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ABFM KSA - Care of Hospitalized Patients With Complete Solutions Latest Update
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ABFM KSA - Care of Hospitalized Patients WithComplete Solutions Latest Update
Clostridioides (Clostridium) difficile colitis is one of the more common diseases, usually affecting patients
recently treated with antibiotics, and often requiring hospital admission. Initial management of a patient
with C. difficile –associated diarrhea should include discontinuation of offending antimicrobials when
possible, routine supportive care including fluid and electrolyte management, and treatment with oral
vancomycin or fidaxomicin. In a meta-analysis and systematic review, fidaxomicin outperformed oral
vancomycin and was cost effective despite higher per dose costs. Oral metronidazole is no longer to be
used for treatment of C. difficile infection as the rate of treatment failure with metronidazole is
increasing with rates of nonresponse now >20%. However, in more acutely ill patients, combination
therapy with intravenous metronidazole and oral vancomycin is recommended. The antibiotics most
commonly implicated in the development of C. difficile colitis include clindamycin, broad-spectrum
penicillins, and cephalosporins and are not effective against the infection. Fluoroquinolones also have
not been effective. There is no evidence to support the routine use of antimotility agents such as
loperamide; the increased risks of toxin-related disease warrant against its usage (SOR B). Intravenous
vancomycin has no effect against C. difficile, inhibiting only oral vancomycin's efficacy in eradicating C.
difficile from the colon.
A new order set was recently implemented at your hospital for the treatment of sepsis. While the order
set seems successful in standardizing treatment, there has been an uptick in acute kidney injuries in the
intensive-care unit since the order set was implemented. Which of the following would NOT be helpful in
decreasing medication-related nephrotoxicity?
Reviewing the medications on the order set for similarly effective but less toxic alternatives
Implementing strategies to identify high-risk clients before receiving a potentially nephrotoxic
medication
Maintaining the patient's fluid volume at a minimum during the course of a potentially nephrotoxic
medication
Closely monitoring serum creatinine levels during a course of nephrotoxic medications
Utilization of the Modification of Diet in Renal Disease Study equation to assess renal function
C
When a new order set is associated with increased acute kidney injury, the new order set likely contains
a medication that is more nephrotoxic than the one used previously. That drug should be replaced, if
,possible, with an equally effective but less nephrotoxic medication. Also, being able to identify risk
factors before the administration of nephrotoxic drugs can reduce nephrotoxicity. SOR C. The common
risk factors for nephroxic reactions to medications include advanced age, depleted fluid status,
underlying chronic renal disease, and concurrent use of medications that can impact renal function such
as NSAIDs, other anti-inflammatory drugs, or ACE inhibitors. Whether or not ACE inhibitors should be
stopped in these settings, and what criteria should be used to make that decision is not clear in the
medical literature. Most other medications such as NSAIDs should be stopped immediately. Medications
that are renally excreted can build up to toxic levels if not appropriately dosed based on renal function.
Generally, the use of the Modification of Diet in Renal Disease [MDRD] Study equation is not appropriate
because it uses race as a determinant in establishing the estimated GFR. Because this calculation yields a
different GFR for a given level of creatinine and age in Black patients, it can lead to inappropriate dosing
of medications and will miss Black patients with significant renal disease. Furthermore, it is suggested
that potentially nephrotoxic medications are given with adequate hydration and that the patient be well
hydrated before a potentially nephrotoxic medication is begun (SOR C). An observational study has also
shown that poor monitoring of serum creatinine contributes to adverse drug events (SOR B).
A 78-year-old man is admitted to the medical floor to be treated for a large ischemic stroke. He has been
unable to eat and has been receiving his nutrition through a nasogastric tube. The morning laboratory
values on his fourth hospital day show that this patient has a serum sodium value of 129 mEq/L (N
135-145).Which one of the following values would be useful for determining the reason for this patient's
hyponatremia?
Total 24-hour urine output
24-hour urine sodium
Spot urine sodium
Urine protein
C
The cause of the hyponatremia can be determined in part by how the patient's kidneys are responding to
the condition. This is based on the serum osmolality. The next step is assessing volume status. This can
be tricky on clinical examination. A spot urine sodium level and urine osmolality are recommended. If
appropriately dilute with a sodium <20 mEq/L, then hyponatremia is secondary to excessive water intake
or inadequate solute intake. If urine is concentrated with a spot urine sodium >20 mEq/L, then patient
may be hypovolemic, or may have the syndrome of inappropriate secretion of antidiuretic hormone
(SIADH). This is typically manifested by a low serum osmolality, a urinary osmolality above 100 mOsm/kg,
normal renal function, euvolemia, and a random urinary sodium level above 20 mEq/L, with no thyroid
,disorders or the use of diuretics. If the serum osmolality is normal or high, no treatment of the
hyponatremia itself is necessary. Both the iso-osmolar hyponatremia and the hyperosmolar
hyponatremia result from an excess of another osmole such as glucose, mannitol, or contrast dye. A
urine protein level is also useless in evaluating hyponatremia. The urine sodium and urine chloride
concentrations can be helpful in differentiating hypovolemic from euvolemic hyponatremia. In
hypovolemic hyponatremic patients with metabolic alkalosis from vomiting, the urine sodium may be
>20 mEq/L, but the urine chloride will be <20 mEq/L.
A 4 yr old male is brought to the ED by his mother for fever to 103°F, irritability, and a skin lesion on his
arm that was first noticed < 24 hours ago. On examination the lesion is 4 cm in diameter, erythematous
with poorly defined borders, warm, and tender. It has a firm, fluctuant center about 2 cm in diameter,
with a central purulent head. There have been no similar infections in household contacts.At this time,
appropriate treatment options for this patient's skin infection include
incision and drainage, and amoxicillin/clavulanate (Augmentin)
incision and drainage, and ceftriaxone
incision and drainage, and clindamycin (Cleocin)
incision and drainage only
ceftriaxone only
C
Historically, MRSA infections have been considered nosocomial. However, since the 1990s, a unique type
of community-acquired strains (CA-MRSA) has emerged. The bacteria are passed by close contact and
can be readily transmitted across abraded skin. For this reason, many homes may experience outbreaks,
and athletes, particularly football players and wrestlers, may acquire the condition from teammates or
opponents. However, only 10%-18% of patients who contract CA-MRSA have a known contact who has
the disease. The child described here shows classic signs of an infection with CA-MRSA. Abscesses similar
to those seen in this patient occur in 50%-75% of patients with CA-MRSA. In cases in which no systemic
signs are present, incision and drainage is usually curative without the use of antibiotics. However, this
child has a high fever and spreading cellulitis, and thus needs an antibiotic as an adjunct to surgical
therapy (SOR B). Decolonization of offending bacteria with topical antibiotic washes is not a goal for an
acute infection, and is recommended only for cases that are recurrent or in which a whole group of
patients, such as a family or athletic team, is symptomatic (SOR C).Clindamycin is FDA approved for the
treatment of MRSA infections and is appropriate in children (SOR B). β-Lactam antibiotics, including
ceftriaxone and amoxicillin/clavulanate, generally represent poor treatment choices for MRSA infections
(SOR B).
, Which one of the following is true regarding the transfusion of PRBCs?
Most patients with previous coronary artery disease who are admitted to the hospital for a
noncardiovascular problem and whose admitting hemoglobin is 8.0-9.0 g/dL should be transfused
because their hospital stay will more than likely continue to lower their hemoglobin .
Anemia, as manifested by a decline in the hemoglobin from an admission value of 11.0 g/dL to 8.0 g/dL
during a 3-day hospital stay, is an absolute indication for transfusion
Generally, transfusion of 1 unit of PRBCs should increase hemoglobin by 2 g/dL and hematocrit by 6
percentage points
Restrictive transfusion practices limiting transfusion to only patients with hemoglobin <7.0 g/dL have
been associated with lower 30-day mortality rates compared to more liberal transfusion practices
In spite of aggressive screening the risk of infection from a blood transfusion has continued to rise
annually since the 1980s
D
Transfusion of blood products can be a lifesaving intervention for properly selected patients. In the past,
fairly liberal transfusion policies often resulted in transfusion based upon the "10/30" rule; any patient
with a hemoglobin level <10 mg/dL or a hematocrit <30% would be considered for transfusion,
regardless of clinical condition. There is now support for more restrictive transfusion rules that
recommend the limitation of transfusion to patients with hemoglobin levels below 7.0 g/dL with a target
range of 7.0-9.0 g/dL. In general, in average-sized adults, one unit of packed red blood cells leads to an
increment in hemoglobin of 1 g/dL or an increment of 3 percentage points in hematocrit. This more
restrictive strategy, as compared to more liberal transfusion practices, significantly reduces the number
of units transfused, resulting in a reduction in 30-day mortality. Other indications for transfusion include
sickle-cell crisis and an acute loss of >1500 mL of blood or 30% of blood volume (SOR C).Transfusion is
also indicated for patients with acute symptoms related to their anemia -ie, shortness of breath,
weakness, altered cognition, angina, and severe heart failure-who are unable to function as a result of
their symptoms (SOR C). Overall, the risk of transfusion-related complications is small. Although there
continues to be some risk of noninfectious complications, the risk of transfusion-transmitted infections
has decreased 10,000-fold since the 1980s due to vigorous screening of potential donors and the supply
of donor blood (SOR C).
An 82-year-old male is brought to the emergency department with confusion after he passed out while
getting up from the toilet. According to his wife, he had lower abdominal pain with associated nausea,
vomiting, and a poor stream over the past 3 days. His chronic medical problems include HTN, HLD,
hypothyroidism, type 2 DM, osteoarthritis, and BPH. His current medications include the
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