NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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April 7th, 2026
MKSAP 19 Gastroenterology & Hepatology, Question 12
A 40-year-old man is evaluated in the emergency department for severe epigastric abdominal pain radiating to the back that has worsened in the past 12 hours.
On physical examination, temperature is 39.4 °C (102.9 °F), blood pressure is 100/60 mm Hg, pulse rate is 110/min, and respiration rate is 28/min. Palpation of abdomen elicits epigastric pain without guarding.
|
Laboratory studies: |
|
|
Leukocyte count |
18,000/μL (18 × 109/L) |
|
Alanine aminotransferase |
178 U/L |
|
Aspartate aminotransferase |
145 U/L |
|
Total bilirubin |
1.1 mg/dL (18.8 μmol/L) |
|
Lipase |
100 U/L |
Blood and urine cultures are pending.
Fluid resuscitation with lactated Ringer solution is initiated.
Which of the following is the most appropriate initial management?
A. Contrast-enhanced CT
B. Empiric antibiotics
C. Endoscopic ultrasonography
D. Triglyceride measurement
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: A. Contrast-enhanced CT
Educational Objective: Diagnose acute pancreatitis
The most appropriate management is contrast-enhanced CT (Option A). This patient probably has acute pancreatitis, the diagnosis of which requires at least two of the following: (1) acute-onset abdominal pain characteristic of pancreatitis (severe, persistent for hours to days, and epigastric in location, often radiating to the back); (2) elevation in pancreatic enzymes (typically lipase) three times the upper limit of normal or higher; and (3) imaging findings characteristic of acute pancreatitis, including peripancreatic fat stranding and inflammation as well as peripancreatic edema. Serum amylase and lipase levels may be elevated in nonpancreatic conditions (e.g., kidney disease, acute appendicitis) and therefore are not specific for acute pancreatitis. This patient has typical symptoms, but his lipase levels do not meet the threshold for diagnosis. Therefore, cross-sectional imaging is recommended to confirm the diagnosis. Cross-sectional imaging is also helpful to assess patients for other conditions that might mimic acute pancreatitis and to evaluate patients with atypical symptoms. Preferred imaging modalities include contrast-enhanced CT and MRI.
Routine use of antibiotics (Option B) is not warranted in acute pancreatitis unless there is evidence of extra pancreatic infection, such as ascending cholangitis, bacteremia, urinary tract infection, or pneumonia. Prophylactic antibiotics do not affect the rates of important outcomes, such as organ failure and hospital length of stay.
Endoscopic ultrasonography (Option C), in which an ultrasound probe is placed in the stomach and small intestine to better visualize the pancreas and biliary system, is not typically used in the initial diagnosis of pancreatitis because of its invasive nature.
Once a diagnosis of pancreatitis is confirmed, patients should undergo an assessment for the cause of acute pancreatitis. Biliary disease and alcohol are the most common causes of acute pancreatitis.
Transabdominal ultrasonography is the preferred imaging modality to assess for a biliary cause of acute pancreatitis. Triglyceride levels (Option D) should be measured in patients without a biliary cause of acute pancreatitis; a triglyceride level exceeding 1000 mg/dL (11.3 mmol/L) can be considered the cause of the acute pancreatitis. Because the diagnosis of acute pancreatitis has not been established and the biliary tree has not been evaluated, measurement of triglyceride levels is premature.
Key Points
- The diagnosis of acute pancreatitis requires at least two of the following: (1) acute-onset abdominal pain characteristic of pancreatitis, (2) elevation in pancreatic enzymes at least three times the upper limit of normal, and (3) findings on cross-sectional imaging characteristic of acute pancreatitis.
- Routine use of antibiotics is not warranted in acute pancreatitis.
Bibliography
Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. N Engl J Med. 2016;375:1972-1981. PMID: 27959604
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.
March 24th, 2026
MKSAP 19 Cardiovascular Medicine, Question 52
An 84-year-old man is evaluated before hospital discharge following an exacerbation of heart failure. He has an implantable cardioverter-defibrillator. Medications are lisinopril, furosemide, carvedilol, and spironolactone. During hospitalization, the patient received intravenous furosemide at a dosage twice that of his home oral dosage.
On physical examination, vital signs are normal. BMI is 28. Central venous pressure is not elevated. There is no S3, and there are no pulmonary crackles.
Serum creatinine level has returned to the baseline level, and electrolytes are normal. Echocardiogram from this hospitalization shows ejection fraction of 25% with left ventricular end- diastolic dimension of 72 mm.
Which of the following is most likely to prevent early hospital readmission in this patient?
A. Echocardiography in 3 months
B. Follow-up office visit in 30 days
C. Follow-up telephone call in 2 days
D. Decrease in furosemide to original home dosage
Responses Received from Members (705 Responses):
The Correct Answer is: C. Follow-up telephone call in 2 days
Educational Objective: Prevent heart failure readmission with early follow-up.
A telephone call within 2 to 3 days (Option C) is recommended to prevent this patient's early readmission to the hospital. The 2019 American College of Cardiology expert consensus decision pathway for patients hospitalized with heart failure notes that up to 25% of patients are readmitted with heart failure within 30 days of the index hospitalization. Two key elements are associated with a successful transition from hospital to home: a follow-up phone call within 2 to 3 days of discharge and an office visit within 7 to 14 days of hospital discharge. The purpose of the follow-up phone call is to address signs of congestion, provide education and review adherence to the medication regimen, and confirm follow-up appointments and adequate transportation. The expert consensus decision pathway recommends a standardized approach to the follow-up telephone call, including use of a checklist to help organize the call.
For patients with an initial diagnosis of heart failure, it is appropriate to repeat echocardiography in 3 months (Option A) to assess the effect of medical therapy on ejection fraction and need for an implantable cardioverter-defibrillator (ICD). Echocardiography was performed in this patient in the hospital, and for a patient with known low ejection fraction and an ICD, there is no reason for echocardiography so soon unless there is a clinical change.
The first postdischarge appointment focuses on changes in clinical status, patient education, medication review and adjustment of dosages, and identification and correction of issues that might lead to worsening of heart failure and readmission. The recommended timing of the first follow-up visit is within 7 to 10 days of hospital discharge; 30 days (Option B) is too late.
Inadequate diuretic dosage is a common cause of heart failure readmissions. This patient required an increased furosemide dosage to achieve adequate diuresis. This suggests that the previous home diuretic dosage was inadequate, and an increase of at least double that dosage should be considered.
Restarting the previous home dosage (Option D) might be considered for a patient who did not adhere to the medication regimen before hospitalization.
Key Point
- Two key elements are associated with a successful transition to home following hospitalization for heart failure: a follow-up phone call within 2 to 3 days of discharge and an office visit within 7 to 14 days of hospital discharge.
Bibliography
Hollenberg SM, Warner Stevenson L, Ahmad T, et al. 2019 ACC expert consensus decision pathway on risk assessment, management, and clinical trajectory of patients hospitalized with heart failure: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol.
2019;74:1966-2011. PMID: 31526538 doi:10.1016/j.jacc.2019.08.001
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
ACP MKSAP. © Copyright 2025 American College of Physicians. All Rights Reserved All Rights Reserved.