Latest ABFM KSA - Care Of Hospitalized Patients
Actual Questions And Verified Answers Grade A+.
CT would usually be indicated as the initial imaging study for which one of the
following patients?
An 8-year-old with a 2-day history of nausea, anorexia, and periumbilical pain that
has migrated to the right lower quadrant with localized tenderness, guarding, and
leukocytosis with a left shift
A 43-year-old with a 1-day history of epigastric pain and nausea with vomiting, and
elevated serum lipase
A 66-year-old with diffuse abdominal pain, leukocytosis, and fever
A 55-year-old with unrelenting severe low back pain associated with right leg pain
and weakness
A 68-year-old with crushing, retrosternal chest pain, an EKG showing sinus
tachycardia with left bundle branch block, and a cardiac troponin I level of 14 ng/mL
(N <0.04)
C
The use of CT has increased significantly in recent years due to increased
availability, better resolution, and faster scan times. However, there are rising
concerns about cumulative radiation exposure and an increasing need to contain costs
in medicine. To assist clinicians in making wise use of all imaging techniques, the
American College of Radiology (ACR) has developed appropriateness criteria that
recommend modalities for various clinical problems.Patients with undifferentiated
abdominal pain often present a diagnostic challenge because of the wide range of
pathology or organ involvement that can produce this symptom. Fever associated
with abdominal pain increases the likelihood of intra-abdominal infection, abscess, or
other conditions that may require an urgent definitive diagnosis or intervention. In
one retrospective study, CT results changed the leading diagnosis in 51% of patients
and the decision to admit patients presenting to the emergency department with
abdominal pain in 25% of patients.In contrast, no imaging may be indicated when the
diagnosis is straightforward based on other clinical indicators. Ultrasonography
should be the first imaging study in a pediatric patient with a classic history and
physical and laboratory findings of appendicitis. Similarly, while CT is unlikely to
provide useful additional information in a patient with unequivocal, uncomplicated
acute pancreatitis, ultrasonography is a reasonable first imaging study to evaluate for
gallstones. Patients with suspected acute coronary syndrome should be taken for
coronary angiography without delay. A patient with severe back pain and leg
weakness should be evaluated with MRI.
,A 75-year-old male is hospitalized with new-onset atrial fibrillation and a rapid
ventricular rate. His current medical problems include COPD, hypertension, coronary
artery disease, and depression. A metabolic panel including a magnesium level is
normal on admission.After a diltiazem continuous intravenous infusion his pulse rate
is 85 beats/min and irregular. The following morning he converts to normal sinus
rhythm.Which one of the following would be appropriate at this point?
Administer a loading dose of warfarin, 10 mg orally
Start apixaban (Eliquis), 5 mg twice daily
Stop the diltiazem infusion and administer metoprolol intravenously
Stop the diltiazem infusion and administer digoxin, 0.25 mg intravenously
B
It is generally not recommended to give a loading dose of warfarin, as the benefit is
minimal, especially if treating atrial fibrillation. There is no benefit to administering
digoxin or metoprolol intravenously once the patient has converted to sinus rhythm.
Apixaban and other direct oral anticoagulants are recommended for stroke
prophylaxis and should be initiated as soon as possible. This could have been started
at the time of admission for this patient because there is no reason to wait until
normal sinus rhythm is achieved. The dosage should be lowered to 2.5 mg twice daily
for patients with two of the following: age ≥80, body weight ≤60 kg (130 lb), or
serum creatinine ≥1.5 mg/dL.
You admit a 74-year-old patient to the hospital with shortness of breath and bilateral
pleural effusions seen on a chest radiograph. Which one of the following is true
regarding pleural effusions?
Noncontrast CT should be performed initially in all patients with pleural effusions if
the cause is unknown
Ultrasound-guided thoracentesis should be performed on admission in all patients
with small bilateral pleural effusions
In patients with heart failure who are treated with diuretics, pleural effusions may be
misclassified as exudative rather than transudative
Negative cytology on an adequate sample of pleural fluid (≥10 mL) effectively rules
out malignancy as the cause of a unilateral pleural effusion
C
,CT can detect effusions not apparent on plain radiographs, distinguish between
pleural fluid and pleural thickening, and provide clues to the underlying cause.
Contrast CT is recommended to provide additional information that can be used in
making the diagnosis. Thoracentesis should not be performed in patients with
bilateral effusions if the clinical findings strongly suggest a pleural transudate, unless
there are atypical features (fever, pleuritic chest pain, or widely asymmetric effusion
size) or the effusion fails to respond to therapy (SOR C). Thoracentesis should be
performed with ultrasound guidance, when possible, to improve the likelihood of
successful aspiration and decrease the risk of organ puncture, especially when
effusions are small. About 20% of patients with a pleural effusion caused by heart
failure may fulfill the criteria for an exudative effusion after receiving diuretics. In
these cases, if the difference between the protein levels in the serum and the pleural
fluid is >3.1 g/dL, the patient should be classified as having a transudative effusion
(SOR C).Cytology is positive in approximately 60% of malignant pleural effusions
(SOR B). The diagnostic yield may be improved by additional pleural taps. If
malignancy is still a concern, thoracoscopy should be considered (SOR C).
A 44-year-old female presents to the emergency department with 2-3 days of
epigastric abdominal pain, vomiting, low-grade fever, and anorexia. She has not had
any change in bowel habits, and no cough, chest pain, or shortness of breath. Her past
medical history includes moderate persistent asthma, diet-controlled type 2 diabetes,
and hypertension.You see the patient on the medical floor for admission. On
examination the patient is uncomfortable and looks ill. She has a temperature of
37.8°C (100.0°F), a heart rate of 120 beats/min, a respiratory rate of 18/min, a blood
pressure of 120/70 mm Hg, and an oxygen saturation of 98% on room air. A
cardiopulmonary examination is significant only for tachycardia. On abdominal
examination she has decreased bowel sounds, epigastric tenderness to palpation, a
negative Murphy's sign, and no rebound or involuntary guarding.Laboratory
FindingsWBCs............14,200/mm3 (N 4300-10,800)Hemoglobin............15.0 g/dL (N
12.0-16.0)Platelets............450,000/mm3 (N 130,000-400,000)Sodium............128
mEq/L (N 136-145)Potassium............3.6 mEq/L (N 3.5-5.1)Chloride............108 mEq/L
(N 98-107)Carbon dioxide............22 mmol/L (N 22-28)BUN............30 mg/dL (N 6-
20)Creatinine............1.5 mg/dL (N 0.6-1.1)AST............65 U/L (N 10-59)ALT............94
U/L (N 10-28)Alkaline phosphatase............213 U/L (N 38-126)Glucose............140
mg/dLCalcium............8.6 mg/dL (N 8.6-10.0)Albumin............3.2 g/dL (N 3.5-5.2)Total
bilirubin............3.2 mg/dL (N 0.2-1.2)Triglycerides............300 mg/dLAlcohol
level............0Lipase............800 U/L (N 23-300)Abdominal ultrasonography shows
gallstones within the gallbladder and a dilated common bile duct with a likely
impacted stone within the duct. There is no pericholecystic fluid to suggest
cholecystitis. You treat her appropriately with intravenous fluids and pain
management.Which one of the following would be most appropriate for this patient?
, Planned cholecystectomy within 4-6 weeks
Endoscopic retrograde cholangiopancreatography (ERCP) only
Cholecystectomy before discharge
ERCP followed by cholecystectomy within 12 hours of admission
Surgical consultation for immediate cholecystectomy
C
In patients with gallstone pancreatitis, cholecystectomy should be performed prior to
discharge unless the patient has contraindications to surgery or has severe acute
pancreatitis with necrosis. This results in shorter hospital stays with no increased
risk of complications, and prevents the readmission and risk of recurrence associated
with delaying surgery until after discharge. Cholecystectomy within 12 hours of
admission is not necessary, especially if endoscopic retrograde
cholangiopancreatography (ERCP) will be performed prior to surgery.
A 78-year-old male lives alone with no known relatives or friends. A social worker
performing a routine welfare check finds him down on the floor and he is hospitalized
for several days with Wernicke-Korsakoff syndrome. He is medically optimized, and
discharge planning is now being discussed. His cognitive assessment scores are
abnormal. There is no advance care plan document or health care power of attorney.
The patient states that he wants to return home, but you have significant concerns
about that decision and do not feel it would be safe. When you discuss your concerns
with the patient and ask about his plans for obtaining and preparing food and other
instrumental activities of daily living, he simply asserts that he'll be "fine." He is not
able to provide any further explanation of his thoughts, and he becomes upset and
refuses to answer further questions.Reasonable strategies for managing this situation
include which one of the following?
Transfer the patient to a skilled nursing facility and perform a capacity and
competency determination at a later time
Consult the ethics committee at your institution to determine his decision-making
capacity
Assign durable power of attorney for health care to one of the medical social workers
who is familiar with his case
Work with the court system to establish guardianship for the patient
D
Actual Questions And Verified Answers Grade A+.
CT would usually be indicated as the initial imaging study for which one of the
following patients?
An 8-year-old with a 2-day history of nausea, anorexia, and periumbilical pain that
has migrated to the right lower quadrant with localized tenderness, guarding, and
leukocytosis with a left shift
A 43-year-old with a 1-day history of epigastric pain and nausea with vomiting, and
elevated serum lipase
A 66-year-old with diffuse abdominal pain, leukocytosis, and fever
A 55-year-old with unrelenting severe low back pain associated with right leg pain
and weakness
A 68-year-old with crushing, retrosternal chest pain, an EKG showing sinus
tachycardia with left bundle branch block, and a cardiac troponin I level of 14 ng/mL
(N <0.04)
C
The use of CT has increased significantly in recent years due to increased
availability, better resolution, and faster scan times. However, there are rising
concerns about cumulative radiation exposure and an increasing need to contain costs
in medicine. To assist clinicians in making wise use of all imaging techniques, the
American College of Radiology (ACR) has developed appropriateness criteria that
recommend modalities for various clinical problems.Patients with undifferentiated
abdominal pain often present a diagnostic challenge because of the wide range of
pathology or organ involvement that can produce this symptom. Fever associated
with abdominal pain increases the likelihood of intra-abdominal infection, abscess, or
other conditions that may require an urgent definitive diagnosis or intervention. In
one retrospective study, CT results changed the leading diagnosis in 51% of patients
and the decision to admit patients presenting to the emergency department with
abdominal pain in 25% of patients.In contrast, no imaging may be indicated when the
diagnosis is straightforward based on other clinical indicators. Ultrasonography
should be the first imaging study in a pediatric patient with a classic history and
physical and laboratory findings of appendicitis. Similarly, while CT is unlikely to
provide useful additional information in a patient with unequivocal, uncomplicated
acute pancreatitis, ultrasonography is a reasonable first imaging study to evaluate for
gallstones. Patients with suspected acute coronary syndrome should be taken for
coronary angiography without delay. A patient with severe back pain and leg
weakness should be evaluated with MRI.
,A 75-year-old male is hospitalized with new-onset atrial fibrillation and a rapid
ventricular rate. His current medical problems include COPD, hypertension, coronary
artery disease, and depression. A metabolic panel including a magnesium level is
normal on admission.After a diltiazem continuous intravenous infusion his pulse rate
is 85 beats/min and irregular. The following morning he converts to normal sinus
rhythm.Which one of the following would be appropriate at this point?
Administer a loading dose of warfarin, 10 mg orally
Start apixaban (Eliquis), 5 mg twice daily
Stop the diltiazem infusion and administer metoprolol intravenously
Stop the diltiazem infusion and administer digoxin, 0.25 mg intravenously
B
It is generally not recommended to give a loading dose of warfarin, as the benefit is
minimal, especially if treating atrial fibrillation. There is no benefit to administering
digoxin or metoprolol intravenously once the patient has converted to sinus rhythm.
Apixaban and other direct oral anticoagulants are recommended for stroke
prophylaxis and should be initiated as soon as possible. This could have been started
at the time of admission for this patient because there is no reason to wait until
normal sinus rhythm is achieved. The dosage should be lowered to 2.5 mg twice daily
for patients with two of the following: age ≥80, body weight ≤60 kg (130 lb), or
serum creatinine ≥1.5 mg/dL.
You admit a 74-year-old patient to the hospital with shortness of breath and bilateral
pleural effusions seen on a chest radiograph. Which one of the following is true
regarding pleural effusions?
Noncontrast CT should be performed initially in all patients with pleural effusions if
the cause is unknown
Ultrasound-guided thoracentesis should be performed on admission in all patients
with small bilateral pleural effusions
In patients with heart failure who are treated with diuretics, pleural effusions may be
misclassified as exudative rather than transudative
Negative cytology on an adequate sample of pleural fluid (≥10 mL) effectively rules
out malignancy as the cause of a unilateral pleural effusion
C
,CT can detect effusions not apparent on plain radiographs, distinguish between
pleural fluid and pleural thickening, and provide clues to the underlying cause.
Contrast CT is recommended to provide additional information that can be used in
making the diagnosis. Thoracentesis should not be performed in patients with
bilateral effusions if the clinical findings strongly suggest a pleural transudate, unless
there are atypical features (fever, pleuritic chest pain, or widely asymmetric effusion
size) or the effusion fails to respond to therapy (SOR C). Thoracentesis should be
performed with ultrasound guidance, when possible, to improve the likelihood of
successful aspiration and decrease the risk of organ puncture, especially when
effusions are small. About 20% of patients with a pleural effusion caused by heart
failure may fulfill the criteria for an exudative effusion after receiving diuretics. In
these cases, if the difference between the protein levels in the serum and the pleural
fluid is >3.1 g/dL, the patient should be classified as having a transudative effusion
(SOR C).Cytology is positive in approximately 60% of malignant pleural effusions
(SOR B). The diagnostic yield may be improved by additional pleural taps. If
malignancy is still a concern, thoracoscopy should be considered (SOR C).
A 44-year-old female presents to the emergency department with 2-3 days of
epigastric abdominal pain, vomiting, low-grade fever, and anorexia. She has not had
any change in bowel habits, and no cough, chest pain, or shortness of breath. Her past
medical history includes moderate persistent asthma, diet-controlled type 2 diabetes,
and hypertension.You see the patient on the medical floor for admission. On
examination the patient is uncomfortable and looks ill. She has a temperature of
37.8°C (100.0°F), a heart rate of 120 beats/min, a respiratory rate of 18/min, a blood
pressure of 120/70 mm Hg, and an oxygen saturation of 98% on room air. A
cardiopulmonary examination is significant only for tachycardia. On abdominal
examination she has decreased bowel sounds, epigastric tenderness to palpation, a
negative Murphy's sign, and no rebound or involuntary guarding.Laboratory
FindingsWBCs............14,200/mm3 (N 4300-10,800)Hemoglobin............15.0 g/dL (N
12.0-16.0)Platelets............450,000/mm3 (N 130,000-400,000)Sodium............128
mEq/L (N 136-145)Potassium............3.6 mEq/L (N 3.5-5.1)Chloride............108 mEq/L
(N 98-107)Carbon dioxide............22 mmol/L (N 22-28)BUN............30 mg/dL (N 6-
20)Creatinine............1.5 mg/dL (N 0.6-1.1)AST............65 U/L (N 10-59)ALT............94
U/L (N 10-28)Alkaline phosphatase............213 U/L (N 38-126)Glucose............140
mg/dLCalcium............8.6 mg/dL (N 8.6-10.0)Albumin............3.2 g/dL (N 3.5-5.2)Total
bilirubin............3.2 mg/dL (N 0.2-1.2)Triglycerides............300 mg/dLAlcohol
level............0Lipase............800 U/L (N 23-300)Abdominal ultrasonography shows
gallstones within the gallbladder and a dilated common bile duct with a likely
impacted stone within the duct. There is no pericholecystic fluid to suggest
cholecystitis. You treat her appropriately with intravenous fluids and pain
management.Which one of the following would be most appropriate for this patient?
, Planned cholecystectomy within 4-6 weeks
Endoscopic retrograde cholangiopancreatography (ERCP) only
Cholecystectomy before discharge
ERCP followed by cholecystectomy within 12 hours of admission
Surgical consultation for immediate cholecystectomy
C
In patients with gallstone pancreatitis, cholecystectomy should be performed prior to
discharge unless the patient has contraindications to surgery or has severe acute
pancreatitis with necrosis. This results in shorter hospital stays with no increased
risk of complications, and prevents the readmission and risk of recurrence associated
with delaying surgery until after discharge. Cholecystectomy within 12 hours of
admission is not necessary, especially if endoscopic retrograde
cholangiopancreatography (ERCP) will be performed prior to surgery.
A 78-year-old male lives alone with no known relatives or friends. A social worker
performing a routine welfare check finds him down on the floor and he is hospitalized
for several days with Wernicke-Korsakoff syndrome. He is medically optimized, and
discharge planning is now being discussed. His cognitive assessment scores are
abnormal. There is no advance care plan document or health care power of attorney.
The patient states that he wants to return home, but you have significant concerns
about that decision and do not feel it would be safe. When you discuss your concerns
with the patient and ask about his plans for obtaining and preparing food and other
instrumental activities of daily living, he simply asserts that he'll be "fine." He is not
able to provide any further explanation of his thoughts, and he becomes upset and
refuses to answer further questions.Reasonable strategies for managing this situation
include which one of the following?
Transfer the patient to a skilled nursing facility and perform a capacity and
competency determination at a later time
Consult the ethics committee at your institution to determine his decision-making
capacity
Assign durable power of attorney for health care to one of the medical social workers
who is familiar with his case
Work with the court system to establish guardianship for the patient
D
