Internal Medicine
Recertification / MOC Exam Review

Educational Objective:

Know what to do when a patient, who has the capacity to make decisions, refuses a potentially life-saving treatment.

Key Point:

The physician or nurse must respect the patient’s decision to refuse a treatment.

Explanation:

In this scenario, the patient's desire not to receive a blood transfusion must be respected. Generally speaking, Jehovah's Witnesses are unable to receive blood products due to their religious beliefs. It would be most appropriate to implement principles of bloodless medicine in these patients.

Because this patient has the capacity to make decisions for himself, the other choices listed are incorrect because they do not respect his wishes.

References:

Crookston KP. The approach to the patient who refuses blood transfusions. Revised January 22, 2016. Accessed August 31, 2016.

Karlawish J. Assessment of decision-making capacity in adults. Revised October 30, 2015. Accessed August 31, 2016.

Kon AA, Davidson JE, Morrison W, et al. Shared decision making in ICUs: an American College of Critical Care Medicine and American Thoracic Society policy statement. Crit Care Med. 2016;44(1):188-201.

Educational Objective:

Recognize that egg allergy is a relative contraindication to flu vaccination.

Key Point:

It is important to understand that it is safe to administer the influenza vaccine to patients that have demonstrated an intolerance to egg containing products in the past.

Explanation:

It would be most appropriate to administer the inactivated influenza vaccine today because the history of an allergy to egg products as a child is questionable and she is now able to tolerate eggs a few times a week without any issues.

It is important to remember that there are 2 types of influenza vaccines: live and inactive. The live vaccine is administered intranasally and the inactive vaccine is given intramuscularly. The other choices are inconsistent with the guidelines regarding influenza vaccination in patients with egg allergy.

References:

Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices, United States, 2015-16 influenza season. MMWR Morb Mortal Wkly Rep. 2015;64(30):818-825.

Kelso JM, Greenhawt MJ, Li JT, et al. Adverse reactions to vaccines practice parameter 2012 update. J Allergy Clin Immunol. 2012;130(1):25-43.

Kelso JM, Wang J. Influenza vaccination in individuals with egg allergy. Accessed March 23, 2016.

Educational Objective:

Identify the core clinical criterion for probable Alzheimer’s dementia.

Key Point:

A core criterion for Alzheimer’s dementia includes cognitive deficits in at least 2 domains.

Explanation:

According to the 2011 recommendations from the National Institute on Aging and Alzheimer’s Association, core clinical criteria for probable Alzheimer dementia include meeting the criteria for all-cause dementia, insidious onset, progressive worsening, and cognitive deficits in at least 2 domains. The initial and most prominent deficit is most often in learning/memory, but it can also be in judgment/reasoning, visuospatial abilities, or language. There should be deficits in 2 or more domains. Of note, imaging and biomarker results are not core criteria in reaching a diagnosis of probable Alzheimer disease.

References:

McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement. 2011;7(3):263-269.

Cummings JL, Dubois BD, et al. International Work Group Criteria for the Diagnosis of Alzheimer’s Disease. Med Clin N. Amer. 2013; 97: 363-368

Educational Objective:

Know the risks of red blood cell transfusions.

Key Point:

Transfusion related lung injury is the leading cause of transfusion-related deaths.

Explanation:

RBC transfusions are associated with an increase in nosocomial infections in critically ill patients. Sites of infection include wounds, the lungs, and the blood products themselves. The introduction of bacteria during collection or through blood processing can result in septic reactions during or immediately after blood transfusion.

Use of RBC transfusion is a risk factor for multiple organ failure as well as systemic inflammatory response syndrome, and it is accompanied by longer stays in the intensive care unit, longer lengths of hospital stay, and increased rates of complications and mortality.

TRALI has become the leading cause of transfusion-related deaths reported to the US Food and Drug Administration. Symptoms range from mild dyspnea to severe, noncardiac pulmonary edema. Large amounts of fluid accumulate in the lungs well beyond infused volumes of blood. The explanation for these changes is that leukocyte antibodies activate neutrophils present in the lungs resulting in leukostasis and edema. Blood donors who are implicated in moderate to severe TRALI reactions should be exempted from being donors.

References:

Choate JA, et al. Transfusion reactions to blood and cell therapy products. In: Hoffman R, et al, eds. Hematology: Basic Principles and Practice. 6th ed., 2016.

Isbister IP. Blood component therapies. In: Vincent J-L, et al. Textbook of Critical Care. 6th ed., 2011.

Johnson JL, Moore EE, Kashuk JL, et al. Effect of blood products transfusion on the development of postinjury multiple organ failure. Arch Surg. 2010;145(10):973-977.

Napolitano LM, Kurek S, Luchette FA, et al; American College of Critical Care Medicine of the Society of Critical Care Medicine; Eastern Association for the Surgery of Trauma Practice Management Workgroup. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med. 2009;37(12):3124-3157.

Educational Objective:

Discuss the surgical staging of ovarian cancer.

Key Point:

The first step in surgical staging of ovarian cancer is the analysis of ascitic fluid or of pelvic irrigation fluid.

Explanation:

The staging surgery for ovarian cancer proceeds as follows. A vertical incision is made to explore the abdomen. Ascitic fluid should be sent for cytologic evaluation if it is present; however, if it is absent, 200 to 400 mL of normal saline should be used to retrieve cytologic samples from the peritoneum. Prior to performing any resection, the upper abdomen, pelvis, and right and left paracolic gutters must be irrigated. To obtain cytologic samples, the healthcare professional will scrape the undersurface of the diaphragm with a sterile tongue depressor. This sample is then put on a glass slide and then a fixative is sprayed. It is preferable to excise any suspicious nodules; however, biopsy is also appropriate. If they are technically possible, the healthcare professional should perform bilateral salpingo-oophorectomy, total abdominal hysterectomy, and infracolic omentectomy. If the ovarian capsule is ruptured, it may seed the surrounding areas with cancerous ascitic fluid; therefore, care must be taken to avoid rupture.

Reference:

Coleman RL, et al. Neoplastic diseases of the ovary. In: Lentz GM, et al. Comprehensive Gynecology. 6th ed., 2012:731-771.