FM COMAT EXAM QUESTIONS WITH
CORRECT ANSWERS
A 60-year-old female presents to her primary care physician with hip pain which she
reports is worse at the end of the day. Vital signs are obtained as follows:
Height 1.32 m (60 in)
Weight 104 kg (230 lbs)
Temperature 37.6ºC (99.8ºF)
Blood Pressure 135/85 mmHg
Pulse 88/min
Respiration 18/min
O2 saturation 98%
Physical examination reveals decreased range of motion in her affected joints and
deformity of her distal interphalangeal joints on her hands. Structural examination
reveals a positive seated flexion test on the left, a sacrum with a deep left sulcus, a left
inferior lateral angle that is inferior and posterior, and springing at the left sulcus.
Most likely diagnosis is: - Correct Answers -Osteoarthritis is a chronic joint disease
caused by articular cartilage degeneration which results in decreased joint space. It
most commonly affects weight bearing joints including hips and knees but can also
affect hands, wrists, shoulders, and vertebrae. Risk factors include increased age,
obesity, family history, and previous joint trauma. Patients will present with pain and
joint stiffness that gets worse with activity and weight-bearing activity and is usually
relieved by rest. Patients will have decreased range of motion. Osteoarthritis commonly
affects the distal interphalangeal joints of the hands causing deformities called
Heberden's nodes. Radiographs of the affected joints will demonstrate joint space
narrowing, osteophytes, subchondral sclerosis and subchondral cysts. Osteoarthritis is
generally non-inflammatory and treatments includes weight loss, lifestyle modification,
analgesics, corticosteroid injections, and as the disease progresses possibly joint
replacement. Osteoporosis is not likely in this patient because of her age and her
weight. Screening for osteoporosis is recommended to start at age 65. Bone density
decreases with a decrease in the amount of estrogen that women experience with
menopause. The typical osteoporosis patient is a thin white female. This patient's
weight increases load bearing on her bones which leads to increase in bone
mineralization to compensate for the extra stress.
,A 40-year-old male presents with fever and pain, swelling, and tenderness of the right
great toe for the past 12 hours. Joint aspiration reveals negatively birefringent crystals.
The most appropriate recommendation at this time is
A. allopurinol
B. colchicine
C. indomethacin
D. low purine diet
E. probenecid - Correct Answers -C. indomethacin
Gout is a crystal-induced arthropathy caused by deposition of monosodium urate
crystals. The most common joint affected is the first metatarsophalangeal joint but it can
also affect other joints including ankle, foot, and knee. Joint aspiration shows needle
shaped, negatively birefringent crystals. These crystals form secondary to high levels of
uric acid. These high levels are typically due to underexcretion although it can be due to
overproduction as well. These crystals cause an inflammatory response and an intense,
sudden onset of pain. Gout flares are typically seen when there is an acute increase or
decrease in uric acid levels. Acute gout attacks are treated primarily with pain relief with
NSAIDs, indomethacin is a commonly used NSAID but any of them can be used.
A 68-year-old male with atrial fibrillation presents to the office for blood testing. History
reveals that he takes warfarin 2 mg by mouth daily. Laboratory studies reveal a
prothrombin time of 17.75 sec and INR of 2.32. The most appropriate recommendation
at this time is to
A. administer vitamin K
B. continue with the current dosing schedule
C. discontinue warfarin and start aspirin 81 mg PO
D. increase warfarin to 4 mg PO daily
E. skip the next dose and continue with 2 mg PO four times per week - Correct Answers
-B. continue with the current dosing schedule
Atrial fibrillation (AF) is caused by multiple foci in the atria that fire continuously in a
chaotic pattern, causing an irregular, rapid ventricular rate. Instead of contracting
intermittently, the atria quiver continuously. Atrial rate is typically over 400/min but most
impulses are blocked, so ventricular rate ranges between 75/min and 175/min. Patients
with AF and underlying heart disease are at a markedly increased risk for adverse
events, such as thromboembolism. Some common causes of AF include heart disease
(coronary artery disease, myocardial infarction, hypertension, mitral valve disease),
pulmonary disease, thyroid disease, systemic illness, stress, excessive alcohol intake,
and pheochromocytoma. Patients typically present with fatigue, palpitations, dizziness,
or angina.
Acute AF in a hemodynamically unstable patient requires immediate electrical
cardioversion to sinus rhythm. In acute AF in a hemodynamically stable patient, rate or
rhythm control and anticoagulation are key. If AF is present for more than 48 hours or
an unknown period of time, the risk of embolization during cardioversion is significant.
Patients are anticoagulated 3 weeks before and 4 weeks after cardioversion. In chronic
,AF, rate control and anticoagulation are key. In lone AF (no underlying heart disease,
patients under age 60), anticoagulation is not required, though aspirin may be
appropriate.
Other patients with chronic AF are treated with chronic anticoagulation. The CHADS2
and CHA2DS2-VASc are risk scores used to evaluate the risk of stroke and arterial
embolization and to determine when the benefits outweigh the risks of antithrombotic
prevention. Though there are several agents available on the market today, warfarin is
the classic anticoagulant in patients who can tolerate it and
A 65-year-old male presents to your clinic to discuss his poorly-controlled
gastroesophageal reflux disease. History reveals that he has been taking a twice daily
proton-pump inhibitor for over five years and that he now notes some difficulty
swallowing. He also relates a long-standing history of smoking, but he has been unable
quit. A fecal occult blood test is obtained and read as positive in the office. You note
paravertebral hypertonicity from T5-9 that is tender to palpation. Which of the following
is the most appropriate diagnostic test at this time?
A. 24-hour pH probe monitoring
B. barium swallow
C. capsule endoscopy
D. colonoscopy
E. esophagogastroduodenoscopy - Correct Answers -E. esophagogastroduodenoscopy
Gastroesophageal reflux is actually a normal process that becomes a disease process
when it causes macroscopic damage to the esophagus or causes symptoms that
reduce quality of life. This occurs when the anti-reflux mechanism fails, either involving
the lower esophageal sphincter, the crural diaphragm, or the part of the
gastroesophageal junction below the hiatus. Patients may present with regurgitation of
sour material in the mouth, along with heartburn (usually postprandial), dysphagia,
chest pain, and hypersalivation. In severe cases, laryngitis, chronic cough, morning
hoarseness, and aspiration may be seen. Typically, physical exam is normal. You may
note TART changes in the thoracic spine as a result of viscerosomatic reflexes from the
esophagus as this is the range of sympathetic innervation. Differential diagnoses to
consider and exclude include: CAD, peptic ulcer disease, esophageal motility disorder,
gastritis, infectious esophagitis, pill esophagitis, functional dyspepsia, and biliary tract
disease. Mild, low-risk cases (without dysphagia, odynophagia, anemia, or weight loss)
are usually diagnosed clinically, with successful treatment typically being diagnostic.
Treatment includes lifestyle modification, specifically elevation of the head of the bed
and dietary modification. Histamine-2 receptor antagonists (ranitidine, cimetidine,
famotidine, nizatidine) work well for mild cases, but proton-pump inhibitors (omeprazole,
lansoprazole, rabeprazole, esomeprazole, pantoprazole) are more effective, with
maintenance therapy usually being required in that the patient will need to stay on the
medication chronically. Surgery can be considered in patients whose symptoms persist
despite optimal medical therapy. GERD is treated to prevent complications, including
those related to prolonged a
, A 89-year-old female nursing home resident presents for follow-up of her recurrent
nausea, vomiting, and loose stools. She has undergone extensive testing but her
providers have been unable to determine an etiology. She has been managing her
symptoms with metoclopramide for over one year. Her past medical history is pertinent
for hypertension and hyperlipidemia. Today, she remarks that her nausea and diarrhea
are improved, but on physical examination she is observed to be constantly smacking
her lips and jerking her head. This finding is called
A. akathisia
B. chorea
C. dystonia
D.secondary parkinsonism
E. tardive dyskinesia - Correct Answers -The correct answer is: E
Tardive dyskinesia (TD) is a hyperkinetic movement disorder that appears with a
delayed onset after prolonged use of dopamine receptor blocking agents. TD can
present with chorea, athetosis, dystonia, akathisia, stereotyped behaviors and rarely,
tremor. The term "tardive" differentiates these dyskinesias from acute dyskinesia,
parkinsonism, and akathisia, which appear very soon after exposure to antipsychotic
drugs. TD can include a variable mixture of orofacial dyskinesia, athetosis, dystonia,
chorea, tics, and facial grimacing. The symptoms involve the mouth, tongue, face, trunk,
or extremities. Oral, facial, and lingual dyskinesia are especially conspicuous in elderly
patients. They may include protruding and twisting movements of the tongue, smacking
movements of the lips, retraction of the corners of the mouth, bulging of the cheeks, or
chewing movements. The onset of TD is insidious and typically occurs while the patient
is receiving an antipsychotic drug. It may appear as early as one to six months following
drug exposure, though it was recently thought to occur only after two or more years of
treatment. Though the diagnosis is relatively straightforward, it must be differentiated
from schizophrenia and Wilson's disease, as well as other antipsychotic drug induced
extrapyramidal syndromes that often coexist. In this patient, we observe lip smacking
and head jerking, which are classic for tardive dyskinesia. Other agents that commonly
cause TD include neuroleptics, older atypical antipsychotics, metoclopramide (as in this
patient), antihistamines, and fluoxetine.
A 52-year-old female presents to your office after a random blood glucose level of 250
mg/dL was discovered at a screening health fair. She is sent for some additional lab
work and you are awaiting the results before initiating pharmacologic therapy. Which of
the following would establish a diagnosis of diabetes mellitus?
A. 2-hour blood glucose level of 190 mg/dL during a 75 gram oral glucose tolerance test
B. fasting blood glucose of 130 mg/dL
C. hemoglobin A1C of 6.0%
D. random blood glucose of 150 mg/dL with classic symptoms of hyperglycemia
E.random blood glucose of 240 mg/dL without symptoms - Correct Answers -The
correct answer is: B
CORRECT ANSWERS
A 60-year-old female presents to her primary care physician with hip pain which she
reports is worse at the end of the day. Vital signs are obtained as follows:
Height 1.32 m (60 in)
Weight 104 kg (230 lbs)
Temperature 37.6ºC (99.8ºF)
Blood Pressure 135/85 mmHg
Pulse 88/min
Respiration 18/min
O2 saturation 98%
Physical examination reveals decreased range of motion in her affected joints and
deformity of her distal interphalangeal joints on her hands. Structural examination
reveals a positive seated flexion test on the left, a sacrum with a deep left sulcus, a left
inferior lateral angle that is inferior and posterior, and springing at the left sulcus.
Most likely diagnosis is: - Correct Answers -Osteoarthritis is a chronic joint disease
caused by articular cartilage degeneration which results in decreased joint space. It
most commonly affects weight bearing joints including hips and knees but can also
affect hands, wrists, shoulders, and vertebrae. Risk factors include increased age,
obesity, family history, and previous joint trauma. Patients will present with pain and
joint stiffness that gets worse with activity and weight-bearing activity and is usually
relieved by rest. Patients will have decreased range of motion. Osteoarthritis commonly
affects the distal interphalangeal joints of the hands causing deformities called
Heberden's nodes. Radiographs of the affected joints will demonstrate joint space
narrowing, osteophytes, subchondral sclerosis and subchondral cysts. Osteoarthritis is
generally non-inflammatory and treatments includes weight loss, lifestyle modification,
analgesics, corticosteroid injections, and as the disease progresses possibly joint
replacement. Osteoporosis is not likely in this patient because of her age and her
weight. Screening for osteoporosis is recommended to start at age 65. Bone density
decreases with a decrease in the amount of estrogen that women experience with
menopause. The typical osteoporosis patient is a thin white female. This patient's
weight increases load bearing on her bones which leads to increase in bone
mineralization to compensate for the extra stress.
,A 40-year-old male presents with fever and pain, swelling, and tenderness of the right
great toe for the past 12 hours. Joint aspiration reveals negatively birefringent crystals.
The most appropriate recommendation at this time is
A. allopurinol
B. colchicine
C. indomethacin
D. low purine diet
E. probenecid - Correct Answers -C. indomethacin
Gout is a crystal-induced arthropathy caused by deposition of monosodium urate
crystals. The most common joint affected is the first metatarsophalangeal joint but it can
also affect other joints including ankle, foot, and knee. Joint aspiration shows needle
shaped, negatively birefringent crystals. These crystals form secondary to high levels of
uric acid. These high levels are typically due to underexcretion although it can be due to
overproduction as well. These crystals cause an inflammatory response and an intense,
sudden onset of pain. Gout flares are typically seen when there is an acute increase or
decrease in uric acid levels. Acute gout attacks are treated primarily with pain relief with
NSAIDs, indomethacin is a commonly used NSAID but any of them can be used.
A 68-year-old male with atrial fibrillation presents to the office for blood testing. History
reveals that he takes warfarin 2 mg by mouth daily. Laboratory studies reveal a
prothrombin time of 17.75 sec and INR of 2.32. The most appropriate recommendation
at this time is to
A. administer vitamin K
B. continue with the current dosing schedule
C. discontinue warfarin and start aspirin 81 mg PO
D. increase warfarin to 4 mg PO daily
E. skip the next dose and continue with 2 mg PO four times per week - Correct Answers
-B. continue with the current dosing schedule
Atrial fibrillation (AF) is caused by multiple foci in the atria that fire continuously in a
chaotic pattern, causing an irregular, rapid ventricular rate. Instead of contracting
intermittently, the atria quiver continuously. Atrial rate is typically over 400/min but most
impulses are blocked, so ventricular rate ranges between 75/min and 175/min. Patients
with AF and underlying heart disease are at a markedly increased risk for adverse
events, such as thromboembolism. Some common causes of AF include heart disease
(coronary artery disease, myocardial infarction, hypertension, mitral valve disease),
pulmonary disease, thyroid disease, systemic illness, stress, excessive alcohol intake,
and pheochromocytoma. Patients typically present with fatigue, palpitations, dizziness,
or angina.
Acute AF in a hemodynamically unstable patient requires immediate electrical
cardioversion to sinus rhythm. In acute AF in a hemodynamically stable patient, rate or
rhythm control and anticoagulation are key. If AF is present for more than 48 hours or
an unknown period of time, the risk of embolization during cardioversion is significant.
Patients are anticoagulated 3 weeks before and 4 weeks after cardioversion. In chronic
,AF, rate control and anticoagulation are key. In lone AF (no underlying heart disease,
patients under age 60), anticoagulation is not required, though aspirin may be
appropriate.
Other patients with chronic AF are treated with chronic anticoagulation. The CHADS2
and CHA2DS2-VASc are risk scores used to evaluate the risk of stroke and arterial
embolization and to determine when the benefits outweigh the risks of antithrombotic
prevention. Though there are several agents available on the market today, warfarin is
the classic anticoagulant in patients who can tolerate it and
A 65-year-old male presents to your clinic to discuss his poorly-controlled
gastroesophageal reflux disease. History reveals that he has been taking a twice daily
proton-pump inhibitor for over five years and that he now notes some difficulty
swallowing. He also relates a long-standing history of smoking, but he has been unable
quit. A fecal occult blood test is obtained and read as positive in the office. You note
paravertebral hypertonicity from T5-9 that is tender to palpation. Which of the following
is the most appropriate diagnostic test at this time?
A. 24-hour pH probe monitoring
B. barium swallow
C. capsule endoscopy
D. colonoscopy
E. esophagogastroduodenoscopy - Correct Answers -E. esophagogastroduodenoscopy
Gastroesophageal reflux is actually a normal process that becomes a disease process
when it causes macroscopic damage to the esophagus or causes symptoms that
reduce quality of life. This occurs when the anti-reflux mechanism fails, either involving
the lower esophageal sphincter, the crural diaphragm, or the part of the
gastroesophageal junction below the hiatus. Patients may present with regurgitation of
sour material in the mouth, along with heartburn (usually postprandial), dysphagia,
chest pain, and hypersalivation. In severe cases, laryngitis, chronic cough, morning
hoarseness, and aspiration may be seen. Typically, physical exam is normal. You may
note TART changes in the thoracic spine as a result of viscerosomatic reflexes from the
esophagus as this is the range of sympathetic innervation. Differential diagnoses to
consider and exclude include: CAD, peptic ulcer disease, esophageal motility disorder,
gastritis, infectious esophagitis, pill esophagitis, functional dyspepsia, and biliary tract
disease. Mild, low-risk cases (without dysphagia, odynophagia, anemia, or weight loss)
are usually diagnosed clinically, with successful treatment typically being diagnostic.
Treatment includes lifestyle modification, specifically elevation of the head of the bed
and dietary modification. Histamine-2 receptor antagonists (ranitidine, cimetidine,
famotidine, nizatidine) work well for mild cases, but proton-pump inhibitors (omeprazole,
lansoprazole, rabeprazole, esomeprazole, pantoprazole) are more effective, with
maintenance therapy usually being required in that the patient will need to stay on the
medication chronically. Surgery can be considered in patients whose symptoms persist
despite optimal medical therapy. GERD is treated to prevent complications, including
those related to prolonged a
, A 89-year-old female nursing home resident presents for follow-up of her recurrent
nausea, vomiting, and loose stools. She has undergone extensive testing but her
providers have been unable to determine an etiology. She has been managing her
symptoms with metoclopramide for over one year. Her past medical history is pertinent
for hypertension and hyperlipidemia. Today, she remarks that her nausea and diarrhea
are improved, but on physical examination she is observed to be constantly smacking
her lips and jerking her head. This finding is called
A. akathisia
B. chorea
C. dystonia
D.secondary parkinsonism
E. tardive dyskinesia - Correct Answers -The correct answer is: E
Tardive dyskinesia (TD) is a hyperkinetic movement disorder that appears with a
delayed onset after prolonged use of dopamine receptor blocking agents. TD can
present with chorea, athetosis, dystonia, akathisia, stereotyped behaviors and rarely,
tremor. The term "tardive" differentiates these dyskinesias from acute dyskinesia,
parkinsonism, and akathisia, which appear very soon after exposure to antipsychotic
drugs. TD can include a variable mixture of orofacial dyskinesia, athetosis, dystonia,
chorea, tics, and facial grimacing. The symptoms involve the mouth, tongue, face, trunk,
or extremities. Oral, facial, and lingual dyskinesia are especially conspicuous in elderly
patients. They may include protruding and twisting movements of the tongue, smacking
movements of the lips, retraction of the corners of the mouth, bulging of the cheeks, or
chewing movements. The onset of TD is insidious and typically occurs while the patient
is receiving an antipsychotic drug. It may appear as early as one to six months following
drug exposure, though it was recently thought to occur only after two or more years of
treatment. Though the diagnosis is relatively straightforward, it must be differentiated
from schizophrenia and Wilson's disease, as well as other antipsychotic drug induced
extrapyramidal syndromes that often coexist. In this patient, we observe lip smacking
and head jerking, which are classic for tardive dyskinesia. Other agents that commonly
cause TD include neuroleptics, older atypical antipsychotics, metoclopramide (as in this
patient), antihistamines, and fluoxetine.
A 52-year-old female presents to your office after a random blood glucose level of 250
mg/dL was discovered at a screening health fair. She is sent for some additional lab
work and you are awaiting the results before initiating pharmacologic therapy. Which of
the following would establish a diagnosis of diabetes mellitus?
A. 2-hour blood glucose level of 190 mg/dL during a 75 gram oral glucose tolerance test
B. fasting blood glucose of 130 mg/dL
C. hemoglobin A1C of 6.0%
D. random blood glucose of 150 mg/dL with classic symptoms of hyperglycemia
E.random blood glucose of 240 mg/dL without symptoms - Correct Answers -The
correct answer is: B
