ABFM KSA - Care Of Hospitalized Patients Exam
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A 65-year-old male is admitted to the hospital after presenting to the emergency
department 30 minutes after a single episode of hematemesis. He continues to
have nausea and mild epigastric pain but has had no further emesis. He has no
previous history of gastrointestinal bleeding or peptic ulcer disease, and has had
no recent melena. His only significant chronic medical problem is osteoarthritis
treated with ibuprofen, 600 mg orally three times daily. He has no history of
significant alcohol use or known liver disease.The patient’s vital signs are stable
and include a heart rate of 90 beats/min, a blood pressure of 120/65 mm Hg,
and an oxygen saturation of 97% on room air. Initial laboratory testing reveals a
hemoglobin level of 10.5 g/dL (N 11.0–16.0), a BUN of 30.0 mg/dL (N 10.0–20.0),
and a serum creatinine level of 1.2 mg/dL (N 0.8–1.2). His AST and ALT levels are
normal, and his INR is 1.1.Initial management of this patient should include
which one of the following?
Antibiotics active against Helicobacter pylori infection
Octreotide (Sandostatin) intravenously
An H2 blocker intravenously and fluid resuscitation
A high-dose proton pump inhibitor intravenously as a bolus, followed by a
continuous infusion
Transfusion of 2 units of packed RBCs
,D
Upper gastrointestinal (UGI) bleeding is a common indication for hospitalization,
accounting for over 300,000 admissions annually in the United States. The
mortality rate for UGI bleeding is approximately 7%–10%, and is significantly
higher in patients who develop UGI while hospitalized for an unrelated illness.
More than 50% of cases result from peptic ulcer disease, with Helicobacter
pylori infection and NSAID use being the major contributing factors.Initial
treatment of a patient with acute UGI bleeding involves adequate fluid
resuscitation to maintain intravascular volume and organ perfusion (SOR A),
initiation of aggressive proton pump inhibitor therapy to promote clot
stabilization, and hemostasis and urgent endoscopic evaluation. Urgent
endoscopy not only allows for further evaluation and risk stratification but also
provides an opportunity for endoscopic therapy (injection with epinephrine,
electrocautery, and/or placement of hemoclips), which can achieve initial
hemostasis and has been shown to reduce rates of rebleeding, surgery, and
mortality in patients with high-risk ulcers (SOR B).Aggressive acid suppression has
been shown to promote clot stabilization by increasing gastric pH to a level that
allows for increased platelet aggregation and inhibition of clot lysis. Intravenous
high-dose PPI therapy for 3 days followed by twice-daily dosing for 14 days and
then daily dosing is indicated for patients with significant stigmata of hemorrhage,
confirmed on initial endoscopy. Use of intravenous PPIs before endoscopy has
been shown to reduce complications. H2 blocker therapy is not
recommended.Although transfusion may be necessary in some patients
presenting with UGI hemorrhage, a Cochrane review could find no evidence to
support routine use of transfusion and actually found evidence of increases in
mortality and the risk of rebleeding in patients managed with transfusion (SOR B).
However, transfusion may be appropriate in the initial management of patients
with a hemoglobin level <7 g/dL or evidence of continued aggressive bleeding and
hemodynamic instability when fluid resuscitation alone is inadequate.Octreotide
is indicated in the management of suspected variceal bleeding in patients with a
history of alcohol abuse or chronic liver disease, but it has no role in the
management of UGI from a peptic ulcer.Although they are indicated for
,eradication of biopsy-proven H. pylori infection associated with peptic ulcer
disease, antibiotics are not part of the initial treatment of UGI bleeding (SOR B).
Which one of the following has the best evidence for preventing pressure ulcers
in high-risk hospitalized patients?
Using an advanced static overlay on the mattress
Turning the patient every 4 hours
Keeping the head of the bed at a minimum of 30°
Minimizing the use of creams on pressure areas
Using alternating-air mattresses
A
Using an advanced static overlay on the mattress, such as sheepskin, has been
shown to be effective for preventing pressure ulcers in at-risk patients. Turning
patients has mixed results for prevention but appears to be beneficial if combined
with other interventions. The maximum elevation of the head of the bed should
be 30° to prevent shearing. Lubricating oils and creams have also shown benefit
and should be used to decrease friction. Use of an alternating-air mattress is not
recommended, as evidence does not show a clear benefit for pressure ulcer
prevention and alternating-air beds are associated with significantly higher costs.
A 67-year-old male is hospitalized with altered mental status, jaundice, cirrhosis,
and ascites related to alcoholic liver disease. He develops a fever to 38.6°C
(101.5°F). His abdomen is distended, with minimal tenderness but no rebound.
The remainder of the physical examination is normal.You perform ultrasound-
guided paracentesis. Which one of the following would provide the best
evidence for a diagnosis of spontaneous bacterial peritonitis?
A peritoneal neutrophil count >250/mL
An elevated amylase level in peritoneal fluid
A low serum-ascites albumin gradient
Positive leukocyte esterase on urine testing strips
A
, Spontaneous bacterial peritonitis is the most frequent bacterial infection in
patients with cirrhosis, followed by urinary tract infection, pneumonia, skin and
soft-tissue infections, and spontaneous bacteremia. A neutrophil count >250/mL
in ascitic fluid from paracentesis indicates a high risk for spontaneous bacterial
peritonitis (SBP) and is an indication for immediate empiric antibiotic therapy. SBP
is associated with a high mortality rate in patients with cirrhosis and ascites (SOR
A), and bacterial infections account for 25%-46% of hospitalizations due to acute
decompensation events in patients with cirrhosis. Bacterial cultures to identify the
etiology of SBP may be helpful in guiding antibiotic choices (SOR C) but cultures
are negative in a significant percentage of patients with SBP. Culture results may
take 48-72 hours, and waiting on results would delay treatment in high-risk
patients.The serum-ascites albumin gradient (SAAG) helps determine whether
peritoneal fluid is a transudate or an exudate. Theoretically, it might be expected
that those with SBP would have higher protein levels and thus a lower SAAG but
this finding is not reliable. An elevated amylase level would be more indicative of
pancreatitis.A large multi-center study has shown that urine test strips are not a
reliable way to rule out infection in SBP.
A 66-year-old male is admitted to the hospital with a cough, fever, and chills. He
was hospitalized 6 months ago for sepsis due to an Escherichia coli urinary tract
infection. Laboratory testing also reveals a serum creatinine level of 2.7 mg/dL
(N 0.6–1.5), which has increased from 2.2 mg/dL at the time of his previous
hospitalization. His hemoglobin level has decreased from 10.8 g/dL to 9.2 g/dL
(N 13.0–18.0). His serum protein level is 9.4 g/dL (N 6.0–8.0) with a reversed
albumin/globulin ratio. Serum protein electrophoresis shows evidence of a
monoclonal protein spike. A blood culture is positive for Streptococcus
pneumoniae.Which one of the following would be most appropriate at this
point?
Immunofixation of serum and urine
A peripheral blood smear
Whole-body MRI
LATEST 2025 UPDATE WITH COMPLETE QUESTIONS
AND CORRECTLY WELL DEFINED ANSWERS
100%GUARANTEED PASS!!!
A 65-year-old male is admitted to the hospital after presenting to the emergency
department 30 minutes after a single episode of hematemesis. He continues to
have nausea and mild epigastric pain but has had no further emesis. He has no
previous history of gastrointestinal bleeding or peptic ulcer disease, and has had
no recent melena. His only significant chronic medical problem is osteoarthritis
treated with ibuprofen, 600 mg orally three times daily. He has no history of
significant alcohol use or known liver disease.The patient’s vital signs are stable
and include a heart rate of 90 beats/min, a blood pressure of 120/65 mm Hg,
and an oxygen saturation of 97% on room air. Initial laboratory testing reveals a
hemoglobin level of 10.5 g/dL (N 11.0–16.0), a BUN of 30.0 mg/dL (N 10.0–20.0),
and a serum creatinine level of 1.2 mg/dL (N 0.8–1.2). His AST and ALT levels are
normal, and his INR is 1.1.Initial management of this patient should include
which one of the following?
Antibiotics active against Helicobacter pylori infection
Octreotide (Sandostatin) intravenously
An H2 blocker intravenously and fluid resuscitation
A high-dose proton pump inhibitor intravenously as a bolus, followed by a
continuous infusion
Transfusion of 2 units of packed RBCs
,D
Upper gastrointestinal (UGI) bleeding is a common indication for hospitalization,
accounting for over 300,000 admissions annually in the United States. The
mortality rate for UGI bleeding is approximately 7%–10%, and is significantly
higher in patients who develop UGI while hospitalized for an unrelated illness.
More than 50% of cases result from peptic ulcer disease, with Helicobacter
pylori infection and NSAID use being the major contributing factors.Initial
treatment of a patient with acute UGI bleeding involves adequate fluid
resuscitation to maintain intravascular volume and organ perfusion (SOR A),
initiation of aggressive proton pump inhibitor therapy to promote clot
stabilization, and hemostasis and urgent endoscopic evaluation. Urgent
endoscopy not only allows for further evaluation and risk stratification but also
provides an opportunity for endoscopic therapy (injection with epinephrine,
electrocautery, and/or placement of hemoclips), which can achieve initial
hemostasis and has been shown to reduce rates of rebleeding, surgery, and
mortality in patients with high-risk ulcers (SOR B).Aggressive acid suppression has
been shown to promote clot stabilization by increasing gastric pH to a level that
allows for increased platelet aggregation and inhibition of clot lysis. Intravenous
high-dose PPI therapy for 3 days followed by twice-daily dosing for 14 days and
then daily dosing is indicated for patients with significant stigmata of hemorrhage,
confirmed on initial endoscopy. Use of intravenous PPIs before endoscopy has
been shown to reduce complications. H2 blocker therapy is not
recommended.Although transfusion may be necessary in some patients
presenting with UGI hemorrhage, a Cochrane review could find no evidence to
support routine use of transfusion and actually found evidence of increases in
mortality and the risk of rebleeding in patients managed with transfusion (SOR B).
However, transfusion may be appropriate in the initial management of patients
with a hemoglobin level <7 g/dL or evidence of continued aggressive bleeding and
hemodynamic instability when fluid resuscitation alone is inadequate.Octreotide
is indicated in the management of suspected variceal bleeding in patients with a
history of alcohol abuse or chronic liver disease, but it has no role in the
management of UGI from a peptic ulcer.Although they are indicated for
,eradication of biopsy-proven H. pylori infection associated with peptic ulcer
disease, antibiotics are not part of the initial treatment of UGI bleeding (SOR B).
Which one of the following has the best evidence for preventing pressure ulcers
in high-risk hospitalized patients?
Using an advanced static overlay on the mattress
Turning the patient every 4 hours
Keeping the head of the bed at a minimum of 30°
Minimizing the use of creams on pressure areas
Using alternating-air mattresses
A
Using an advanced static overlay on the mattress, such as sheepskin, has been
shown to be effective for preventing pressure ulcers in at-risk patients. Turning
patients has mixed results for prevention but appears to be beneficial if combined
with other interventions. The maximum elevation of the head of the bed should
be 30° to prevent shearing. Lubricating oils and creams have also shown benefit
and should be used to decrease friction. Use of an alternating-air mattress is not
recommended, as evidence does not show a clear benefit for pressure ulcer
prevention and alternating-air beds are associated with significantly higher costs.
A 67-year-old male is hospitalized with altered mental status, jaundice, cirrhosis,
and ascites related to alcoholic liver disease. He develops a fever to 38.6°C
(101.5°F). His abdomen is distended, with minimal tenderness but no rebound.
The remainder of the physical examination is normal.You perform ultrasound-
guided paracentesis. Which one of the following would provide the best
evidence for a diagnosis of spontaneous bacterial peritonitis?
A peritoneal neutrophil count >250/mL
An elevated amylase level in peritoneal fluid
A low serum-ascites albumin gradient
Positive leukocyte esterase on urine testing strips
A
, Spontaneous bacterial peritonitis is the most frequent bacterial infection in
patients with cirrhosis, followed by urinary tract infection, pneumonia, skin and
soft-tissue infections, and spontaneous bacteremia. A neutrophil count >250/mL
in ascitic fluid from paracentesis indicates a high risk for spontaneous bacterial
peritonitis (SBP) and is an indication for immediate empiric antibiotic therapy. SBP
is associated with a high mortality rate in patients with cirrhosis and ascites (SOR
A), and bacterial infections account for 25%-46% of hospitalizations due to acute
decompensation events in patients with cirrhosis. Bacterial cultures to identify the
etiology of SBP may be helpful in guiding antibiotic choices (SOR C) but cultures
are negative in a significant percentage of patients with SBP. Culture results may
take 48-72 hours, and waiting on results would delay treatment in high-risk
patients.The serum-ascites albumin gradient (SAAG) helps determine whether
peritoneal fluid is a transudate or an exudate. Theoretically, it might be expected
that those with SBP would have higher protein levels and thus a lower SAAG but
this finding is not reliable. An elevated amylase level would be more indicative of
pancreatitis.A large multi-center study has shown that urine test strips are not a
reliable way to rule out infection in SBP.
A 66-year-old male is admitted to the hospital with a cough, fever, and chills. He
was hospitalized 6 months ago for sepsis due to an Escherichia coli urinary tract
infection. Laboratory testing also reveals a serum creatinine level of 2.7 mg/dL
(N 0.6–1.5), which has increased from 2.2 mg/dL at the time of his previous
hospitalization. His hemoglobin level has decreased from 10.8 g/dL to 9.2 g/dL
(N 13.0–18.0). His serum protein level is 9.4 g/dL (N 6.0–8.0) with a reversed
albumin/globulin ratio. Serum protein electrophoresis shows evidence of a
monoclonal protein spike. A blood culture is positive for Streptococcus
pneumoniae.Which one of the following would be most appropriate at this
point?
Immunofixation of serum and urine
A peripheral blood smear
Whole-body MRI
