ABFM KSA - Care of Hospitalized Patients
1. CT would usually be indicated as C
the initial imaging study for which
one of the following patients? The use of CT has increased sig-
An 8-year-old with a 2-day history nificantly in recent years due to in-
of nausea, anorexia, and periumbil- creased availability, better resolution,
ical pain that has migrated to the and faster scan times. However, there
right lower quadrant with localized are rising concerns about cumulative
tenderness, guarding, and leukocy- radiation exposure and an increasing
tosis with a left shift need to contain costs in medicine. To
A 43-year-old with a 1-day history assist clinicians in making wise use of
of epigastric pain and nausea with all imaging techniques, the American
vomiting, and elevated serum lipase College of Radiology (ACR) has de-
A 66-year-old with diffuse abdomi- veloped appropriateness criteria that
nal pain, leukocytosis, and fever recommend modalities for various clin-
A 55-year-old with unrelenting se- ical problems.Patients with undifferen-
vere low back pain associated with tiated abdominal pain often present a
right leg pain and weakness diagnostic challenge because of the
A 68-year-old with crushing, ret- wide range of pathology or organ in-
rosternal chest pain, an EKG show- volvement that can produce this symp-
ing sinus tachycardia with left bun- tom. Fever associated with abdomi-
dle branch block, and a cardiac tro- nal pain increases the likelihood of
ponin I level of 14 ng/mL (N <0.04) intra-abdominal infection, abscess, or
other conditions that may require an
urgent definitive diagnosis or interven-
tion. In one retrospective study, CT
results changed the leading diagno-
sis in 51% of patients and the deci-
sion to admit patients presenting to the
emergency department with abdomi-
nal pain in 25% of patients.In contrast,
no imaging may be indicated when the
diagnosis is straightforward based on
other clinical indicators. Ultrasonogra-
phy should be the first imaging study
in a pediatric patient with a classic his-
tory and physical and laboratory find-
ings of appendicitis. Similarly, while CT
is unlikely to provide useful additional
information in a patient with unequiv-
, ABFM KSA - Care of Hospitalized Patients
ocal, uncomplicated acute pancreati-
tis, ultrasonography is a reasonable
first imaging study to evaluate for gall-
stones. Patients with suspected acute
coronary syndrome should be taken
for coronary angiography without de-
lay. A patient with severe back pain
and leg weakness should be evaluat-
ed with MRI.
2. A 75-year-old male is hospitalized B
with new-onset atrial fibrillation and
a rapid ventricular rate. His current It is generally not recommended to
medical problems include COPD, give a loading dose of warfarin, as the
hypertension, coronary artery dis- benefit is minimal, especially if treating
ease, and depression. A metabolic atrial fibrillation. There is no benefit to
panel including a magnesium level administering digoxin or metoprolol in-
is normal on admission.After a dilti- travenously once the patient has con-
azem continuous intravenous infu- verted to sinus rhythm. Apixaban and
sion his pulse rate is 85 beats/min other direct oral anticoagulants are
and irregular. The following morn- recommended for stroke prophylaxis
ing he converts to normal sinus and should be initiated as soon as pos-
rhythm.Which one of the following sible. This could have been started at
would be appropriate at this point? the time of admission for this patient
Administer a loading dose of war- because there is no reason to wait
farin, 10 mg orally until normal sinus rhythm is achieved.
Start apixaban (Eliquis), 5 mg twice The dosage should be lowered to 2.5
daily mg twice daily for patients with two of
Stop the diltiazem infusion and ad- the following: age e80, body weight d60
minister metoprolol intravenously kg (130 lb), or serum creatinine e1.5
Stop the diltiazem infusion and mg/dL.
administer digoxin, 0.25 mg intra-
venously
3. You admit a 74-year-old patient C
to the hospital with shortness of
breath and bilateral pleural effu- CT can detect effusions not apparent
sions seen on a chest radiograph. on plain radiographs, distinguish be-
Which one of the following is true tween pleural fluid and pleural thick-
, ABFM KSA - Care of Hospitalized Patients
regarding pleural effusions? ening, and provide clues to the un-
Noncontrast CT should be per- derlying cause. Contrast CT is recom-
formed initially in all patients with mended to provide additional informa-
pleural effusions if the cause is un- tion that can be used in making the di-
known agnosis. Thoracentesis should not be
Ultrasound-guided thoracentesis performed in patients with bilateral ef-
should be performed on admission fusions if the clinical findings strongly
in all patients with small bilateral suggest a pleural transudate, unless
pleural effusions there are atypical features (fever, pleu-
In patients with heart failure who ritic chest pain, or widely asymmet-
are treated with diuretics, pleural ric effusion size) or the effusion fails
effusions may be misclassified as to respond to therapy (SOR C). Tho-
exudative rather than transudative racentesis should be performed with
Negative cytology on an adequate ultrasound guidance, when possible,
sample of pleural fluid (e10 mL) ef- to improve the likelihood of success-
fectively rules out malignancy as ful aspiration and decrease the risk of
the cause of a unilateral pleural ef- organ puncture, especially when effu-
fusion sions are small. About 20% of patients
with a pleural effusion caused by heart
failure may fulfill the criteria for an ex-
udative effusion after receiving diuret-
ics. In these cases, if the difference be-
tween 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).Cytol-
ogy is positive in approximately 60%
of malignant pleural effusions (SOR
B). The diagnostic yield may be im-
proved by additional pleural taps. If
malignancy is still a concern, thora-
coscopy should be considered (SOR
C).
4. A 44-year-old female presents to C
the emergency department with 2-3
days of epigastric abdominal pain, In patients with gallstone pancreatitis,
vomiting, low-grade fever, and cholecystectomy should be performed
anorexia. She has not had any prior to discharge unless the patient
, ABFM KSA - Care of Hospitalized Patients
change in bowel habits, and no has contraindications to surgery or
cough, chest pain, or shortness of has severe acute pancreatitis with
breath. Her past medical history necrosis. This results in shorter hos-
includes moderate persistent pital stays with no increased risk of
asthma, diet-controlled type 2 complications, and prevents the read-
diabetes, and hypertension.You mission and risk of recurrence as-
see the patient on the medical floor sociated with delaying surgery un-
for admission. On examination the til after discharge. Cholecystectomy
patient is uncomfortable and looks within 12 hours of admission is not
ill. She has a temperature of 37.8°C necessary, especially if endoscopic
(100.0°F), a heart rate of 120 retrograde cholangiopancreatography
beats/min, a respiratory rate of (ERCP) will be performed prior to
18/min, a blood pressure of 120/70 surgery.
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)Hemoglo-
bin............15.0 g/dL (N
12.0-16.0)Platelets............450,000/mm3
(N
130,000-400,000)Sodi-
um............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
