14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

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5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

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6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

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11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture

Key Takeaways Explain This Topic AI

Venous ulcers and chronic wounds, constipation, disorders of swallowing, nutrition, hip fracture, rehabilitation and common foot problems are separately enumerated Geriatric Syndromes subsections.

Compression is the cornerstone of venous ulcer treatment and requires an ankle-brachial index first to exclude significant arterial disease.

Oropharyngeal dysphagia causes coughing and choking at swallow initiation, whereas esophageal dysphagia causes a sensation of food sticking seconds later.

Feeding tubes do not reduce aspiration, improve survival or heal pressure injuries in advanced dementia.

Hip fracture surgery within 24 to 48 hours reduces mortality and complications, and orthogeriatric co-management improves outcomes.

Last updated: August 2026

1. Venous Ulcers and Chronic Wounds

Venous ulcers account for the large majority of leg ulcers. They occur in the gaiter area, classically over the medial malleolus , are shallow with irregular borders and exudate, and sit in skin showing hemosiderin staining, lipodermatosclerosis, atrophie blanche and varicosities . Pain improves with elevation.

Treatment rests on three pillars:

Compression therapy — multilayer compression is the single most effective intervention and the strongest determinant of healing

• Leg elevation and calf muscle pump exercise
• Moist wound care with appropriate dressings

Before compression, measure the ankle-brachial index. Applying full compression to a limb with significant arterial disease causes ischemic necrosis. This is the highest-yield safety point in wound care.

Recurrence is the rule without lifelong compression stockings; endovenous ablation of incompetent superficial veins reduces recurrence.

Diabetic (neuropathic) foot ulcers occur at plantar pressure points , are surrounded by callus, and are painless . The essential treatment is offloading , together with glycemic control, debridement, infection management and vascular assessment. Common foot problems in the elderly — an enumerated blueprint subsection — include onychomycosis, ingrown nails, hallux valgus, hammer toes, corns and calluses; in a person with neuropathy or vascular disease these are not cosmetic issues but the origin of limb-threatening ulceration, which is why annual foot examination and appropriate footwear matter.

An ulcer that fails to heal after several months of appropriate therapy should be biopsied to exclude malignancy (Marjolin ulcer) or an inflammatory cause such as pyoderma gangrenosum.

2. Nutrition in the Elderly

Weight loss in an older adult is never benign. Unintentional loss of 5% of body weight over 6 to 12 months warrants evaluation.

A structured differential:

Domain Examples

Medical Malignancy, hyperthyroidism, heart failure, COPD, malabsorption, chronic infection, uncontrolled diabetes

Psychiatric Depression — a leading and treatable cause; anxiety; late-life eating disorder

Medications Digoxin, metformin, SSRIs, anticholinergics causing dry mouth, opioids causing constipation and nausea

• Oral and swallowing Poor dentition, ill-fitting dentures, xerostomia, dysphagia
• Social Poverty, food insecurity, isolation, inability to shop or cook, caregiver absence
• Functional and cognitive Dementia impairing self-feeding; tremor; visual impairment

Ask specifically about who buys and prepares the food. Social and functional causes are common and invisible unless asked about directly.

Sarcopenia — loss of muscle mass, strength and function — is treated with resistance exercise plus adequate protein intake , generally higher than in younger adults. Appetite stimulants have limited evidence and meaningful harms: megestrol increases thromboembolism and adrenal suppression, and mirtazapine is reasonable when depression coexists.

Deficiencies to consider: vitamin B12 (common with atrophic gastritis and metformin), vitamin D, calcium, and protein-energy undernutrition.

3. Disorders of Swallowing

The first distinction is oropharyngeal versus esophageal , because it determines both the test and the specialist.

• Oropharyngeal (transfer) Esophageal (transport)
• Timing Immediate , at swallow initiation Seconds after swallowing
• Symptoms Coughing, choking, nasal regurgitation, drooling , repeated swallows Food sticking , chest discomfort
• Localization Cervical Retrosternal, but poorly localizing

Causes Stroke , Parkinson disease, dementia, myasthenia gravis, Zenker diverticulum, head and neck cancer, prior radiation Stricture, ring, achalasia, cancer, eosinophilic esophagitis, motility disorder

Test Videofluoroscopic modified barium swallow Endoscopy

Solids only, progressive suggests a mechanical obstruction; solids and liquids from the outset suggests a motility disorder.

Aspiration risk is highest with oropharyngeal dysphagia, and silent aspiration without cough occurs in patients with reduced laryngeal sensation, especially after stroke. Management includes texture modification, postural techniques, swallowing therapy and rigorous oral hygiene , which independently reduces aspiration pneumonia.

Feeding tubes in advanced dementia are the highest-yield exam point in this area: percutaneous gastrostomy does not reduce aspiration, does not improve survival, does not heal or prevent pressure injuries, and does not improve comfort or function. It increases the use of restraints and the burden of tube-related complications. Careful hand feeding is the recommended alternative , and this discussion belongs in goals-of-care conversations early rather than at a crisis point.

4. Constipation in the Elderly

A named blueprint subsection, and a source of substantial morbidity — fecal impaction with overflow diarrhea, urinary retention, delirium and stercoral ulceration.

Contributors: reduced mobility and fluid intake, low fiber, medications ( opioids, anticholinergics, calcium channel blockers, iron, calcium, antipsychotics ), hypothyroidism, hypercalcemia, hypokalemia, diabetes, Parkinson disease, and colorectal obstruction.

Red flags requiring colonoscopy: new-onset constipation in an older adult, rectal bleeding, iron deficiency anemia, weight loss, or a family history of colorectal cancer.

Management ladder: address reversible causes and deprescribe; increase fluid, fiber and activity as tolerated; osmotic laxatives such as polyethylene glycol are first-line pharmacotherapy ; stimulants as needed. Fiber supplementation can worsen symptoms in slow-transit constipation and in patients with limited fluid intake or obstruction.

Opioid-induced constipation does not develop tolerance and must be anticipated: prescribe a bowel regimen with every opioid , and use peripherally acting mu-opioid receptor antagonists when standard laxatives fail.

Always examine for fecal impaction when an older adult has overflow diarrhea, delirium or urinary retention; treating the diarrhea as infectious is a classic error.

5. Hip Fracture

A named blueprint subsection, and one of the defining events of later life: roughly a fifth to a quarter of older adults die within a year of hip fracture, and many survivors never regain prior function.

Classification determines the operation:

Fracture Blood supply concern Typical management

Femoral neck (intracapsular) Disrupted retrograde supply — osteonecrosis and nonunion risk Arthroplasty in older adults; internal fixation if non-displaced or in younger patients

Intertrochanteric (extracapsular) Preserved Internal fixation with a sliding hip screw or intramedullary nail

Perioperative principles supported by evidence:

Surgery within 24 to 48 hours reduces mortality, delirium, pressure injury and pneumonia. Medical optimization should not become an open-ended delay.

Orthogeriatric co-management improves outcomes.

Regional or general anesthesia are broadly comparable; avoid meperidine and minimize benzodiazepines and anticholinergics to reduce delirium.

Multimodal analgesia including nerve blocks reduces opioid requirements and delirium. Under-treated pain is itself a delirium risk factor , so opioid avoidance can backfire.

Early mobilization , ideally on the first postoperative day.

Venous thromboembolism prophylaxis.

Delirium prevention protocols.

The secondary prevention gap is the most tested point. A hip fracture from a fall from standing height is an osteoporotic fracture and establishes the diagnosis of osteoporosis regardless of bone density . Yet a majority of patients leave the hospital without osteoporosis treatment. Before discharge: check vitamin D and calcium, correct deficiency, initiate antiresorptive or anabolic therapy , review fall risk and deprescribe culprit medications, and arrange rehabilitation.

6. Rehabilitation and the Elderly

A named blueprint subsection. The internist decides the level of post-acute care , which materially affects outcomes.

Setting Intensity Typical candidate

Inpatient rehabilitation facility ~3 hours daily, physician-led Able to tolerate intensive therapy with expectation of functional gain

• Skilled nursing facility Lower intensity Needs skilled nursing or lower-intensity therapy
• Home health Intermittent visits Homebound with adequate support
• Outpatient therapy Scheduled visits Mobile with transportation

Prognostic factors: pre-morbid functional status is the strongest predictor of recovery; cognitive impairment, depression, malnutrition, delirium and inadequate social support all impair rehabilitation potential. Depression and delirium are treatable barriers and should be sought and addressed rather than accepted as reduced potential.

Immobility itself causes harm — deconditioning of roughly 1 to 5% of muscle strength per day of bed rest, pressure injury, venous thromboembolism, atelectasis, constipation, orthostatic intolerance and delirium. Hospital-associated disability — new functional loss occurring during an admission independent of the presenting illness — is common, frequently permanent, and largely preventable by mobilizing patients and avoiding unnecessary tethers such as urinary catheters, telemetry and continuous infusions.

7. Urinary Tract Infection in the Elderly

A named Geriatric Syndromes subsection, and the source of one of the most consequential errors in geriatric medicine.

Asymptomatic bacteriuria is common in older adults — highly prevalent in nursing home residents and near-universal in those with chronic catheters — and should not be screened for or treated , with the exceptions of pregnancy and before urologic procedures with anticipated mucosal bleeding.

A positive urine culture does not diagnose a urinary tract infection. Diagnosis requires localizing genitourinary symptoms — dysuria, new urgency or frequency, suprapubic or costovertebral angle pain, gross hematuria — or systemic features attributable to the urinary tract.

The delirium trap: an older adult with delirium and a positive urine culture very often has delirium from another cause — a new medication, dehydration, constipation, pain, hypoxia — with incidental bacteriuria. Reflexively attributing delirium to a urinary tract infection stops the search for the real cause and exposes the patient to antibiotic harm, Clostridioides difficile infection and resistance. Look for another cause even after starting antibiotics.

Recurrent infection in postmenopausal women is reduced by vaginal estrogen , which is preferable to long-term antibiotic prophylaxis.