ABFM COMPREHENSIVE QUESTIONS AND
COMPLETE SOLUTIONS
◉ A 36-year-old female presents for evaluation of elevated blood
pressure. She is asymptomatic and does not take any medications.
On examination her blood pressure is 160/96 mm Hg and her BMI is
26 kg/m2. Fasting laboratory studies include the following:
Sodium 142.
Potassium 3.0.
Creatinine 0.76.
Glucose 97.
Which one of the following additional laboratory evaluations should
be performed to assess her blood pressure?
A) A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-
HIAA)
B) A serum aldosterone/renin ratio
C) A serum cortisol level
D) A serum cystatin C level.
Answer: ANSWER: B
,Primary hyperaldosteronism should be suspected as a cause for
hypertension if a patient has a spontaneously low potassium level or
persistent hypertension despite the use of three or more
antihypertensive medications, including a diuretic. This can be
evaluated by checking a serum renin activity level and a serum
aldosterone concentration and determining the aldosterone/renin
ratio. Primary hyperaldosteronism typically presents with a very
low serum renin activity level and an elevated serum aldosterone
concentration.
A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA)
would be used to evaluate for a neuroendocrine tumor, which can
present as chronic flushing and diarrhea. Cortisol levels can be
checked if Cushing syndrome is suspected. Hypertension can be
present in Cushing syndrome, but it is typically associated with
other signs such as obesity and an elevated blood glucose level due
to insulin resistance. Cystatin C is a marker of renal function and
measurement would not be indicated given this patient's normal
creatinine level.
◉ A 26-year-old male diagnosed with coccidioidomycosis (valley
fever) develops a rash on the extensor surfaces of his lower legs
consisting of painful, subcutaneous, nonulcerated, erythematous
nodules. This rash is consistent with which one of the following?
A) Erythema ab igne
B) Erythema infectiosum
,C) Erythema migrans
D) Erythema multiforme
E) Erythema nodosum.
Answer: ANSWER: E
Erythema nodosum, a panniculitis that typically affects the
subcutaneous fat on the anterior surface of the lower legs, is
associated with coccidioidomycosis (valley fever) and can suggest
the diagnosis. It is a manifestation of the patient's immune response
and often indicates a good prognosis. In addition to
coccidioidomycosis, it can also be associated with streptococcal
infections as well as tuberculosis.
Erythema ab igne is a cutaneous rash caused by prolonged heat
exposure (such as a heating pad) presenting as an otherwise
asymptomatic, red, reticulated pattern on the skin. Erythema
infectiosum is associated with parvovirus B19 infection and is
usually seen in young children. It manifests as an erythematous rash
of the face (slapped cheek appearance), arms, and legs. Erythema
migrans is an expanding, erythematous, annular rash with or
without central clearing and is often associated with tick exposure
(Lyme disease). Erythema multiforme consists of raised, annular,
target-like lesions with central erythema and is usually associated
with herpes simplex virus type 1.
◉ A 50-year-old male presents with chronic abdominal pain. A
workup leads you to suspect peptic ulcer disease, and you refer him
, for endoscopy, which shows a small duodenal ulcer. The endoscopist
also notes some small esophageal varices without red wale signs.
Further evaluation confirms that the patient has compensated
cirrhosis in the setting of alcohol use disorder. He readily accepts
this diagnosis and enters an Alcoholics Anonymous program. His
ulcer symptoms resolve with antibiotic therapy for Helicobacter
pylori. He says he has abstained from alcohol for 6 weeks, and he
would like to further reduce his risks from cirrhosis.
The most appropriate next step in the management of his
esophageal varices would be:
A) octreotide (Sandostatin)
B) omeprazole (Prilosec)
C) propranolol
D) endoscopic variceal ligation
E) repeat endoscopy in 1-2 years.
Answer: ANSWER: E
Primary prevention of variceal hemorrhage is an important
consideration in the management of patients with cirrhosis.
Although this patient's varices were diagnosed incidentally, patients
with cirrhosis and clinically significant portal hypertension should
be screened for varices every 2-3 years with
esophagogastroduodenoscopy (EGD). EGD can be deferred in
patients with platelet counts <150,000/mm3 and transient
elastography with liver stiffness <20 kPa. Once esophageal varices
are identified, the criteria for initiating prophylaxis to prevent
COMPLETE SOLUTIONS
◉ A 36-year-old female presents for evaluation of elevated blood
pressure. She is asymptomatic and does not take any medications.
On examination her blood pressure is 160/96 mm Hg and her BMI is
26 kg/m2. Fasting laboratory studies include the following:
Sodium 142.
Potassium 3.0.
Creatinine 0.76.
Glucose 97.
Which one of the following additional laboratory evaluations should
be performed to assess her blood pressure?
A) A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-
HIAA)
B) A serum aldosterone/renin ratio
C) A serum cortisol level
D) A serum cystatin C level.
Answer: ANSWER: B
,Primary hyperaldosteronism should be suspected as a cause for
hypertension if a patient has a spontaneously low potassium level or
persistent hypertension despite the use of three or more
antihypertensive medications, including a diuretic. This can be
evaluated by checking a serum renin activity level and a serum
aldosterone concentration and determining the aldosterone/renin
ratio. Primary hyperaldosteronism typically presents with a very
low serum renin activity level and an elevated serum aldosterone
concentration.
A 24-hour urine collection for 5-hydroxyindoleacetic acid (5-HIAA)
would be used to evaluate for a neuroendocrine tumor, which can
present as chronic flushing and diarrhea. Cortisol levels can be
checked if Cushing syndrome is suspected. Hypertension can be
present in Cushing syndrome, but it is typically associated with
other signs such as obesity and an elevated blood glucose level due
to insulin resistance. Cystatin C is a marker of renal function and
measurement would not be indicated given this patient's normal
creatinine level.
◉ A 26-year-old male diagnosed with coccidioidomycosis (valley
fever) develops a rash on the extensor surfaces of his lower legs
consisting of painful, subcutaneous, nonulcerated, erythematous
nodules. This rash is consistent with which one of the following?
A) Erythema ab igne
B) Erythema infectiosum
,C) Erythema migrans
D) Erythema multiforme
E) Erythema nodosum.
Answer: ANSWER: E
Erythema nodosum, a panniculitis that typically affects the
subcutaneous fat on the anterior surface of the lower legs, is
associated with coccidioidomycosis (valley fever) and can suggest
the diagnosis. It is a manifestation of the patient's immune response
and often indicates a good prognosis. In addition to
coccidioidomycosis, it can also be associated with streptococcal
infections as well as tuberculosis.
Erythema ab igne is a cutaneous rash caused by prolonged heat
exposure (such as a heating pad) presenting as an otherwise
asymptomatic, red, reticulated pattern on the skin. Erythema
infectiosum is associated with parvovirus B19 infection and is
usually seen in young children. It manifests as an erythematous rash
of the face (slapped cheek appearance), arms, and legs. Erythema
migrans is an expanding, erythematous, annular rash with or
without central clearing and is often associated with tick exposure
(Lyme disease). Erythema multiforme consists of raised, annular,
target-like lesions with central erythema and is usually associated
with herpes simplex virus type 1.
◉ A 50-year-old male presents with chronic abdominal pain. A
workup leads you to suspect peptic ulcer disease, and you refer him
, for endoscopy, which shows a small duodenal ulcer. The endoscopist
also notes some small esophageal varices without red wale signs.
Further evaluation confirms that the patient has compensated
cirrhosis in the setting of alcohol use disorder. He readily accepts
this diagnosis and enters an Alcoholics Anonymous program. His
ulcer symptoms resolve with antibiotic therapy for Helicobacter
pylori. He says he has abstained from alcohol for 6 weeks, and he
would like to further reduce his risks from cirrhosis.
The most appropriate next step in the management of his
esophageal varices would be:
A) octreotide (Sandostatin)
B) omeprazole (Prilosec)
C) propranolol
D) endoscopic variceal ligation
E) repeat endoscopy in 1-2 years.
Answer: ANSWER: E
Primary prevention of variceal hemorrhage is an important
consideration in the management of patients with cirrhosis.
Although this patient's varices were diagnosed incidentally, patients
with cirrhosis and clinically significant portal hypertension should
be screened for varices every 2-3 years with
esophagogastroduodenoscopy (EGD). EGD can be deferred in
patients with platelet counts <150,000/mm3 and transient
elastography with liver stiffness <20 kPa. Once esophageal varices
are identified, the criteria for initiating prophylaxis to prevent
