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 21st, 2026
MKSAP 19 General Internal Medicine 1, Question 29
A 74-year-old woman is evaluated before hospital discharge. She was hospitalized 3 days ago for surgical repair of a left hip fracture after a fall. She has been evaluated by physical and occupational therapists and is thought to be unsafe for discharge home, where she lives alone, because of her inability to safely stand with a walker and ambulate in the hospital room. Her tolerance for physical therapy is estimated to be less than 3 hours per day. Medical history is significant for hypertension and prior stroke with residual right-sided weakness. She required a cane to ambulate before the fall. Medications are aspirin, amlodipine, atorvastatin, and acetaminophen as needed for pain.
On physical examination, blood pressure is 130/80 mm Hg and pulse rate is 78/min. Physical examination confirms the findings of the physical and occupational therapists and reveals frailty and right-sided arm and leg weakness. There is a healing surgical incision on the left hip.
Which of the following is the most appropriate management of this patient?
A. Continue care in the hospital until she is able to ambulate safely
B. Discharge home with home physical and occupational therapy
C. Discharge to a skilled nursing facility
D. Discharge to an acute rehabilitation hospital
Responses Received from Members (Responses will be uploaded on Thursday):
The Correct Answer is: C. Discharge to a skilled nursing facility
Educational Objective: Select an appropriate level of care for posthospital rehabilitation.
Subacute rehabilitation in a skilled nursing facility (Option C) is most appropriate for this frail older woman who no longer requires acute inpatient hospital care. In this setting, she can gradually improve her functional status over a period of up to 100 days, such that she can be discharged to independent living. Her current functional status, coupled with a medical history of preexisting functional impairment due to stroke, suggests that she requires a rehabilitation environment that allows for a slow recovery pace.
Continued care in the inpatient setting (Option A), where rehabilitation resources are limited, is not a reasonable or cost-effective strategy for this patient, whose medical condition no longer substantiates a need for acute inpatient treatment.
For this patient to be discharged home with outpatient or home physical and occupational therapy (Option B), she would need to be able to function unsupervised or have continuous assistance to compensate for any functional deficiencies. This patient lives alone and has demonstrated that she is in need of supervision when working with therapists in the inpatient setting.
Discharge to an acute rehabilitation hospital (Option D) would require that the patient be able to participate in 3 hours of therapy on 5 days per week. A clinical estimation of her tolerance for therapy is less than 3 hours daily.
Key Point
- In patients requiring posthospitalization care to improve functional status who cannot tolerate 3 hours of physical or occupational therapy on 5 days per week, subacute rehabilitation is an appropriate option.
Bibliography
Boland L, Légaré F, Perez MM, et al. Impact of home care versus alternative locations of care on elder health outcomes: an overview of systematic reviews. BMC Geriatr. 2017;17:20. PMID:
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
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 (714 Responses):
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