Internal Medicine
Recertification / MOC Exam Review

Educational Objective:

Confirm the clinical diagnosis of MS.

Key Point:

Almost all patients (95%) with established MS have abnormalities on brain scan (MRI) with evidence of temporal and spatial progression.

Explanation:

No definitive diagnostic laboratory test exists for MS, but MRI of the brain can be extremely useful and should be performed in all patients when MS is in the differential diagnosis.

More than 95% of patients with clinically definite MS have an abnormal result on a brain MRI. Specific findings on MRI can provide evidence of disease disseminated in time and space (more than one lesion in different parts of the brain or spine appearing in at least two different occasions). MS plaques typically appear as high-signal (white) areas on T2-weighted images. Features of lesions seen on MRI suggestive of MS include an elliptical shape, discrete borders, lack of mass effect, and gadolinium enhancement. Typical locations include the periventricular area (as seen on the brain MRI), the corpus callosum and the dorsolateral spinal cord (as noted on the MRI of his spine).

References:

Ferri FF. Multiple sclerosis. In: Ferri FF. Ferri’s Clinical Advisor. 2015:785-787.

Calabresi PA, Multiple sclerosis and demyelinating conditions of the central nervous system. In: Goldman-Cecil Medicine. 2016; 411: 2471-2480.

Educational Objective:

Diagnose and manage hypertension in the elderly.

Key Point:

First-line therapy of new-onset hypertension in the elderly may be a trial of lifestyle changes.

Explanation:

This patient is elderly and presents with what appears to be new-onset hypertension. Given that his blood pressure was previously noted to be normal and that the patient smokes, it would be reasonable to refer him to a qualified program of lifestyle changes and, if his blood pressure remains elevated, to initiate treatment. According to a recently published guideline by the American College of Physicians and the American Academy of Family Physicians, adults aged 60 years or older with systolic blood pressure greater than 150 mm Hg should be treated to achieve a target systolic pressure of less than 150 mm Hg. 

There are 3 types of medications thought to be first-line therapy for the treatment of hypertension in the elderly: long-acting calcium channel blockers, low-dose thiazide diuretics, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers.

The European Society of Hypertension and the European Society of Cardiology state that either a long-acting calcium channel blocker or a thiazide diuretic can be used as first-line therapy and those patients who require combination therapy can take a medication from 2 of the 3 above-mentioned classes of medications. The Eighth Joint National Committee does not recommend a specific class of medication for combination therapy or monotherapy.

References:

James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.

Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic Treatment of Blood Pressure in Adults aged 60 and older to Higher versus Lower Blood Pressure Targets: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017; 166: 430-437

Educational Objective:

Know the common causes of nosocomial infections in the ICU setting.

Key Point:

Acute sinusitis should be considered in patients with unexplained fever who are receiving nasotracheal intubation.

Explanation:

The next most appropriate next step would be to obtain computed tomography of the patient's sinuses.

The development of fever in a patient in the ICU is often a diagnostic dilemma. Multiple potential sources of infection may be evident. In addition, fever may be of a noninfectious origin. Pneumonias, urinary tract infections, and line infections are all common causes of fever in the ICU setting. Sinusitis is also quite common, particularly among patients with nasotracheal intubation. Acalculous cholecystitis, pulmonary embolism, and deep venous thrombosis can also account for fever, but they do not seem plausible in this patient. Fungal cultures would be appropriate if computed tomography demonstrates sinusitis, but no bacteria were identified on nasal culture.

References:

Rehman T, Deboisblanc BP. Persistent fever in the ICU. Chest. 2014;145(1):158-165.

Roth Y, Sokolov M, Adler M, Ezry T, Harell M. Otorhinolaryngological problems occurring within the intensive care unit. Intensive Care Med. 2003;29(6):884-889.

Educational Objective:

Recognize the risk for development of corneal ulcers from prolonged wear of contact lenses.

Key Point:

Prolonged wearing of contact lenses predisposes to corneal ulcer due to local hypoxia.

Explanation:

All comatose or obtunded patients should be evaluated for the presence of contact lenses and if found, removed to prevent corneal ulcers due to hypoxia.

References:

Babineau MR – “Ophthalmic Procedures in the Emergency Department”. Emerg Med Clin North Am - 01-FEB-2008; 26(1): 17-34

Tarff A, Behrens A, Ocular Emergencies. Medical Clinics of North America. 2017; 101: 615-639

Educational Objective:

Recognize the increased risk of Pseudomonas-associated osteomyelitis with puncture wounds.

Key Point:

Puncture wounds through a tennis shoe are associated with an increased risk of P osteomyelitis infection.

Explanation:

Puncture wounds of the foot may result in osteomyelitis by direct inoculation. Such infections occur most frequently in children. The most common pathogen is Pseudomonas. The main symptom in such infections is foot pain often in conjunction with surrounding cellulitis and pain on deep pressure.

Cat bites often result in Pasteurella multocida osteomyelitis. Fresh-water wounds are often contaminated by Aeromonas hydrophilia. Gonococcal arthritis is the most common infectious arthritis in sexually active individuals younger than 30 years of age.

References:

Falagas ME, Rafailidis PI. Pseudomonas and related gram-negative bacillary infections (chapter 306). In: Goldman L, Schafer A. Goldman-Cecil Medicine. 25th ed., 2016:1962-1968.

Raukar NP, Zink BJ. Bone and joint infections (chapter 128). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1693-1709.