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ABFM KSA - CARE OF HOSPITALIZED PATIENTS EXAM QUESTIONS AND ANSWERS 2024
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ABFM KSA - CARE OF HOSPITALIZED PATIENTS EXAM QUESTIONS AND ANSWERS 2024
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ABFM KSA - CARE OF 2024HOSPITALIZED PATIENTS
EXAM
ANSWER ALL QUESTIONS IN THIS SECTION
QUESTION 1
An 85-year-old female presents with a fever, decreased oral intake for the past 1-2
weeks, and intermittent delirium. A chest radiograph reveals left lower lobe
pneumonia. She is admitted to the hospital for intravenous fluids, antibiotics, and
supportive care.Which one of the following is the best laboratory test for assessing
this patient's nutritional status?
Prealbumin
Albumin
Transferrin
Plasma adiponectin
A
Prealbumin is the single best laboratory test for assessing nutritional status in
acutely ill patients because serum concentrations change relatively quickly in
response to changes in nutritional status (SOR B). Prealbumin is a measure of
hepatic protein synthesis and has a half-life of only 48 hours. It can be measured
serially in hospitalized patients to help determine if and when parenteral nutritional
support should be implemented. Low levels correlate with poor clinical outcomes
in a variety of diseases, including heart failure, stroke, and cancer. Albumin and
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, ABFM KSA - CARE OF 2024
HOSPITALIZED PATIENTS
EXAM
transferrin levels have longer half-lives and are therefore not as sensitive to acute
nutritional status changes. Prealbumin levels are also independent of the patient's
hydration status and are not affected by vitamin deficiencies. It should be noted
that acute alcohol intoxication and corticosteroid therapy may artificially raise
prealbumin levels, thereby limiting the utility of the test in some patients. Levels of
plasma adiponectin, a protein secreted solely by adipocytes with anti-inflammatory
and insulin-sensitizing properties, are not helpful for assessing nutritional status.
QUESTION 2
A 69-year-old female with a history of type 2 diabetes, hypertension, COPD, and
stage 4 chronic kidney disease is admitted to the hospital with abdominal pain and
fever. Examination of the abdomen reveals moderate diffuse tenderness that is
localized to the left lower quadrant. Noncontrast CT is indeterminate, and it is
recommended that she undergo either contrast-enhanced CT or contrast-enhanced
MRI for further evaluation. Laboratory testing is remarkable for a WBC count of
16,000/mm3 (N 4300-10,800) with a left shift, a serum creatinine level of 2.5
mg/dL (N 0.6-1.5), and a glomerular filtration rate of 28 mL/min/1.73 m2.Which
one of the following is true regarding the diagnosis and management of this
patient?
MRI with contrast can be safely performed
It would be reasonable to delay contrast CT until her acute condition has totally
resolved
Sodium bicarbonate administration and intravenous fluids would prevent
nephrogenic systemic fibrosis from gadolinium
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, ABFM KSA - CARE OF 2024
HOSPITALIZED PATIENTS
EXAM
Reduced doses of gadolinium would prevent nephrogenic systemic fibrosis
A
Stage 4 chronic kidney disease puts a patient at risk for contrast-induced
nephropathy. The risk of acute kidney injury in patients with reduced kidney
function following exposure to intravenous iodinated contrast media has been
overstated. Intravenous hydration with normal saline is recommended for patients
with a glomerular filtration rate <30 mL/min/1.73 m2. Rare cases of nephrogenic
systemic fibrosis have been associated with the group II gadolinium-based contrast
agents which are now being used. Group I agents, which are associated with a
higher risk of nephropathy, are no longer used.There is no evidence that sodium
bicarbonate and intravenous fluids reduce the risk of nephrogenic systemic fibrosis
in patients with advanced kidney disease. Delaying imaging would potentially lead
to a failure to detect serious complications that may need surgical intervention.
Contrast MRI would generally be safer than contrast CT in this setting, with
hydration as described above. Reducing the dose of gadolinium due to renal
dysfunction will lead to a suboptimal scan.
QUESTION 3
A 78-year-old male with Alzheimer's dementia is brought to the hospital from his
assisted living facility because of confusion greater than his baseline, generalized
weakness, and hypothermia. A comprehensive physical examination does not
indicate the cause of the increased confusion. His WBC count is 17,300/mm3 (N
4000-10,000). A basic metabolic panel is normal except for a serum creatinine
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, ABFM KSA - CARE OF 2024
HOSPITALIZED PATIENTS
EXAM
level of 2.3 mg/dL (N 0.74-1.35), and his serum lactate level is 4.2 mmol/L (N 0.5-
2.2). A procalcitonin level is normal. A chest radiograph shows a right lower lobe
pneumonia. Blood cultures are pending. You institute appropriate therapy with
antibiotics and fluids.Which one of the following should be repeated in the next 4-
6 hours?
The WBC count
The basic metabolic panel
Serum lactate
Serum procalcitonin
Blood cultures
C
In patients with sepsis and elevated serum lactate, it is important to repeat the
lactate measurement every 4-6 hours to assure appropriate tissue perfusion.
Lactate-guided fluid resuscitation reduces overall mortality compared with no
lactate monitoring. If the lactate does not decline to a normal level further
evaluation should be performed urgently. An elevated lactate level should not be
ignored even if blood pressure and other vital signs are normal. Procalcitonin
levels are a marker for inflammation and signal bacterial sepsis. Procalcitonin
levels should be drawn to monitor therapy, but it is unlikely that any clinically
important change would be noted in a 4- to 6-hour time period. If procalcitonin
levels normalize then discontinuation of antibiotic therapy can be considered.
Blood cultures are already pending, and repeat cultures would have a low yield in
the presence of ongoing antibiotic therapy. Likewise, a WBC count would not be
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