Page 1 of 87
ABFM KSA-Care of Hospitalized Patients Exam NEWEST
VERSION QUESTIONS AND CORRECT VERIFIED ANSWERS
WITH RATIONALES LATEST UPDATE JUST RELEASED THIS
YEAR
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.
CT would usually be indicated as the initial imaging study for which one of the following
patients?
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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.
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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.
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
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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
4
SUCCESS!
ABFM KSA-Care of Hospitalized Patients Exam NEWEST
VERSION QUESTIONS AND CORRECT VERIFIED ANSWERS
WITH RATIONALES LATEST UPDATE JUST RELEASED THIS
YEAR
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.
CT would usually be indicated as the initial imaging study for which one of the following
patients?
1
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,Page 2 of 87
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.
2
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,Page 3 of 87
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.
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
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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
4
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