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ABFM KSA EXAM 2024 AND STUDY GUIDE
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ABFM KSA EXAM 2024 AND STUDY GUIDE | CONTAINS 60 ACCURATE EXAM QUESTIONS AND ANSWERS WITH RATIONALES | VERIFIED FOR GUARANTEED PASS | EXPERT VERIFIED LATEST UPDATE
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ABFM KSA EXAM 2024 AND STUDY GUIDE |CONTAINS 60 ACCURATE EXAM QUESTIONS AND
ANSWERS WITH RATIONALES | VERIFIED FOR
GUARANTEED PASS | EXPERT VERIFIED LATEST
UPDATE
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. 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 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)
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-
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
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