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To this end, and con online to earn CME credits in 24 hours or less. Take any of the on, patients. Contributors are required to use generic names following approaches: in the discussion of therapeutic options and are required to identify an ' unapproved, off-label, or investigative use of 1.
Use the printed answer sheet at the back of this book to commercial products or devices. Where a trade name is record your answers. Go to mksap. If trade-name products manufactured by answers, and submit your test for same-day CME credits.
There is no additional fee for this service. The information is answer sheet, directly enter your answers, and submit reviewed by the committee responsible for producing this VI text. Further, all readers of this text are asked to evaluate program. Copyright American College of Physicians. All rights reserved. Resolution of Conflicts This publication is protected by copyright.
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Improved health outcomes have been shown even be measured. Emphasis is placed on behaviors such as substance abuse and risky sexual behavior. Many domestic violence victims are Several important quality improvement models have helped by the acknowledgment that violence is unacceptable. These changes are tested and providers have given validation. In the report To Err is Human: The key to quality improve ment using this model is to establish what is to be accom with health.
Patients with repeated traumas. Domestic violence is associated with high-risk ent in the structure of those systems. The harms to patients from such excessive testing are being increasingly recognized and docu mented. Other systems sometimes utilized are Six Sigma Health care providers' primary responsibilities in car and the Malcolm Baldrige Model for Performance Excellence.
Patient Safety pain. Human error: Model for Improvement. Patient safety been on computerized order entry. Diagnostic errors tend to result from a Measurement of Quality Improvement faulty cognitive approach for example. Inpatient ications or to adjust dosing to account for impaired kidnev or quality indicators assess quality of care inside hospitals as well liver function or other conditions requiring dosing adjust as across geographic areas.
Despite the fact diat A Medication Errors set of quality indicators have been developed to measure Between The focus of efforts to reduce medication errors has medical conditions and surgical procedures. One in five patients discharged from deadis result from misdiagnosis annually in the United States die hospital will suffer an adverse event related to medical The Baldrige model focuses on seven as claims for medication errors.
Forty per delayed. The lack of attention to this organizational performance results. Suggestions to help avoid diagnostic errors are This movement gathered momentum in timely way.
Information gathered at the time of hospitalization within 30 days. Patients should fails to arrive to the primary care physician in a timely fashion receive a list of medications at the time of discharge and be and frequently does not convey important information about informed of previous medications which have been discon diagnosis. When The quality of discharge summaries is which are related to medications.
Medication hand-off. This form can effective hospitalist-to-priniary care physician communica then be compared with medications prescribed throughout tion both during hospitalization and at the time of discharge the hospitalization and at the time of discharge. Based on Trowbridge RL. Settling on a diagnosis early in the diagnostic process despite data that refute the diagnosis or support another premature closure Representativeness heuristic: Application of pattern recognition a patient's presentation fits a "typical" case.
Med Teach. This infor month. Fourteen percent of elderly improved with the use of standardized content Table Timely follow-up with a primary care mary care providers. Twelve tips for teaching avoidance of diagnostic errors. Patient Safety table Diagnosing based upon what is most easily available in the physician's mind e.
Health Information Technology and Patient Safety Professionalism and Health information technology comes in three general forms: Ethics computerized physician order entry CPOE. Follow-up issues CPOE can allow multiple physicians to enter potentially con Pending studies and laboratory tests flicting orders simultaneously.
The Discharge medications and reasons for any changes from admission medications potential for new errors is present in all systems. An EHR interface can prompt Results of procedures and significant testing physicians to order needed medications.
Poorly designed systems can introduce even more errors. This obligation requires that cian. A patient's EHR comprises a collection of clinical data Reason for hospitalization notes. Each goal provides specific nize drug interactions among prescribed medications or to adjust dosing to account for impaired kidney or objectives and metrics. CPOE eliminates medication error related to physician physicians honestly assess their knowledge and skills and Health information technology is not a panacea.
CPOE improves efficiency Dates of admission and discharge by eliminating delays between order entry and order receipt. The EHR should Discharge diagnosis allow multiple users. Each of Professionalism these technologies can be used in an inpatient or outpatient In exchange for the authority to train. Suggested Content of a Standardized handwriting. Health informa dential physicians.
Patient autonomy Patients' decisions about their care must be paramount. European Federation of Internal Medicine. Report and analyze medical errors in order to maintain trust. Manage conflicts of interest Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage.
Providing unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others.
Participate in the processes of self-regulation. It also creates the expecta professionalism with the public's health: Improve quality of care Work collaboratively with other professionals to reduce medical errors. Improve access to care Work to eliminate barriers to access based on education. Professionalism and Ethics pursue learning where gaps exist.
In the routine delivery of patient care. Appropriate patient relations Given the inherent vulnerability and dependency of patients. Equity requires the promotion of public health and preventive medicine. Professional responsibilities Undergo self-assessment and external scrutiny of all aspects of one's performance. The Charter on Cost-Conscious Care initiative strives to promote this com Medical Professionalism comprises three principles and mitment by helping physicians assess die value and the costs ten commitments Table Three commitments link of specific interventions.
Honesty with patients Obtain informed consent for treatment or research. Patient confidentiality Privacy of information is essential to patient trust and even more pressing with electronic medical records. Scientific knowledge Uphold scientific standards.
Just distribution of resources Work with other physicians. Professional Commitment Competence Physicians must be committed to lifelong learning and to maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. Principles and Commitments of Professionalism Principle or Commitment Comment Fundamental Principle Primacy of patient welfare Altruism is a central trust factor in the physician-patient relationship.
A commitment to social justice today's healdi care environment and fundamental to demon requires physicians to guard the health of the public by elim strating professionalism with trainees.
Medical professionalism in the new millennium: Ann Intern Med. Such compromises are especially threatening with for-profit industries. Physicians have an obligation to recognize. Teamwork and collabora sons have access to quality health care.
Market forces. Social justice Physicians should work actively to eliminate discrimination in health care. American Board of Internal Medicine. A given Consent decision does not have to be rational. The greater the complexity of the decision. To obtain informed consent. Advance directives fall into two broad cat a recommendation if there is a preferred course of action.
Advance addition. The core components of decisional capacity are understand The role of the surrogate is to strive to make decisions ing the situation at hand. Although example. A decision that seems inconsistent is a prompt to further explore the patient's beliefs. Instructive directives are subject such as surgery require written informed consent. The clinician must assess harm and little to no benefit to the patient. A living cate a decision. Most jurisdic of complex decisions were considered fully informed.
If it does. A common reflect what most people would do in that situation. In a study of outpatient practices. They may also be be characterized by three domains: For exam patients to read and understand. This is typically standards for informed decision-making. Assessing understanding can be challenging. Complexity' can receive cardiopulmonary resuscitation. Many U.
Informed consent requires that the patient understand the nature of the decision being made or intervention being pro Advance Directives and Surrogate Decision- posed. Patients source of ethical challenges in practice is that while the who are able to understand the consequences may refuse life- authority' for decision-making rests with the patient.
Mksap 15 General Internal Medicine
In egories: If not. By convention. A diagnosis of dementia or a men the public by eliminating unsafe and low-value serv tal illness does not necessarily mean that a patient is incapable ices that generate expenses for care with potential of making health care decisions. Withholding or Withdrawing Treatment Physician-Assisted Suicide and Euthanasia Although a primary goal of care is usually to sustain life. A treatment is futile either when it has a very low Active administration of a drug with die intent to cause death is illegal in all states.
KEY POINTS A scenario in which life-sustaining treatment no longer A terminally ill patient may be given a treatment that offers benefit to the patient who wants it can be more chal may hasten death when the primary intent is to pro lenging.
The emotional implica may hasten the death of" a dying patient is a heavily debated tions may differ whether one withholds care never starts a area of medical ethics. Professionalism and Ethics decisions. All ment. In some circumstances. A common example is high The two most common reasons to withhold or withdraw doses of"opiate analgesics used to relieve pain or dyspnea in a treatment are that the patient or the surrogate has decided patient who is dying. In most cases.
If the care providers' intentions. Most agree by virtue of the principle treatment or withdraws care stops a treatment previously of double effect that it is ethically permissible to give a termi started. If"the physician feels that a specific intervention is unlikely to produce an out C o n fi d e n t i a l i t y come that the patient would find to be meaningfully benefi Implicit in the physician-patient relationship is a commitment cial.
Although physicians have to confidentiality. If the surrogate has no knowledge of what the patient wants them. If the patient has decided that he or she no longer cian aid in dying. Although the American Medical Association and the American College of"Physicians have both taken posi usually straightforward.
The practice of prescribing medications or interventions or that life-sustaining treatment no longer offers benefit to with the primary intent of"hastening a patient's death physi die patient.
Information disclosed by a patient to a no ethical obligation to provide futile treatments. Although one is on solid ethical ground denying vide therapy for another condition. Ethics consultations are helpful in reconcil factors that may shape patients' and their families' attitudes ing conflicts.
Caution is indi tunities for conflicts of interest. Both ethics and law regarding confidentiality can be compli guidelines. Aldiough these relationships are regulated by federal law in the United poses a serious risk of"harm to a specific person. When interviewing adolescents. In the case of"minor children. At the most basic level. Many physicians also benefit indirecdy from cated for adolescents.
If the clinician believes that the patient subcutaneous or oral medication administration. A consider for confidentiality. In die aspects of"the patient's condition that pertain to the deci sion.
Another situation The relationships between physicians and companies in in which confidentiality may be sacrificed for the public wel die health care industry that profit from physician decisions fare is for reportable communicable diseases.
There are. The manufacturers ally determined by local jurisdictions and public health of prescription drugs and medical devices devote considerable departments.
A major dictates that the physician place die interests of the patient ity of U. Patients may specify such as those prevalent in the United States. The National Quality Forum endorsed guide information if the patient poses a serious risk of harm to self or others or has a reportable communicable lines in that included three key components oferror dis disease.
Situations in which there is an established risk of patients harming them peutic services. If" the patient is unable to make an impor able amount of"medical research is funded by companies that tant medical decision. In f'ee-for-service systems ilar requirement for confidentiality. A common area of conflict cated.
Professionalism and Ethics involved in the patient's care and therefore bound by a sim can generate conflicts of" interest. The Institute of the physician should perform at least some of the interview Medicine has published recommendations for controlling without die parents present and explicitly discuss with the conflicts ofinterest Table This is usually best handled with States. If a physician volun a colleague puts patients at risk. In a survey. December Sexual relationships with former patients are also con Increased secrecy Decrease in quality of care.
Do not meet with pharmaceutical and medical device sales representatives except by documented appointment and at the physician's express invitation. Do not make educational presentations or publish scientific articles that are controlled by industry or contain substantial portions written by someone who is not identified as an author or who is not properly acknowledged.
Once the PHP Members of the medical profession have an obligation to pro is notified of a possibly impaired physician. Relationships with patients whom the physician Decrease in productivity or efficiency was treating for a mental health disorder are particularly prob Increased conflicts with colleagues lematic and may result in civil liability or professional discipli Increased irritability and aggression nary action in some jurisdictions.
Volume 5. Palliative care involves a multifaccted PHPs that allow for anonymous reporting of impaired approach that includes clarifying goals of treatment. Introduction Common signs ofphysician impairment at work are shown in The primary focus of palliative care is to relieve patient suffer Table In general. The greater the depth and duration of the previous professional physician-patient relationship. Copyright Adapted with permission from Steinbrook R. The viewpoints expressed in Virtual Mentor are those of the authors and do not necessarily reflect the views and policies of relationship.
Virtual Mentor. Controlling conflict of interest—proposals from the Institute of Medicine. The Impaired Physician and Colleague Responsibility physicians. Massachusetts Medical Society. Accessed at http: Identifying an Impaired Physician. Until institutions change their policies. Many states have mandatory tarily participates in the PHP's treatment and monitoring reporting statutes diat require a physician to report to appro program.
American Medical Association. Beliefs that someone else Palliative Care was taking care of"the problem or that nothing would happen were the most common reasons for failure to report. New Engl J Med. Number Do not accept drug samples except in certain situations for patients who lack financial access to medications.
Despite its widespread availability. Palliative Care symptoms. Nonhospice palliative High care may be offered along with curative or life-prolonging Mostly cancer therapies for patients with complex. Trajectories of late-life illness. The problem with estimating when the last year of" life has Reprinted with permission from Lorenz KA. Lynn J. Palliative care is often thought of as end-of-life care only. Time Emerging data for concurrent palliative care intervention Low in die treatment ofcancer strongly suggest that patients using Short Period of Evident Decline palliative care services have higher scores for quality of life and mood than diose undergoing cancer treatment alone.
The intervention group also experienced less depression and bet ter quality of"life. In patients with cancer. Evidence for improving pal liative care at the end of life: A third group of patients are ing suffering and improving quality of"care. These patients have long. Dy SM. Hospice palliative care is offered when patients reach their final weeks or months of life.
Evidence suggests diat more aggres Low sive care at the end of life—whether prolonged hospitaliza Prolonged Dwindling tion. Much of" die final weeks or months of"disease.
Hospice services can be provided in a patient's home. In a study of" patients with newly diagnosed metastatic High non-small cell lung cancer randomly assigned to standard oncologic therapy alone versus early palliative care with stan dard oncologic therapy. Patients with organ failure resistance to initiating palliative care stems from the traditional often have gradual decline with serious exacerbations fol care dichotomy between "doing everything" versus providing lowed by improvement.
Palliative care consultation programs are also associated Death with significant hospital cost savings. There is a lack of studies providing strong evidence on effective ways to Assessment and Communication treat pain in advanced heart failure or dementia. The Edmonton Symptom Assessment Scale is a brief survey that asks patients to rate several symptoms on a scale pain. These symptoms more intensive care at the end of life than they would if they may occur because of the underlying disease or secondary to were more adequately communicated with regarding advance treatments for symptoms of the disease.
The first step in this communication is to establish goals of The World Health Organization analgesic ladder pro care in a patient-centered. Numerous symptom assess ment instruments have been validated in the medical litera ture. World Health Organization analgesic ladder. Adequate time vides a stepwise approach to the management of pain needs to be allotted to ensure that these discussions provide Figure 4.
Chronic Noncancer Pain. The initial Symptoms. Several meetings may be necessary to allow further process ing of information and preparation of more questions by the patient or family members. Adjuvant pain med ications are used to treat pain symptoms that respond meeting or meetings should emphasize discovery of what the patient knows and understands regarding the diagnosis and poorly to analgesic agents. Symptom Management Symptoms common in patients with cancer and other life- threatening illnesses are myriad.
Palliative Care Recent evidence suggests that minority patients receive add one additional symptom and rate it. Pain management in palliative care. Next steps should be outlined and. Assessment of pain can tation with cancer as well as at subsequent visits. This discussion should allow opportunity to clar ify how much the patient actually wants to know and should respect the diverse ways in which patients and their families process information about life-altering or life-threatening medical conditions.
As issues are addressed and worked through. Opioid The cornerstone of both hospice and nonhospice palliative use in the treatment of noncancer pain continues to be care is communication with patients. Medical jargon should be avoided and medical information conveyed succinctly and empathetically. Meperidine In contrast to fatigue in a healthy person. Palliative Care D metastatic pain.
A ments. It is defined as fewer than three bowel movements per patients who are elderly or have dementia. Fatigue can also be an early harbinger of takes up to 24 hours to take effect. It should be used with tressing symptoms related to cancer and cancer treatment.
Fcntanyl is more expensive but can be administered as a lollipop. Other important side effects of morphine include xerostomia. If establish a baseline.
Constipation is also exacer bated by decreased activity and. Opioids cause constipation by binding to the p receptor in the bowel. Various modalities have extremely rare for patients to become addicted to opioids in been evaluated in reducing cancer-related fatigue. Beliefs about "maximum" dosages do not tulose. Shorter-acting morphine can be used for breakthrough pain but should bc changed to long-acting reducing intestinal secretions.
It is important to obtain weaker opioid analgesic such as oxycodone can be added at a history about a patient's premorbid bowel habits in order to any point along the World Health Organization ladder. This is a poorly understood phenomenon whereby However. Benzo Constipation diazepines should generally be avoided as they may actually Constipation is common in cancer patients.
Some data indicate that opioid rotation can improve In the elderly. Examples of these medications include E anticonvulsants. This obstruction from primary or metastatic disease or treatment- related adhesions. Hydromorphone is a semisynthetic opioid laxatives when oral morphine was switched to a fentanyl trans agonist that is similar to morphine but has a more favorable dermal patch. It is energy conservation and distraction. Other contributing day or beyond 24 hours of"treatment with shorter-acting opi oids.
Three studies have showed reduced reliance on lower range. When using opioids. The usual starting dose of"short-acting morphine is 5 to 15 mg orally in opiate-naive patients and the elderly or 1 report constipation. Treatment of fatigue in cancer and other end-stage ill slightly more complicated.
No fixed conversion ratio is likely to be satisfactory in all patients. Dose should not be adjusted upward based on supplemental opiate need for 3 days after initial placement or 6 days after subsequent dose changes. The fentanyl comparison is a pg-to-mg conversion. Dose adjustment required with kidney failure.
Mksap 16 general internal medicine pdf
Hydrocodone 1: Codeine 1: Extended pg patch q 72 h h 72 h Not recommended for release opioid-naive patients. Hydromorphone 4: Limit to 4 or fewer daily— additional doses mark need for adjustment of basal pain medication. Extended mg q 24 h h 24 h For use in opioid-tolerant release patients only. Variable efficacy due to differences in metabolism to morphine with CYP2D6 enzyme. Palliative Care table Fentanyl 4: Reassurance often needs to be studied.
Benzodiazepines are also used to palliate symptoms. Q life regardless of whether they receive chemotherapy.
Side Overview effects include thromboembolism. Dexamethasone has been increasingly an essential part of" hospice palliative care. If opioid dosage cannot be ment is lacking.
Strong evidence supports the use of 3-agonists.
Common ing regimen has not been established. Two classes of drugs have been shown to improve appetite in patients with cancer but Common Symptoms do not provide a survival advantage.
Dronabinol is a cannabi- noid that is effective in chemotherapy-related nausea and Bereavement and Grief AIDS-related wasting. Oxygen may also be used in treating can delirium is common. Opioid analgesia can be reduced pro cer-related dyspnea.
Its chief symp Anorexia and Nutrition tom is a yearning for a loved one so intense that it inca Loss of" appetite can bc one of the most disturbing symptoms pacitates all other desires. It is should ideally be clarified in advance of the anorexia diat important.
It has a short half-life but can be given intravenously. Progestational agents. Randomized controlled trials have also found consistent morphine.
Additional Nausea sedative agents such as benzodiazepines may bc required Chronic nausea. A trial of 2 to 4 mg to do this are not well demonstrated in the medical liter intravenously can be tried for patients not responding to ature. Many interventions have been for patients and their providers. Feeding tubes are controversial and needs of bereaved survivors given the depth of" despair for probably do not confer a survival advantage to cancer patients which they are at risk.
Corticosteroids have also been found to gories. Up the end of" life. It may cause somnolence. Although opioids are fiequendy used therapv'. Behavioral barriers include low motivation.
Chronic Noncancer Pain Tests for certain conditions may be considered. Common Symptoms internist. Chronic noncancer pain types: Palliative Care. Before betic neuropathy. Cancer pain is discussed in treatment plan. Up to one third of symptoms pre naire. A history of" physical.
Social barriers include time constraints. Pain may nerve conduction studies may be helpful in select patients if" be considered chronic if it persists for longer than the the diagnosis or etiology of neuropathy is uncertain. Examples of these hidden diagnoses may significantly affect treatment options. Most symptoms improve within 2 weeks. Screening for depression Some patients may feel uncomfortable discussing sensitive or and anxiety.
Examples of" tal and nervous systems. Asking patients if they have other con cerns during the visit can often uncover these issues. This associated with many conditions encountered in primary classification is helpful for choosing mechanism-specific treat care. Patients involved in litigation may display pain location. CNCP exacts a sig initiating treatment. Assessment and passivity.
There is a for diagnosing absent or abnormal sensory states. Systems barriers include formulary and coverage restrictions and difficulty accessing behavioral health care. The patient's symptoms and goals for treatment need to appointment for follow-up of chronic medical conditions. Physicians should first obtain information about of a patient's pain. Patients may present with symptoms as the primary level. Testing of sensation is essential which patients with ankle injuries require imaging.
Common Symptoms ta b l e Adverse events. A graded exer CBT techniques include biofeedback. Activities of daily living. The Diagnosis. Action plan. TCAs erythematous.
Follow-up The 6 A's are a useful framework for follow-up visits: Back pain.
A be particularly beneficial for patients with low back pain. Mental health disorders depression. Aberrant behavior. All patients should be tation. Included are: general internists and primary care physicians; subspecialists who need to remain up-to-date in internal medicine; residents preparing for the Certification Exam in internal medicine; physicians preparing for the Maintenance of Certification Exam in internal medicine.
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It also marks its evolution into an innovative learning system to better meet the changing educational needs and learning styles of all internists. All of these topics are uniquely focused on the needs of generalists and subspecialists outside of endocrinology and metabolism. Places its emphasis on concepts, not formulas, for more clinical-based guidance. Next Mksap 17 Nephrology Provides examples, analogies, and memorization tips to make the material easier to absorb.
Uses an easy-to-understand presentation and writing style to make the material easily accessible. The book contains more than multiple-choice questions that follow the exam format. Preface In these pages, you will find updated information on the clinical evaluation of kidney function, fluids and electrolytes, acidbase disorders, hypertension, chronic tubulointerstitial diseases, glomerular diseases, kidney manifestations of gammopathies, genetic disorders and kidney disease, acute kidney injury, kidney stones, the kidney in pregnancy, and chronic kidney disease.
Next MKSAP 16 Sample Using this source, physicians will access a virtual blueprint for exam preparation and acquire clear guidance on question format, types of questions, and hints on topics commonly encountered on the test.Brief interventions usually involve one been experienced when trying to exercise in die past. Value in health care is defined by the outcomes achieved Frail elderly persons with limited life expectancies radier than by the volumes of procedures performed or services should have different outcome measures than younger rendered.
Patients should be may identify patients who would benefit from genetic testing. Vaccination also reduces transmission and spread of a cern about risk to a future pregnancy because of family his disease in the population at large. Common Symptoms classes that may modify die intensity of symptoms.
Provider barriers include limited clinic time. Assessment of pain can tation with cancer as well as at subsequent visits.
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