ABFM 2023 EXAM Questions AND Correct Answers
. You are caring for a 21-year-old female with previously diagnosed
bipolar II disorder, generalized anxiety disorder, attention-
deficit/hyperactivity disorder, and insomnia. The patient presents
with new symptoms of chills, excess sweating, flushing, and nausea of
approximately 2 hours' duration. The patient felt normal upon
awakening, took methylphenidate (Ritalin), 5 mg with breakfast, and
went to work. She began to feel shaky around lunchtime and took a
second dose of methylphenidate, 5 mg. Thirty minutes later she
began having agitation, chills, sweating, flushing, and nausea and had
to leave work. Her current medications include the following:
Desvenlafaxine , 50 mg daily Doxepin, 10 mg daily Methylphenidate, 5
mg twice daily Ziprasidone (Geodon), 40 mg twice daily ; examination
reveals an alert and anxious patient with damp skin, a temperature of
38.1°C (100.6°F), and a heart rate of 110 beats/min. The pup -
✔✔Discontinue All Meds; Serotonin syndrome is a serious condition
that can be life-threatening. This patient is taking multiple
serotonergic medications and displays features suggestive of
serotonin syndrome. Signs and symptoms of serotonin syndrome
include mental status changes (e.g., agitation, hallucinations,
delirium, coma), autonomic instability (e.g., hyperthermia,
tachycardia, labile blood pressure, diaphoresis, dizziness, flushing),
neuromuscular changes (e.g., tremor, rigidity, hyperreflexia), and
gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). A timely
diagnosis and immediate discontinuation of serotonergic medications
can help prevent worsening of the condition. Supportive care,
sometimes in a hospital or intensive-care setting depending on
severity, is the mainstay of treatment. Severe symptoms that
necessitate hospital management include a temperature >38.5°C,
confusion, delirium, and rigidity. Multiple classes of medications are
,associated with serotonin syndrome, including SSRIs/SNRIs, tricyclic
antidepressants, antipsychotics, stimulants, triptans, and others.
Changing to a different stimulant, or to a nonstimulant, would not
help resolve serotonin syndrome, nor would symptomatic treatment
with diphenhydramine or similar agents. Serotonin syndrome has
been reported with 5-HT3 receptor antagonists such as ondansetron,
particularly when used in combination with other serotonergic
medications.
12-year-old transgender female accompanied by her mother comes to
your office to discuss persistent gender dysphoria. The patient has
been in counseling for 2 years along with her family, who is
supportive of her gender identity. The patient's mother asks about
puberty blockers. In discussing GnRH analogs with her, you note that
the current recommendation for beginning this medication is when
she is at which Tanner stage of development? - ✔✔Tanner Stage 2;
The 2022 World Professional Association for Transgender Healthcare
(WPATH) standards of care recommends that in eligible adolescents,
pubertal suppression may begin at Tanner stage 2. Treatment prior to
the onset of puberty is not recommended. Tanner stage 1 is
prepubescent and Tanner stage 2 is the initial pubescent stage. It is
not necessary and may be harmful to wait for further pubertal stages
before initiating puberty blockers in an eligible transgender
adolescent.
20-year-old college student comes to your office on Monday morning
after injuring his right arm during a rugby match 2 days earlier. He is
not certain of the mechanism of injury but was struck forcefully on
the lower posterior part of his upper arm above the elbow. He
,describes paresthesias on the extensor side of his forearm and the
back of his hand. His upper arm is bruised and mildly swollen at the
described location. In addition to the paresthesias on the extensor
forearm and the back of the hand, which one of the following motor
findings would you expect? - ✔✔Radial Nerve; This student athlete
likely has a contusion to the radial nerve in the spiral groove of the
distal humerus, resulting in the so-called "Saturday night palsy" after
undue pressure on the distal upper arm. This could be the result of
significant direct pressure over several hours, or such an injury could
happen acutely, as in the described scenario. Findings include
paresthesias and possible decreased light or sharp touch sensation on
the back of the hand and extensor forearm. Motor findings include
weakness of finger and wrist extension, best evaluated by testing
while the examiner applies resistance to the actions. Thumb
apposition is controlled by the median nerve and splaying out the
fingers (lumbricals) is mainly an ulnar nerve function. Unless the
nerve has been severed, the sensory loss and motor weakness
typically resolve within days to weeks.
24-year-old male presents for evaluation of a soft-tissue mass on his
arm. Which one of the following features, if present, should prompt
further evaluation with advanced imaging? - ✔✔Soft-tissue masses
that are >5 cm in diameter carry a higher risk of malignancy and
should prompt further evaluation with advanced imaging. Other
features that raise concern for possible malignancy include rapid
growth, sudden presentation without explanation, and lesions that
are firm, deep, and adhere to surrounding structures. Both benign and
malignant masses can be painless, but a lack of tenderness with
palpation alone would not prompt the need for advanced imaging.
, Advanced imaging would also not be necessary for a mass that has a
fluctuant texture, has grown persistently and slowly over several
years, or is superficially located (above the fascia).
25-year-old male presents for a pretravel consultation prior to
embarking on a 10-day mission trip to Central America with his
church. His past medical history includes GERD, irritable bowel
syndrome, and generalized anxiety disorder. The last time he traveled
internationally he experienced a prolonged bout of traveler's
diarrhea, despite his best efforts at practicing good hand hygiene and
careful food and drink selection. He asks if there are any medications
that he can take to prevent a similar experience this time. Which one
of the following is most appropriate for prophylactic use in this
situation? - ✔✔Bismuth subsalicylate has been shown to decrease the
risk of contracting traveler's diarrhea by 50%-65% and may be
considered for patients who are at increased risk. Drawbacks include
the frequent dosing of four times daily and the risk of developing a
black tongue and black stool. Bismuth subsalicylate is contraindicated
in the setting of aspirin allergy, kidney disease, breastfeeding, or
concurrent anticoagulant use. Medications that decrease gastric
acidity, such as proton pump inhibitors, H2-blockers, and antacids,
substantially increase one's risk of contracting traveler's diarrhea.
Therefore, avoiding calcium carbonate and omeprazole would be
preferable for this patient. Prophylactic antibiotics typically are not
recommended in this situation although may be considered for those
who are at particularly high risk of health complications from a
gastrointestinal illness. If a prophylactic antibiotic is desired, rifaximin
should be considered. Fluoroquinolones such as ciprofloxacin,
however, should be avoided for prophylactic use due to risks of
. You are caring for a 21-year-old female with previously diagnosed
bipolar II disorder, generalized anxiety disorder, attention-
deficit/hyperactivity disorder, and insomnia. The patient presents
with new symptoms of chills, excess sweating, flushing, and nausea of
approximately 2 hours' duration. The patient felt normal upon
awakening, took methylphenidate (Ritalin), 5 mg with breakfast, and
went to work. She began to feel shaky around lunchtime and took a
second dose of methylphenidate, 5 mg. Thirty minutes later she
began having agitation, chills, sweating, flushing, and nausea and had
to leave work. Her current medications include the following:
Desvenlafaxine , 50 mg daily Doxepin, 10 mg daily Methylphenidate, 5
mg twice daily Ziprasidone (Geodon), 40 mg twice daily ; examination
reveals an alert and anxious patient with damp skin, a temperature of
38.1°C (100.6°F), and a heart rate of 110 beats/min. The pup -
✔✔Discontinue All Meds; Serotonin syndrome is a serious condition
that can be life-threatening. This patient is taking multiple
serotonergic medications and displays features suggestive of
serotonin syndrome. Signs and symptoms of serotonin syndrome
include mental status changes (e.g., agitation, hallucinations,
delirium, coma), autonomic instability (e.g., hyperthermia,
tachycardia, labile blood pressure, diaphoresis, dizziness, flushing),
neuromuscular changes (e.g., tremor, rigidity, hyperreflexia), and
gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). A timely
diagnosis and immediate discontinuation of serotonergic medications
can help prevent worsening of the condition. Supportive care,
sometimes in a hospital or intensive-care setting depending on
severity, is the mainstay of treatment. Severe symptoms that
necessitate hospital management include a temperature >38.5°C,
confusion, delirium, and rigidity. Multiple classes of medications are
,associated with serotonin syndrome, including SSRIs/SNRIs, tricyclic
antidepressants, antipsychotics, stimulants, triptans, and others.
Changing to a different stimulant, or to a nonstimulant, would not
help resolve serotonin syndrome, nor would symptomatic treatment
with diphenhydramine or similar agents. Serotonin syndrome has
been reported with 5-HT3 receptor antagonists such as ondansetron,
particularly when used in combination with other serotonergic
medications.
12-year-old transgender female accompanied by her mother comes to
your office to discuss persistent gender dysphoria. The patient has
been in counseling for 2 years along with her family, who is
supportive of her gender identity. The patient's mother asks about
puberty blockers. In discussing GnRH analogs with her, you note that
the current recommendation for beginning this medication is when
she is at which Tanner stage of development? - ✔✔Tanner Stage 2;
The 2022 World Professional Association for Transgender Healthcare
(WPATH) standards of care recommends that in eligible adolescents,
pubertal suppression may begin at Tanner stage 2. Treatment prior to
the onset of puberty is not recommended. Tanner stage 1 is
prepubescent and Tanner stage 2 is the initial pubescent stage. It is
not necessary and may be harmful to wait for further pubertal stages
before initiating puberty blockers in an eligible transgender
adolescent.
20-year-old college student comes to your office on Monday morning
after injuring his right arm during a rugby match 2 days earlier. He is
not certain of the mechanism of injury but was struck forcefully on
the lower posterior part of his upper arm above the elbow. He
,describes paresthesias on the extensor side of his forearm and the
back of his hand. His upper arm is bruised and mildly swollen at the
described location. In addition to the paresthesias on the extensor
forearm and the back of the hand, which one of the following motor
findings would you expect? - ✔✔Radial Nerve; This student athlete
likely has a contusion to the radial nerve in the spiral groove of the
distal humerus, resulting in the so-called "Saturday night palsy" after
undue pressure on the distal upper arm. This could be the result of
significant direct pressure over several hours, or such an injury could
happen acutely, as in the described scenario. Findings include
paresthesias and possible decreased light or sharp touch sensation on
the back of the hand and extensor forearm. Motor findings include
weakness of finger and wrist extension, best evaluated by testing
while the examiner applies resistance to the actions. Thumb
apposition is controlled by the median nerve and splaying out the
fingers (lumbricals) is mainly an ulnar nerve function. Unless the
nerve has been severed, the sensory loss and motor weakness
typically resolve within days to weeks.
24-year-old male presents for evaluation of a soft-tissue mass on his
arm. Which one of the following features, if present, should prompt
further evaluation with advanced imaging? - ✔✔Soft-tissue masses
that are >5 cm in diameter carry a higher risk of malignancy and
should prompt further evaluation with advanced imaging. Other
features that raise concern for possible malignancy include rapid
growth, sudden presentation without explanation, and lesions that
are firm, deep, and adhere to surrounding structures. Both benign and
malignant masses can be painless, but a lack of tenderness with
palpation alone would not prompt the need for advanced imaging.
, Advanced imaging would also not be necessary for a mass that has a
fluctuant texture, has grown persistently and slowly over several
years, or is superficially located (above the fascia).
25-year-old male presents for a pretravel consultation prior to
embarking on a 10-day mission trip to Central America with his
church. His past medical history includes GERD, irritable bowel
syndrome, and generalized anxiety disorder. The last time he traveled
internationally he experienced a prolonged bout of traveler's
diarrhea, despite his best efforts at practicing good hand hygiene and
careful food and drink selection. He asks if there are any medications
that he can take to prevent a similar experience this time. Which one
of the following is most appropriate for prophylactic use in this
situation? - ✔✔Bismuth subsalicylate has been shown to decrease the
risk of contracting traveler's diarrhea by 50%-65% and may be
considered for patients who are at increased risk. Drawbacks include
the frequent dosing of four times daily and the risk of developing a
black tongue and black stool. Bismuth subsalicylate is contraindicated
in the setting of aspirin allergy, kidney disease, breastfeeding, or
concurrent anticoagulant use. Medications that decrease gastric
acidity, such as proton pump inhibitors, H2-blockers, and antacids,
substantially increase one's risk of contracting traveler's diarrhea.
Therefore, avoiding calcium carbonate and omeprazole would be
preferable for this patient. Prophylactic antibiotics typically are not
recommended in this situation although may be considered for those
who are at particularly high risk of health complications from a
gastrointestinal illness. If a prophylactic antibiotic is desired, rifaximin
should be considered. Fluoroquinolones such as ciprofloxacin,
however, should be avoided for prophylactic use due to risks of
