ABFM KSA - Care of Hospitalized Patients Exam
Practice 2025-2026 Guide
1. 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, guard-
ing, 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
unditterentiated 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.
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 mag-
, ABFM KSA - Care of Hospitalized Patients Exam
Practice 2025-2026 Guide
nesium 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 8e0 , body weight 6d0 kg (130 lb), or serum creatinine 1e. 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?
Noncontrast CT should be performed initially in all patients with pleural effu-
sions 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 ( e1 0 mL) effectively
rules out malignancy as the cause of a unilateral pleural effusion: C
CT can detect ettusions 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 ettusions if the clinical
findings strongly suggest a pleural transudate, unless there are atypical features (fever, pleuritic chest pain, or widely
asymmetric ettusion size) or the ettusion fails to respond to therapy (SOR C). Thoracentesis should be performed with
, ABFM KSA - Care of Hospitalized Patients Exam
Practice 2025-2026 Guide
ultrasound guidance, when possible, to improve the likelihood of successful aspiration and decrease the risk of organ
puncture, especially when ettusions are small. About 20% of patients with a pleural ettusion caused by heart failure
may fulfill the criteria for an exudative ettusion after receiving diuretics. In these cases, if the ditterence 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
ettusion (SOR C).Cytology is positive in approximately 60% of malignant pleural ettusions (SOR B). The diagnostic yield
may be improved by additional pleural taps. If malignancy is still a concern, thoracoscopy should be considered (SOR
C).
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.You see the pa-
tient 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 pres-
sure of 120/70 mm Hg, and an oxygen saturation of 98% on room air.
A cardiopulmonary examination is significant only for tachycardia. On ab-
dominal examination she has decreased bowel sounds, epigastric tender-
ness to palpation, a negative Murphy's sign, and no rebound or involuntary
guarding.Laboratory FindingsWBCs............14,200/mm3 (N 4300-10,800)He-
moglobin............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)Alka-
line phosphatase............213 U/L (N 38-126)Glucose............140 mg/dLCalci-
um............8.6 mg/dL (N 8.6-10.0)Albumin............3.2 g/dL (N 3.5-5.2)Total biliru-
bin............3.2 mg/dL (N 0.2-1.2)Triglycerides............300 mg/dLAlcohol lev-
el............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
, ABFM KSA - Care of Hospitalized Patients Exam
Practice 2025-2026 Guide
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.
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 cogni-
tive 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-mak-
ing capacity
Assign durable power of attorney for health care to one of the medical social
workers who is familiar with his case
Practice 2025-2026 Guide
1. 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, guard-
ing, 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
unditterentiated 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.
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 mag-
, ABFM KSA - Care of Hospitalized Patients Exam
Practice 2025-2026 Guide
nesium 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 8e0 , body weight 6d0 kg (130 lb), or serum creatinine 1e. 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?
Noncontrast CT should be performed initially in all patients with pleural effu-
sions 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 ( e1 0 mL) effectively
rules out malignancy as the cause of a unilateral pleural effusion: C
CT can detect ettusions 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 ettusions if the clinical
findings strongly suggest a pleural transudate, unless there are atypical features (fever, pleuritic chest pain, or widely
asymmetric ettusion size) or the ettusion fails to respond to therapy (SOR C). Thoracentesis should be performed with
, ABFM KSA - Care of Hospitalized Patients Exam
Practice 2025-2026 Guide
ultrasound guidance, when possible, to improve the likelihood of successful aspiration and decrease the risk of organ
puncture, especially when ettusions are small. About 20% of patients with a pleural ettusion caused by heart failure
may fulfill the criteria for an exudative ettusion after receiving diuretics. In these cases, if the ditterence 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
ettusion (SOR C).Cytology is positive in approximately 60% of malignant pleural ettusions (SOR B). The diagnostic yield
may be improved by additional pleural taps. If malignancy is still a concern, thoracoscopy should be considered (SOR
C).
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.You see the pa-
tient 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 pres-
sure of 120/70 mm Hg, and an oxygen saturation of 98% on room air.
A cardiopulmonary examination is significant only for tachycardia. On ab-
dominal examination she has decreased bowel sounds, epigastric tender-
ness to palpation, a negative Murphy's sign, and no rebound or involuntary
guarding.Laboratory FindingsWBCs............14,200/mm3 (N 4300-10,800)He-
moglobin............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)Alka-
line phosphatase............213 U/L (N 38-126)Glucose............140 mg/dLCalci-
um............8.6 mg/dL (N 8.6-10.0)Albumin............3.2 g/dL (N 3.5-5.2)Total biliru-
bin............3.2 mg/dL (N 0.2-1.2)Triglycerides............300 mg/dLAlcohol lev-
el............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
, ABFM KSA - Care of Hospitalized Patients Exam
Practice 2025-2026 Guide
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.
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 cogni-
tive 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-mak-
ing capacity
Assign durable power of attorney for health care to one of the medical social
workers who is familiar with his case
