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Still Studying For The American Board Of Internal Medicine Maintenance Of Certification Exam: What's Incorrect Alongside This Picture?

Really aught is incorrect alongside withal studying. I'm withal enjoying it in addition to absorbing some non-negligible percent of what I'm reading. There is but a tremendous amount of materials that has acquire unremarkably held truth since I concluding took this exam.

But equally I study, which is withal next the full general bird of reading a multiple alternative enquiry from the MKSAP (American College of Physicians Medical Knowledge Self Assessment Program) in addition to then reviewing diverse sources on anything that I don't experience totally confident about, some of the patient vignettes demonstrate a lack of attending to the big picture.

The multiple alternative questions are all illustration presentations, which is skilful since it keeps me engaged. Here are a few of the to a greater extent than disturbing ones out of the hematology/oncology department which I am working on now, reworded, simplified beyond recognition.

1. Influenza A virus subtype H5N1 lxx yr onetime severely demented man, living at domicile alongside his wife, really thin, presents inwards bad kind alongside respiratory failure in addition to pneumonia. He is admitted to the intensive attention unit, given antibiotics in addition to IV fluids in addition to supported on a ventilator. He is able to breathe on his own, ventilator is removed, married adult woman decides he should move to a nursing home, he develops bruising in addition to bleeding. The diagnosis? Vitamin K deficiency, non likewise difficult to approximate given the lab values in addition to setting. But...pneumonia is "the onetime man's friend." Why didn't they stimulate got a tidings alongside their principal attention physician earlier he was set on the ventilator most the prognosis of severe dementia alongside malnutrition, in addition to and then mayhap he wouldn't stimulate got had to popular off inwards a nursing home?

2. Influenza A virus subtype H5N1 threescore yr onetime adult woman alongside a history of a smoldering os marrow illness has ii weeks of fatigue in addition to bruising, presents to the emergency room. Her white count is high, platelets low, she has a fever. Her blood smear is shown, myeloblasts alongside Auer rods, diagnosis is acuate myeloid leukemia. She also has some infection, equally yet unidentified. But...why is she inwards the emergency room? She would stimulate got to await hours, probably, surrounded alongside sick people from whom she could acquire fifty-fifty to a greater extent than infections, feeling lousy, in addition to and then run across an ER physician who didn't stimulate got the internal medicine board training course, in addition to mightiness potentially fifty-fifty immature adult woman the diagnosis. Certainly she has a principal attention physician in addition to an oncologist somewhere who could coordinate her care. ER attention is trend to a greater extent than expensive than part attention but is becoming class of a measure for dealing alongside unplanned medical needs.

3. Influenza A virus subtype H5N1 healthy 59 yr onetime adult woman without guide chances factors for a deep venous thrombosis (blood clot inwards the leg) presents the the ER alongside a swollen leg, but non terribly swollen in addition to inwards a blueprint that is to a greater extent than suggestive of an injury than a clot. Clearly the big worry is whether she has a blood clot. She could stimulate got whatever of a publish of expensive imaging procedures, they suggest, or a relatively elementary blood seek called the D dimer which, if negative, effectively removes worry that she has a clot inwards the leg. But...D dimers are oft fake positive for diverse reasons, in addition to doing a elementary bedside ultrasound, which the ER physician could produce if the ultrasound tech wasn't correct there, in addition to could genuinely produce it for complimentary since it takes 10 minutes or less, could acquire her reassured in addition to out of at that topographic point inwards adjacent to no time. Most ER doctors don't know how to produce this, but it would stimulate got them most an threescore minutes to learn. It wasn't 1 of the multiple alternative options.

4. Influenza A virus subtype H5N1 48 yr onetime human presents alongside a swollen leg afterwards a long trip somewhere. His ultrasound did demo a blood clot, requiring anticoagulation. How long does he ask to remain on expensive, injectible anticoagulation earlier he tin transition to pills for 3-6 months? v days, of course. That's the trend it has been forever, withal is, related to how speedily the pills (warfarin is standard) stimulate got to genuinely move to preclude farther clotting. But...in the concluding half dozen months at that topographic point stimulate got been ii articles demonstrating that rivaroxaban (Xarelto), a novel oral anticoagulant which industrial plant inside minutes or hours rather than days, tin effectively supplant the injectible anticoagulant in addition to the warfarin, which would hateful that whatever but the most disabled or unstable patient could acquire a prescription in addition to move home. Probably fifty-fifty move dorsum to work, depending on what move was. This drug is expensive, but absolutely aught compared to a 24-hour interval inwards the hospital. Plus rivaroxaban requires no blood seek monitoring. How long volition it stimulate got us to change? It volition likely live pretty quick since the novel drug has powerful Janssen pharmaceuticals equally its champion. Maybe a year. Maybe longer.
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