Internal Medicine
Recertification / MOC Exam Review

Educational Objective:

Examine appropriate barrier precautions when preparing patients for minor surgical procedures.

Key Point:

Maximum barrier precaution lowers the infection rate at the surgical site > 50%.

Explanation:

Maximal barrier precautions are indicated for central line insertion. These precautions include cap, mask, gown, and gloves for the operator placing the line and a whole-body sterile cover for the patient with a small opening for the site of insertion. Maximal barrier precautions lower the infection rate by at least 50%. Use of a fenestrated drape or failure to use mask and cap result in a higher rate of infection at the surgical site.

References:

Heffner AC, Androes MP. Overview of central venous access. Updated October 24, 2017. Accessed November 22, 2018.

Institute for Healthcare Improvement. 5 Million Lives Campaign. Getting Started Kit: Prevent Ventilator-Associated Pneumonia How-to Guide. 2010.

Educational Objective:

Recognize systemic Candida infection in immunocompromised patients.

Key Point:

Immunocompromised patients are at risk for candidemia and invasive candidiasis. Patients whose blood cultures are positive for Candida always require treatment.

Explanation:

The patient most likely has candidal fungemia. The clinical picture of invasive candidiasis is similar to that of systemic bacterial infections. Findings of fungus in blood cultures should never be considered a contaminant and should prompt a search for the source and extent of infection. The skin lesions observed in this patient could be the primary site of infection or could be a sign of disseminated disease. The fungi of aspergillosis, mucormycosis, and trichosporosis are rarely found in blood.

Reference:

Kauffman CA. Candidemia and invasive candidiasis (chapter 338). In: Goldman L, Schafer A. Goldman-Cecil Medicine. 25th ed., 2016:2079-2083.

Educational Objective:

Treat community-acquired pneumonia.

Key Point:

The drugs of choice for community-acquired pneumonia in a patient with no comorbidities and no prior antibiotic use are macrolides.

Explanation:

This patient has community-acquired pneumonia (CAP), which is defined as an acute infection of the pulmonary parenchyma not acquired in a hospital or health care facility. Testing for the causative agent (eg, sputum, blood cultures) is not necessary for patients can be treated as outpatients. Macrolides (eg, azithromycin) are first-line treatment options for CAP in patients without comorbidities and no prior antibiotic use, if local pneumococcal resistance is low. The alternative therapy for this patient would be doxycycline or amoxicillin. Combination of amoxicillin/azithromycin would be more appropriate for a patient whose symptoms and signs suggest the need for hospitalization. Neither cephalexin nor trimethoprim/sulfamethoxazole is an antibiotic of choice for CAP.

References:

 Elsevier Point of Care. Updated October 12, 2018.

File TM. Treatment of community-acquired pneumonia in adults in the outpatient setting. Revised October 16, 2018. Accessed October 30, 2018.

Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Resp and Crit Care Medicine. 2019; 200 Number 7

Educational Objective:

Review the diagnosis and treatment ofRocky Mountain spotted fever.

Key Point:

An early diagnosis of Rocky Mountain spotted fever rests with a high index of suspicion after a history and physical examination findings.

Explanation:

There are no early tests to confirm the diagnosis of Rocky Mountain spotted fever (RMSF). Health care professionals must have a high index of suspicion and should begin treatment with doxycycline based on history and physical examination findings. The illness typically begins 2 to 14 days after being bitten by an infected tick, but only one-half of patients recall the bite. Frequently, the disease begins with sudden-onset headache and fever. Other multiple, nonspecific symptoms include conjunctivitis, vomiting, rash, muscle pain, nausea, and abdominal pain.

Most patients with RMSF (90%) have some type of rash during the course of illness, Classically, RMSF presents as a rash that first appears 2 to 5 days following the onset of fever as small, pink, flat, nonpruritic macules on the ankles, wrists, and forearms that spread to the trunk and, in some instances, the palms and soles.

White blood cell counts are not helpful because they may be high, normal, or low. Azotemia, thrombocytopenia, elevated transaminase levels, hyponatremia, and evidence of disseminated intravascular coagulation may be observed.

If the patient presents with rash, then polymerase chain reaction or immunohistochemical staining can be performed on skin biopsy taken from the rash site. Often, skin biopsy can deliver a rapid result and has good sensitivity. Routine hospital blood cultures cannot detect R rickettsia.

R rickettsii antibody titers are usually detectable 7 to 10 days after the onset of illness. It is uncommon to find detectable antibodies prior to this time period.

References:

Centers for Disease Control and Prevention. Rocky Mountain spotted fever (RMSF): symptoms, diagnosis, and treatment. Reviewed October 26, 2018. Accessed January 14, 2019.

Raoult D. Rickettsial infections (chapter 327). In: Goldman L, Schafer A. Goldman-Cecil Medicine. 25th ed., 2016:2046-2056.

Educational Objective:

Discuss the various approaches to the treatment of breakthrough pain.

Key Point:

Buccal administration of medications is a simple, efficient and quick way of relieving symptoms.

Explanation:

Although all of the medications listed can assist in stabilizing BTP, the quickest and easiest to administer is fentanyl buccal tablet. Absorption from the buccal mucosa is rapid. All other approaches are either more difficult to administer or less effective. However, because of the higher cost of buccal fentanyl, short-acting oral opioids should be usually tried first.

References:

Slatkin NE, Xie F, Messina J, Segal TJ. Fentanyl buccal tablet for relief of breakthrough pain in opioid-tolerant patients with cancer-related chronic pain. J Support Oncol. 2007;5(7):327-334. 

Portenoy RK, Taylor D, Messina J, Tremmel L. A randomized, placebo-controlled study of fentanyl buccal tablet for breakthrough pain in opioid-treated patients with cancer. Clin J Pain. 2006;22(9):805-811.

Mercadante S, Adile C, et al. Support Care Cancer 2017; 25: 645-649