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ABPS Hospital Medicine study materials
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ABPS Hospital Medicine practice questions

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Question 1Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 68-year-old man with atrial fibrillation is admitted with pneumonia. His CHA2DS2-VASc score is 4. Which anticoagulation strategy is most appropriate during hospitalization?

  1. Continue therapeutic anticoagulation with a direct oral anticoagulant or warfarin Correct answer.
  2. Start prophylactic-dose low-molecular-weight heparin
  3. Hold all anticoagulation until infection resolves
  4. Start aspirin 81 mg daily

Explanation

Patients with a CHA2DS2-VASc score of 2 or higher in men warrant therapeutic anticoagulation, and acute illness does not generally justify interruption. Bridging to prophylactic dosing or aspirin does not provide adequate stroke prevention. Anticoagulation should be continued unless there is active bleeding or another contraindication.

Question 2Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which finding most strongly suggests that a hospitalized patient's delirium is due to a non-convulsive seizure rather than a metabolic cause?

  1. Hyperactive reflexes with clonus
  2. Symmetric asterixis
  3. Brief unresponsiveness with postictal confusion Correct answer.
  4. Fluctuating attention with myoclonic jerks

Explanation

Non-convulsive status epilepticus often presents as altered mental status with stereotyped episodes of unresponsiveness followed by a postictal phase. Asterixis and myoclonus point toward metabolic encephalopathy. EEG is required to confirm the diagnosis.

Question 3Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient is scheduled for elective surgery and takes clopidogrel for a drug-eluting coronary stent placed 4 months ago. What is the most appropriate perioperative management?

  1. Delay elective surgery until dual antiplatelet therapy can be safely modified per cardiology guidance Correct answer.
  2. Stop clopidogrel 5 days before surgery without bridging
  3. Proceed with surgery and continue clopidogrel
  4. Switch to aspirin monotherapy immediately before surgery

Explanation

Premature discontinuation of dual antiplatelet therapy after recent stent placement risks stent thrombosis, so elective surgery should generally be deferred until the minimum mandatory duration has elapsed. The decision requires cardiology input. Simply stopping the drug or substituting aspirin does not mitigate stent thrombosis risk.

Question 4Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which laboratory abnormality is most consistent with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

  1. Serum osmolality 270 mOsm/kg with urine osmolality 400 mOsm/kg and hypovolemia
  2. Serum osmolality 265 mOsm/kg with urine osmolality 600 mOsm/kg and euvolemia Correct answer.
  3. Serum osmolality 285 mOsm/kg with urine osmolality 100 mOsm/kg
  4. Serum osmolality 250 mOsm/kg with urine osmolality 80 mOsm/kg

Explanation

SIADH requires hypotonic hyponatremia with inappropriately concentrated urine (urine osmolality typically >100 mOsm/kg) in a euvolemic patient with normal thyroid and adrenal function. The combination of low serum osmolality and high urine osmolality reflects continued ADH activity.

Question 5Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 72-year-old with decompensated heart failure has a creatinine of 2.1 mg/dL (baseline 1.3) and is on furosemide. Which management step is most appropriate?

  1. Continue diuresis if the patient remains congested and the rise is modest Correct answer.
  2. Proceed directly to ultrafiltration
  3. Start a nephrotoxic antibiotic empirically
  4. Stop diuretics and give intravenous fluids

Explanation

A modest rise in creatinine during aggressive diuresis in a congested patient often reflects hemoconcentration and does not mandate stopping diuresis. The goal is decongestion; worsening renal function alone in this setting does not consistently worsen outcomes. Diuretics should be continued if the patient remains volume overloaded.

Question 6Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which of the following is the most common cause of community-acquired pneumonia requiring hospitalization in the United States?

  1. Haemophilus influenzae
  2. Legionella pneumophila
  3. Streptococcus pneumoniae Correct answer.
  4. Mycoplasma pneumoniae

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia across all severity levels, including hospitalized patients. Atypical organisms and Haemophilus are less common overall. Empiric regimens therefore always cover pneumococcus.

Question 7Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient with cirrhosis and ascites presents with fever and abdominal pain. Diagnostic paracentesis shows 400 polymorphonuclear cells/mm³. What is the most appropriate next step?

  1. Start intravenous cefotaxime and albumin Correct answer.
  2. Place a peritoneal drain
  3. Start lactulose
  4. Await culture results before starting antibiotics

Explanation

Spontaneous bacterial peritonitis is diagnosed with an ascitic fluid PMN count of 250 cells/mm³ or greater, and empiric intravenous third-generation cephalosporin should be started immediately. Adding albumin reduces the risk of hepatorenal syndrome and mortality. Waiting for cultures delays life-saving therapy.

Question 8Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which finding best distinguishes diabetic ketoacidosis from hyperosmolar hyperglycemic state?

  1. Presence of infection as a precipitant
  2. Serum osmolality greater than 320 mOsm/kg
  3. Serum bicarbonate less than 18 mEq/L with ketonemia Correct answer.
  4. Serum glucose greater than 500 mg/dL

Explanation

DKA is defined by the triad of hyperglycemia, ketonemia, and high-anion-gap metabolic acidosis, reflected in a low bicarbonate. HHS typically lacks significant ketosis and acidosis despite marked hyperosmolality. Both can share triggers such as infection.

Question 9Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 55-year-old with alcohol use disorder is admitted with confusion and ataxia. He is given intravenous thiamine. Which additional electrolyte abnormality should be corrected to prevent Wernicke encephalopathy progression?

  1. Hypocalcemia
  2. Hyperkalemia
  3. Hypomagnesemia Correct answer.
  4. Hyperphosphatemia

Explanation

Hypomagnesemia impairs thiamine utilization and is common in alcohol use disorder, so magnesium should be repleted alongside thiamine. Hypocalcemia may coexist but is not the primary driver of Wernicke progression. Magnesium repletion also helps correct refractory hypokalemia.

Question 10Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which intervention has the strongest evidence for reducing the incidence of ventilator-associated pneumonia?

  1. Routine prophylactic antibiotics
  2. Elevating the head of the bed to 30-45 degrees Correct answer.
  3. Scheduled ventilator circuit changes every 48 hours
  4. Daily chest radiographs

Explanation

Head-of-bed elevation to 30-45 degrees is a core component of ventilator-associated pneumonia prevention bundles, along with sedation interruption and oral care. Routine circuit changes and prophylactic antibiotics do not reduce VAP and may cause harm. Daily chest radiographs have not been shown to prevent VAP.

Question 11Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient with a history of heparin-induced thrombocytopenia (HIT) requires anticoagulation for a new pulmonary embolism. Which agent is most appropriate?

  1. Unfractionated heparin
  2. Enoxaparin
  3. Argatroban Correct answer.
  4. Warfarin alone initially

Explanation

Patients with prior HIT must avoid heparin and low-molecular-weight heparin because of the risk of recurrent HIT and thrombosis. Direct thrombin inhibitors such as argatroban are the preferred agents. Warfarin alone is inappropriate acutely because it can worsen thrombosis before anticoagulation is established.

Question 12Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which clinical feature is most characteristic of acute adrenal crisis in a hospitalized patient?

  1. Hypertension with hypokalemia
  2. Hyperglycemia with metabolic alkalosis
  3. Bradycardia with hypercalcemia
  4. Hypotension refractory to fluids with hyponatremia and hyperkalemia Correct answer.

Explanation

Adrenal crisis presents with volume depletion and shock that is often refractory to fluids, along with hyponatremia, hyperkalemia, and hypoglycemia due to aldosterone and cortisol deficiency. Prompt hydrocortisone and fluid resuscitation are required. Hyperkalemia and hyponatremia reflect mineralocorticoid deficiency.

Question 13Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient with severe community-acquired pneumonia has a CURB-65 score of 3. What is the most appropriate disposition?

  1. Admit to the intensive care unit for mechanical ventilation
  2. Observe in the emergency department for 4 hours then discharge
  3. Discharge home on oral antibiotics
  4. Admit to the hospital for intravenous antibiotics and monitoring Correct answer.

Explanation

A CURB-65 score of 2 or more generally warrants hospital admission, and scores of 3 or higher indicate severe pneumonia requiring close monitoring. ICU admission is reserved for patients with respiratory failure, septic shock, or other organ dysfunction. Antibiotics should be started promptly.

Question 14Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which of the following is the most appropriate initial fluid resuscitation strategy for a patient with septic shock and no contraindications?

  1. 500 mL of 0.9% saline over 24 hours
  2. 250 mL of 5% albumin as the first fluid
  3. Restrict fluids and start norepinephrine immediately
  4. 30 mL/kg of balanced crystalloid or 0.9% saline within the first 3 hours Correct answer.

Explanation

Surviving Sepsis Campaign guidance recommends at least 30 mL/kg of intravenous crystalloid within the first 3 hours for sepsis-induced hypoperfusion. Balanced crystalloids are often preferred, though 0.9% saline is acceptable. Vasopressors are added if hypotension persists despite adequate fluids.

Question 15Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 60-year-old with type 2 diabetes is admitted for surgery. His HbA1c is 9.5% and he takes metformin and glipizide. Which perioperative approach is most appropriate?

  1. Continue metformin and start a sulfonylurea dose increase
  2. Continue glipizide on the morning of surgery
  3. Hold metformin and glipizide on the day of surgery and use insulin sliding scale or basal insulin Correct answer.
  4. Stop all diabetes medications for 1 week before surgery

Explanation

Sulfonylureas should be held on the day of surgery to avoid hypoglycemia, and metformin is typically held around surgery because of the risk of lactic acidosis with renal hypoperfusion. Insulin-based management is preferred for glycemic control in the perioperative period.

Question 16Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which of the following best describes the appropriate use of stress-dose corticosteroids in septic shock?

  1. Give corticosteroids only if the random cortisol is below 5 mcg/dL
  2. Give dexamethasone to all patients with sepsis on admission
  3. Add hydrocortisone when shock persists despite adequate fluids and vasopressors Correct answer.
  4. Use corticosteroids as first-line therapy before vasopressors

Explanation

Stress-dose hydrocortisone is generally reserved for septic shock that remains vasopressor-dependent despite adequate fluid resuscitation. Routine corticosteroids for all sepsis or as first-line therapy are not recommended. Cortisol testing is not required to initiate therapy in this setting.

Question 17Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient with advanced cirrhosis develops confusion, asterixis, and a serum ammonia of 120 µmol/L. Which treatment is most appropriate?

  1. Intravenous flumazenil
  2. Lactulose titrated to two to three soft stools per day Correct answer.
  3. Protein restriction to 20 g per day
  4. Rifaximin alone

Explanation

Lactulose is first-line therapy for hepatic encephalopathy, titrated to two to three soft bowel movements daily. Rifaximin is typically added for secondary prophylaxis after a second episode. Severe protein restriction is not recommended because it worsens malnutrition.

Question 18Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 45-year-old is admitted with severe acute pancreatitis. Which intervention improves outcomes?

  1. Prophylactic broad-spectrum antibiotics
  2. Immediate ERCP in all patients
  3. Early aggressive intravenous fluid resuscitation with lactated Ringer's Correct answer.
  4. Immediate nasogastric feeding with a high-fat formula

Explanation

Early aggressive fluid resuscitation, often with lactated Ringer's solution, is a cornerstone of acute pancreatitis management and reduces complications. Prophylactic antibiotics are not recommended in the absence of infection. Early enteral feeding is favored, but a low-fat formula is preferred over high-fat.

Question 19Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which finding is most consistent with a diagnosis of upper gastrointestinal bleeding from a peptic ulcer?

  1. Bright red blood per rectum with hemodynamic stability
  2. Occult blood-positive stool with iron deficiency anemia
  3. Coffee-ground emesis with melena Correct answer.
  4. Hematochezia with normal nasogastric lavage

Explanation

Coffee-ground emesis and melena are classic signs of upper gastrointestinal bleeding, often from peptic ulcer disease. Hematochezia more commonly reflects a lower source, though brisk upper bleeding can present this way. Occult blood positivity alone is nonspecific.

Question 20Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient with a mechanical mitral valve on warfarin has an INR of 6.5 and is not bleeding. What is the most appropriate management?

  1. Hold warfarin and consider low-dose oral vitamin K, then resume at a lower dose when INR is therapeutic Correct answer.
  2. Continue the same warfarin dose and recheck in 1 week
  3. Give vitamin K 10 mg intravenously and fresh frozen plasma
  4. Give protamine sulfate

Explanation

For an INR above therapeutic range without bleeding, warfarin is typically held and low-dose oral vitamin K may be considered, especially at higher INR values. High-dose intravenous vitamin K and plasma are reserved for serious bleeding. Protamine reverses heparin, not warfarin.

Question 21Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which of the following is the most appropriate initial imaging study for a hemodynamically stable patient with suspected pulmonary embolism and normal renal function?

  1. Ventilation-perfusion scan
  2. Chest radiograph
  3. Computed tomography pulmonary angiography Correct answer.
  4. Lower extremity ultrasound

Explanation

CT pulmonary angiography is the preferred initial imaging modality for hemodynamically stable patients with suspected pulmonary embolism and adequate renal function. V/Q scanning is reserved for patients with contrast allergy or renal impairment. Lower extremity ultrasound is useful when CT is contraindicated.

Question 22Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient on chronic opioid therapy is admitted with acute pain. Which principle best guides inpatient pain management?

  1. Rely solely on nonsteroidal anti-inflammatory drugs
  2. Use equianalgesic conversion and continue baseline opioid requirements plus additional analgesia for acute pain Correct answer.
  3. Restrict opioid dosing to the prior outpatient dose regardless of pain
  4. Discontinue all opioids to prevent dependence

Explanation

Patients on chronic opioids have tolerance and require continuation of their baseline equianalgesic dose plus additional analgesia for acute pain. Abrupt discontinuation risks withdrawal and uncontrolled pain. Opioid-sparing adjuncts are useful but not a sole substitute in severe acute pain.

Question 23Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient with decompensated cirrhosis has a prolonged INR of 2.3 and is scheduled for a paracentesis. What is the most appropriate management?

  1. Give fresh frozen plasma to correct the INR before the procedure
  2. Give vitamin K and delay the procedure 24 hours
  3. Proceed with the procedure without correcting the INR Correct answer.
  4. Cancel the procedure indefinitely

Explanation

The INR in cirrhosis reflects liver synthetic dysfunction rather than a true bleeding diathesis, and paracentesis is generally safe without correction. Routine plasma transfusion is not indicated and can cause volume overload and complications. Vitamin K deficiency is uncommon as the sole cause in decompensated cirrhosis.

Question 24Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

Which of the following is the most appropriate initial ventilator strategy for a patient with acute respiratory distress syndrome?

  1. High tidal volume with permissive hypercapnia
  2. Tidal volume of 12 mL/kg predicted body weight with high plateau pressures
  3. Tidal volume of 6 mL/kg predicted body weight with plateau pressure below 30 cm H2O Correct answer.
  4. Pressure support ventilation alone

Explanation

Lung-protective ventilation with a tidal volume of 6 mL/kg predicted body weight and plateau pressure below 30 cm H2O reduces mortality in ARDS. Higher tidal volumes cause volutrauma. Pressure support alone is generally insufficient for moderate to severe ARDS.

Question 25Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A patient is admitted with a suspected transfusion reaction during a packed red blood cell transfusion. What is the first step in management?

  1. Obtain a chest radiograph before stopping the transfusion
  2. Slow the transfusion and give diphenhydramine
  3. Give additional units to complete the target hemoglobin
  4. Stop the transfusion and maintain intravenous access Correct answer.

Explanation

The first step in any suspected transfusion reaction is to stop the transfusion immediately and maintain intravenous access with crystalloid. Further evaluation and treatment depend on the type of reaction. Continuing or slowing the transfusion risks worsening harm.

Question 26Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 68-year-old man is admitted with a 3-day history of productive cough, fever, and dyspnea. Chest radiograph shows a right lower lobe infiltrate. Which of the following is the most appropriate initial antibiotic regimen for community-acquired pneumonia in a patient requiring hospitalization on a general ward?

  1. Azithromycin monotherapy
  2. Levofloxacin plus vancomycin
  3. Ceftriaxone plus azithromycin Correct answer.
  4. Ampicillin-sulbactam plus gentamicin

Explanation

For hospitalized patients with community-acquired pneumonia who are not in the ICU, guidelines recommend a beta-lactam plus a macrolide or a respiratory fluoroquinolone alone. Ceftriaxone plus azithromycin is a standard regimen covering typical and atypical pathogens. Levofloxacin plus vancomycin is broader than necessary and risks unnecessary vancomycin use.

Question 27Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 72-year-old woman is admitted with acute decompensated heart failure. She is hypotensive with a blood pressure of 82/50 mm Hg, has cool extremities, and has a lactate of 4.2 mmol/L. Which of the following is the most appropriate initial management?

  1. Norepinephrine and inotropic support Correct answer.
  2. Intravenous furosemide
  3. High-dose nitroglycerin
  4. Aggressive intravenous fluid bolus

Explanation

This patient has cardiogenic shock, indicated by hypotension, hypoperfusion (cool extremities, elevated lactate), and evidence of heart failure. Initial management includes vasopressors (norepinephrine) to maintain perfusion and inotropic support to improve cardiac output. Diuretics and nitrates are used for congestion without shock, and fluid boluses can worsen pulmonary edema.

Question 28Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 55-year-old man is admitted with a COPD exacerbation. He has a pH of 7.28, PaCO2 of 65 mm Hg, and PaO2 of 55 mm Hg on room air. Which of the following is the most appropriate initial oxygen therapy?

  1. High-flow oxygen to maintain SpO2 at 100%
  2. Intravenous corticosteroids alone
  3. Immediate endotracheal intubation
  4. Noninvasive positive pressure ventilation Correct answer.

Explanation

This patient has acute hypercapnic respiratory acidosis due to COPD exacerbation. Noninvasive positive pressure ventilation (NPPV) is the preferred initial therapy for respiratory acidosis (pH <7.35 and PaCO2 >45 mm Hg) because it reduces intubation rates and mortality. High-flow oxygen can worsen hypercapnia, and intubation is reserved for failure of NPPV or severe deterioration.

Question 29Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 30-year-old woman is admitted with diabetic ketoacidosis. After initial fluid resuscitation, her blood glucose is 450 mg/dL, and her potassium is 5.2 mEq/L. Which of the following is the most appropriate next step in management?

  1. Give intravenous sodium bicarbonate
  2. Hold insulin until potassium is below 5.0 mEq/L
  3. Administer intravenous calcium gluconate
  4. Start an insulin infusion and recheck potassium in 2 hours Correct answer.

Explanation

In DKA, insulin therapy is indicated to close the anion gap and reduce glucose, even when potassium is elevated, because total body potassium is depleted and insulin will drive potassium into cells. Potassium should be monitored closely and replaced when it falls below 5.0-5.2 mEq/L. Bicarbonate is not routinely recommended unless pH is severely low (<6.9).

Question 30Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 65-year-old man is admitted with an acute exacerbation of heart failure. He has a history of gout and chronic kidney disease stage 3. Which of the following diuretic strategies is most appropriate for his volume overload?

  1. Oral spironolactone
  2. Oral hydrochlorothiazide
  3. Intravenous mannitol
  4. Intravenous furosemide Correct answer.

Explanation

Intravenous loop diuretics such as furosemide are the mainstay for acute decompensated heart failure with volume overload, especially when oral absorption may be impaired. Thiazides are less effective in CKD and can worsen gout, spironolactone is not for acute diuresis and risks hyperkalemia, and mannitol is an osmotic diuretic not used for heart failure.

Question 31Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 70-year-old woman is admitted with a non-ST-elevation myocardial infarction. She is hemodynamically stable and pain-free after nitroglycerin. Which of the following is the most appropriate timing for coronary angiography?

  1. Immediate angiography within 2 hours
  2. No angiography unless symptoms recur
  3. Early invasive strategy within 24 hours Correct answer.
  4. Elective angiography after 72 hours

Explanation

For patients with NSTEMI who are hemodynamically stable, an early invasive strategy within 24 hours is recommended, especially with elevated troponin and risk features. Immediate angiography is reserved for cardiogenic shock or refractory ischemia, and a conservative approach is less favored in high-risk NSTEMI.

Question 32Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 50-year-old man is admitted with severe acute pancreatitis. He has persistent organ failure and a high CRP. Which of the following is the most appropriate nutritional strategy?

  1. Total parenteral nutrition
  2. Nasojejunal tube feeding
  3. Nasogastric tube feeding Correct answer.
  4. Clear liquid diet

Explanation

Enteral nutrition is preferred over parenteral nutrition in severe acute pancreatitis to maintain gut barrier function and reduce infectious complications. Nasogastric feeding is as effective as nasojejunal and is easier to place. Parenteral nutrition is reserved for patients who cannot tolerate enteral feeding.

Question 33Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 60-year-old woman is admitted with a upper gastrointestinal bleed. She is hemodynamically stable after initial resuscitation. Which of the following is the most appropriate next step in management?

  1. Immediate surgery
  2. Transfuse platelets
  3. Start a proton pump inhibitor infusion and observe
  4. Upper endoscopy within 24 hours Correct answer.

Explanation

For patients with upper GI bleeding who are hemodynamically stable after resuscitation, upper endoscopy within 24 hours is recommended for diagnosis and potential therapeutic intervention. Immediate surgery is reserved for refractory bleeding, and PPI infusion alone without endoscopy is insufficient. Platelet transfusion is not indicated unless thrombocytopenia is severe or there is active bleeding with platelet dysfunction.

Question 34Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 45-year-old man is admitted with confusion and ataxia. He has a history of alcohol use disorder. He is given intravenous thiamine. Which of the following is the most appropriate next step to prevent Wernicke encephalopathy?

  1. Give oral thiamine only
  2. Give intravenous glucose before thiamine
  3. Give thiamine before or with glucose Correct answer.
  4. Give intravenous magnesium

Explanation

In patients with alcohol use disorder and suspected Wernicke encephalopathy, thiamine should be administered before or concurrently with glucose to prevent precipitation of Wernicke encephalopathy. Glucose alone can worsen thiamine deficiency. Oral thiamine is insufficient for acute treatment, and magnesium is not the primary preventive measure.

Question 35Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 55-year-old man is admitted with acute decompensated heart failure and atrial fibrillation with rapid ventricular response. He is hypotensive with a blood pressure of 88/60 mm Hg. Which of the following is the most appropriate initial rate control strategy?

  1. Intravenous amiodarone Correct answer.
  2. Intravenous metoprolol
  3. Oral digoxin
  4. Intravenous diltiazem

Explanation

In atrial fibrillation with rapid ventricular response and hypotension, intravenous amiodarone is preferred for rate control because beta-blockers and calcium channel blockers can worsen hypotension. Amiodarone has less negative inotropic effect. Digoxin is slow-acting and not first-line for acute rate control.

Question 36Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 60-year-old woman is admitted with a suspected pulmonary embolism. She is hemodynamically stable with a heart rate of 100 bpm and oxygen saturation of 94% on room air. Which of the following is the most appropriate initial diagnostic test?

  1. D-dimer assay
  2. Ventilation-perfusion scan
  3. CT pulmonary angiography Correct answer.
  4. Lower extremity ultrasound

Explanation

For a hemodynamically stable patient with suspected pulmonary embolism and a high pretest probability (e.g., based on Wells score), CT pulmonary angiography is the diagnostic test of choice. D-dimer is used to rule out PE in low or intermediate pretest probability; V/Q scan is an alternative if CT is contraindicated; ultrasound is used if CT is not available or contraindicated.

Question 37Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 70-year-old man with a history of heart failure and chronic kidney disease is admitted with pneumonia. He is started on ceftriaxone and azithromycin. On day 3, he develops watery diarrhea and is found to have Clostridioides difficile infection. Which of the following is the most appropriate initial treatment?

  1. Oral vancomycin Correct answer.
  2. Oral fidaxomicin
  3. Intravenous vancomycin
  4. Intravenous metronidazole

Explanation

For initial treatment of Clostridioides difficile infection, oral vancomycin or oral fidaxomicin is recommended, especially for severe cases. Intravenous metronidazole is an alternative for mild disease when oral therapy is not possible. Intravenous vancomycin is not effective for C. difficile because it does not reach the colon lumen.

Question 38Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 65-year-old man with a history of cirrhosis and ascites is admitted with fever and abdominal pain. Diagnostic paracentesis shows 500 polymorphonuclear cells/mm³. Which of the following is the most appropriate initial antibiotic?

  1. Intravenous metronidazole
  2. Oral ciprofloxacin
  3. Intravenous ceftriaxone Correct answer.
  4. Intravenous vancomycin

Explanation

Spontaneous bacterial peritonitis is diagnosed when the ascitic fluid polymorphonuclear cell count is ≥250/mm³. The most common pathogens are Enterobacteriaceae and streptococci, and a third-generation cephalosporin such as ceftriaxone is first-line therapy. Oral ciprofloxacin is used for prophylaxis, not treatment.

Question 39Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 55-year-old woman is admitted with acute respiratory distress syndrome (ARDS) from pneumonia. She is intubated and mechanically ventilated. Which of the following ventilator strategies is most appropriate?

  1. High positive end-expiratory pressure (PEEP) without lung protective ventilation
  2. High tidal volume ventilation (12 mL/kg predicted body weight)
  3. Prone positioning alone without low tidal volume ventilation
  4. Low tidal volume ventilation (6 mL/kg predicted body weight) Correct answer.

Explanation

Lung-protective ventilation with low tidal volumes (6 mL/kg predicted body weight) and plateau pressures ≤30 cm H2O is the standard of care for ARDS and reduces mortality. Higher tidal volumes can cause volutrauma. Prone positioning is an adjunct for severe ARDS but does not replace low tidal volume ventilation.

Question 40Clinical Hospital Medicine - General Internal Medicine and Perioperative Care

A 75-year-old man is admitted with a hip fracture. He is on chronic warfarin for atrial fibrillation. His INR is 3.5 on admission. Which of the following is the most appropriate perioperative management?

  1. Continue warfarin and proceed with surgery
  2. Hold warfarin and give fresh frozen plasma Correct answer.
  3. Hold warfarin and give vitamin K
  4. Hold warfarin and give prothrombin complex concentrate

Explanation

For urgent surgery in a patient on warfarin with an elevated INR, reversal is needed. Fresh frozen plasma is commonly used, but prothrombin complex concentrate is preferred for rapid reversal in life-threatening situations. Vitamin K is slow-acting and not sufficient alone for urgent reversal. Continuing warfarin increases bleeding risk.

Question 41Critical Care Medicine

A patient with septic shock remains hypotensive after 30 mL/kg of crystalloid. Which vasopressor is recommended as the first-line agent to restore mean arterial pressure?

  1. Dopamine
  2. Norepinephrine Correct answer.
  3. Vasopressin
  4. Phenylephrine

Explanation

Norepinephrine is the recommended first-line vasopressor in septic shock because it raises mean arterial pressure with less arrhythmogenicity than dopamine and is more effective than phenylephrine for this purpose. Vasopressin and phenylephrine are generally added as second-line agents or used in specific situations.

Question 42Critical Care Medicine

Which finding best defines acute respiratory distress syndrome by the Berlin definition?

  1. Bilateral opacities with PaO2/FiO2 of 350 on room air
  2. Unilateral infiltrate with PaO2/FiO2 of 150
  3. Any hypoxia with a normal chest radiograph
  4. Bilateral opacities with PaO2/FiO2 of 250 on PEEP of at least 5 cm H2O not fully explained by cardiac failure Correct answer.

Explanation

ARDS requires acute onset within one week, bilateral opacities not fully explained by effusions, lobar collapse, or nodules, and a PaO2/FiO2 ratio of 300 or less on PEEP of at least 5 cm H2O. A ratio of 250 fits the moderate category.

Question 43Critical Care Medicine

A patient is intubated for status asthmaticus. Which ventilator strategy is most appropriate initially?

  1. High tidal volume to overcome airway resistance
  2. High respiratory rate to normalize PaCO2 rapidly
  3. Low tidal volume with prolonged expiratory time and permissive hypercapnia Correct answer.
  4. Zero positive end-expiratory pressure to avoid air trapping

Explanation

In severe asthma, the goal is to avoid dynamic hyperinflation by using low tidal volumes, low respiratory rates, and long expiratory times while tolerating hypercapnia. Rapid correction of PaCO2 risks air trapping and barotrauma.

Question 44Critical Care Medicine

Which electrocardiographic finding is most characteristic of hyperkalemia in a critically ill patient?

  1. Prolonged QT interval with torsades
  2. Peaked T waves with widened QRS Correct answer.
  3. Diffuse ST elevation with PR depression
  4. Prominent U waves

Explanation

Hyperkalemia classically produces tall peaked T waves and, as it worsens, QRS widening and sine-wave morphology. These changes reflect slowed myocardial conduction.

Question 45Critical Care Medicine

A trauma patient has hypotension, distended neck veins, and muffled heart sounds. Which bedside finding would most support cardiac tamponade?

  1. Right ventricular diastolic collapse on echocardiography Correct answer.
  2. Left ventricular ejection fraction below 30 percent
  3. Mitral regurgitation on color Doppler
  4. Increased inferior vena cava collapsibility with inspiration

Explanation

Cardiac tamponade physiology is supported by echocardiographic signs of chamber compression, including right ventricular diastolic collapse and right atrial systolic collapse. These reflect elevated pericardial pressure exceeding intracardiac pressures.

Question 46Critical Care Medicine

Which parameter is used to calculate the oxygen delivery (DO2) to tissues?

  1. Pulmonary capillary wedge pressure divided by systemic vascular resistance
  2. Arterial oxygen saturation divided by cardiac index
  3. Cardiac output multiplied by arterial oxygen content Correct answer.
  4. Mixed venous oxygen saturation multiplied by hemoglobin

Explanation

Oxygen delivery equals cardiac output times arterial oxygen content, where content depends on hemoglobin and saturation. This relationship explains why anemia and low output both reduce tissue oxygen delivery.

Question 47Critical Care Medicine

A patient with acute decompensated heart failure and cardiogenic shock has cold extremities and a low cardiac index. Which agent provides both inotropic support and vasodilation?

  1. Norepinephrine
  2. Furosemide
  3. Phenylephrine
  4. Milrinone Correct answer.

Explanation

Milrinone is a phosphodiesterase-3 inhibitor that increases contractility and produces vasodilation, making it an inodilator. It is used in cardiogenic shock when inotropic support with afterload reduction is desired.

Question 48Critical Care Medicine

Which ventilator setting change is most appropriate to reduce the risk of ventilator-induced lung injury in a patient with ARDS?

  1. Target plateau pressure below 30 cm H2O with tidal volumes of 4 to 8 mL/kg predicted body weight Correct answer.
  2. Target peak inspiratory pressure below 50 cm H2O only
  3. Increase tidal volume to 12 mL/kg to improve oxygenation
  4. Use zero PEEP to minimize barotrauma

Explanation

Lung-protective ventilation in ARDS uses low tidal volumes based on predicted body weight and targets plateau pressure below 30 cm H2O to limit alveolar overdistension. This strategy reduces mortality.

Question 49Critical Care Medicine

A patient develops sudden pulseless electrical activity. Which reversible cause should be considered first when the rhythm follows a recent needle decompression attempt for tension pneumothorax?

  1. Hypoglycemia
  2. Hyponatremia
  3. Hypercalcemia
  4. Tension pneumothorax Correct answer.

Explanation

Pulseless electrical activity requires evaluation for reversible causes, and tension pneumothorax is a classic obstructive cause. It must be decompressed promptly to restore venous return and cardiac output.

Question 50Critical Care Medicine

A patient with severe metabolic acidosis from diabetic ketoacidosis has a pH of 7.05. Which statement about bicarbonate administration is most accurate?

  1. It is generally reserved for severe acidemia and may worsen hypokalemia and cause rebound alkalosis Correct answer.
  2. It reliably improves outcomes and should target a pH above 7.4
  3. It should be given routinely to every patient with DKA
  4. It is contraindicated in all circumstances

Explanation

Bicarbonate therapy in DKA is generally limited to severe acidemia because it can worsen hypokalemia, cause paradoxical CSF acidosis, and produce rebound metabolic alkalosis. Routine use is not supported.