ABFM KSA - Care of Hospitalized
Patients
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) - ANSWER 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 -
ANSWER 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 - ANSWER
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 4300-10,8 -
ANSWER 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 includ - ANSWER
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
Patients
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) - ANSWER 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 -
ANSWER 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 - ANSWER
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 4300-10,8 -
ANSWER 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 includ - ANSWER
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
