-lactam
(ampicillin plus sulbactam, 1.5–3 g every 6 hours; cefotaxime, 1–2 g
every 8 hours; ceftriaxone, 1–2 g daily; or ceftaroline, 600 mg every 12
hours) AND a macrolide (azithromycin, 500 mg daily, or
clarithromycin, 500 mg twice daily)(2) monotherapy with a respiratory
,fluoroquinolone (levofloxacin, 750 mg daily, or moxifloxacin, 400 mg
daily)A combination of ceftriaxone and levofloxacin is not
recommended.It should be noted that β-lactam/macrolide therapy
reduced mortality in patients with CAP compared with patients
treated with β-lactam monotherapy, so monotherapy with a β-lactam
for hospital-treated pneumonia is not recommended. β-
Lactam/macrolide combinations may decrease all-cause death, but
mainly for patients with severe CAP. The Infectious Diseases Society
of America recommends that monotherapy with a β-lactam not be
used routinely for inpatient treatment of pneumonia.
A 67-year-old male is hospitalized with altered mental status, jaundice,
cirrhosis, and ascites related to alcoholic liver disease. He develops a
fever to 38.6°C (101.5°F). His abdomen is distended, with minimal
tenderness but no rebound. The remainder of the physical examination
is normal.You perform ultrasound-guided paracentesis. Which one of
the following would provide the best evidence for a diagnosis of
spontaneous bacterial peritonitis?
A peritoneal neutrophil count >250/mL
An elevated amylase level in peritoneal fluid
A low serum-ascites albumin gradient
Positive leukocyte esterase on urine testing strips
A
Spontaneous bacterial peritonitis is the most frequent bacterial
infection in patients with cirrhosis, followed by urinary tract infection,
, pneumonia, skin and soft-tissue infections, and spontaneous
bacteremia. A neutrophil count >250/mL in ascitic fluid from
paracentesis indicates a high risk for spontaneous bacterial peritonitis
(SBP) and is an indication for immediate empiric antibiotic therapy.
SBP is associated with a high mortality rate in patients with cirrhosis
and ascites (SOR A), and bacterial infections account for 25%-46% of
hospitalizations due to acute decompensation events in patients with
cirrhosis. Bacterial cultures to identify the etiology of SBP may be
helpful in guiding antibiotic choices (SOR C) but cultures are negative
in a significant percentage of patients with SBP. Culture results may
take 48-72 hours, and waiting on results would delay treatment in
high-risk patients.The serum-ascites albumin gradient (SAAG) helps
determine whether peritoneal fluid is a transudate or an exudate.
Theoretically, it might be expected that those with SBP would have
higher protein levels and thus a lower SAAG but this finding is not
reliable. An elevated amylase level would be more indicative of
pancreatitis.A large multi-center study has shown that urine test
strips are not a reliable way to rule out infection in SBP.
A 32-year-old male is admitted to the hospital for management of a
perirectal abscess. He reports severe pain in the rectal area, and
palpitations. His vital signs are normal, with the exception of a heart
rate of 132 beats/min and a temperature of 38.9°C (102.0°F). He rates
his pain as 8 out of 10. An EKG is shown below.Appropriate treatment
of the patient's cardiac arrhythmia would include intravenous
adenosine
PATIENTS EXAM | NEWEST ACTUAL
ACCURATE EXAM COMPLETE
QUESTIONS AND DETAILED VERIFIED
ANSWERS GRADED A+ | 100% VERIFIED
| 2024 UPDATE!!!
A 42-year-old construction worker with a 3-day history of cough, fever,
chills, dyspnea, and right posterolateral chest pain with inspiration is
brought to the emergency department by his wife. He has been in good
health until this illness and has never been hospitalized. He does not
take any routine medications, does not smoke, and drinks alcohol only
occasionally.On examination he appears ill and in mild respiratory
distress. His temperature is 40.3°C (104.5°F), pulse rate 126 beats/min,
respiratory rate 32/min, blood pressure 136/70 mm Hg, and oxygen
saturation 88% on room air. He has diminished breath sounds in the
right posterolateral chest. His Pneumonia Severity Index is 97. Based on
the severity of his illness you recommend hospital admission.Antibiotic
choices recommended for empiric treatment in this patient include
which of the following?
Ceftriaxone plus azithromycin (Zithromax)
Cefuroxime
Ciprofloxacin (Cipro) intravenously
,Piperacillin/tazobactam (Zosyn) plus vancomycin (Vancocin)
A
Relative risk stratification should be performed for patients with
community-acquired pneumonia (CAP), using a clinical prediction tool
such as the Pneumonia Severity Index (PSI) or the CURB-65 (SOR A).
These tools can be used along with the judgment of the physician to
decide whether or not a patient can be treated as an outpatient or
should be admitted to the hospital. This patient is moderately ill and
has a PSI score of 97 based on his age, heart rate, respiratory rate,
temperature, and oxygenation. This score indicates that he should
initially be treated in the hospital.A macrolide plus a β-lactam is
recommended for combination therapy in patients hospitalized with
CAP who are at low risk (PSI score of 71–130) (SOR A). A respiratory
fluoroquinolone (levofloxacin or moxifloxacin) can also be used as
monotherapy (SOR A). Because of concerns about increasing levels of
resistance, macrolides are not recommended as monotherapy for a
moderately ill patient (SOR C). Ciprofloxacin, a first-generation
quinolone, has poor potency against Streptococcus pneumoniae and
is therefore not appropriate treatment for CAP (SOR C). Treatment
with piperacillin/tazobactam is not indicated since there are no risk
factors for Pseudomonas. Vancomycin is likewise not indicated since
there are no MRSA risk factors.Adults hospitalized with non-severe
CAP who do not have risk factors for MRSA can be treated by either of
the following regimens:(1) combination therapy with a β-lactam
(ampicillin plus sulbactam, 1.5–3 g every 6 hours; cefotaxime, 1–2 g
every 8 hours; ceftriaxone, 1–2 g daily; or ceftaroline, 600 mg every 12
hours) AND a macrolide (azithromycin, 500 mg daily, or
clarithromycin, 500 mg twice daily)(2) monotherapy with a respiratory
,fluoroquinolone (levofloxacin, 750 mg daily, or moxifloxacin, 400 mg
daily)A combination of ceftriaxone and levofloxacin is not
recommended.It should be noted that β-lactam/macrolide therapy
reduced mortality in patients with CAP compared with patients
treated with β-lactam monotherapy, so monotherapy with a β-lactam
for hospital-treated pneumonia is not recommended. β-
Lactam/macrolide combinations may decrease all-cause death, but
mainly for patients with severe CAP. The Infectious Diseases Society
of America recommends that monotherapy with a β-lactam not be
used routinely for inpatient treatment of pneumonia.
A 67-year-old male is hospitalized with altered mental status, jaundice,
cirrhosis, and ascites related to alcoholic liver disease. He develops a
fever to 38.6°C (101.5°F). His abdomen is distended, with minimal
tenderness but no rebound. The remainder of the physical examination
is normal.You perform ultrasound-guided paracentesis. Which one of
the following would provide the best evidence for a diagnosis of
spontaneous bacterial peritonitis?
A peritoneal neutrophil count >250/mL
An elevated amylase level in peritoneal fluid
A low serum-ascites albumin gradient
Positive leukocyte esterase on urine testing strips
A
Spontaneous bacterial peritonitis is the most frequent bacterial
infection in patients with cirrhosis, followed by urinary tract infection,
, pneumonia, skin and soft-tissue infections, and spontaneous
bacteremia. A neutrophil count >250/mL in ascitic fluid from
paracentesis indicates a high risk for spontaneous bacterial peritonitis
(SBP) and is an indication for immediate empiric antibiotic therapy.
SBP is associated with a high mortality rate in patients with cirrhosis
and ascites (SOR A), and bacterial infections account for 25%-46% of
hospitalizations due to acute decompensation events in patients with
cirrhosis. Bacterial cultures to identify the etiology of SBP may be
helpful in guiding antibiotic choices (SOR C) but cultures are negative
in a significant percentage of patients with SBP. Culture results may
take 48-72 hours, and waiting on results would delay treatment in
high-risk patients.The serum-ascites albumin gradient (SAAG) helps
determine whether peritoneal fluid is a transudate or an exudate.
Theoretically, it might be expected that those with SBP would have
higher protein levels and thus a lower SAAG but this finding is not
reliable. An elevated amylase level would be more indicative of
pancreatitis.A large multi-center study has shown that urine test
strips are not a reliable way to rule out infection in SBP.
A 32-year-old male is admitted to the hospital for management of a
perirectal abscess. He reports severe pain in the rectal area, and
palpitations. His vital signs are normal, with the exception of a heart
rate of 132 beats/min and a temperature of 38.9°C (102.0°F). He rates
his pain as 8 out of 10. An EKG is shown below.Appropriate treatment
of the patient's cardiac arrhythmia would include intravenous
adenosine
