Page 1 of 67
ABFM KSA Care of Hospitalized Patients EXAM
ACTUAL EXAM ALL QUESTIONS AND CORRECT
ANSWERS LATEST UPDATE THIS YEAR
ABFM KSA - Care of Hospitalized Patients
A 64-year-old female presents to the emergency department with 3-4 days of worsening
abdominal pain, nonbloody diarrhea, a subjective fever, and chills. She has not had any
vomiting or urinary symptoms. Her abdominal pain is somewhat localized to the entire left
side of her abdomen, but she reports that her whole abdomen feels tender. She has not
eaten anything for at least 36 hours. She tried to drink some water earlier today but says it
made her abdominal pain worse. Her previous medical history includes hypertension,
uncontrolled diabetes mellitus treated with insulin, and COPD.On examination the patient
appears uncomfortable and ill. Her vital signs include a temperature of 38.2°C (100.8°F), a
blood pressure of 140/91 mm Hg, a heart rate of 102 beats/min, a respiratory rate of 16/min,
and an oxygen saturation of 94% on room air. A cardiopulmonary examination is
unremarkable except for mild tachycardia. An abdominal examination reveals normal active
bowel sounds and tenderness to palpation in the left lower quadrant with voluntary guarding
but no rebound.Laboratory FindingsSodium............129 mEq/L (N 136-
145)Potassium............3.4 mEq/L (N 3.5-5.1)Carbon dioxide............19 mmol/L (N 22-
28)Chloride............109 mEq/L (N 98-107)Creatinine............1.8 mg/dL (N 0.6-
1.1)Glucose............315 mg/dLCalcium............8.6 mg/dL (N 8.6-
10.0)WBCs............14,200/mm3 (N 4300-10,800)Hemoglobin............15.0 g/dL (N 12.0-
16.0)Platelets............365,000/mm3 (N 130,000-400,000)Lipase............75 U/L (N 23-
300)AST............35 U/L (N 10-59)ALT............30 U/L (N 10-28)Total bilirubin............0.9 mg/dL
(N 0.2-1.2)Urinalysis............normalFindings on CT with contrast include localized thickening
of the sigmoid colon, pericolonic fat stranding, and a 2.5-cm pericolonic abscess of the
sigmoid colon. CT is otherwise unremarkable.In addition to fluid resuscitation, which one of
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the following would be appropriate treatment?
Oral amoxicillin/clavulanate (Augmentin) and metronidazole
Intravenous piperacillin/tazobactam (Zosyn)
Intravenous vancomycin and ceftriaxone
Partial sigmoid resection
B
This patient has acute complicated diverticulitis. Given that she has a small diverticular abscess,
the initial management should be intravenous antibiotics that cover gram-negative and
anaerobic bacteria, such as piperacillin/tazobactam. There are no randomized, controlled trials
that delineate the best antibiotic course. Patients presenting with a diverticular abscess <3 cm
or sometimes even 4 cm in diameter often respond to antibiotics alone and do not need
surgery or percutaneous drainage. This patient should be hospitalized, given her uncontrolled
diabetes mellitus, fever, and inability to eat or drink. Outpatient management with antibiotics
and bowel stimulation with magnesium citrate may be appropriate for patients with mild
uncomplicated disease. Oral antibiotics can be used in cases with small abscesses, as they have
been shown to be as effective as intravenous antibiotics, and some patients may not require
any antibiotics. Surgery is not indicated in the acute management of diverticulitis unless
pneumoperitoneum or peritonitis is present.
A 58-year-old male with type 2 diabetes has undergone elective knee surgery. After the
surgery all of his usual medications were restarted, with intensive glucose monitoring. The
next morning he is found to be confused and lethargic with a blood glucose level of 32
mg/dL.When used alone, which one of the following diabetes medications is most likely to
cause hypoglycemia?
Glipizide (Glucotrol)
Metformin (Glucophage)
Pioglitazone (Actos)
Sitagliptin (Januvia)
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A
Some diabetes medications can lead to hypoglycemia in hospitalized patients, including
glipizide, which stimulates insulin production (SOR B). Metformin and pioglitazone both help
control diabetes by sensitizing the body to the effects of insulin. Sitagliptin is a DPP-4 inhibitor
and works by blocking the enzyme that releases GLP-1. Its greatest effect is reducing
postprandial hyperglycemia. These medications are not a direct cause of hypoglycemia when
given at usual dosages in most situations (SOR B).
Which one of the following is an advantage of a durable power of attorney for health care
compared to a living will?
It is not legally binding
It is the only advance directive that satisfies the Patient Self-Determination Act
It is applicable in more clinical scenarios than a living will
It allows first responders to avoid cardiopulmonary resuscitation
It allows the person designated to make health care decisions to manage the patient's
finances and legal matters as well
C
The durable power of attorney for health care (DPOA-HC) is a type of advance directive in
which a competent person designates someone to make health care decisions if the person
becomes unable to do so. A living will is a different type of advance directive in which a person
writes down instructions to avoid or receive specific medical care in the event that the person is
diagnosed with a terminal medical condition. Living wills go into effect only in the event that a
patient is diagnosed with a terminal condition, which is often difficult to determine. A living will
is therefore not useful if a patient is suffering from an acute illness such as a reversible
infection, or from a chronic debilitating disease such as a stroke or other neurologic condition.
The National Institute on Aging has a helpful website for educating patients and clinicians about
these documents at https://www.nia.nih.gov/health/advance-care-planning-health-care-
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directives.A DPOA-HC is legally binding if filled out according to the law of the state in which it
was written. The DPOA-HC limits a designated person to decisions related only to health care.
Establishing legal and/or financial power of attorney requires a separate document. The Patient
Self-Determination Act of 1990 is national legislation that requires hospitals to offer every
patient the opportunity to complete an advance directive. The law does not describe any
specific advance directive.First responders are required to provide needed cardiopulmonary
resuscitation unless there is a valid do-not-resuscitate order such as a POLST document
(Physician Orders for Life Sustaining Treatment) present at the time of their evaluation. A
POLST is not a legal document, but is a physician order set that reflects the patient's wishes for
care and is many times useful in end-of-life care.
A 78-year-old male has been hospitalized for an acute exacerbation of heart failure and is
now being discharged to his home. Which one of the following has the most impact on
reducing readmissions and all-cause mortality?
Simplification of his medication regimen
A phone call from a nurse within 48 hours of discharge
A home visit from a nurse
A visit with his primary care physician 1 month after discharge
C
The most effective intervention for reducing readmissions and all-cause mortality is a home
visit from a nurse. Structured telephone support has been shown to reduce readmissions for
heart failure, but not all-cause mortality. Telephone, telemonitoring, pharmacist, and education
interventions have not consistently been proven to significantly improve clinical outcomes.
Other measures should also be employed, such as simplification of medication regimens,
providing written materials in the patient's language, and pharmacy review at the bedside with
teach-back before discharge. Transitional care management codes can be employed for the
primary care physician and they consist of a phone call from a nurse within 48 hours and an in-
person or virtual visit within 7-14 days to address post-hospital care and plan for future care.
4
ABFM KSA Care of Hospitalized Patients EXAM
ACTUAL EXAM ALL QUESTIONS AND CORRECT
ANSWERS LATEST UPDATE THIS YEAR
ABFM KSA - Care of Hospitalized Patients
A 64-year-old female presents to the emergency department with 3-4 days of worsening
abdominal pain, nonbloody diarrhea, a subjective fever, and chills. She has not had any
vomiting or urinary symptoms. Her abdominal pain is somewhat localized to the entire left
side of her abdomen, but she reports that her whole abdomen feels tender. She has not
eaten anything for at least 36 hours. She tried to drink some water earlier today but says it
made her abdominal pain worse. Her previous medical history includes hypertension,
uncontrolled diabetes mellitus treated with insulin, and COPD.On examination the patient
appears uncomfortable and ill. Her vital signs include a temperature of 38.2°C (100.8°F), a
blood pressure of 140/91 mm Hg, a heart rate of 102 beats/min, a respiratory rate of 16/min,
and an oxygen saturation of 94% on room air. A cardiopulmonary examination is
unremarkable except for mild tachycardia. An abdominal examination reveals normal active
bowel sounds and tenderness to palpation in the left lower quadrant with voluntary guarding
but no rebound.Laboratory FindingsSodium............129 mEq/L (N 136-
145)Potassium............3.4 mEq/L (N 3.5-5.1)Carbon dioxide............19 mmol/L (N 22-
28)Chloride............109 mEq/L (N 98-107)Creatinine............1.8 mg/dL (N 0.6-
1.1)Glucose............315 mg/dLCalcium............8.6 mg/dL (N 8.6-
10.0)WBCs............14,200/mm3 (N 4300-10,800)Hemoglobin............15.0 g/dL (N 12.0-
16.0)Platelets............365,000/mm3 (N 130,000-400,000)Lipase............75 U/L (N 23-
300)AST............35 U/L (N 10-59)ALT............30 U/L (N 10-28)Total bilirubin............0.9 mg/dL
(N 0.2-1.2)Urinalysis............normalFindings on CT with contrast include localized thickening
of the sigmoid colon, pericolonic fat stranding, and a 2.5-cm pericolonic abscess of the
sigmoid colon. CT is otherwise unremarkable.In addition to fluid resuscitation, which one of
1
, Page 2 of 67
the following would be appropriate treatment?
Oral amoxicillin/clavulanate (Augmentin) and metronidazole
Intravenous piperacillin/tazobactam (Zosyn)
Intravenous vancomycin and ceftriaxone
Partial sigmoid resection
B
This patient has acute complicated diverticulitis. Given that she has a small diverticular abscess,
the initial management should be intravenous antibiotics that cover gram-negative and
anaerobic bacteria, such as piperacillin/tazobactam. There are no randomized, controlled trials
that delineate the best antibiotic course. Patients presenting with a diverticular abscess <3 cm
or sometimes even 4 cm in diameter often respond to antibiotics alone and do not need
surgery or percutaneous drainage. This patient should be hospitalized, given her uncontrolled
diabetes mellitus, fever, and inability to eat or drink. Outpatient management with antibiotics
and bowel stimulation with magnesium citrate may be appropriate for patients with mild
uncomplicated disease. Oral antibiotics can be used in cases with small abscesses, as they have
been shown to be as effective as intravenous antibiotics, and some patients may not require
any antibiotics. Surgery is not indicated in the acute management of diverticulitis unless
pneumoperitoneum or peritonitis is present.
A 58-year-old male with type 2 diabetes has undergone elective knee surgery. After the
surgery all of his usual medications were restarted, with intensive glucose monitoring. The
next morning he is found to be confused and lethargic with a blood glucose level of 32
mg/dL.When used alone, which one of the following diabetes medications is most likely to
cause hypoglycemia?
Glipizide (Glucotrol)
Metformin (Glucophage)
Pioglitazone (Actos)
Sitagliptin (Januvia)
2
, Page 3 of 67
A
Some diabetes medications can lead to hypoglycemia in hospitalized patients, including
glipizide, which stimulates insulin production (SOR B). Metformin and pioglitazone both help
control diabetes by sensitizing the body to the effects of insulin. Sitagliptin is a DPP-4 inhibitor
and works by blocking the enzyme that releases GLP-1. Its greatest effect is reducing
postprandial hyperglycemia. These medications are not a direct cause of hypoglycemia when
given at usual dosages in most situations (SOR B).
Which one of the following is an advantage of a durable power of attorney for health care
compared to a living will?
It is not legally binding
It is the only advance directive that satisfies the Patient Self-Determination Act
It is applicable in more clinical scenarios than a living will
It allows first responders to avoid cardiopulmonary resuscitation
It allows the person designated to make health care decisions to manage the patient's
finances and legal matters as well
C
The durable power of attorney for health care (DPOA-HC) is a type of advance directive in
which a competent person designates someone to make health care decisions if the person
becomes unable to do so. A living will is a different type of advance directive in which a person
writes down instructions to avoid or receive specific medical care in the event that the person is
diagnosed with a terminal medical condition. Living wills go into effect only in the event that a
patient is diagnosed with a terminal condition, which is often difficult to determine. A living will
is therefore not useful if a patient is suffering from an acute illness such as a reversible
infection, or from a chronic debilitating disease such as a stroke or other neurologic condition.
The National Institute on Aging has a helpful website for educating patients and clinicians about
these documents at https://www.nia.nih.gov/health/advance-care-planning-health-care-
3
, Page 4 of 67
directives.A DPOA-HC is legally binding if filled out according to the law of the state in which it
was written. The DPOA-HC limits a designated person to decisions related only to health care.
Establishing legal and/or financial power of attorney requires a separate document. The Patient
Self-Determination Act of 1990 is national legislation that requires hospitals to offer every
patient the opportunity to complete an advance directive. The law does not describe any
specific advance directive.First responders are required to provide needed cardiopulmonary
resuscitation unless there is a valid do-not-resuscitate order such as a POLST document
(Physician Orders for Life Sustaining Treatment) present at the time of their evaluation. A
POLST is not a legal document, but is a physician order set that reflects the patient's wishes for
care and is many times useful in end-of-life care.
A 78-year-old male has been hospitalized for an acute exacerbation of heart failure and is
now being discharged to his home. Which one of the following has the most impact on
reducing readmissions and all-cause mortality?
Simplification of his medication regimen
A phone call from a nurse within 48 hours of discharge
A home visit from a nurse
A visit with his primary care physician 1 month after discharge
C
The most effective intervention for reducing readmissions and all-cause mortality is a home
visit from a nurse. Structured telephone support has been shown to reduce readmissions for
heart failure, but not all-cause mortality. Telephone, telemonitoring, pharmacist, and education
interventions have not consistently been proven to significantly improve clinical outcomes.
Other measures should also be employed, such as simplification of medication regimens,
providing written materials in the patient's language, and pharmacy review at the bedside with
teach-back before discharge. Transitional care management codes can be employed for the
primary care physician and they consist of a phone call from a nurse within 48 hours and an in-
person or virtual visit within 7-14 days to address post-hospital care and plan for future care.
4
