Page 1 of 87
ABFM KSA:Care of Hospitalized Patients Exam WITH 600
QUESTIONS AND CORRECT DETAILED RATIONALISED
SOLUTIONS LATEST UPDATED VERSION JUST RELEASED
NEWEST!!
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
, Page 2 of 87
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?
, Page 3 of 87
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.
A 75-year-old female was recently hospitalized with suspected aspiration pneumonia and was
treated with a 10-day course of amoxicillin/clavulanate (Augmentin). Her initial symptoms
have resolved, but this evening she presents to the emergency department with fever, chills,
diffuse abdominal pain, and recurrent diarrhea. On examination she has a temperature of
38.6°C (101.5°F), a heart rate of 105 beats/min, and a blood pressure of 110/70 mm Hg. She
appears mildly dehydrated and an abdominal examination reveals mild, diffuse tenderness
without rebound or guarding, and slightly hyperactive bowel sounds. She is admitted to the
hospital for treatment.In addition to fluids and electrolyte management, the initial treatment
of choice is
loperamide (Imodium)
oral fidaxomicin (Dificid)
oral metronidazole (Flagyl)
, Page 4 of 87
intravenous metronidazole
intravenous vancomycin
B
Clostridioides (Clostridium) difficile colitis is a common condition, typically occurring in patients
recently treated with antibiotics and often resulting in hospitalization. The initial treatment of a
patient with C. difficile–associated diarrhea should include discontinuation of offending
antibiotics if possible, routine supportive care including fluid and electrolyte management, and
treatment with oral vancomycin or fidaxomicin. In a meta-analysis and systematic review
fidaxomicin performed better than oral vancomycin and was cost effective even though it is
more expensive. Oral metronidazole is no longer recommended for treatment of C.
difficile infection because the rate of treatment failure with metronidazole is increasing, with a
rate of nonresponse now >20%. However, in patients who are more acutely ill, combination
therapy with intravenous metronidazole and oral vancomycin is recommended.Clindamycin,
broad-spectrum penicillins, and cephalosporins are the antibiotics most often associated with
the development of C. difficile colitis and have no efficacy against the infection (SOR B).
Fluoroquinolones have also not been shown to be effective. Routine use of antimotility agents
such as loperamide is discouraged due to the increased risk of toxin-related disease (SOR B).
While oral vancomycin is effective in eradicating C. difficile from the colon, intravenous
vancomycin has no effect against C. difficile.
A new order set has just been implemented in your hospital for the treatment of sepsis. Since
it was put into place there has been a sharp increase in cases of acute kidney injury in the
intensive-care unit.Which one of the following would NOT be beneficial for decreasing
nephrotoxicity from medications?
Reassessing the medications used in the order set to find equally effective but less toxic
treatments
Instituting systems to identify high-risk patients before a potentially toxic medication is
dispensed
Keeping patients' effective fluid volume low when administering potentially nephrotoxic
ABFM KSA:Care of Hospitalized Patients Exam WITH 600
QUESTIONS AND CORRECT DETAILED RATIONALISED
SOLUTIONS LATEST UPDATED VERSION JUST RELEASED
NEWEST!!
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
, Page 2 of 87
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?
, Page 3 of 87
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.
A 75-year-old female was recently hospitalized with suspected aspiration pneumonia and was
treated with a 10-day course of amoxicillin/clavulanate (Augmentin). Her initial symptoms
have resolved, but this evening she presents to the emergency department with fever, chills,
diffuse abdominal pain, and recurrent diarrhea. On examination she has a temperature of
38.6°C (101.5°F), a heart rate of 105 beats/min, and a blood pressure of 110/70 mm Hg. She
appears mildly dehydrated and an abdominal examination reveals mild, diffuse tenderness
without rebound or guarding, and slightly hyperactive bowel sounds. She is admitted to the
hospital for treatment.In addition to fluids and electrolyte management, the initial treatment
of choice is
loperamide (Imodium)
oral fidaxomicin (Dificid)
oral metronidazole (Flagyl)
, Page 4 of 87
intravenous metronidazole
intravenous vancomycin
B
Clostridioides (Clostridium) difficile colitis is a common condition, typically occurring in patients
recently treated with antibiotics and often resulting in hospitalization. The initial treatment of a
patient with C. difficile–associated diarrhea should include discontinuation of offending
antibiotics if possible, routine supportive care including fluid and electrolyte management, and
treatment with oral vancomycin or fidaxomicin. In a meta-analysis and systematic review
fidaxomicin performed better than oral vancomycin and was cost effective even though it is
more expensive. Oral metronidazole is no longer recommended for treatment of C.
difficile infection because the rate of treatment failure with metronidazole is increasing, with a
rate of nonresponse now >20%. However, in patients who are more acutely ill, combination
therapy with intravenous metronidazole and oral vancomycin is recommended.Clindamycin,
broad-spectrum penicillins, and cephalosporins are the antibiotics most often associated with
the development of C. difficile colitis and have no efficacy against the infection (SOR B).
Fluoroquinolones have also not been shown to be effective. Routine use of antimotility agents
such as loperamide is discouraged due to the increased risk of toxin-related disease (SOR B).
While oral vancomycin is effective in eradicating C. difficile from the colon, intravenous
vancomycin has no effect against C. difficile.
A new order set has just been implemented in your hospital for the treatment of sepsis. Since
it was put into place there has been a sharp increase in cases of acute kidney injury in the
intensive-care unit.Which one of the following would NOT be beneficial for decreasing
nephrotoxicity from medications?
Reassessing the medications used in the order set to find equally effective but less toxic
treatments
Instituting systems to identify high-risk patients before a potentially toxic medication is
dispensed
Keeping patients' effective fluid volume low when administering potentially nephrotoxic
