Page 1 of 49
Care of Hospitalized Patients ABFM KSA EXAM
COMPLETE NEWEST QUESTIONS AND VERIFIED
SOLUTIONS LATEST UPDATE THIS YEAR
ABFM KSA - Care of Hospitalized Patients
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
1
, Page 2 of 49
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).
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,
2
, Page 3 of 49
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 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
3
, Page 4 of 49
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
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. It
is important to distinguish the terms precisely in clinical practice. 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. According to their strict definitions, 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.
4
Care of Hospitalized Patients ABFM KSA EXAM
COMPLETE NEWEST QUESTIONS AND VERIFIED
SOLUTIONS LATEST UPDATE THIS YEAR
ABFM KSA - Care of Hospitalized Patients
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
1
, Page 2 of 49
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).
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,
2
, Page 3 of 49
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 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
3
, Page 4 of 49
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
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. It
is important to distinguish the terms precisely in clinical practice. 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. According to their strict definitions, 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.
4
