ABFM HOSPITAL MEDICINE
1. 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 ex- amination he appears ill and in mild
respiratory distress. His temperature
is 40.3°C (104.5°F), pulse rate 130 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? (Mark all that are true.) Ceftriaxone (Rocephin)
plus azithromycin (Zithromax)
Ceftriaxone plus doxycycline Ciprofloxacin (Cipro)
Clarithromycin (Biaxin) Levofloxacin (Levaquin): A, B, E
Relative risk stratification should be performed for patients with
community-acquired pneumonia, 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, based on his presentation, has a PSI score of
97 (based on his age, respiratory rate, temperature, and pulse
oximetry). This score indicates that he should initially be treated in
the hospital.A macrolide plus a ²lactam is recommended for
combination therapy in patients hospitalized with community-
acquired pneumonia who are at low risk (PSI score of 71-130)
(SOR A). In addition to a ²lactam, doxycycline can be used as
,an alternative to a macrolide (SOR B). A respiratory
fluoroquinolone (levofloxacin, gemifloxacin, moxifloxacin) can 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 no antimicrobial activity against
Streptococcus pneumoniae and is therefore not appropriate
treatment for community-acquired pneumonia (SOR C).
2. A 32-year-old nonpregnant female with a history of poorly
controlled type
2 diabetes mellitus is admitted to the hospital for abdominal
wall cellulitis. On hospital day 2 she develops mild shortness
of breath. Her physical ex- amination is normal, with the
exception of a respiratory rate of 22/min and abdominal wall
erythema, warmth, and tenderness. Laboratory findings are
, normal with the exception of a fasting blood glucose level of
268 mg/dL and mild leukocytosis. Her D-dimer level is 250
ng/mL.True statements regarding the use of the D-dimer
assay for diagnosing pulmonary embolism in this situation
include which of the following? (Mark all that are true.)
It has good sensitivity
It has good specificity
It has a good positive predictive value
It has a good negative predictive value: A, D
D-dimer is a degradation product of cross-linked fibrin. The
PIOPED II investigators recommend stratification of all patients
with suspected pulmonary embolism accord- ing to an objective
clinical probability assessment. D-dimer should be measured by a
quantitative rapid enzyme-linked immunosorbent assay (ELISA),
and the combi- nation of a negative D-dimer with a low or
moderate clinical probability can safely exclude pulmonary
1. 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 ex- amination he appears ill and in mild
respiratory distress. His temperature
is 40.3°C (104.5°F), pulse rate 130 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? (Mark all that are true.) Ceftriaxone (Rocephin)
plus azithromycin (Zithromax)
Ceftriaxone plus doxycycline Ciprofloxacin (Cipro)
Clarithromycin (Biaxin) Levofloxacin (Levaquin): A, B, E
Relative risk stratification should be performed for patients with
community-acquired pneumonia, 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, based on his presentation, has a PSI score of
97 (based on his age, respiratory rate, temperature, and pulse
oximetry). This score indicates that he should initially be treated in
the hospital.A macrolide plus a ²lactam is recommended for
combination therapy in patients hospitalized with community-
acquired pneumonia who are at low risk (PSI score of 71-130)
(SOR A). In addition to a ²lactam, doxycycline can be used as
,an alternative to a macrolide (SOR B). A respiratory
fluoroquinolone (levofloxacin, gemifloxacin, moxifloxacin) can 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 no antimicrobial activity against
Streptococcus pneumoniae and is therefore not appropriate
treatment for community-acquired pneumonia (SOR C).
2. A 32-year-old nonpregnant female with a history of poorly
controlled type
2 diabetes mellitus is admitted to the hospital for abdominal
wall cellulitis. On hospital day 2 she develops mild shortness
of breath. Her physical ex- amination is normal, with the
exception of a respiratory rate of 22/min and abdominal wall
erythema, warmth, and tenderness. Laboratory findings are
, normal with the exception of a fasting blood glucose level of
268 mg/dL and mild leukocytosis. Her D-dimer level is 250
ng/mL.True statements regarding the use of the D-dimer
assay for diagnosing pulmonary embolism in this situation
include which of the following? (Mark all that are true.)
It has good sensitivity
It has good specificity
It has a good positive predictive value
It has a good negative predictive value: A, D
D-dimer is a degradation product of cross-linked fibrin. The
PIOPED II investigators recommend stratification of all patients
with suspected pulmonary embolism accord- ing to an objective
clinical probability assessment. D-dimer should be measured by a
quantitative rapid enzyme-linked immunosorbent assay (ELISA),
and the combi- nation of a negative D-dimer with a low or
moderate clinical probability can safely exclude pulmonary
