ABFM HOSPITAL MEDICINE
A042-year-old0construction0worker0with0a03-
day0history0of0cough,0fever,0chills,0dyspnea,0and0right0posterolateral0chest0pain0with0in
spiration0is0brought0to0the0emergency0department0by0his0wife.0He0has0been0in0good0h
ealth0until0this0illness,0and0has0never0been0hospitalized.0He0does0not0take0any0routine
0medications,0does0not0smoke,0and0drinks0alcohol0only0occasionally.On0examination0h
e0appears0ill0and0in0mild0respiratory0distress.0His0temperature0is040.3°C0(104.5°F),0pul
se0rate01300beats/min,0respiratory0rate032/
min,0blood0pressure0136/700mm0Hg,0and0oxygen0saturation088%0on0room0air.0He0has
0diminished0breath0sounds0in0the0right0posterolateral0chest.0His0Pneumonia0Severity0I
ndex0is097.0Based0on0the0severity0of0his0illness0you0recommend0hospital0admission.A
ntibiotic0choices0recommended0for0empiric0treatment0in0this0patient0include0which0of0th
e0following?0(Mark0all0that0are0true.)
Ceftriaxone0(Rocephin)0plus0azithromycin0-0ans✔A,0B,0E
Relative0risk0stratification0should0be0performed0for0patients0with0community-
acquired0pneumonia,0using0a0clinical0prediction0tool0such0as0the0Pneumonia0Severity0I
ndex0(PSI)0or0the0CURB-
650(SOR0A).0These0tools0can0be0used0along0with0the0judgment0of0the0physician0to0de
cide0whether0or0not0a0patient0can0be0treated0as0an0outpatient0or0should0be0admitted0t
o0the0hospital.0This0patient0is0moderately0ill0and,0based0on0his0presentation,0has0a0PS
I0score0of0970(based0on0his0age,0respiratory0rate,0temperature,0and0pulse0oximetry).0T
his0score0indicates0that0he0should0initially0be0treated0in0the0hospital.A0macrolide0plus0
a0β-
lactam0is0recommended0for0combination0therapy0in0patients0hospitalized0with0commun
ity-acquired0pneumonia0who0are0at0low0risk0(PSI0score0of071-
130)0(SOR0A).0In0addition0to0a0β-
lactam,0doxycycline0can0be0used0as0an0alternative0to0a0macrolide0(SOR0B).0A0respirat
ory0fluoroquinolone0(levofloxacin,0gemifloxacin,0moxifloxacin)0can0be0used0as0monothe
rapy0(SOR0A).0Because0of0concerns0about0increasing0levels0of0resistance,0macrolides
0are0not0recommended0as0monotherapy0for0a0moderately0ill0patient0(SOR0C).0Ciproflo
xacin,0a0first-
generation0quinolone,0has0no0antimicrobial0activity0against0Streptococcus0pneumoniae
0and0is0therefore0not0appropriate0treatment0for0community-
acquired0pneumonia0(SOR0C).
, A032-year-
old0nonpregnant0female0with0a0history0of0poorly0controlled0type020diabetes0mellitus0is0
admitted0to0the0hospital0for0abdominal0wall0cellulitis.0On0hospital0day020she0develops0
mild0shortness0of0breath.0Her0physical0examination0is0normal,0with0the0exception0of0a0
respiratory0rate0of022/
min0and0abdominal0wall0erythema,0warmth,0and0tenderness.0Laboratory0findings0are0n
ormal0with0the0exception0of0a0fasting0blood0glucose0level0of02680mg/
dL0and0mild0leukocytosis.0Her0D-dimer0level0is02500ng/
mL.True0statements0regarding0the0use0of0the0D-
dimer0assay0for0diagnosing0pulmonary0embolism0in0this0situation0include0which0of0the0
following?0(Mark0all0that0are0true.)
It0has0good0sensitivity
It0has0good0specificity
It0has0a0good0positive0predictive0value
It0has0a0good0negative0predictive0value0-0ans✔A,0D
D-dimer0is0a0degradation0product0of0cross-
linked0fibrin.0The0PIOPED0II0investigators0recommend0stratification0of0all0patients0with0
suspected0pulmonary0embolism0according0to0an0objective0clinical0probability0assessm
ent.0D-dimer0should0be0measured0by0a0quantitative0rapid0enzyme-
linked0immunosorbent0assay0(ELISA),0and0the0combination0of0a0negative0D-
dimer0with0a0low0or0moderate0clinical0probability0can0safely0exclude0pulmonary0emboli
sm0in0many0patients.0The0sensitivity0of0the0D-dimer0assay0is090%-
95%0for0pulmonary0embolus,0but0D-dimer0levels0are0normal0in0only040%-
68%0of0patients0without0pulmonary0embolus0(SOR0A).0A0D-dimer0value0>5000ng/
mL0is0considered0to0be0abnormal.0Values0≤5000ng/
mL0have0a0high0negative0predictive0value0for0pulmonary0embolism0in0patients0with0a0l
ow0to0moderate0pretest0probability0(SOR0A).
A058-year-
old0male0with0type020diabetes0mellitus0undergoes0elective0knee0surgery.0After0the0sur
gery0he0is0restarted0on0all0of0his0usual0medications0with0intensive0glucose0monitoring.0
On0his0first0postoperative0day0he0is0found0to0be0confused0and0lethargic0with0a0blood0g
lucose0level0of0320mg/
dL.When0used0alone,0which0of0the0following0diabetes0medications0can0cause0this0prob
lem?0(Mark0all0that0are0true.)
Nateglinide0(Starlix)
Glipizide0(Glucotrol)
Insulin0glargine0(Lantus)
Metformin0(Glucophage)
Pioglitazone0(Actos)0-0ans✔A,0B,0C
Some0diabetes0medications0can0lead0to0hypoglycemia0in0hospitalized0patients.0Both0n
ateglinide0and0glipizide0stimulate0insulin0production,0which0can0lead0to0hypoglycemia0(
SOR0B).0All0insulin0products0lower0blood0glucose0directly,0with0hypoglycemia0as0a0kno
wn0side0effect0(SOR0B).0Metformin0and0pioglitazone0both0help0control0diabetes0by0sen
A042-year-old0construction0worker0with0a03-
day0history0of0cough,0fever,0chills,0dyspnea,0and0right0posterolateral0chest0pain0with0in
spiration0is0brought0to0the0emergency0department0by0his0wife.0He0has0been0in0good0h
ealth0until0this0illness,0and0has0never0been0hospitalized.0He0does0not0take0any0routine
0medications,0does0not0smoke,0and0drinks0alcohol0only0occasionally.On0examination0h
e0appears0ill0and0in0mild0respiratory0distress.0His0temperature0is040.3°C0(104.5°F),0pul
se0rate01300beats/min,0respiratory0rate032/
min,0blood0pressure0136/700mm0Hg,0and0oxygen0saturation088%0on0room0air.0He0has
0diminished0breath0sounds0in0the0right0posterolateral0chest.0His0Pneumonia0Severity0I
ndex0is097.0Based0on0the0severity0of0his0illness0you0recommend0hospital0admission.A
ntibiotic0choices0recommended0for0empiric0treatment0in0this0patient0include0which0of0th
e0following?0(Mark0all0that0are0true.)
Ceftriaxone0(Rocephin)0plus0azithromycin0-0ans✔A,0B,0E
Relative0risk0stratification0should0be0performed0for0patients0with0community-
acquired0pneumonia,0using0a0clinical0prediction0tool0such0as0the0Pneumonia0Severity0I
ndex0(PSI)0or0the0CURB-
650(SOR0A).0These0tools0can0be0used0along0with0the0judgment0of0the0physician0to0de
cide0whether0or0not0a0patient0can0be0treated0as0an0outpatient0or0should0be0admitted0t
o0the0hospital.0This0patient0is0moderately0ill0and,0based0on0his0presentation,0has0a0PS
I0score0of0970(based0on0his0age,0respiratory0rate,0temperature,0and0pulse0oximetry).0T
his0score0indicates0that0he0should0initially0be0treated0in0the0hospital.A0macrolide0plus0
a0β-
lactam0is0recommended0for0combination0therapy0in0patients0hospitalized0with0commun
ity-acquired0pneumonia0who0are0at0low0risk0(PSI0score0of071-
130)0(SOR0A).0In0addition0to0a0β-
lactam,0doxycycline0can0be0used0as0an0alternative0to0a0macrolide0(SOR0B).0A0respirat
ory0fluoroquinolone0(levofloxacin,0gemifloxacin,0moxifloxacin)0can0be0used0as0monothe
rapy0(SOR0A).0Because0of0concerns0about0increasing0levels0of0resistance,0macrolides
0are0not0recommended0as0monotherapy0for0a0moderately0ill0patient0(SOR0C).0Ciproflo
xacin,0a0first-
generation0quinolone,0has0no0antimicrobial0activity0against0Streptococcus0pneumoniae
0and0is0therefore0not0appropriate0treatment0for0community-
acquired0pneumonia0(SOR0C).
, A032-year-
old0nonpregnant0female0with0a0history0of0poorly0controlled0type020diabetes0mellitus0is0
admitted0to0the0hospital0for0abdominal0wall0cellulitis.0On0hospital0day020she0develops0
mild0shortness0of0breath.0Her0physical0examination0is0normal,0with0the0exception0of0a0
respiratory0rate0of022/
min0and0abdominal0wall0erythema,0warmth,0and0tenderness.0Laboratory0findings0are0n
ormal0with0the0exception0of0a0fasting0blood0glucose0level0of02680mg/
dL0and0mild0leukocytosis.0Her0D-dimer0level0is02500ng/
mL.True0statements0regarding0the0use0of0the0D-
dimer0assay0for0diagnosing0pulmonary0embolism0in0this0situation0include0which0of0the0
following?0(Mark0all0that0are0true.)
It0has0good0sensitivity
It0has0good0specificity
It0has0a0good0positive0predictive0value
It0has0a0good0negative0predictive0value0-0ans✔A,0D
D-dimer0is0a0degradation0product0of0cross-
linked0fibrin.0The0PIOPED0II0investigators0recommend0stratification0of0all0patients0with0
suspected0pulmonary0embolism0according0to0an0objective0clinical0probability0assessm
ent.0D-dimer0should0be0measured0by0a0quantitative0rapid0enzyme-
linked0immunosorbent0assay0(ELISA),0and0the0combination0of0a0negative0D-
dimer0with0a0low0or0moderate0clinical0probability0can0safely0exclude0pulmonary0emboli
sm0in0many0patients.0The0sensitivity0of0the0D-dimer0assay0is090%-
95%0for0pulmonary0embolus,0but0D-dimer0levels0are0normal0in0only040%-
68%0of0patients0without0pulmonary0embolus0(SOR0A).0A0D-dimer0value0>5000ng/
mL0is0considered0to0be0abnormal.0Values0≤5000ng/
mL0have0a0high0negative0predictive0value0for0pulmonary0embolism0in0patients0with0a0l
ow0to0moderate0pretest0probability0(SOR0A).
A058-year-
old0male0with0type020diabetes0mellitus0undergoes0elective0knee0surgery.0After0the0sur
gery0he0is0restarted0on0all0of0his0usual0medications0with0intensive0glucose0monitoring.0
On0his0first0postoperative0day0he0is0found0to0be0confused0and0lethargic0with0a0blood0g
lucose0level0of0320mg/
dL.When0used0alone,0which0of0the0following0diabetes0medications0can0cause0this0prob
lem?0(Mark0all0that0are0true.)
Nateglinide0(Starlix)
Glipizide0(Glucotrol)
Insulin0glargine0(Lantus)
Metformin0(Glucophage)
Pioglitazone0(Actos)0-0ans✔A,0B,0C
Some0diabetes0medications0can0lead0to0hypoglycemia0in0hospitalized0patients.0Both0n
ateglinide0and0glipizide0stimulate0insulin0production,0which0can0lead0to0hypoglycemia0(
SOR0B).0All0insulin0products0lower0blood0glucose0directly,0with0hypoglycemia0as0a0kno
wn0side0effect0(SOR0B).0Metformin0and0pioglitazone0both0help0control0diabetes0by0sen
