ABFM KSA - CARE OF HOSPITALIZED PATIENTS 300
ACTUAL QUESTION AND CORRECT ANSWERS WITH
ALREADY GRADED A+ NEW!!!!!!!!!!!!!!!!!!
This comprehensive 300-question review covers the ABFM Knowledge Self-
Assessment (KSA) on Care of Hospitalized Patients. It addresses the full
spectrum of hospital medicine, including diagnostic imaging selection (CT,
ultrasound, MRI), acute management of cardiovascular conditions (atrial
fibrillation, myocardial infarction, heart failure), pulmonary disorders
(COPD exacerbation, asthma, ARDS, pneumonia), gastrointestinal
emergencies (pancreatitis, cholecystitis, bowel obstruction, GI bleeding), renal
and electrolyte disturbances (acute kidney injury, fluid resuscitation), and
perioperative management. The questions also thoroughly cover
anticoagulation management, appropriate antibiotic selection, ventilator
strategies, and discharge planning for complex patients, providing complete
preparation for the hospital medicine KSA examination.
1. CT would usually be indicated as the initial imaging study for which one of the
following patients?
A. 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
B. A 43-year-old with a 1-day history of epigastric pain and nausea with vomiting,
and elevated serum lipase
C. A 66-year-old with diffuse abdominal pain, leukocytosis, and fever
D. A 55-year-old with unrelenting severe low back pain associated with right leg
pain and weakness
E. 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
Answer: C
Rationale: 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, ultrasonography should be the first imaging study in a
pediatric patient with a classic history of appendicitis. 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.
2. 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?
A. Administer a loading dose of warfarin, 10 mg orally
B. Start apixaban (Eliquis), 5 mg twice daily
C. Stop the diltiazem infusion and administer metoprolol intravenously
D. Stop the diltiazem infusion and administer digoxin, 0.25 mg intravenously
Answer: B
Rationale: 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.
3. 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?
A. Noncontrast CT should be performed initially in all patients with pleural
effusions if the cause is unknown
B. Ultrasound-guided thoracentesis should be performed on admission in all
patients with small bilateral pleural effusions
C. In patients with heart failure who are treated with diuretics, pleural effusions
may be misclassified as exudative rather than transudative
,D. Negative cytology on an adequate sample of pleural fluid (≥10 mL) effectively
rules out malignancy as the cause of a unilateral pleural effusion
Answer: C
Rationale: 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. 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. Cytology is positive in approximately 60% of malignant pleural
effusions. The diagnostic yield may be improved by additional pleural taps. If
malignancy is still a concern, thoracoscopy should be considered.
4. 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. 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 findings include WBCs 14,200/mm3, lipase 1000
U/L, and normal liver function tests. Which of the following statements is true
regarding the management of this patient?
A. Cholecystectomy should be performed within 12 hours of admission
B. Delay cholecystectomy until after discharge for all patients
C. Cholecystectomy should be performed prior to discharge unless
contraindications exist
D. ERCP is indicated emergently in all cases
Answer: C
, Rationale: 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.
5. 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:
A. Determining whether the patient has medical decision-making capacity and
involving a surrogate decision maker if not
B. Discharging the patient to home against medical advice since he states he will
be fine
C. Forcing placement in a skilled nursing facility due to safety concerns
D. Ignoring advance care planning as no documents exist
Answer: A
Rationale: As with any medical procedure, discharge planning should be done with
the consent of the patient involved. Because this patient does not appear to have
the capacity to consent to any plan, a surrogate decision maker should be sought.
Capacity is not the same as competence. Competence is a legal term that is
determined by the court system, whereas capacity is a medical term that is
determined by the treating physician. Lack of competence refers to impairment of
global decision-making regarding matters such as finances, property, and wills,
whereas lack of capacity refers to the inability to make decisions about proposed
medical treatments and other aspects of care. Capacity can vary with circumstance
and the relative complexity of the decision that is being made. Once the physician
has determined that no communication barriers exist, such as hearing loss,
language barriers, or dysarthria, and that no medically reversible causes are
present, medical decision-making capacity should be assessed. The patient should
ACTUAL QUESTION AND CORRECT ANSWERS WITH
ALREADY GRADED A+ NEW!!!!!!!!!!!!!!!!!!
This comprehensive 300-question review covers the ABFM Knowledge Self-
Assessment (KSA) on Care of Hospitalized Patients. It addresses the full
spectrum of hospital medicine, including diagnostic imaging selection (CT,
ultrasound, MRI), acute management of cardiovascular conditions (atrial
fibrillation, myocardial infarction, heart failure), pulmonary disorders
(COPD exacerbation, asthma, ARDS, pneumonia), gastrointestinal
emergencies (pancreatitis, cholecystitis, bowel obstruction, GI bleeding), renal
and electrolyte disturbances (acute kidney injury, fluid resuscitation), and
perioperative management. The questions also thoroughly cover
anticoagulation management, appropriate antibiotic selection, ventilator
strategies, and discharge planning for complex patients, providing complete
preparation for the hospital medicine KSA examination.
1. CT would usually be indicated as the initial imaging study for which one of the
following patients?
A. 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
B. A 43-year-old with a 1-day history of epigastric pain and nausea with vomiting,
and elevated serum lipase
C. A 66-year-old with diffuse abdominal pain, leukocytosis, and fever
D. A 55-year-old with unrelenting severe low back pain associated with right leg
pain and weakness
E. 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
Answer: C
Rationale: 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, ultrasonography should be the first imaging study in a
pediatric patient with a classic history of appendicitis. 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.
2. 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?
A. Administer a loading dose of warfarin, 10 mg orally
B. Start apixaban (Eliquis), 5 mg twice daily
C. Stop the diltiazem infusion and administer metoprolol intravenously
D. Stop the diltiazem infusion and administer digoxin, 0.25 mg intravenously
Answer: B
Rationale: 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.
3. 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?
A. Noncontrast CT should be performed initially in all patients with pleural
effusions if the cause is unknown
B. Ultrasound-guided thoracentesis should be performed on admission in all
patients with small bilateral pleural effusions
C. In patients with heart failure who are treated with diuretics, pleural effusions
may be misclassified as exudative rather than transudative
,D. Negative cytology on an adequate sample of pleural fluid (≥10 mL) effectively
rules out malignancy as the cause of a unilateral pleural effusion
Answer: C
Rationale: 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. 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. Cytology is positive in approximately 60% of malignant pleural
effusions. The diagnostic yield may be improved by additional pleural taps. If
malignancy is still a concern, thoracoscopy should be considered.
4. 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. 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 findings include WBCs 14,200/mm3, lipase 1000
U/L, and normal liver function tests. Which of the following statements is true
regarding the management of this patient?
A. Cholecystectomy should be performed within 12 hours of admission
B. Delay cholecystectomy until after discharge for all patients
C. Cholecystectomy should be performed prior to discharge unless
contraindications exist
D. ERCP is indicated emergently in all cases
Answer: C
, Rationale: 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.
5. 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:
A. Determining whether the patient has medical decision-making capacity and
involving a surrogate decision maker if not
B. Discharging the patient to home against medical advice since he states he will
be fine
C. Forcing placement in a skilled nursing facility due to safety concerns
D. Ignoring advance care planning as no documents exist
Answer: A
Rationale: As with any medical procedure, discharge planning should be done with
the consent of the patient involved. Because this patient does not appear to have
the capacity to consent to any plan, a surrogate decision maker should be sought.
Capacity is not the same as competence. Competence is a legal term that is
determined by the court system, whereas capacity is a medical term that is
determined by the treating physician. Lack of competence refers to impairment of
global decision-making regarding matters such as finances, property, and wills,
whereas lack of capacity refers to the inability to make decisions about proposed
medical treatments and other aspects of care. Capacity can vary with circumstance
and the relative complexity of the decision that is being made. Once the physician
has determined that no communication barriers exist, such as hearing loss,
language barriers, or dysarthria, and that no medically reversible causes are
present, medical decision-making capacity should be assessed. The patient should
