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ABFM KSA - Care of Hospitalized Patients exam question and answer latest update
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ABFM KSA - Care of HospitalizedPatients
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, 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 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
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).
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
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. The patient should be able to demonstrate understanding of the situation, appreciation of the
consequences of the decision, and reasoning in the thought process. They also must be able to
communicate their wishes. If it is still unclear whether the patient has the capacity to make decisions, a
structured interview should be done using a validated tool. Common assessment tools include the Aid to
Capacity Evaluation (ACE), the Hopkins Competency Assessment Test (HCAT), the Understanding
Treatment Disclosure, and the MacArthur Competence Assessment Tool for Treatment. Assessing
cognition with a mental status examination is not always necessary to determine medical decision-
making capacity.If there is no valid medical power of attorney, the closest relative usually becomes the
surrogate. Currently, 44 states have enacted surrogate consent laws. There are two types of laws
pertaining to this: hierarchy surrogate consent laws and consensus surrogate consent laws. In four of the
states with surrogate consent laws, the law is only applicable to consent for medical research and certain
facility admissions. Currently, there are seven states with no surrogate consent laws (Massachusetts,
Minnesota, Missouri, Nebraska, New Hampshire, Rhode Island, and Vermont). The hierarchy laws set up
a hierarchy of who should be the designated relative to act as surrogate if a patient has not left written
instructions. In Colorado and Hawaii, consensus surrogate statutes require that all reasonably available
"interested persons" come to a consensus about who should act as the decision-maker.Most hospitals
have an ethics committee available with reasonable notice, allowing the hospital to convene a
multidisciplinary group of caregivers who are familiar with the legal and ethical requirements of
situations such as the one presented here. Their determinations are not binding, and they do not
determine capacity or competency.The durable power of attorney for health care is a form of advance
directive that a patient creates while competent, and goes into effect when the person is unable to make
medical decisions. Most power-of-attorney forms specifically prohibit members of the medical team
from serving as a patient's decision-making proxy.The legal determination that a patient is unable to
make decisions on his or her own behalf most often requires the opinion of at least two different
professionals (SOR C). This can be two physicians or a physician and a psychologist.The court system is
the appropriate venue for designating a guardian (or conservator) for patients who have lost the capacity
to make or communicate decisions about their own care (SOR C). This is a legal proceeding that will
require due process on behalf of the patient. Counsel will be assigned to represent the patient and an
attempt will be made to contact interested friends and family. Temporary guardianship may be assigned
if action is required before a more permanent representative can be found. This guardian will (at the
discretion of the judge) be allowed to manage the patient's finances, determine his/her living situation,
and consent to or refuse medical care.
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.
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