This document provides an overview of a self-evaluation process module for hospital-based internal medicine from 2011. It contains a warning that the document is copyrighted and cannot be reproduced without permission. It also lists an annual internal medicine review session taking place on July 16th 2011 presented by two physicians.

1. Self-Evaluation Process
2011 Update in Hospital-Based Internal
Medicine
Module 83-L Version 2011-1
Confidential
Only for use at the Scott & White Learning Sessions held July 16th 2012.
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2. 31st Annual Internal Medicine Review
July 16th 2011
Stephen Sibbitt, MD, FACP Curtis Mirkes, DO, FACP
CMO Scott & White Program Director
Memorial Hospital IM Residency

3. Question 1
Toxidrome Examples Vital signs Pupils Other findings
Cocaine, Hyperthermia Mydriasis Piloerection
Sympatho-mimetic Amphetamine Tachycardia Hyperreflexia
Pseudo-ephedrine Hypertension Diaphoresis
Tachypnea Tremors
Atropine Hyperthermia Mydriasis Hot, dry, red, blind
Anticholinergic TCA Tachycardia Seizures
Antihistamine Hypertension
BZD Hypothermia Miosis Hyporeflexia
Sedative- hypnotic Barbiturates Bradycardia (usually) Confusion
Alcohol Hypotension Stupor
Anticonvulsant Hypopnea coma
Opiates Hypothermia Miosis CNS depression,
Opioid Heroin Bradycardia Coma
Hypotension

4. Question 1
Psychoactive:
Club Drugs &
Inhalants
3, 4-Methylenedioxy-methamphetamine
(―ecstasy‖)

5. Question 1
 Duration of action
 Methamphetamine (approximately 20 hours)
 Cocaine (duration of action 30 minutes)
 PCP (duration of action less than 8 hours)

6. Question 1

7. Question 1
 Oral burns
Meth-mouth

8. Question 1
A. Hallucinogenic mushrooms
B. Phencyclidine (PCP)
C. MDMA (Ecstasy)
D. Methamphetamine

9. Question 2

10. A working definition of ACS
1. Presence of a new pulmonary infiltrate, not due to atelectasis, involving
at least one complete lung segment
2. Chest pain
3. Temperature >38.5ºC
4. Tachypnea, wheezing, or cough

11. Question 2

12. Question 2
 Transfusions
 Hypoxemia PaO2 < 70 mmHg

13. Question 2

14. Question 2
A. Ceftriaxone and azithromycin
B. Hydroxyurea
C. Packed red blood cells
D. Hydromorphone via patient-controlled analgesia
E. Exchange transfusion

15. Question 3

16. Question 3

17. Question 3
It is unclear what to do with aspirin in patients who have
transient ischemic attacks or cerebrovascular accidents.
However, this patient is asymptomatic, so she likely
would not benefit from intervention.

18. Question 3
A. Aspirin
B. Warfarin
C. Resection
D. No further intervention

19. Question 4

21. Question 4
A. Discontinuation now
B. For 48 hours following admission
C. Until follow-up blood cultures are negative
D. Until skin lesions have resolved
E. Until completion of therapy

22. Question 5

23. Question 5

24. Question 5

25. Question 5
A. Endocarditis
B. Wound infection, possibly osteomyelitis
C. Central venous catheter infection
D. Skin contamination when culture was drawn

26. Question 6

27. Question 6
Need to start antibiotics

28. Question 6

29. Question 6

30. Question 6

31. Question 6
A. Noninvasive ventilation
B. Amoxicillin
C. Levofloxacin
D. Low-molecular-weight heparin
E. Prednisone

32. Question 7

33. Question 7

34. Question 7

35. Question 7

36. Question 7
A. Repeat lumbar puncture
B. Discontinue current medications and discharge
C. Discontinue current medications and observe
D. Discontinue current medications, initiate oral valacyclovir,
and discharge
E. Discontinue current medications, initiate oral
cefpodoxime and valacyclovir, and discharge

37. Question 8
 I- Nonblanchable erythema caused
by extravasation of erythrocytes
into the interstitium, without
damage to deeper layers.
 II- Ulceration that involves the
epidermis and dermis; depth is no
more than several millimeters;
underlying tissue should appear
normal.
 III- Full-thickness ulcerations
through the dermis; ulcerations can
be extensive and deep and may
involve subcutaneous fat;
underlying tissue should appear
normal.
 IV- Ulcerations exposing muscle,
tendon, or bone; stage IV heel
ulcers can be only 4 to 5 mm deep;
stage IV sacral ulcers in obese
patients can be many centimeters
deep.

38. Question 8

39. Question 8
Stage 2 pressure ulcers on the lower sacrum do not
require Foley catheterization to heal. Foley
catheters in ulcer scenarios are only indicated for
stage 4 sacral or perineal ulcers.

40. Question 8
A. Continue the indwelling urinary catheter while the
patient remains hospitalized
B. Remove the indwelling urinary catheter while the
patient remains hospitalized but replace before
discharge
C. Remove the indwelling urinary catheter and replace
with a condom catheter
D. Remove the indwelling urinary catheter

41. Question 9

42. Question 9
A. Oral metronidazole
B. Oral vancomycin alone
C. Intravenous metronidazole alone
D. Oral vancomycin and intravenous
metronidazole

43. Question 10

44. Question 10

45. Question 10
The patient has responded clinically and is known
to have gram-negative rods in her urine. That
the blood culture took three days to become
positive suggests this is a low-grade bacteremia,
and her clinical response suggests that the drugs
she has received are working. The other options
are excessive for this scenario and would
unnecessarily prolong her hospitalization.

46. Question 10
A. Order immediate echocardiography
B. Begin amoxicillin–clavulanate and order abdominal
computed tomography
C. Begin amoxicillin–clavulanate and continue discharge
planning
D. Continue ticarcillin–clavulanate and postpone discharge

47. Question 9

48. Question 9

49. Question 11
A. Metronidazole orally
B. Metronidazole intravenously
C. Vancomycin orally
D. Vancomycin intravenously

50. Question 12
Haloperidol Antipsychotic - Typical Non Phenothiazines
Haldol
Benzodiazepin
Lorazepam e
Ativan
Olanzapine Atypical Antipsychotics-2nd and 3rd generation
Zyprexa
Risperidone Atypical Antipsychotics-2nd and 3rd generation
Risperdal

51. Question 12
Antipsychotic medications
 Cause high rates of extrapyramidal side effects
 Rigidity
 Bradykinesia
 Tremor
 Akathisia
 Tardive dyskinesia—hyperkinetic, involuntary
movements most readily observed in the face and
extremities.

52. Question 12
A. Haloperidol
B. Lorazepam
C. Olanzapine
D. Risperidone

53. Question 13

54. Question 13
A. Hepatitis C viral load
B. Hepatitis C genotype
C. Serum albumin level
D. Serum ALT and AST levels
E. Prothrombin time

55. Question 14
Treatment of Ascites

56. Question 14
Treatment of Refractory Ascites

57. Question 14

58. Question 14
A. Amiloride
B. Bumetanide
C. Eplerenone
D. Indapamide
E. Midodrine

59. Question 15

60. Question 15

61. Question 15
A. 180/100
B. 160/95
C. 140/90
D. 130/80

62. Question 16

63. Question 16
A. Bacteremia
B. Endocarditis
C. Osteomyelitis
D. Pneumonia

64. Question 17

68. Question 17
A. Calcitonin
B. Hip protectors
C. Alendronate
D. Teriparatide

69. Question 18

70. Question 18

71. Question 18
A. The cause of the error is not yet known but will be
fully investigated
B. Occasional errors are unavoidable because of human
factors
C. The administering nurse failed to check the patient's
allergies and will be disciplined
D. An error most likely occurred due to an oversight on
the part of the administering nurse and dispensing
pharmacist, and system changes will be implemented
to ensure the error does not happen again

72. Question 19

73. Question 19
A. Confirm the diagnosis of coronary artery
disease in low-risk patients
B. Confirm the diagnosis of coronary artery
disease in high-risk patients
C. Exclude the diagnosis of coronary artery
disease in low-risk patients
D. Exclude the diagnosis of coronary artery
disease in high-risk patients

74. Question 20

75. Question 20

76. Question 20
A. Aspirin, 325 mg daily
B. Clopidogrel, 75 mg daily
C. Warfarin adjusted to achieve an INR of 2-3
D. Unfractionated heparin bolus followed by
infusion
E. Enoxaparin, 1 mg/kg subcutaneously every
12 hours

77. Question 21

78. Question 21

79. Question 21
With chronic kidney disease and heart failure, the patient
will require diuretics at discharge. It would be futile to
discharge her on less than she came in on (e.g., no
diuretics, hydrochlorothiazide, or lower-dose
furosemide), because she will get volume overloaded
again. Sending her out on the same dose of furosemide
she came in with carries some risk of recurrent volume
overload, but it may be the safest option pending
follow-up evaluation. She will eventually need a higher
furosemide dose, but it is prudent not to raise the dose
until her renal function has stabilized.

80. Question 21
A. Decrease home furosemide dosage
B. Continue home furosemide dosage
C. Switch to metolazone
D. Withhold diuretics until follow-up with
primary care physician

81. Question 22
What is her condition?

82. Question 22

83. Question 22

84. Question 22
A. Discharge with prescription for metoclopramide, 10 mg before
every meal
B. Obtain barium swallow
C. Obtain esophagogastroduodenoscopy
D. Obtain gastric emptying study
E. Change insulin therapy to insulin glargine at bedtime and insulin
aspart with meals; discharge

85. Question 23

86. Question 23

87. Question 24

88. Question 24

89. Question 24
A. Measurement of plasma D-dimer
B. Computed tomographic angiography of the
pulmonary vasculature
C. Venous duplex compression
ultrasonography of the lower extremities
D. Ventilation–perfusion lung scan

90. Question 25

91. Question 25
A. 400 IU daily
B. 1000 IU daily
C. 2000 IU daily
D. 50,000 IU weekly

92. Questions