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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September 9, 2025
MKSAP 19 Endocrinology & Metabolism, Question 68
A 67-year-old man is evaluated in the hospital for hyperglycemia 3 days after admission for a COPD exacerbation. Appropriate treatment was initiated with antibiotics, bronchodilators, supplemental oxygen, and systemic glucocorticoids. The patient's oral intake remains good. Since the initiation of systemic glucocorticoids, fasting blood glucose levels have been consistently greater than 180 mg/dL (10.0 mmol/L) and postprandial levels occasionally greater than 250 mg/dL (13.9 mmol/L).
On admission, hemoglobin A1c was 5.3%.
Which of the following is the most appropriate management of this patient's hyperglycemia?
A. Basal and correctional insulin
B. Basal, prandial, and correctional insulin
C. Correctional insulin
D. Metformin
Responses Received from Members (667 Responses):
The Correct Answer is: B. Basal, prandial, and correctional insulin
Educational Objective:
Treat hyperglycemia in a hospitalized patient who has good oral intake.
Point-of-care glucose measurement is important to identify hyperglycemia in hospitalized patients prescribed glucocorticoids. The most appropriate management of this patient's hyperglycemia is the initiation of basal, prandial, and correctional insulin (Option B). The American Diabetes Association (ADA) recommends initiation of insulin therapy for treatment for persistent hyperglycemia starting at a threshold of 180 mg/dL (10.0 mmol/L). After insulin therapy is started, a target glucose range of 140 to 180 mg/dL (7.8-10.0 mmol/L) is recommended for most critically ill and non-critically ill patients.
Basal insulin is long-acting insulin given once daily; prandial insulin is scheduled short-acting insulin given three times daily with each meal; and correctional insulin is dosing in response to continued elevated glucose rather than preemptively. A correctional dose of short-acting insulin should be given in addition to the scheduled prandial insulin to correct for hyperglycemia before eating. This approach leads to improved outcomes and avoids large fluctuations in glucose values through the day. A randomized controlled trial has shown that basal-prandial insulin treatment improved glycemic control and reduced hospital complications compared with use of only correctional insulin (“sliding scale insulin”) regimens in general surgery patients with type 2 diabetes mellitus.
The ADA notes that basal insulin, or a basal plus correction regimen (Option A), is the preferred treatment for non-critically ill hospitalized patients with poor oral intake or those with oral intake restriction. Because this patient's oral intake is good, the preferred management of hyperglycemia is basal, prandial, and correctional insulin.
The sole use of correctional insulin (Option C) for the management of inpatient hyperglycemia is not recommended. This approach to hyperglycemia is reactive and can cause large fluctuations in glucose values and lag times between measurement and insulin injection. The use of correctional insulin in hospitalized patients as the only means to control hyperglycemia is strongly discouraged by the ADA.
Research on the safety of oral hypoglycemic drugs in the hospital setting is ongoing, and conclusive findings have not yet been established. Harm is also a concern, particularly in patients who may experience changes in volume status, exposure to contrast agents, and unpredictable meals because of testing or clinical status changes. Initiating metformin (Option D) is not the best choice for this patient.
Key Point
Basal, prandial, and correctional insulin is the recommended treatment for hyperglycemia in non-critically ill hospitalized patients who have good oral intake.
The use of correctional insulin in hospitalized patients as the only means to control hyperglycemia is strongly discouraged by the American Diabetes Association.
Bibliography
American Diabetes Association. 15. Diabetes care in the hospital: standards of medical care in diabetes-2021. Diabetes Care. 2021;44:S211-S220. PMID: 33298426 doi:10.2337/dc21-S015
Copyright 2019, American College of Physicians.
August 26, 2025
MKSAP 18 Gastroenterology & Hepatology, Question 20
A 36-year-old woman is evaluated 3 days after being hospitalized for gallstone pancreatitis. An abdominal ultrasound showed multiple gallstones in the gallbladder and a normal-diameter common bile duct. She was treated with intravenous hydration and pain medication. Over the course of 3 days, she tolerated eating and her pain subsided.
On physical examination, vital signs are normal; BMI is 32. Minimal tenderness to palpation is noted on abdominal examination. All other findings are unremarkable.
All laboratory studies have returned to baseline normal values.
Which of the following is the most appropriate treatment?
A. Endoscopic retrograde cholangiopancreatography
B. Laparoscopic cholecystectomy before discharge from the hospital
C. Laparoscopic cholecystectomy 4 weeks after discharge from the hospital
D. MR cholangiopancreatography
E. Ursodeoxycholic acid
Responses Received from Members (721 Responses):
The Correct Answer is: B. Laparoscopic cholecystectomy before discharge from the hospital
Educational Objective:
Treat gallstone pancreatitis with prompt cholecystectomy.
Laparoscopic cholecystectomy before discharge from the hospital is the most appropriate treatment. Gallstone acute pancreatitis can be diagnosed based on elevated liver transaminases on presentation, a lipase level elevated to more than three times the upper limit of normal, characteristic severe abdominal pain, and ultrasonographic evidence of cholelithiasis. This patient showed clinical improvement within 3 days of hospitalization. Her laboratory values have normalized, suggesting spontaneous passage of a gallstone through the common bile duct, which occurs in most patients with gallstone pancreatitis. In a multicenter randomized controlled trial, same-admission cholecystectomy reduced rates of gallstone-related complications compared with interval cholecystectomy 25 to 30 days after hospital discharge for patients with mild gallstone pancreatitis.
Endoscopic retrograde cholangiopancreatography (ERCP) is indicated urgently for patients with acute pancreatitis and ascending cholangitis (fever, abdominal pain, and jaundice) due to choledocholithiasis. If there is evidence of ongoing biliary obstruction in patients hospitalized with acute pancreatitis, ERCP may be indicated to remove a retained gallstone from the common bile duct. This patient's symptoms and laboratory abnormalities resolved quickly, which supports the spontaneous passage of a gallstone without evidence of ongoing biliary obstruction.
MR cholangiopancreatography (MRCP) can be used to identify causes of biliary obstruction. MRCP is not needed in this patient because she has normal-caliber bile ducts on abdominal ultrasonography and normal liver chemistry test results, indicating that a biliary obstruction is unlikely.
Ursodeoxycholic acid has been used to medically dissolve small cholesterol gallstones in patients who are not candidates for surgery. The medication works slowly and may take longer than 1 year to dissolve small stones, leaving patients at risk for recurrent attacks of gallstone pancreatitis or other gallstone-related complications. This patient is young and without comorbidities, making surgery a more appropriate treatment.
Key Point
Same-admission cholecystectomy reduces rates of gallstone-related complications compared with cholecystectomy after hospital discharge for patients with mild gallstone pancreatitis.
Bibliography
da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S, et al; Dutch Pancreatitis Study Group. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet. 2015;386:1261-8. PMID: 26460661 doi:10.1016/S0140-6736(15)00274-3
Copyright 2018, American College of Physicians.