NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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May 6, 2025
MKSAP 19 General Internal Medicine 1, Question 98
A 45-year-old man is evaluated after admission to the hospital for pneumonia. He has a history of T4 paraplegia from a motor vehicle accident 20 years ago. He performs intermittent bladder catheterization for urinary retention. He has no other medical conditions and takes no medications.
On physical examination, temperature is 37.3 °C (99.2 °F), blood pressure is 108/70 mm Hg, pulse rate is 99/min, and respiration rate is 20/min. Oxygen saturation is 92% on 2 L of oxygen by nasal cannula. BMI is 33. The patient is supine in a hospital bed. He has crackles and reduced breath sounds in the right lower lobe. The skin over the back, buttocks, and lower extremities shows no evidence of pressure injury. He is asensate below T4.
Which of the following is the most appropriate measure to prevent pressure injury in this patient?
A. Alternating air mattress
B. Hourly repositioning
C. Local skin care with emollients
D. Nutritional supplementation
E. Static mattress overlay
Responses Received from Members (658 Responses):
The Correct Answer is: E. Static mattress overlay
Educational Objective:
Prevent a pressure injury.
A static mattress overlay (Option E) is the best measure for prevention of pressure injury in this high- risk patient. The most important risk factors for pressure injury are immobility, malnutrition, sensory loss, and reduced skin perfusion, which can occur with hypovolemia, hypotension, and systemic vasoconstriction. The first step in pressure injury prevention is a comprehensive history and physical examination to assess risk. Regular, structured risk assessment should be performed to identify at- risk patients. Pressure redistribution through pressure-reducing equipment and proper patient positioning is of paramount importance in the prevention of pressure injuries in at-risk patients.
Advanced static mattresses or overlays should be used in patients at increased risk. An advanced static mattress is made of specialized sheepskin, foam, or gel and is immobile when a patient lies on it, whereas an advanced static overlay is a pad composed of foam or gel that is secured to the top of a regular mattress. Harms associated with overlays include increased heat-related discomfort leading to removal of the overlay.
Alternating air mattresses (Option A) for pressure injury prevention are not recommended, primarily based on cost considerations and lack of data demonstrating a clear advantage.
Repositioning every 3 hours compared with usual care has been shown to slightly reduce pressure injury formation, but data from nursing homes assessing repositioning at 2-, 3-, or 4-hour intervals showed no difference in the incidence of pressure injury. Repositioning every hour (Option B) has not been studied and would be burdensome for the patient and nurse colleagues caring for this patient.
Keeping the skin clean and free from maceration due to excess moisture, and possibly the application of emollients (Option C) to chronically dry skin, may be useful adjunctive therapy to pressure redistribution in the prevention of pressure injury. However, skin care alone has not been shown to prevent pressure injury.
Data are insufficient to recommend the routine use of dietary supplements (Option D) for pressure injury prevention. Nutritional supplementation has been studied in inpatients and nursing home residents, and five of six studies showed no difference in pressure injury risk.
Key Point
Prevention of pressure injuries in hospitalized patients requires regular risk assessment and pressure redistribution through proper patient positioning and an advanced static mattress or overlay.
Bibliography
Hajhosseini B, Longaker MT, Gurtner GC. Pressure injury. Ann Surg. 2020;271:671-79. PMID: 31460882 doi:10.1097/SLA.0000000000003567
Copyright 2019, American College of Physicians.
April 22, 2025
MKSAP 19 Gastroenterology & Hepatology, Question 19
A 68-year-old woman is evaluated in the emergency department for sudden-onset, crampy, left- lower-quadrant abdominal pain followed several hours later by passage of bright red blood per rectum. She has hypertension and hyperlipidemia. Current medications are lisinopril and simvastatin.
On physical examination, vital signs are normal. Abdomen is soft and nondistended, with left-lower- quadrant tenderness and no rebound or guarding. Anorectal examination shows scant bright red blood in the rectal vault.
Laboratory testing shows a leukocyte count of 12,000/μL (12 × 109/L) and a blood urea nitrogen level of 24 mg/dL (8.5 mmol/L); other routine laboratory results are normal.
Abdominal and pelvic CT scan shows only segmental thickening of the descending and sigmoid colon.
Which of the following is the most likely diagnosis?
A. Acute diverticulitis
B. Clostridioides difficile infection
C. Colonic ischemia
D. Ulcerative colitis
Responses Received from Members (767 Responses):
The Correct Answer is: C. Colonic ischemia
Educational Objective:
Diagnose colonic ischemia.
The most likely diagnosis is colonic ischemia (Option C). This form of ischemic bowel disease is the most common and usually results from a nonocclusive low-flow state in microvessels. The
term colonic ischemia is preferred to ischemic colitis because some patients do not have a documented inflammatory phase of disease. Risk factors for colonic ischemia include age (>60 years), female sex, vasoconstrictive and antihypertension medications, constipation, and thrombophilia.
Colonic ischemia presents with abrupt onset of lower abdominal discomfort that is mild to moderate and cramping, followed within 24 hours by hematochezia (passage of fresh blood or clots from the colon). Physical examination usually reveals lower abdominal tenderness over the involved colonic segment without peritoneal signs. Leukocyte count and blood urea nitrogen may be mildly elevated. Abdominal CT is indicated to assess the severity, phase, and distribution of colonic ischemia. CT findings are nonspecific, including segmental bowel wall thickening and pericolonic fat stranding, often in the distribution of the “watershed” areas of the colon (splenic flexure and rectosigmoid junction). Colonoscopy is the primary method to diagnose colonic ischemia, usually after CT has shown a thickened segment of colon.
Acute diverticulitis (Option A) often presents with colicky lower abdominal pain and left-lower- quadrant abdominal tenderness on physical examination. However, acute diverticulitis does not present with rectal bleeding, making this diagnosis unlikely. In addition, CT scans in acute diverticulitis typically show pericolonic fat stranding of the sigmoid colon with associated diverticulosis, which is not seen on this patient's CT scan.
Clostridioides difficile infection (Option B) can mimic the presentation of colonic ischemia and must be excluded by stool tests. However, bloody diarrhea is uncommon in C. difficile colitis, and the infection often involves the colon in a diffuse fashion rather than the segmental pattern seen on this patient's CT scan.
Ulcerative colitis (Option D) can present with abdominal pain and bloody stools. However, it usually involves the rectum and extends proximally in a continuous and symmetric pattern. This patient's CT scan, showing segmental thickening of the descending and sigmoid colon with sparing of the rectum, makes ulcerative colitis unlikely, as do the abrupt symptom onset and older patient age.
Key Point
Colonic ischemia is the most common form of ischemic bowel disease and usually results from a nonocclusive low-flow state in microvessels.
Colonic ischemia presents with abrupt-onset lower abdominal discomfort and cramping, followed within 24 hours by hematochezia.
Bibliography
Brandt LJ, Feuerstadt P, Longstreth GF, et al; American College of Gastroenterology. ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia (CI). Am J Gastroenterol. 2015;110:18-44; quiz 45. PMID:
25559486 doi:10.1038/ajg.2014.395
Copyright 2019, American College of Physicians.