Test Bank – ACP: Interdisciplinary Medicine
Management of Poisoning and Drug Overdose
1. A 48-year-old white man arrives at the emergency department obtunded. He is accompanied by his wife, who states, “He took a lot of pills, trying to hurt himself.” She also reports that he drinks a pint of whiskey every day and more on the weekends and that he has prescription pain pills for chronic back pain. The patient is taken to an examination room; a brief clinical assessment reveals a patent and protected airway. The patient has pinpoint pupils.
Which of the following medications is NOT appropriate for this patient?
A. 25 g of 50% dextrose
B. 100 mg of vitamin B1 (thiamine)
C. Nalaxone, 0.2 to 0.4 mg
D. Flumazenil
Key Concept/Objective: To know the appropriate pharmacotherapy for an overdose patient with decreased sensorioum
Poisoning or drug overdose depresses the sensorium; symptoms may range from stupor or obtundation to unresponsive coma. All patients with a depressed sensorium should be evaluated for hypoglycemia because many drugs and poisons can directly reduce or contribute to the reduction of blood glucose levels. A fingerstick blood glucose test and bedside assessment should be performed immediately; if such testing and assessment are impractical, an intravenous bolus of 25 g of 50% dextrose in water should be administered empirically before the laboratory report arrives. For alcoholic or malnourished persons, who may have vitamin deficiencies, 50 to 100 mg of vitamin B1 (thiamine) should be administered I.V. or I.M. to prevent the development of Wernicke syndrome. If signs of recent opioid use (e.g., suspicious-looking pill bottles or I.V. drug paraphernalia) are in evidence or if the patient has clinical manifestations of excessive opioid effect (e.g., miosis or respiratory depression), the administration of naloxone may have both therapeutic and diagnostic value. Flumazenil, a short-acting, specific benzodiazepine antagonist with no intrinsic agonist effects, can rapidly reverse coma caused by diazepam and other benzodiazepines. However, it has not found a place in the routine management of unconscious patients with drug overdose, because it has the potential to cause seizures in patients who are chronically consuming large quantities of benzodiazepines or who have ingested an acute overdose of benzodiazepines and a tricyclic antidepressant or other potentially convulsant drug. (Answer: D—Flumazenil)
2. A 26-year-old African-American man is brought to the emergency department by his roommate. The roommate discovered the patient 1 hour ago taking a handful of pills. When he asked the patient what he was doing, the patient replied, “I am going to sleep for a very long time and I am not going to wake up.” The patient confirms the roommate’s story. Physical examination reveals a healthy, well-nourished, well-developed man in no acute distress. Vital signs are stable; his affect is mildly depressed, but he is neurologically alert.
Which of the following decontamination methods is NOT appropriate in this patient?
A. Gastric lavage
B. Activated charcoal administration
C. Ipecac-induced emesis
D. Whole bowel irrigation (Colyte or GoLYTELY)
Key Concept/Objective: To know the appropriate decontamination methods for a patient after acute ingestion
Gastric lavage is still an accepted method for gut decontamination in hospitalized patients who are obtunded or comatose, but several prospective, randomized, controlled trials have failed to show that emesis or lavage and charcoal provide better clinical results than administration of activated charcoal alone. Activated charcoal, a finely divided product of the distillation of various organic materials, has a large surface area that is capable of adsorbing many drugs and poisons. In the awake patient who has taken a moderate overdose of a drug or poison, most clinicians now employ oral activated charcoal without first emptying the gut; some clinicians still recommend lavage after a massive ingestion of a highly toxic drug. Whole bowel irrigation is a technique that involves the use of a large volume of an osmotically balanced electrolyte solution, such as Colyte or GoLYTELY, that contains nonabsorbable polyethylene glycol and that cleans the gut by mechanical action without net gain or loss of fluids or electrolytes. Although no controlled clinical trials to date have demonstrated improved outcome, it is recommended for those who have ingested large doses of poisons that are not well adsorbed by charcoal (e.g., iron or lithium), for those who have ingested sustained-release or enteric-coated products, and for those who have ingested drug packets or other potentially toxic foreign bodies. (Answer: C—Ipecac-induced emesis)
3. A 75-year-old woman comes to the emergency department after experiencing a presyncope event approximately 1 hour ago. Her daughter informs you that the patient saw her primary care physician yesterday and that she is now taking a new medication for high blood pressure. The patient reports she occasionally takes an extra dose of her blood pressure medicine when she has a headache, but on this day, she took two extra pills because she also forgot to take her medicine the day before. The patient brought the new medicine with her; it is atenolol, 100 mg tablets. Physical examination reveals an elderly woman in no distress. Her pulse is 32 beats/min, her blood pressure is 78/43 mm Hg, and her respiratory rate is 14 breaths/min. She is afebrile.
After I.V. access is established, what is the preferred antidote for this patient’s hypotension and bradycardia?
A. Atropine, 1 mg I.V.
B. Dopamine drip, titrate to desired effect
C. Glucagon, 5 to 10 mg I.V.
D. Isoproterenol drip, titrate to desired effect
Key Concept/Objective: To understand the treatment of a patient with beta-blocker toxicity
Treatment of overdose with a beta blocker includes aggressive gut decontamination. In cases involving a large or recent ingestion, gastric lavage and the administration of activated charcoal and a cathartic agent should be initiated. Hypotension and bradycardia are unlikely to respond to beta-adrenergic–mediated agents such as dopamine and isoproterenol; instead, the patient should receive high dosages of glucagon (5 to 10 mg I.V., followed by 5 to 10 mg/hr). Glucagon is a potent inotropic agent that does not require beta-adrenergic receptors to activate cells. When glucagon fails, an epinephrine drip may be more beneficial in increasing heart rate and contractility than isoproterenol or dopamine. If pharmacologic therapy is unsuccessful, transvenous or external pacing should be used to maintain heart rate. Use of hemodialysis in atenolol poisoning has been reported. (Answer: C—Glucagon, 5 to 10 mg I.V.)
4. A 75-year-old man is admitted to the intensive care unit for confusion, repeated emesis, and tachycardia. His medical history is significant only for chronic obstructive pulmonary disease, for which he uses ipratropium bromide, albuterol inhalers, and theophylline. After 2 hours in the ICU, his theophylline level is found to be 55 mg/L (10 to 20 mg/L is therapeutic). The electrocardiogram was significant only for sinus tachycardia of 132 beats/min. Activated charcoal is given. Over the next hour, despite two 500 ml boluses of normal saline, the patient’s hypotension worsens.
What is the preferred method of treating this patient’s hypotension?
A. External overdrive pacing to slow the heart rate
B. Dopamine drip, titrated to the desired mean arterial pressure
C. Hemodialysis
D. Esmolol drip, titrated to the desired mean arterial pressure
Key Concept/Objective: To understand the treatment of theophylline-induced hypotension
This patient’s hypotension is caused by toxic levels of theophylline; because the hypotension is probably caused by beta2-adrenergic–mediated vasodilatation, it should be treated with esmolol, 25 to 100 mg/kg/min, rather than a beta-adrenergic agonist such as dopamine. External pacing plays no role in the management of hypotension in a patient with sinus tachycardia. Hemodialysis has a role in the management of theophylline toxicity, especially if seizures develop or levels are greater than 100 mg/L; however, hemodialysis would likely worsen the existing hypotension acutely, and the hypotension would have to be improved before dialysis could be implemented. (Answer: D—Esmolol drip, titrated to the desired mean arterial pressure)
5. A 70-year-old woman with chronic atrial fibrillation who is on warfarin therapy was prescribed erythromycin 10 days ago for a community-acquired pneumonia. Today, she is found comatose. A CT scan of the head reveals a large intracranial hemorrhage, and her prothrombin time (international normalized ratio [INR]) is 20.
Overanticoagulation may have been avoided if, instead of erythromycin, this patient had been prescribed which of the following?
A. Cefoxitin
B. Clarithromycin
C. Ofloxacin
D. Trimethoprim-sulfamethoxazole
E. None of the above
Key Concept/Objective: To know that warfarin interacts with a vast number of commonly prescribed drugs
Drugs that interact with warfarin include many antibiotics that are frequently used to treat community-acquired pneumonia (cephalosporins, quinolones, macrolides, tetracyclines, and long-acting sulfonamides). Use of these antibiotics in patients on warfarin requires vigilant monitoring of their anticoagulation status. Among the available newer-generation quinolone antibiotics, trovafloxacin and sparfloxacin do not seem to interact with warfarin. (Answer: E—None of the above)
6. A 33-year-old man who suffers from depression and chronic pain attempts suicide by overdosing on the collection of pain killers he has accumulated from multiple physicians. He is in the emergency department with stupor, pinpoint pupils, and hypotension.
Which of the following tests should you order for this patient?
A. Electrocardiogram
B. Benzodiazepine level
C. Acetaminophen level
D. Aspirin level
E. Electrocardiogram, acetaminophen level, and aspirin level
Key Concept/Objective: To understand that intentional overdose may involve multiple substances
Prescription narcotic pain killers are often compounded with either aspirin or acetaminophen. Early recognition and treatment of toxic levels of either of these are critical to preventing subsequent metabolic acidosis (aspirin) or hepatic injury (acetaminophen). This patient, who has had multiple physicians and has been diagnosed with depression, may also have ingested tricyclic antidepressants. Electrocardiographic abnormalities, including widening of the QRS interval, prolongation of the QT interval, and right axis deviation of the terminal 40 msec of the QRS complex, may provide early clues to this potentially lethal ingestion. Although this patient is at risk for having a coexistent benzodiazepine ingestion, management is limited to supportive measures, so there is no clinical utility to checking a serum level. If he has or is suspected of having also ingested tricyclic antidepressants, use of flumazenil is contraindicated because of the risk of seizures. (Answer: E—Electrocardiogram, acetaminophen level, and aspirin level)
7. Having misunderstood your instructions on how she should adjust the dosages of her 12 different medications, a 68-year-old woman is now in the intensive care unit after taking an excess of propranolol. Her pulse is 35 beats/min, her blood pressure is 65/35 mm Hg, she is unresponsive, and her skin is mottled.
Therapeutic options for this patient include which of the following?
A. Dopamine drip
B. Intravenous glucagon
C. Isoproterenol drip
D. Epinephrine drip
E. Intravenous glucagon and epinephrine drip
Key Concept/Objective: To understand that dopamine and isoproterenol exert their effects primarily through beta-adrenergic pathways
In the setting of profound beta blockade, dopamine and isoproterenol are likely to be ineffective. Glucagon does not require beta-adrenergic receptors to exert its positive inotropic effect. Epinephrine works through alpha-adrenergic receptors. (Answer: E— Intravenous glucagon and epinephrine drip)
8. A 58-year-old farmer is brought in from the fields to the emergency department sweating, vomiting, and confused. On examination, his blood pressure is 100/60 mm Hg, his pulse is 80 beats/min, and his respiratory rate is 24 breaths/min. He appears to be in moderate respiratory distress and has generalized muscle weakness. His pupils are pinpoint. He is salivating profusely and has gurgling upper respiratory sounds.
This patient most likely is suffering from which of the following conditions?
A. Heatstroke and dehydration
B. Illicit opiate use/overdose
C. Organophosphate poisoning
D. Myocardial infarction
E. Mushroom poisoning
Key Concept: To know the constellation of cholinergic symptoms created by organophosphate poisoning
Agricultural workers are at risk for exposure to organophosphates, which are widely used in pesticides. Organophosphates are absorbed from the skin, lungs, gut, and conjunctiva. They inhibit acetylcholinesterase; therefore, presenting signs and symptoms are those of cholinergic excess. Prompt diagnosis and treatment are essential because some organophosphates undergo aging, whereby they become permanently bound to acetylcholinesterase. After this occurs, treatment with pralidoxime becomes much less effective. (Answer: C—Organophosphate poisoning)
9. A 44-year-old chronic alcoholic man is once again in the emergency department, intoxicated. He is stuporous and has slurred speech. His blood pressure is 130/85 mm Hg, his pulse is 89 beats/min, and his respiratory rate is 26 breaths/min. His skin is warm, dry, and pink. Besides his altered mental status, his neurologic examination is nonfocal, and he has no external evidence of trauma. Laboratory results are as follows: WBC, 7,400; HCT, 45; platelets, 200,000; Na, 130; K, 3.5; Cl, 90; HCO3, 15; Glu, 110.
You should order a serum level of which of the following for this patient?
A. Methanol
B. Ethylene glycol
C. Aspirin
D. Methanol and ethylene glycol
E. Methanol, ethylene glycol, and aspirin
Key Concept/Objective: To be able to recognize anion-gap metabolic acidosis and to know the differential diagnosis
The differential diagnosis for anion-gap metabolic acidosis includes methanol overdose, uremia, diabetic ketoacidosis, paraldehyde overdose, aspirin overdose, lactic acidosis, and ethylene glycol overdose (MUDPALE). (Answer: E—Methanol, ethylene glycol, and aspirin)
For more information, see Olson KR, Patel MM: 8 Interdisciplinary Medicine: I Management of Poisoning and Drug Overdose. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, January 2003
Bites and Stings
10. A mother brings her 2-year-old son to the acute care clinic. She explains that when she picked him up from day care, she was told he had suffered some sort of bite in the playground. It is unclear who or what bit him, but there are puncture wounds in his right hand, which is red and swollen. The mother is worried about infection.
The bite of which of the following mammals is LEAST likely to result in infection?
A. Human
B. Cat
C. Dog
D. Rat
Key Concept/Objective: To recognize the risk of infection associated with various mammalian bites
Infection is the most common complication of bite wounds. The microbes responsible for infection originate either from the mouth of the mammal inflicting the wound or the victim’s skin flora. Most infections resulting from the bites of mammals are polymicrobial. The incidence of infection depends on the location of the bite and the type of mammal inflicting the wound. The infection rate for dog bites is 2% to 20%; the infection rate for human bites is 10% to 50%; the rate for cat bites is 30% to 50%. Infections from rat bites are very infrequent. Prophylactic use of antibiotics for bites from mammals is debatable. The decision should be based on the location and appearance of the wound and the type of animal involved. For most mammalian bites, amoxicillin-clavulanic acid is the drug of choice. (Answer: D—Rat)
11. A 30-year-old man presents to the emergency department with a bite wound. He had been camping at a local wildlife preserve. While he was looking for firewood, his hand was bitten by what he thought was a squirrel. He was not able to capture the animal, but he did not think the animal was acting strangely. He believes he just “scared the critter.” You are worried about the risk of rabies.
Which of the following animals should be regarded as rabid if it bites someone (assuming the animal cannot be tested for rabies in the laboratory)?
A. Squirrel
B. Skunk
C. Rabbit
D. Rat
Key Concept/Objective: To know common animals that have a very low probability of causing rabies
The clinician should always consider the possibility of rabies exposure in patients suffering bite wounds. The use of soap and a virucidal agent to clean the wound has been shown to help prevent rabies. With domestic-animal bites, postexposure rabies prophylaxis is warranted if (1) the animal is observed to be abnormal; (2) the animal is not available for observation and the rate of rabies in domestic animals in the region is high; or (3) the animal exhibited abnormal behavior, such as an unprovoked attack. With bites from wild animals, recommendations for rabies prophylaxis depend on the species. Skunks, bats, raccoons, foxes, and most other carnivores should be regarded as rabid unless immediate brain testing can be performed on the animal. The bites of squirrels, rats, rabbits, mice, hamsters, guinea pigs, gerbils, chipmunks, and other small rodents virtually never require postexposure prophylaxis for rabies. (Answer: B—Skunk)
12. A 42-year-old park ranger presents after being bitten by a snake on his right forearm. He informs you that the snake was a copperhead. He complains of pain and swelling at the site of the bite. Examination shows two puncture wounds on his right forearm. An area of tenderness, erythema, and swelling, which measures approximately 2 in. in diameter, surrounds the wounds. The patient is otherwise asymptomatic.
For which of the following patients is antivenin therapy most appropriate?
A. A 42-year-old man presenting 2 hours after a copperhead bite who is experiencing a grade 1 envenomation
B. A 42-year-old man presenting 2 hours after a rattlesnake bite who is experiencing a grade 3 envenomation
C. A 42-year-old man presenting 24 hours after a copperhead bite who is experiencing a grade 1 envenomation
D. A 42-year-old man presenting 24 hours after a rattlesnake bite who is experiencing a grade 3 envenomation
Key Concept/Objective: To be able to identify those patients most likely to benefit from therapy with antivenin and to be familiar with the classification system for envenomation
This patient has a grade 1 envenomation, characterized by pain and throbbing at the site of the bite, with 1 to 5 in. of surrounding erythema and edema and with no evidence of systemic involvement. Grade 0 envenomation is characterized by minimal local findings; grade 2 envenomation is characterized by severe pain over a larger area, with possible systemic involvement; envenomations of grades 3 and 4 are severe and are characterized by systemic manifestations such as fever, nausea, emesis, tachycardia, hypotension, diaphoresis, or mental status changes. Antivenins are available for North American pit vipers and eastern coral snakes, but they are indicated only for severe envenomations. Water moccasin and copperhead bites are usually managed without antivenin. Most antivenins are horse-serum based and can therefore cause serum sickness. Antivenin is most effective when given within 4 hours of the snakebite. It is of little value if administered more than 12 hours after the patient was bitten. Before using antivenin, the clinician should consider potential adverse effects and the situations in which antivenin is most effective. This patient does not need antivenin at this time. (Answer: B—A 42-year-old man presenting 2 hours after a rattlesnake bite who is experiencing a grade 3 envenomation)
13. A 25-year-old woman presents to your office in Missouri with a spider bite. She states that she was getting firewood from the woodpile outside of her house the evening before and felt a sharp pain on the back of her right hand. She was unable to bring the spider to your office. On examination, you note an area of pallor with surrounding erythema over the dorsum of the patient’s right hand. You suspect that she was bitten by a brown recluse spider.
Which of the following therapies is LEAST likely to benefit the victim of a brown recluse spider bite?
A. Administraton of steroids within 24 hours of the bite
B. Administration of dapsone in patients who do not have glucose-6phosphate dehydrogenase deficiency
C. Use of antibiotics if there are signs of infection at the bite site
D. Use of hyperbaric oxygen
Key Concept/Objective: To know the therapies that have proven roles in the treatment of brown recluse spider bites
This patient’s history is typical for someone who has suffered a brown recluse spider bite. These spiders are found under rocks and woodpiles in the south central United States. Brown recluses are more active at night. Their bite can cause pain within the first few hours of envenomation. Physical findings are a ring of pallor surrounded by erythema. These may eventually evolve to form a bleb, which can become necrotic. The necrosis can spread and may eventually form an eschar. There is some evidence of benefit from treatment with systemic steroids within 24 hours of envenomation. Dapsone has been shown to be helpful in treating the local damage caused by the venom. However, dapsone can cause a serious hemolytic reaction in those with glucose-6-phosphate dehydrogenase deficiency. Antibiotics are useful if there is evidence of infection. Hyperbaric oxygen has not been conclusively proven to be effective for brown recluse spider envenomations. (Answer: D—Use of hyperbaric oxygen)
For more information, see Lewis LM, Levine MD, Dribben WH: 8 Interdisciplinary Medicine: II Bites and Stings. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, September 2002
Cardiac Resuscitation
14. You find a 72-year-old man lying unresponsive in a restroom of a local airport. He is alone, and you don’t know how long he has been unconscious. You speak loudly, trying to wake him up, and you shake him; he continues to be unresponsive.
On the basis of the chain of survival, what should be your sequential response in this situation?
A. Start cardiopulmonary response (CPR); call for help by activating the emergency medical system (EMS); and call for a defibrillator
B. Look in his pocket or wallet for information about his medical history; start CPR; call for help by activating EMS; and call for a defibrillator
C. Immediately call for help by activating EMS; call for a defibrillator; and start CPR
D. Immediately call for help by activating EMS; call for a defibrillator; wait for EMS to come and to start an I.V.; and start CPR
Key Concept/Objective: To understand the chain of survival
The resuscitation of an adult victim of sudden cardiac arrest should follow an orderly sequence, no matter where the patient collapse occurs. This sequence is called the chain of survival. It comprises four elements: activation of EMS, CPR, defibrillation, and provision of advanced care. When a person is found to be unresponsive, the first thing to do is to confirm the unresponsiveness by speaking loudly and shaking the patient. If the patient remains unresponsive, the next step should be to call for help by activating EMS. If an automated external defibrillator is available, also call for it. After this is done, the next step is to assess the patient’s airway, breathing, and circulation. CPR should then be initiated, and advanced care should begin once EMS arrives. (Answer: C— Immediately call for help by activating EMS; call for a defibrillator; and start CPR)
15. A 56-year-old woman is found pulseless in her room at a local hospital. The nurse calls “code blue,” and you are the first doctor responding. The nurse has started CPR, and the patient has a patent I.V. line. After 2 minutes, the patient is still pulseless. A defibrillator has now been brought to the room.
What is the best intervention to take next in the care of this patient?
A. Continue CPR; look for a pulse again; establish an airway; give 1 mg of epinephrine I.V.; and repeat these measures until circulation has been restored
B. Attach the defibrillator; analyze the rhythm; attempt to defibrillate if the rhythm is ventricular tachycardia (VT) or ventricular fibrillation (VF); continue CPR if unsuccessful; establish an airway; and proceed with I.V. medications
C. Establish an airway; give 1 mg of epinephrine I.V.; continue CPR; attach the defibrillator and analyze the rhythm; and defibrillate if the rhythm is VF or VT
D. Immediately give 1 mg of atropine; attach the defibrillator and analyze the rhythm; defibrillate if the rhythm is VF or VT; continue with CPR if unsuccessful; and establish an airway
Key Concept/Objective: To understand the importance of analyzing the rhythm and providing immediate defibrillation if needed
In the chain of survival, the importance of rapid access to defibrillation cannot be overemphasized. In a patient who is dying from a shockable rhythm, the chance of survival declines by 7% to 10% for every minute that defibrillation is delayed. When provided immediately after the onset of VT, the success of defibrillation is extremely high. Early defibrillation is so critical that if a defibrillator is immediately available, its use takes precedence over CPR in patients with pulseless VT or VF. If CPR is already in progress, it should be halted while defibrillation takes place. (Answer: B—Attach the defibrillator; analyze the rhythm; attempt to defibrillate if the rhythm is ventricular tachycardia [VT] or ventricular fibrillation [VF]; continue CPR if unsuccessful; establish an airway; and proceed with I.V. medications)
16. A 66-year-old male patient in the intensive care unit (ICU) is found in pulseless VT. He is intubated, and the nurse has started CPR. You try to defibrillate him three times without success, using shocks of 200 joules, 300 joules, and 360 joules.
What is the best step to take next in the treatment of this patient?
A. Continue CPR and try to defibrillate again with repeated shocks of 360 joules every 1 min
B. Give 1 mg of epinephrine I.V., continue CPR, and give another shock of 360 joules in 30 to 60 sec
C. Give 1 mg of atropine, continue CPR, and give another shock of 360 joules in 30 to 60 sec
D. Give 300 mg of amiodarone I.V., continue CPR, and give another shock of 360 joules after 1 min
Key Concept/Objective: To understand the appropriate management of pulseless VT and VF
When a monitor-defibrillator is available, the patient’s rhythm is immediately analyzed. There are four rhythm possibilities: pulseless VT, pulseless VF, pulseless electrical activity, and asystole. Pulseless VT and pulseless VF are managed identically. The first step is to try to defibrillate with 200 joules; if the VT or VF persists, subsequent attempts should use 200 to 300 joules and 360 joules. After these attempts, the next action is to administer drug therapy. The first medication to be given is a vasoconstrictor (either epinephrine or vasopressin). If there is no I.V. access, these drugs can be given endotracheally. The rescuer should continue with CPR for 30 to 60 sec to allow the drug to reach the heart, then defibrillation should be attempted again. If pulseless VT or VF persists, antiarrhythmic drug therapy (i.e., amiodarone or lidocaine) should be added. (Answer: B—Give 1 mg of epinephrine I.V., continue CPR, and give another shock of 360 joules in
30 to 60 sec)
17. A 60-year-old homeless man is found unresponsive in a park. There are no witnesses. EMS is called and finds him in asystole. The appropriate protocol for asystole, including epinephrine, is started. The patient is intubated, and he is brought to a local emergency department after 12 minutes. On physical examination, there is no pulse; temperature is 80° F (26.7° C).
What is the best step to take next in the treatment of this patient?
A. Attach a monitor; confirm asystole; defibrillate; and proceed with CPR
B. Consider stopping measures after 10 min if resuscitation has been unsuccessful and the patient remains in asystole
C. Treat the hypothermia aggressively; continue with resuscitation and asystole protocol
D. Attach a monitor; confirm asystole; administer 40 mg of vasopressin I.V., followed by CPR for 1 min, and then defibrillate; continue CPR
Key Concept/Objective: To understand the appropriate management of asystole
The prognosis for asystole is generally regarded as dismal unless the patient is hypothermic or there are other extenuating but treatable circumstances. The sequence of resuscitation steps in the management of asystole is as follows: activation of EMS; CPR, rhythm evaluation, and asystole confirmation; intubation; I.V. access with epinephrine and atropine administration; and immediate transcutaneous pacing, if available. If asystole persists for more than 10 min despite optimal CPR, oxygenation, ventilation, and epinephrine or atropine administration, efforts should stop unless there is hypothermia or drug overdose. (Answer: C—Treat the hypothermia aggressively; continue with resuscitation and asystole protocol)
For more information, see Mengert TJ: 8 Interdisciplinary Medicine: III Cardiac Resucitation. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, April 2003
Preoperative Assessment
18. A 66-year-old female patient is admitted to the orthopedic surgery service with a left hip fracture. She has a history of hypertension and osteoporosis but is otherwise in good health. She has no history of chest pain, but she says she gets short of breath when she walks about a half mile. She smoked one pack of cigarettes a day for 30 years, but she quit 5 years ago. She is taking an ACE inhibitor for her hypertension. Review of systems is otherwise negative.
Which of the following statements regarding preoperative cardiovascular risk assessment is true?
A. The most important risk factor for cardiac death or complication perioperatively is a recent myocardial infarction
B. The most important preoperative use of echocardiography is to assess the degree of systolic dysfunction
C. Most patients who do not have an independent clinical need for coronary revascularization can proceed to surgery without further cardiac investigation
D. There is good evidence that diastolic dysfunction increases perioperative risk significantly
Key Concept/Objective: To understand the basic principles of preoperative cardiovascular risk assessment
Uncontrolled heart failure is the most important risk factor for cardiac death or complications. A history of functional limitation appears to be the most helpful of all the historical points in this assessment. Patients who can perform activities that require four metabolic equivalents have a good chance of survival for most surgical procedures; such patients require no further testing. The use of echocardiography as a predictive tool is controversial. Although many experts advocate echocardiography as a good tool for assessing heart failure control, the procedure may provide little prognostic information beyond that available from a careful history and physical examination. The most important preoperative use of echocardiography is in the differentiation of systolic dysfunction from diastolic dysfunction in patients with new-onset heart failure. The distinction is important, because data clearly show that systolic dysfunction, in a patient with substantial clinical manifestations (i.e., overt congestive failure), adds significantly to the risk of surgery. On the other hand, there are no data showing that echocardiographic evidence of systolic dysfunction in a patient without symptoms or signs of heart failure has any prognostic implications. There are also no good data indicating that diastolic dysfunction increases risk significantly. The preoperative evaluation of the patient with established or probable coronary artery disease (CAD) is of great importance. Recent myocardial infarction is second only to decompensated heart failure as a risk factor for perioperative complications. Decisions regarding the evaluation of chest pain in patients without a history of CAD can be difficult under any circumstance. The American College of Physicians clinical guidelines on the perioperative assessment and management of risk from CAD state that most patients who do not have an independent clinical need for coronary revascularization can proceed to surgery without further cardiac investigation. In other words, if there is no prior reason to perform coronary artery bypass surgery, further cardiac investigation usually does not need to be carried out for the anticipated surgery, unless there is some other overriding consideration. (Answer: C—Most patients who do not have an independent clinical need for coronary revascularization can proceed to surgery without further cardiac investigation)
19. A 63-year-old white man has severe osteoarthritis and wants to have knee replacement surgery. His orthopedic surgeon has referred him to you for preoperative evaluation. The patient has smoked 1.5 packs of cigarettes a day for 50 years and states that he has a chronic productive cough, dyspnea, and wheezing. The patient uses an albuterol and ipratropium bromide combination inhaler.
Which of the following statements regarding assessment of preoperative pulmonary risk is false?
A. Performance on pulmonary function tests (PFTs) correlates well with mortality
B. Acute reversible pulmonary disease, such as asthma or a respiratory tract infection, must be identified and treated before surgery
C. Any patient with cardiovascular or pulmonary disease should receive a chest x-ray before surgery
D. Patients who can exercise without significant symptoms are at low risk
Key Concept/Objective: To understand the basic principles of preoperative pulmonary risk assessment
The pulmonary evaluation process is unfortunately much more subjective than the cardiac evaluation. Acute reversible disease, such as asthma or a respiratory tract infection, must be identified so that it can be treated and reversed before the procedure, if possible. Patients who can exercise without significant symptoms are at low risk. Shortness of breath on exercise, in the absence of heart disease, identifies patients at higher risk. Preoperative use of PFTs is controversial. PFTs do not readily identify individual patients who are at prohibitive risk of mortality; there is poor correlation between PFT results and mortality, despite some statistical correlation. If the history and physical examination do not suggest significant pulmonary disease, there is no advantage in performing PFTs. Most experts believe that any patient older than 60 years should have a baseline chest x-ray. Clearly, any patient with cardiovascular or pulmonary disease needs a chest x-ray. (Answer: A—Performance on pulmonary function tests [PFTs] correlates well with mortality)
20. A 59-year-old African-American man is admitted to the trauma surgery service after sustaining fractures of the tibia and fibula in a motor vehicle accident. You are consulted for perioperative management. The patient’s medical history is significant for hypertension, which is uncontrolled; CAD status post myocardial infarction 5 years ago; and benign prostatic hypertrophy. The patient lost his job, as well as health insurance coverage, 6 months ago and is currently on no medications.
Which of the following statements regarding medical management of the surgical patient is false?
A. In patients with CAD, use of perioperative beta blockers can prevent complications after surgery, both short term and long term
B. Patients with diastolic blood pressure below 100 mm Hg can proceed with surgical procedures
C. Asymptomatic patients with hypothyroidism are at significant risk for myxedema coma
D. Patients who are receiving long-term corticosteroid therapy need replacement therapy perioperatively
Key Concept/Objective: To understand the management of surgical risk factors
It is now clear that the use of perioperative beta blockers can prevent complications after surgery, both short term and long term. Patients with known CAD who can tolerate beta blockers should already be taking these drugs. If they are not, a beta blocker should be started. Many experts recommend starting beta blockade before surgery in patients at high risk for CAD. Patients with a diastolic blood pressure below 110 mm Hg are not at significantly greater risk and do not require specific blood pressure management. However, it is clear that in patients with poorly controlled blood pressure who undergo surgery, blood pressure may swing widely, both in hypertensive and hypotensive directions. Both high and low blood pressures can cause problems perioperatively. Unless surgery is urgent or emergent, hurried attempts at blood pressure control are not advised. Patients with hypothyroidism, provided they are functional, do not have significant problems with surgery and do not require special treatment. Patients who are clinically hyperthyroid are at risk for thyroid storm perioperatively, so hyperthyroidism should be well controlled before surgery is undertaken. Patients who are taking corticosteroids (e.g., for rheumatic disease or asthma) usually need replacement therapy perioperatively. In normal persons, the daily output of cortisone is approximately 30 mg; peak stress levels are approximately 300 mg a day. Unfortunately, no good studies have been done to determine which patients definitely need supplementation and how long the increase in dose should be maintained. Current practice is to give additional medication to patients who are taking the equivalent of 30 mg or more of hydrocortisone a day. For patients at lower dosage ranges, supplemental doses (e.g., 50 mg) given twice daily are adequate; for those taking more than 150 mg a day, three doses a day of 50 to 100 mg are usually recommended. (Answer: C—Asymptomatic patients with hypothyroidism are at significant risk for myxedema coma)
For more information, see Lubin MF: 8 Interdisciplinary Medicine: IV Preoperative Assessment. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, July 2004
Bioterrorism
21. A 24-year-old man presents to the emergency department for evaluation. He is accompanied by his wife.
The patient was in his usual state of health until 7 days ago, when he developed fever and malaise with headache, backache, nausea, vomiting, and abdominal pain. Five days ago, he developed a rash on his face and arms, which has spread over most of his body. He takes no medications. Physical examination is remarkable for a prominent rash consisting of diffuse, small macules and papules and occasional pustules. Your first consideration is that the patient may have a viral syndrome, such as varicella infection. The possibility occurs to you that a patient with smallpox could present in this way.
Which of the following statements regarding smallpox infection is true?
A. In infections of smallpox or varicella, skin lesions typically appear in different stages of development on any given part of the body
B. Infectious mononucleosis is the disease most likely to be confused with smallpox
C. Patients suspected of having smallpox require significant contact precautions, but airborne precautions are not required
D. Only personnel who have been successfully vaccinated within 3 years and who are wearing appropriate barrier protection should be involved in specimen collection for suspected cases of smallpox
Key Concept/Objective: To know the clinical manifestations of and appropriate containment methods for smallpox virus
Severe varicella is the disease most likely to be confused with smallpox. However, familiarity with the clinical features of the two diseases, particularly the rash, should help differentiate them. In smallpox infection, lesions are in the same stage of development on any given part of the body, whereas lesions in varicella are polymorphic. In the event of a limited outbreak, patients should be admitted to the hospital and confined to rooms that are under negative atmospheric pressure and equipped with high-efficiency particulate air (HEPA) filtration. Standard, contact, and airborne precautions, including use of gloves, gowns, and masks, should be strictly observed. Unvaccinated personnel caring for patients suspected of having smallpox should wear fit-tested N95 or higher-quality respirators. Only personnel who have undergone successful smallpox vaccination within 3 years and who are wearing appropriate barrier protection (i.e., gloves, gown, and shoe covers) should be involved in specimen collection for suspected cases of smallpox. (Answer: D—Only personnel who have been successfully vaccinated within
3 years and who are wearing appropriate barrier protection should be involved in specimen collection for suspected cases of smallpox)
22. A 22-year-old man who is in the military visits your clinic complaining of diffuse body aches, fatigue, shortness of breath, and midsternal chest pain. He has had these symptoms for 3 days. He notes that his chest pain worsens with deep inspiration. He has no significant medical history and takes no medications. He has a patch on his arm, which he explains was placed there by medical personnel to cover his smallpox vaccination site. He states that he received his vaccination 2 weeks ago. On physical examination, the patient’s temperature is 99.9° F (37.7° C). His heart rate is 110 beats/min, and he has a pericardial rub on auscultation. His physical examination is otherwise normal. An electrocardiogram reveals sinus tachycardia, diffuse ST segment elevation, and PR interval depression.
Which of the following statements regarding smallpox vaccination is true?
A. The most common complication of smallpox vaccination is eczema vaccinatum
B. The occurrence of myopericarditis after smallpox vaccination has been reported
C. Complications of smallpox vaccination are more common after revaccination
D. The most common serious complication of smallpox vaccination is myopericarditis
Key Concept/Objective: To know the complications of smallpox vaccination
Moderate and severe complications of vaccinia vaccination include eczema vaccinatum, generalized vaccinia, progressive vaccinia, and postvaccinial encephalitis. These complications are rare but are at least 10 times more common after primary vaccination than after revaccination. The most common complication of smallpox vaccination, occurring in 529.2 cases per million doses, is localized vaccinia infection resulting from inadvertent transfer (autoinoculation) of vaccinia from the vaccination site to other parts of the body. Eczema vaccinatum (38.5/million doses) is a localized or systemic dissemination of vaccinia virus that occurs in persons who have eczema or a history of eczema or other chronic or exfoliative skin conditions (e.g., atopic dermatitis). The most common serious complication is postvaccinial encephalitis (12.3/million doses). It occurs mostly in infants younger than 1 year and, less often, in adolescents and adults receiving a primary vaccination. Among 450,293 United States military service members vaccinated from December 2002 to May 2003, 37 cases of suspected, probable, or confirmed myopericarditis were observed. Symptoms of myopericarditis after smallpox vaccination began 7 to 19 days after vaccination (range, 1 to 42 days). (Answer: B—The occurrence of myopericarditis after smallpox vaccination has been reported)
23. You are called urgently to the emergency department to evaluate a 35-year-old man who is suspected of having undergone a cerebrovascular accident. The patient’s wife is at his bedside. On questioning, she states that the patient has no medical history and was in his usual state of health until 24 hours ago, when he developed double vision and had difficulty speaking and swallowing. His illness has been rapidly progressive. He is now almost mute and has developed severe shortness of breath. He has had no contact with persons who are ill. The emergency department physician informs you that two other patients with similar presentations were seen earlier today and that one more patient with the same complaints is in triage. Further discussions with these patients reveal that they were all at the same music concert 2 days ago.
Which of the following statements regarding botulism is true?
A. The classic clinical triad in patients with botulism is lack of fever, symmetrical descending flaccid paralysis with prominent bulbar palsies, and a clear sensorium
B. Contamination of food supplies is the most likely way that botulinum toxin would be used in bioterrorism
C. Botulism is easily confused with Guillain-Barré syndrome, because both illnesses are typified by descending flaccid paralysis
D. Initiation of treatment with botulinum antitoxin should be withheld until botulism is confirmed by laboratory testing
Key Concept/Objective: To know the clinical presentation of and appropriate therapy for botulism
The so-called classic triad of botulism summarizes the clinical presentation: an afebrile patient, symmetrical descending flaccid paralysis with prominent bulbar palsies, and a clear sensorium. Symptoms of cranial nerve abnormalities nearly always begin in the bulbar musculature; patients typically present with difficulty seeing, speaking, or swallowing. Clinical hallmarks include ptosis, blurred vision, and the so-called four Ds: diplopia, dysarthria, dysphonia, and dysphagia. Cranial nerve abnormalities and bulbar weakness are followed by symmetrical descending weakness and paralysis with progression from the head to the arms, thorax, and legs. Guillain-Barré syndrome typically results in ascending paralysis and sensory abnormalities. An aerosol attack is considered the most likely use of botulinum toxin for bioterrorism, although intentional contamination of food supplies is possible. Initiation of treatment with botulinum antitoxin should be based on the clinical diagnosis and should not await laboratory confirmation. A clinician who suspects botulism should immediately contact the local or state health department to facilitate procurement of antitoxin for treatment. (Answer: A—The classic clinical triad in patients with botulism is lack of fever, symmetrical descending flaccid paralysis with prominent bulbar palsies, and a clear sensorium)
24. A 35-year-old white man presents with fever, malaise, muscle aches, and cough. He reports no significant medical history. He works for the state government, and a letter with an unknown powder was sent to his office 3 days ago. He is concerned that he has anthrax. Four other people in his office have developed similar symptoms. Results of physical examination are as follows: heart rate, 106 beats/min; respiratory rate, 24 breaths/min; temperature, 101.8° F (38.8° C); and blood pressure, 124/78 mm Hg. The patient is in mild distress, and he is profusely diaphoretic. Pulmonary examination shows decreased breath sounds at the right base, with scattered crackles. The heart examination is significant only for tachycardia.
Given the likelihood of anthrax exposure in this patient, which of the following test would NOT be indicated to confirm the diagnosis of inhalational anthrax?
A. Blood cultures
B. Chest x-ray
C. Chest CT scan
D. Sputum culture and Gram stain
Key Concept/Objective: To understand the diagnosis of anthrax
There is no rapid screening test to diagnose inhalational anthrax in its early stages. In persons with a compatible clinical illness for whom there is a heightened suspicion of anthrax based on clinical and epidemiologic data, the appropriate initial diagnostic tests are (1) a chest x-ray, chest CT scan, or both and (2) culture and smear of peripheral blood. Mediastinal widening or hyperdense mediastinal lymphadenopathy (secondary to hemorrhagic lymph nodes) on a nonenhanced CT scan should raise the suspicion of pulmonary anthrax. Most persons with flulike illnesses do not have radiologic findings of pneumonia; those findings occur most often in the very young, the elderly, and persons with chronic lung disease. Pleural fluid and cerebrospinal fluid, as well as biopsy specimens taken from the pleura and lung, are also potentially useful for culture and other testing when disease is present in these sites, whereas sputum culture and Gram stain are unlikely to be useful. (Answer: D—Sputum culture and Gram stain)
25. A 56-year-old African-American woman comes to the clinic with complaints of blurred vision, difficulty speaking, and difficulty swallowing solids and liquids. She has recently returned from North Africa, where she serves in a United States government post. Upon further questioning, she remembers that some other people in her office had similar symptoms. Review of systems reveals xerostomia, nausea, and constipation. Physical examination reveals a middle-aged woman who is alert and oriented. There is prominent bilateral ptosis, and the patient has 4+/5 strength in deltoids and triceps bilaterally. Sensory examination is unremarkable.
What is the most likely diagnosis for this patient, given her constellation of symptoms?
A. Guillain-Barré syndrome
B. Myasthenia gravis
C. Botulism
D. Cerebral vascular accident
Key Concept/Objective: To understand the symptoms and signs of botulism
The incubation period for foodborne botulism is 2 hours to 8 days; the typical incubation period is 12 to 72 hours. The so-called classic triad of botulism summarizes the clinical presentation: an afebrile patient, symmetrical descending flaccid paralysis with prominent bulbar palsies, and a clear sensorium. Clinical hallmarks include ptosis, blurred vision, and the so-called four Ds: diplopia, dysarthria, dysphonia, and dysphagia. Cranial nerve abnormalities and bulbar weakness are followed by symmetrical descending weakness and paralysis with progression from the head to the arms, thorax, and legs. Anticholinergic symptoms are common; such symptoms include dry mouth, ileus, constipation, nausea and vomiting, urinary retention, and mydriasis. The differential diagnosis of botulism includes stroke, myasthenia gravis, Guillain-Barré syndrome, tick paralysis; poliomyelitis; Eaton-Lambert syndrome; paralytic shellfish poisoning; pufferfish ingestion; and anticholinesterase intoxication with organophosphates, atropine, carbon monoxide, or aminoglycosides. Because other people in the office where this patient worked had similar symptoms and because it is likely they shared a common source of food, botulism poisoning should be highly suspected. (Answer: C—Botulism)
26. A 45-year-old Asian man who is currently serving in the United States Marine Corps comes to the emergency department because of fever, which has persisted for 8 days. He reports returning from the Middle East 2 days ago. He states that, before his departure, several other marines had become ill and that some of them were so ill that they had to be transported to a hospital off the base. His symptoms also include headache, muscle aches, diarrhea with blood, and a rash on his extremities. On physical examination, the patient’s temperature is 103.4° F (39.7° C); his heart rate is 73 beats/min; his respiratory rate is 23 breaths/min; and his blood pressure is 103/67 mm Hg. The patient is in moderate distress. Petechiae are noted on the oral pharynx. The lungs show crackles throughout. A digital rectal examination is positive for heme. The skin shows diffuse purpura.
On the basis of World Health Organization (WHO) data, which of the following findings would NOT support the diagnosis of acute hemorrhagic fever?
A. Temperature of 101° F (38.3° C) persisting for more than 1 month
B. Blood in stools
C. Severe illness and no predisposing factors for hemorrhagic manifestations
D. Hemorrhagic rash
Key Concept/Objective: To understand the diagnosis and presentation of hemorrhagic fever viruses
Initial symptoms of the acute hemorrhagic fever virus syndrome may include fever, headache, myalgia, rash, nausea, vomiting, diarrhea, abdominal pain, arthralgias, myalgias, and malaise. Illness caused by Ebola virus, Marburg virus, Rift Valley fever virus, yellow fever virus, Omsk hemorrhagic fever virus, and Kyasanur Forest disease virus has an abrupt onset, whereas Lassa fever and the diseases caused by Machupo, Junin, Guarinito, and Sabia viruses have a more insidious onset. Initial signs may include fever, tachypnea, relative bradycardia, hypotension (which may progress to circulatory shock), conjunctival injection, pharyngitis, and lymphadenopathy. Hemorrhagic symptoms, when they occur, develop later in the course of illness and include petechiae, purpura, bleeding into mucous membranes and conjunctiva, hematuria, hematemesis, and melena. Hepatic involvement is common, and renal involvement is proportional to cardiovascular compromise. Clinical diagnostic criteria based on WHO surveillance standards for acute hemorrhagic fever syndrome include temperature greater than 101° F (38.3° C) of less than 3 weeks’ duration; severe illness and no predisposing factors for hemorrhagic manifestations; and at least two of the following hemorrhagic symptoms: hemorrhagic or purple rash, epistaxis, hematemesis, hematuria, hemoptysis, blood in stools, or other hemorrhagic symptom with no established alternative diagnosis. (Answer: A— Temperature of 101° F [38.3° C] persisting for more than 1 month)
For more information, see Duchin JS: 8 Interdisciplinary Medicine: V Bioterrorism. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, June 2004
Assessment of the Geriatric Patient
27. A 90-year-old man presents to his primary care physician with his 87-year-old wife, who is his primary caregiver. The patient has fallen once at home, and his appetite has diminished recently. The physician adjusts the patient’s antihypertensive regimen, and the patient is scheduled to undergo a follow-up examination in 3 months. He returns in 3 months after having fallen two more times. He is generally failing to thrive.
Which of the following interventions is NOT consistent with the general principles of geriatric assessment?
A Arranging for the patient to see a social worker, physical therapist, and home nurse in addition to his primary care physician
B. Addressing the falls to prevent injury from subsequent falls
C. Monitoring results of dietary recommendations to assess improvement in intake
D. Always placing the physician in charge of the geriatric assessment team because he is most qualified to direct patient care
E. Questioning the patient about issues related to sexuality
Key Concept/Objective: To understand the fundamental principles of geriatric assessment
General features of geriatric assessment include the following: (1) an interdisciplinary team approach to patient care; (2) a focus on prevention, including the prevention of decline (maintaining functional status); and (3) a feedback loop to promote adherence to recommendations by other health care providers, patients, and caregivers, as well as to promote patient self-efficacy or confidence in the ability to perform specific activities. This patient will benefit from seeing members of an interdisciplinary team, with team leadership rotating, depending on the major concern for the patient at any particular time. The prevention of falls will promote well-being. Addressing sexuality in this age group represents another form of preventive care that may require special intervention. Any intervention, such as a dietary modification, needs to be monitored for success or failure so that further adjustments can be made. (Answer: D—Always placing the physician in charge of the geriatric assessment team because he is most qualified to direct patient care)
28. An 85-year-old man is admitted to a geriatric acute care unit from home for treatment of nausea and vomiting related to a urinary tract infection.
Which of the following statements does NOT accurately characterize the benefits of a geriatric acute care unit over a general inpatient ward?
A. The geriatric acute care unit provides a specially prepared environment
B. Patients who receive care in a geriatric acute care unit have improved functional status 3 months after discharge, compared with those in a general inpatient ward
C. The geriatric acute care unit provides patient-centered care that emphasizes independence
D. There is an increased likelihood that patients receiving care in a geriatric acute care unit will be able to return home upon discharge
E. The geriatric acute care unit provides intensive review of medical care to minimize the adverse effects of medications
Key Concept/Objective: To understand the benefits of specialized geriatric inpatient care
Geriatric acute care units were designed to improve functional outcomes for older patients. The programs comprise four key elements: (1) a specially prepared environment (e.g., uncluttered hallways, large clocks and calendars, and handrails); (2) patientcentered care emphasizing independence, including specific protocols for prevention of disability and for rehabilitation; (3) discharge planning, with the goal of returning the patient home; and (4) intensive review of medical care to minimize the adverse effects of procedures and medications. A randomized, controlled trial of 651 acutely ill patients 70 years of age or older demonstrated that at the time of hospital discharge, patients admitted to the geriatric acute care unit were better able to perform basic activities of daily living and were more likely to return home. However, by 90 days after discharge, the functional status of patients receiving care in the acute care unit was similar to those receiving usual care. (Answer: B—Patients who receive care in a geriatric acute care unit have improved functional status 3 months after discharge, compared with those in a general inpatient ward)
29. A 90-year-old man is brought by his daughter to see a geriatrician for the first time. He had formerly been cared for by a general internist. The geriatrician employs a trained receptionist, a nurse practitioner, and a social worker to help perform geriatric assessment on her patients.
Which of the following statements regarding outpatient geriatric assessment for this patient is false?
A. The patient completes a questionnaire in the waiting room to screen for common conditions in older persons
B. The patient completes easily observed tasks, and his performance is assessed
C. The daughter may be less likely to report increased burden of care during the ensuing year
D. The cost of the assessment is covered by Medicare
Key Concept/Objective: To understand methods of geriatric assessment in the outpatient setting
Outpatient geriatric assessment programs may be used as an adjunct to or a substitute for routine primary care. These programs utilize self-administered questionnaires to screen for common conditions in older persons. Patients can complete these questionnaires themselves or with the assistance of a trained receptionist. The questionnaire can be used to evaluate malnutrition, visual impairment, hearing loss, cognitive impairment, urinary incontinence, depression, physical limitations, and reduced leg mobility. The patient may be asked to perform easily observed tasks that relate to daily life, such as instrumental and basic activities of daily living. Outpatient geriatric assessment can benefit caregivers as well as patients. At present, Medicare does not cover hospital or physician geriatric assessment services. (Answer: D—The cost of the assessment is covered by Medicare)
30. A 76-year-old woman who is recovering from a hip fracture is hospitalized at a regional hospital, where she is to undergo geriatric assessment.
Which of the following statements regarding geriatric assessment units is true?
A. Although geriatric assessment units improve quality of life, they do not affect the risk of nursing home placement
B. The costs associated with geriatric assessment units are universally offset by decreased institutional charges the following year
C. A shortage of trained geriatricians nationwide may prevent formation of a formal geriatric assessment unit
D. Geriatric assessment units are more likely to be found in the private setting because of their ability to generate revenue
Key Concept/Objective: To understand the role of formal geriatric assessment programs
Treatment in a geriatric assessment unit results in improved function and decreased risk of nursing home placement. The availability of formal geriatric assessment programs is limited because of the nationwide shortage of trained geriatricians. Assessment programs are more likely to be found in large regional or academic medical centers. (Answer: C—A shortage of trained geriatricians nationwide may prevent formation of a formal geriatric assessment unit)
For more information, see Edelberg HK: 8 Interdisciplinary Medicine: VIII Assessment of the Geriatric Patient. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, September 2002
Disorders in Geriatric Patients
31. A 79-year-old woman is admitted to the hospital with productive cough, fever, and dyspnea. She has a fever of 101.9° F (38.8° C) and rales in the right base of her posterior lung fields. A chest x-ray reveals a right-lower-lobe infiltrate. The patient is treated with a third-generation cephalosporin and a macrolide for community-acquired pneumonia. On her second day of hospitalization, the patient becomes becomes acutely confused, is throwing food in the room, and is attempting to get out of bed.
Which of the following statements regarding delirium in the elderly patient is false?
A. In medically ill patients, delirium is most commonly associated with acute infections, hypoxemia, hypotension, and the use of psychoactive medications
B. By definition, delirium can be an acute or chronic disorder
C. Medications frequently associated with delirium include antiarrhythmic agents, tricyclic antidepressants, neuroleptics, gastrointestinal medications, and antihistamines
D. Patients with delirium can have perceptual disturbances such as hallucinations and can have a fluctuating level of alertness
Key Concept/Objective: To understand the definition, etiology, and clinical features of delirium
Common causes of cognitive dysfunction in elderly patients are delirium, dementia, and depression. Delirium, an acute disorder of attention and global cognitive function, is a common and potentially preventable cause of adverse health outcomes. The criteria for delirium caused by a general medical condition include the following: disturbance of consciousness (i.e., reduced awareness of the environment), with reduced ability to focus, sustain, or shift attention; change in cognition (e.g., memory deficit, disorientation, language disturbance) or perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia; increased or reduced psychomotor activity; disorganized sleep-wake cycle; acute onset of disturbance (usually hours to days), with fluctuation over the course of the day; and evidence from the history, physical examination, or laboratory findings that the disturbance is caused by an etiologically related general medical condition. Independent risk factors for delirium in elderly medical patients during hospitalization include the use of psychoactive medications, severe illness, cognitive impairment (dementia), vision impairment, and a high ratio of BUN to creatinine, implying dehydration. Precipitating factors for delirium in hospitalized elderly persons include the use of physical restraints, more than three medications added to the patient’s drug regimen, bladder catheterization, and any iatrogenic event (e.g., unintentional injury). In medically ill patients, delirium is most commonly associated with acute infections, such as pneumonia and urosepsis; hypoxemia; hypotension; and the use of psychoactive medications. Psychoactive medications include many antiarrhythmic agents, tricyclic antidepressants, neuroleptics, gastrointestinal medications, and antihistamines. When used in large doses or in combination at therapeutic doses, these agents may induce delirium. The patient with delirium presents with an acute change in mental status and clinical features of disturbed consciousness, impaired cognition, and a fluctuating course. Perceptual disturbances, such as misperceptions, illusions or frank delusions, and hallucinations, are often accompanied by increased psychomotor activity. Most patients with delirium vacillate between hypoalertness and hyperalertness. (Answer: B—By definition, delirium can be an acute or chronic disorder)
32. A 76-year-old white woman presents to your clinic with a complaint of incontinence. She says that she has had this problem for “years” and has never undergone evaluation for it. She denies having dysuria or hematuria. The patient has five grown children.
Which of the following statements regarding urinary incontinence in the geriatric population is true?
A. The most common predisposing factors are overactive bladder resulting from changes in the bladder smooth muscle; prostatic hypertrophy; bladder wall relaxation or prolapse; medication side effects; and cognitive impairment
B. The preferred management strategy includes thorough diagnostic workup before implementation of therapy, because empirical management is largely unsuccessful
C. In female patients with stress incontinence, first-line therapy includes medications
D. To be considered abnormal, the postvoiding residual volume (PVR) of urine must be greater than 500 ml
Key Concept/Objective: To understand the causes, diagnostic workup, and management of urinary incontinence in the geriatric population
Urinary incontinence—the involuntary loss of urine of sufficient severity to be a social or health problem—is a common, costly, and potentially disabling condition that is never a consequence of normal aging. It is always treatable and often curable. An overactive bladder associated with changes in the smooth muscle of the bladder, prostatic hyperplasia in men, bladder wall relaxation or prolapse in women, medication side effects, and cognitive impairment are the most common factors predisposing older patients to urinary incontinence. Acute incontinence typically has a sudden onset and is associated with an acute illness (e.g., infection or delirium) or iatrogenic event (e.g., polypharmacy or restricted mobility). There are four basic types of established incontinence: stress, urge, overflow, and functional incontinence. In patients with established incontinence, blood tests should measure renal function, electrolytes, blood glucose, and serum calcium; these measurements help to exclude polyuric conditions that may cause incontinence. The most useful bedside test of lower urinary tract function is measurement of the PVR urine. Accurate measurement of the PVR is most often accomplished by straight catheterization of the urinary bladder after the patient attempts complete voiding. Pelvic ultrasonography and portable bladder scanning are safe and accurate alternative methods of estimating PVR. A PVR of less than 50 ml of urine is considered normal. A PVR of greater than 150 ml is abnormal even in elderly patients and indicates the need for further urologic evaluation or repeat measurement of PVR. Strategies for the management of urinary incontinence include behavioral modification techniques, medications, patient and caregiver education, surgical procedures, catheter placement, and incontinence supplies. The acute onset of incontinence should be evaluated and treated promptly. Urinary tract infection, acute urinary retention, stool impaction, and adverse effects of medications (e.g., diuretics) should be excluded. After the initial diagnostic evaluation, most patients should be treated on the basis of the most likely type of incontinence. This empirical approach will lead to successful management of a large percentage of incontinent patients. In female outpatients, behavioral interventions (e.g., biofeedback), bladder training, and pelvic muscle exercises are effective first-line therapies for established stress incontinence. Medications play a modest role in the treatment of stress incontinence. (Answer: A—The most common predisposing factors are overactive bladder resulting from changes in the bladder smooth muscle; prostatic hypertrophy; bladder wall relaxation or prolapse; medication side effects; and cognitive impairment)
33. An 80-year-old man comes to your clinic accompanied by his daughter. She is concerned because her father recently lost his balance while walking through the house. The daughter explains that if she hadn’t been walking with her father, he would have fallen and injured himself. He has hypertension, benign prostatic hypertrophy, and coronary artery disease but is able to perform activities of daily living.
Which of the following statements regarding the primary care assessment of gait and falls in elderly patients is false?
A. Older patients should be assessed yearly for risk of falls
B. Risk factors for falls include weakness, gait and balance deficits, visual impairment, depression, poor lighting, and loose carpet in the home
C. Exercise programs such as Tai Chi have not been shown to reduce the fall rate, although they do improve balance
D. Medications associated with falls include loop diuretics, vasodilators, adrenergic antagonists, antidepressants, and sedative-hypnotic agents
Key Concept/Objective: To understand the risk factors for falls in the geriatric population, as well as the prevention and management of falls in this population
Accidental falls are common and potentially preventable causes of morbidity and mortality in elderly adults. The risk factors for falls and the effectiveness of multifactorial interventions to prevent recurrent falls in carefully targeted patients are well established. Intrinsic risk factors include lower extremity weakness, poor grip strength, gait and balance deficits, impaired performance of daily activities, visual impairment, cognitive impairment, and depression. Extrinsic risk factors include use of four or more prescription drugs and environmental impediments such as poor lighting, loose carpets, and the absence of bathroom safety equipment. The maintenance of normal balance and gait requires the successful integration of sensory (afferent), central nervous (brain and spinal cord), and musculoskeletal systems. A disturbance in sensory input (e.g., peripheral neuropathy), central nervous system functioning (e.g., dementia), or motor function (e.g., arthritis or muscle weakness) will predispose elderly patients to falls. The aging process may also predispose patients to falls by increasing postural sway and reducing adaptive reflexes. Patients at risk for falls can be identified through a medical history, physical examination, and a few laboratory studies. Older persons should be asked at least once a year whether they experience falls. Among those reporting a fall, a review of the circumstances surrounding the fall, including symptoms before and after the event, provides clues to the likely causes. Medications associated with falls most notably include those that cause postural hypotension, such as loop diuretics, vasodilators, or adrenergic antagonists, and those with psychotropic properties, such as antidepressants and sedative-hypnotic agents. Successful components of interventions used in clinical trials include review and alterations in medications, balance and gait training, muscle-strengthening exercises, improvement of postural hypotension, home-hazard modifications, and specific medical and cardiovascular treatments. Tai Chi exercises to enhance balance and body awareness, when combined with balance training, may also reduce the rate of falls. A randomized trial of Tai Chi exercise for 15 weeks in 200 persons 70 years of age and older resulted in a 47% decrease in falls after a 4-month follow-up period. (Answer: C—Exercise programs such as Tai Chi have not been shown to reduce the fall rate, although they do improve balance)
34. A 77-year-old man presented to your clinic for evaluation 2 weeks ago and was noted to be hypertensive (this was the second time his blood pressure was determined to be elevated). The patient was started on a diuretic and an ACE inhibitor for his hypertension. He was also started on a regimen of daily low-dose aspirin. Today the patient is brought in by family members for evaluation of confusion. They state that his change in mental status is new and began after he started taking his new medications.
Which of the following statements regarding iatrogenic illness in the geriatric population is false?
A. The most common documented cause of iatrogenic illness is adverse drug reactions, usually associated with polypharmacy
B. Because most drugs are eliminated via the hepatic system, lower maintenance doses of medications are needed to avoid iatrogenic side effects of prescribed medications
C. Ways to prevent nosocomial infections include hand washing, elevating the patient’s head to prevent aspiration, and using narrowspectrum antibiotic agents when indicated
D. Drug distribution is altered by aging, primarily because of bodycomposition changes, with a decrease in total body water and lean body mass and a relative increase in body fat
Key Concept/Objective: To understand the most common causes of iatrogenic illnesses in geriatric patients and how to prevent them
Iatrogenic, or physician-induced, illness results from a diagnostic procedure or therapeutic intervention that is not a natural consequence of the patient’s disease. Iatrogenic illnesses include complications of drug therapy and of diagnostic or therapeutic procedures, nosocomial infections, fluid and electrolyte disorders, and trauma. The most common documented cause of iatrogenic illness is adverse drug reactions, usually associated with polypharmacy. Adverse drug events are more likely to occur in elderly patients because of the age-related changes in drug metabolism, the occurrence of multiple comorbidities, and the use of polypharmacy. The incidence of adverse drug reactions increases with advancing age and the number of chronic diseases requiring drug therapy. The concomitant use of several medications increases the risk of drug interactions, unwanted effects, and adverse reactions. Many medications should be used with special caution in elderly patients because of age-related changes in drug pharmacokinetics (drug disposition) and pharmacodynamics (target tissue effects). Although drug absorption is not reduced in healthy elderly persons, absorption of medications can be reduced by disease states (e.g., malabsorption) or concomitant administration of drugs that decrease absorption of medications (e.g., antacids). Drug distribution is altered by aging, primarily because of body-composition changes, with a decrease in total body water and lean body mass and a relative increase in body fat. Consequently, water-soluble drugs achieve a higher serum concentration, whereas lipid-soluble drugs have a prolonged elimination half-life. Drug elimination is mainly influenced by renal function. The age-associated decrease in renal function, which results in decreased creatinine clearance, necessitates lower maintenance doses of renally excreted drugs in elderly patients. The prevention of iatrogenic illness resulting from the inappropriate prescribing of drugs begins with an understanding of the rational use of medications in elderly patients. In general, prescribing the fewest medications at the lowest needed dosages is a rational approach to the prevention of iatrogenic illness. Nosocomial pathogens are primarily transmitted through contact with hospital or nursing home personnel. Nosocomial infection can be prevented by washing hands and cleaning medical equipment (e.g., stethoscopes) between patient contacts, by wearing gloves during invasive procedures or during contact with wounds or mucous membranes, by using aseptic techniques when inserting or changing urinary catheters, by isolating infected patients (e.g., in nursing homes), by elevating the patient’s head (to lessen the risk of aspiration), by replacing broad-spectrum antibiotics with narrow-spectrum antibiotics on the basis of bacterial sensitivity reports, and by limiting the use of urinary catheters. Prophylactic antimicrobial therapies and routine catheter replacement are not recommended. (Answer: B—Because most drugs are eliminated via the hepatic system, lower maintenance doses of medications are needed to avoid iatrogenic side effects of prescribed medications)
35. An 80-year-old male nursing home resident with a history of Alzheimer disease, atrial fibrillation, and congestive heart failure is admitted to the hospital with pneumonia and poor oral intake. His medications include lisinopril, warfarin, donepezil, and digoxin. The initial examination reveals a cognitively impaired man who is alert and oriented to person and place. The patient’s score on the Mini-Mental State examination is 24/30. After 48 hours, you are called to see him because of altered mental status. Nurses report that over the past shift, the patient has become increasingly disoriented and agitated. On examination, he has a temperature of 100.4° F (38° C), he is lethargic, and he cannot sustain attention or follow commands.
Which of the following statements regarding the development of delirium is false?
A. The most important risk factor for delirium in this patient is his underlying dementia
B. The therapeutic dosage of digoxin excludes this medication as a contributing cause of this patient’s delirium
C. Delirium develops in up to 15% of older hospitalized patients
D. This patient’s risk of mortality or of further decline in activities of daily living and cognitive function is significantly higher than would be the case in a similar patient who has not experienced delirium
E. The use of physical restraints has been associated with the precipitation of delirium in elderly hospitalized patients
Key Concept/Objective: To understand the significant risks of delirium in elderly hospitalized patients
Elderly patients are at increased risk for developing delirium during hospitalization. Delirium is an important condition to recognize, as the majority of cases are reversible with treatment of the underlying illness. Dementia or cognitive impairment is the single most important risk factor for the development of delirium. Other factors include acute infections, hypoxemia, and medications with psychoactive or anticholinergic effects. Cardiac medications such as digoxin and other antiarrhythmics can also cause delirium; elderly patients may be susceptible even when taking the drug at therapeutic doses. In addition, studies have linked the use of physical restraints and the addition of more than three medications to a patient’s regimen during hospitalization to the development of delirium. In a multicenter cohort study, delirium in the hospital setting was associated with higher rates of mortality and future nursing home admissions. (Answer: B—The therapeutic dosage of digoxin excludes this medication as a contributing cause of this patient’s delirium)
36. A 71-year-old woman presents to your clinic complaining of urinary incontinence of several months’ duration. She has hypertension that is well controlled on hydrochlorothiazide. She states that intermittently, she experiences a sudden overwhelming need to void, which often results in loss of urine before she is able to reach the toilet. She denies having dysuria or abdominal pain. She is otherwise active and highly functional but has lately been limiting her social activities because of embarrassment. She has no loss of urine with coughing or ambulation. Her physical examination is unremarkable, and the results of urinalysis are within normal limits. Postvoid residual urine volume obtained in the office is 45 ml.
What is the appropriate classification and the best initial approach to the management of this patient’s urinary incontinence?
A. Stress incontinence; prescribe an intravaginal estrogen preparation and consider surgical referral
B. Overflow incontinence; discontinue the diuretic and teach the patient intermittent self-catheterization
C. Urge incontinence; recommend behavioral therapies, including scheduled voiding and bladder retraining
D. Functional incontinence; reassure the patient that the changes are age-related, and recommend diapers during excursions out of the house
E. Detrusor hyperactivity secondary to chronic urinary tract infection;
check urine culture and prescribe appropriate antibiotics
Key Concept/Objective: To recognize and treat urinary incontinence in the elderly
Urinary incontinence is an important condition in elderly patients; it is not a normal consequence of aging and is often curable. This patient describes symptoms of urge incontinence caused by involuntary detrusor muscle contractions at relatively low bladder volumes. Urge incontinence can be improved with bladder retraining and scheduled voiding. Additionally, bladder relaxant medications such as oxybutinin or tolterodine are frequently helpful. This patient’s history is not suggestive of stress incontinence, which would be characterized by loss of variable amounts of urine with coughing or straining and is caused by failure of sphincter mechanisms to remain closed during bladder filling. This patient’s normal postvoid residual urine volume (less than 50 ml) helps rule out overflow incontinence, which is caused by detrusor inactivity or bladder outlet obstruction. Functional incontinence describes an inability or refusal to toilet, usually as a result of cognitive impairment or physical limitations. There is no evidence on urinalysis that this patient has a urinary tract infection, and culture in this setting would not be helpful. (Answer: C—Urge incontinence; recommend behavioral therapies, including scheduled voiding and bladder retraining)
37. An 86-year-old resident of a long-term care facility who has suffered multiple strokes in the past is noted to have an ulcer measuring 2 × 2 cm over the sacrum. On examination, the wound appears to extend partially through the dermis but not to the fascial plane (i.e., the patient has a stage II ulcer). There is minimal surrounding erythema and no apparent eschar formation or undermining.
Which of the following interventions is most likely to prevent progression and promote healing of the ulcer?
A. Daily topical antibiotic therapy with silver sulfadiazene
B. Dressings with povidone-iodine–soaked gauze applied daily
C. Sharp debridement followed by wet-to-dry dressings
D. Frequent turning and use of a low-air-loss mattress to reduce pressure under bony prominences
E. Initiation of tube feeding to improve nutrition
Key Concept/Objective: To understand the treatment of pressure ulcers in the elderly
Pressure is the most important factor in the development and progression of pressure ulcers. Other etiologic factors include shearing forces, moisture, and injury from friction. The first step in managing ulcers of all stages is pressure reduction. This patient does not have evidence of full-thickness ulcer or eschar that would require surgical debridement. Topical antibiotics are appropriate for use in clean ulcers that are not healing with pressure relief and dressings, but their use alone is unlikely to result in healing. It is also important to optimize nutrition to promote wound healing, but it would be inappropriate to initiate tube feeding without first attempting local measures, such as pressure relief and use of wet-to-dry dressings with saline-soaked gauze. Povidone-iodine should not be applied to open wounds because of its toxic cellular effects. (Answer: D—Frequent turning and use of a low-air-loss mattress to reduce pressure under bony prominences)
38. A 78-year-old man is brought to clinic from a nursing home for evaluation after a fall. He has a history of hypertension, benign prostatic hypertrophy, and Parkinson disease, which was diagnosed 5 years ago. The fall was unwitnessed and occurred shortly after the patient had breakfast. He was awake and oriented to person and place after the fall. His medications include terazosin, hydrochlorothiazide, aspirin, carbidopa-levodopa, and temazepam. On physical examination, the patient appears frail; he has an unsteady, shuffling gait, and he uses a cane for support. No significant change in heart rate or blood pressure is found on orthostatic testing. There is a contusion over the left trochanter. Radiography is negative for fracture.
Which of the following statements regarding falls in nursing home residents receiving long-term care is false?
A. There is a consistent association between falling and the use of psychotropic medications such as neuroleptics and antidepressants
B. Widespread use of physical restraints has been shown to reduce the rates of falls in long-term care facilities
C. The incidence of falls among nursing home residents is close to three times that of the community-dwelling elderly
D. A timed “get up and go” test performed in clinic (consisting of observing the patient stand up, walk 10 ft, turn, walk back, and sit down unassisted) is a valid tool that can predict gait impairment and falls
E. A significant proportion of patients who fall develop a fear of falling that is itself associated with an increased risk of gait problems
Key Concept/Objective: To know the risk factors for falls in elderly patients
Accidental falls are a common and serious problem in elderly patients. Multiple studies have identified risk factors for falling; these risk factors are either intrinsic (e.g., muscular weakness, poor balance) or extrinsic (e.g., poor lighting, polypharmacy). Among the most important are muscle weakness, a history of falls, gait and balance deficits, visual deficits, cognitive impairment, and age greater than 80 years. In studies both of patients receiving care in the home and of those receiving care in long-term care facilities, an association between psychotropic medications and falls has been demonstrated. The American Geriatrics Society recommends that all older persons be asked at least once a year about falls, and any patient who reports a single fall should be observed performing “get up and go” maneuvers (described in choice D).1 Patients demonstrating difficulty with this test should undergo further assessment, including review of the circumstances associated with the fall, medications, and directed assessment of vision and neurologic and cardiac function, as indicated. There is no evidence to support the routine use of restraints for the prevention of falls, given their significant drawbacks, which include deconditioning, depression, and development of pressure sores. (Answer: B—Widespread use of physical restraints has been shown to reduce the rates of falls in long-term care facilities)
1. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc 49:664, 2001
For more information, see Palmer RM: 8 Interdisciplinary Medicine: IX Management of Common Clinical Disorders in Geriatric Patients. ACP Medicine Online (www. acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, August 2004
Rehabilitation of Geriatric Patients
39. A 75-year-old male patient is considered to be medically stable for discharge after suffering a stroke 5 days ago. His neurologic deficits include hemiplegia of his right arm and mild cognitive disturbances; he scored 2.0 on the Orpington Prognostic Scale. His medical history is significant for diabetes and hypertension, which is well controlled. Before his stroke, he was living by himself.
Which of the following is true regarding rehabilitation for this patient?
A. Rehabilitation should be deferred until the patient is discharged from the hospital, and the patient should receive therapy in an outpatient setting
B. His initial Orpington Prognostic Scale score indicates only a 20% chance of independence in personal care and homemaking activities at 6 months
C. Rehabilitation efforts need not be extended beyond the first 3 months, because functional recovery will not occur after this period
D. The patient should be screened and treated for depression during rehabilitation
E. During the rehabilitation of his right hemiplegia, aggressive therapy can be undertaken without concern for pain or shoulder dislocation, owing to muscle flaccidity
Key Concept/Objective: To understand the rehabilitation for geriatric stroke patients
Major depression occurs in at least one third of patients after stroke. Poststroke rehabilitation should include screening for and treatment of this commonly overlooked complication. Increased socialization, counseling, and medication are appropriate. Cognitive impairment caused by depression may improve with treatment of depression and use of medications that cause less sedation and fewer anticholinergic side effects. In the first weeks after stroke, the patient’s motor function, sensory function, balance, and cognition can be assessed through use of the Orpington Prognostic Scale. The patient’s score is a strong predictor of functional status at 3 and 6 months; a score of 2.4 or less is associated with an 80% chance of the patient’s being independent with regard to personal care and homemaking activities at 6 months. The potential for neuroplastic change is revolutionizing approaches to neurologic rehabilitation. The potential for neural reorganization is also changing the timing of rehabilitation; recent studies have demonstrated significant gains in function in chronic stroke patients who undergo treatments that focus on repetitive and forced practice. Shoulder pain and dislocation are especially likely in patients with a flaccid upper extremity, and reflex sympathetic dystrophy occurs in as many as 25% of patients with hemiplegia. (Answer: D—The patient should be screened and treated for depression during rehabilitation)
40. A 76-year-old female patient with diabetes and severe peripheral vascular disease undergoes a left belowthe-knee amputation. Before the surgery, she was ambulatory and had no difficulty in weight bearing with the contralateral leg. Her diabetes is moderately well stabilized with insulin, and she has no other medical history. She smokes approximately 1 pack of cigarettes a day and has been doing so for 50 years.
Which of the following is NOT a key aspect in rehabilitation for this patient?
A. The patient should be counseled to stop smoking to promote wound healing and decrease the risk of future amputations
B. The patient should be instructed as to the proper care of the contralateral leg
C. The physician should be actively involved in the choice of the prosthetic limb and in the training of the patient
D. Weight bearing and mobilization should be delayed until full healing of the residual limb has taken place
E. Early angioplasty of the contralateral leg should be performed to prevent the need for its amputation
Key Concept/Objective: To understand the rehabilitation of geriatric amputation patients
Early mobilization using a rigid, removable dressing and sometimes a temporary artificial leg can simultaneously protect the fragile healing tissues and prevent complications caused by prolonged immobility. About 25% of patients who undergo unilateral amputation because of peripheral vascular disease and 50% of patients who undergo the procedure because of diabetes will need to have the other leg amputated within 5 years. Care of the contralateral extremity is essential, and each amputee should have a program of regular foot care that includes checking for foot lesions; in addition, each amputee should practice peripheral vascular control measures, including smoking cessation and control of diabetes. Smoking delays wound healing. The role of angioplasty in reducing the need for amputation is unclear. Successful prosthetic ambulation depends on selection of an appropriate device, progressive ambulation, and management of concurrent problems. The physician should form a relationship with a reputable prosthetist who can integrate the technical issues involved in designing a prosthetic with the medical and functional status of the amputee. The prosthetic limb should be adapted to existing comorbidity, and the patient should be examined for signs of skin breakdown, edema, and infection occurring in association with use of the prosthesis. (Answer: D—Weight bearing and mobilization should be delayed until full healing of the residual limb has taken place)
41. An 87-year-old woman with severe dementia and advanced renal disease sustains a nondisplacement fracture across the trochanter of the left hip. She is a nursing home resident but was able to ambulate with assistance before sustaining the hip fracture.
When considering rehabilitation for this patient, which of the following considerations is most pertinent?
A. An inpatient multidisciplinary approach to rehabilitation can significantly improve the prognosis after surgery
B. Rehabilitation without surgical intervention would be beneficial
C. To prevent complications, early mobilization should be avoided in this patient
D. This type of hip fracture is associated with avascular necrosis and nonunion
E. This type of hip fracture usually requires a complete hip arthroplasty
Key Concept/Objective: To understand the importance of rehabilitation for geriatric patients with hip fractures
Rehabilitation should be offered to all patients in the absence of near-terminal conditions and possibly to bedridden patients with end-stage dementia. Such patients may be treated nonsurgically with early mobilization from bed to chair, control of pain, and treatment of complications. Patients with even mild to moderate dementia can benefit from rehabilitation after fracture. Hip fractures in elderly patients result in increased mortality. For such patients, 1-year mortality is 20%. After hip fracture, the care setting may not influence outcome much, and coordinated multidisciplinary approaches to inpatient rehabilitation of older patients have been found to have borderline effectiveness in reducing outcomes such as death and institutionalization. Early mobilization reduces all the complications of immobility, including bedsores, constipation, loss of strength, and risk of thromboembolism. Two thirds of hip fractures occur across the trochanter. Intertrochanteric fractures are often associated with significant bleeding into the surrounding soft tissue. Femoral neck fractures occur in the remaining one third of hip fractures; such fractures are likely to disrupt blood supply to the femoral head and may lead to avascular necrosis and nonunion. Surgical treatment of trochanteric fractures usually consists of open reduction and internal fixation, but femoral neck fractures may require complete hip arthroplasty. (Answer: B—Rehabilitation without surgical intervention would be beneficial)
42. An 82-year-old male patient with severe osteoarthritis of his left knee has been advised to have a total left knee replacement by an orthopedist. Until now, he has needed narcotic pain medications. He has diabetes and hypertension, both of which are moderately well controlled. He inquires about rehabilitation after the surgery.
Which of the following is true regarding rehabilitation after total knee replacement?
A. Total knee replacement in patients older than 80 years is associated with an increased rate of complications and increased length of hospital stay
B. Strength training is an important component of rehabilitation and should be instituted within the first week after surgery
C. After surgery, long-term benefits of rehabilitation include significant pain relief, improved function, and an increase in strength and mobility to a degree that is similar to that of other persons of the same age
D. Aggressive physical therapy alone is adequate in the rehabilitation process after surgery
E. Use of a machine that provides continuous passive motion helps with recovery and may shorten the length of stay in the hospital
Key Concept/Objective: To understand the rehabilitation of geriatric arthroplasty patients
Improved range of motion is a critical step in recovery after below-the-knee amputations and is often aided by the use of a continuous passive motion (CPM) machine. Early postoperative CPM has been shown to be more effective than physical therapy alone in reducing flexion contracture and shortening length of stay. Home CPM produced satisfactory range of motion at about half the cost of home physical therapy in a recent clinical trial. Joint replacement in selected patients older than 80 years does not increase complication rates or length of stay. Strength training is often deferred for several weeks to promote stable healing of tissues, and isometric and resistive exercise with gradually increasing loads can be introduced safely by 8 weeks after surgery. Long-term outcomes include significant pain relief and improved function, although many patients do not achieve levels of strength or mobility comparable to those of age-matched control subjects. (Answer: E—Use of a machine that provides continuous passive motion helps with recovery and may shorten the length of stay in the hospital)
For more information, see Studenski S, Brown CJ: 8 Interdisciplinary Medicine: X Rehabilitation of Geriatric Patients. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, March 2004