ABFM ITE UPDATED EXAM EVALUATION QUESTIONS AND
ANSWERS RATED A+
✔✔A 30-year-old male is treated with topical medications for his papulopustular rosacea
with only partial improvement. The preferred antibiotic is - ✔✔Doxycycline
✔✔Pre-op evaluation - ✔✔A healthy patient would be classified as ASA I, while a
patient with mild systemic disease would be classified as ASA II. All patients who are
having major surgery should be offered preoperative laboratory testing, including a CBC
and renal function testing.
For patients who are ASA III or IV and have chronic liver disease or take anticoagulants,
coagulation testing should be considered.
There is no compelling evidence to support either a chest radiograph or an EKG as part
of a routine preoperative evaluation.
✔✔Most common hip disorder in adolescents (ages 8-15) - ✔✔SUFE should be
suspected in an adolescent who has unexplained pain in the hip, groin, thigh, or knee. It
is rarely associated with trauma, overuse, or prior illness. On examination the most
indicative sign is limited internal rotation of the involved hip. Bilateral radiographs of the
hips, including frog-leg lateral views, should be obtained.
Legg-Calve-Perthes disease (insidious) and transient synovitis (acute onset with fever)
are more common in children under age 10.
✔✔COPD GOLD - ✔✔A risk category of A (low risk, fewer symptoms) requires either a
SAMA/SABA as the initial
pharmacologic management. LABA/LAMA are indicated for patients with a GOLD
combined assessment category of B or worse. Long-acting inhaled corticosteroids are
indicated for patients with
a GOLD combined assessment category of C or worse.
✔✔ACEi and ARB as anti-hypertensives with renoprotective effects - ✔✔May tolerate a
rise of <30% in serum creatinine after initiation. Rises in serum creatinine of >30% from
baseline increase the risk of renal failure, adverse cardiac outcomes, and death.
✔✔Metatarsal stress fractures (common second and third) - ✔✔No weight bearing for a
few days, possibly using a posterior splint, transitioning to a walking boot or short leg
cast, and then a rigid-soled shoe in 4-6 weeks.
Other recommended conservative therapy includes modified rest for 6-8 weeks with
continuation of activities of daily living and limited walking. Normal activity can be
resumed after 2-3 weeks with no pain. Additionally, the use of NSAIDs, ice, and
stretching, as well as cross-training is recommended.
,✔✔Uterine fibroid tumors (leiomyomas) are the most common tumors of the female
reproductive tract. - ✔✔Many fibroids are asymptomatic and are discovered incidentally,
with observation being the preferred management in this situation. The risk of malignant
leiomyosarcoma is exceedingly small (0.23% in one study) and there is a risk of side
effects or complications from other treatment modalities.
✔✔Diarrhea that develops in patients with ileal Crohn's disease or following ileal
resection is usually due to increased amounts of bile acid remaining in the stool. This
affects colonic secretion and motility and various protein factors in the gut, resulting in
the development of bile acid diarrhoea (BAD). - ✔✔A therapeutic trial with a bile acid
sequestrant such as cholestyramine is most often used for both the diagnosis and
treatment of BAD.
Reducing fat intake may also be beneficial.
Fiber supplementation may help to produce a more formed stool and could be used as
an adjunct treatment when appropriate.
✔✔Treatment of PTSD - ✔✔An SSRI or SNRI should be used first as monotherapy and
should be optimized before an additional agent is added.
Prazosin is an effective augmenting therapy for patients with PTSD and sleep
disturbance/nightmares.
✔✔Injections for shoulder impingement syndrome - ✔✔Subacromial injection of a
corticosteroid may provide pain relief for up to several weeks but does not alter long-
term outcomes.
✔✔Acne appearing at which one of the following ages should prompt detailed endocrine
laboratory testing for possible underlying systemic disease? - ✔✔Mid-childhood i.e. 5yo
✔✔A 5-year-old male is brought to your office after passing an intestinal worm. He lives
on a farm with cattle, pigs, and dogs. He has never travelled very far from home. He
does not have any respiratory symptoms or diarrhoea, but has experienced some
abdominal bloating. - ✔✔Ascaris lumbricoides is a large roundworm that typically infects
the ileum. Symptoms are variable but large infections can lead to intestinal obstruction.
Pinworms are much smaller and typically present with anal pruritus.
Tapeworms can be large, but are flat and segmental in appearance, and are typically
found in the stool as segments called proglottids.
Hookworms are also round, but are typically 6-12 mm in length. They are a significant
cause of anemia in children globally.
,✔✔Precocious puberty in boys - ✔✔Penile enlargement before 9yo
Isolated sparse pubic and axillary hair growth and axillary odour is referred to as
premature adrenarche, and represents high levels of dehydroepiandrosterone rather
than activation of the hypothalamic-pituitary-gonadal axis that leads to puberty.
✔✔Incidental isolated leukocytosis - ✔✔For most cases without a clear cause, a repeat
CBC with differential and a peripheral smear review are indicated to confirm
leukocytosis, determine subtypes, and look for concerning abnormalities on the smear.
✔✔The drug class of choice for the management of breathlessness in end-of-life care is
- ✔✔Opiates
When administered at appropriate doses, opiates do not reduce or compromise
respiratory status and do not hasten dying. Opiates help to reduce the sense of air
hunger in patients with dyspnea.
✔✔Avoid Donepezil (used in Alzheimer's, cholinesterase inhibitor) in those with
syncope - ✔✔Due to increased risk of bradycardia (+ prolonged PR)
✔✔Hypertension in paediatric population - ✔✔All paediatric patients with confirmed
hypertension should have further evaluation to check for renal dysfunction as well as
other cardiac risk factors.
Additionally, renal ultrasonography is recommended to evaluate for renal disease and
echocardiography to evaluate for end-organ damage that would affect treatment goals.
Additional studies, such as plasma renin and catecholamine levels or renovascular
imaging, may be indicated in children with abnormalities on initial evaluation that
suggest secondary causes of hypertension.
✔✔Patients on valproate who present with altered mental status or encephalopathy -
✔✔Hyperammonaemia
✔✔Somatic symptom disorder - ✔✔Characterized by multiple unexplained physical
symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical
history.
SSRIs and tricyclic antidepressants (esp. Amitriptyline) have been found to be the most
effective pharmacotherapy.
✔✔What is the most accurate and appropriate manoeuvre to detect an
anterior cruciate ligament tear? - ✔✔Lachman test
, ✔✔De Quervain's tenosynovitis usually occurs with repeated use of the thumb and is
characterized by pain in the radial wrist. The course is typically self-limited but can last
for up to a year, so waiting would not be a good option. - ✔✔Immobilization in a thumb
spica splint and an NSAID for 1-4 weeks.
✔✔Parvovirus 19 (erythema infectiosum) - ✔✔The rash is a faint, maculopapular,
irregular, reticulate exanthem that covers thighs and the inner aspects of upper arms.
Symmetric synovitis is present in several distal and proximal interphalangeal joints and
in the metacarpophalangeal joints. Small effusions, warmth, and tenderness are noted
in her left wrist and right elbow.
✔✔Cervical lymphadenopathy with signs of infection i.e. fever, inflammation - ✔✔Treat
empirically with antibiotics and evaluate for improvement in 2-3 days
✔✔H pylori treat and test strategy - ✔✔Appropriate for patients with dyspepsia who are
younger than 55 years of age and have no alarm symptoms for gastric cancer.
✔✔What additional test results must be documented before offering preexposure
prophylaxis for HIV with emtricitabine/tenofovir (Truvada)? - ✔✔Antibody testing for HIV
(as Truvada is inadequate in treating HIV), Hepatitis B surface antibody and antigen,
renal panel, STI screening, UPT
✔✔Scaphoid fracture is the most common carpal bone injury. This injury tends to occur
when the wrist is hyperextended and the hand is pronated and radially deviated. - ✔✔A
thumb spica cast (a short arm cast with the thumb immobilized) for 6-10 weeks is
appropriate for nondisplaced distal fractures. Surgical treatment should be considered
for displaced or proximal fractures.
✔✔Red flags for tinnitus - ✔✔Pulsatile, unilateral, or tinnitus associated with asymmetric
hearing loss is more likely to be associated with a pathologic cause.
✔✔Nursemaid's elbow/pulled elbow - ✔✔Subluxation of the radial head is one of the
most common injuries in children under 5 years of age. It occurs when the child's hand
is suddenly jerked up, forcing the elbow into extension and causing the radial head to
slip out from the annular ligament.
This is a clinical diagnosis that usually does not require imaging prior to attempted
reduction, either by hyperpronation or the supination and flexion method.
✔✔Treating moderate non purulent cellulitis - ✔✔Penicillin, ceftriaxone, cefazolin, or
clindamycin alone.
ANSWERS RATED A+
✔✔A 30-year-old male is treated with topical medications for his papulopustular rosacea
with only partial improvement. The preferred antibiotic is - ✔✔Doxycycline
✔✔Pre-op evaluation - ✔✔A healthy patient would be classified as ASA I, while a
patient with mild systemic disease would be classified as ASA II. All patients who are
having major surgery should be offered preoperative laboratory testing, including a CBC
and renal function testing.
For patients who are ASA III or IV and have chronic liver disease or take anticoagulants,
coagulation testing should be considered.
There is no compelling evidence to support either a chest radiograph or an EKG as part
of a routine preoperative evaluation.
✔✔Most common hip disorder in adolescents (ages 8-15) - ✔✔SUFE should be
suspected in an adolescent who has unexplained pain in the hip, groin, thigh, or knee. It
is rarely associated with trauma, overuse, or prior illness. On examination the most
indicative sign is limited internal rotation of the involved hip. Bilateral radiographs of the
hips, including frog-leg lateral views, should be obtained.
Legg-Calve-Perthes disease (insidious) and transient synovitis (acute onset with fever)
are more common in children under age 10.
✔✔COPD GOLD - ✔✔A risk category of A (low risk, fewer symptoms) requires either a
SAMA/SABA as the initial
pharmacologic management. LABA/LAMA are indicated for patients with a GOLD
combined assessment category of B or worse. Long-acting inhaled corticosteroids are
indicated for patients with
a GOLD combined assessment category of C or worse.
✔✔ACEi and ARB as anti-hypertensives with renoprotective effects - ✔✔May tolerate a
rise of <30% in serum creatinine after initiation. Rises in serum creatinine of >30% from
baseline increase the risk of renal failure, adverse cardiac outcomes, and death.
✔✔Metatarsal stress fractures (common second and third) - ✔✔No weight bearing for a
few days, possibly using a posterior splint, transitioning to a walking boot or short leg
cast, and then a rigid-soled shoe in 4-6 weeks.
Other recommended conservative therapy includes modified rest for 6-8 weeks with
continuation of activities of daily living and limited walking. Normal activity can be
resumed after 2-3 weeks with no pain. Additionally, the use of NSAIDs, ice, and
stretching, as well as cross-training is recommended.
,✔✔Uterine fibroid tumors (leiomyomas) are the most common tumors of the female
reproductive tract. - ✔✔Many fibroids are asymptomatic and are discovered incidentally,
with observation being the preferred management in this situation. The risk of malignant
leiomyosarcoma is exceedingly small (0.23% in one study) and there is a risk of side
effects or complications from other treatment modalities.
✔✔Diarrhea that develops in patients with ileal Crohn's disease or following ileal
resection is usually due to increased amounts of bile acid remaining in the stool. This
affects colonic secretion and motility and various protein factors in the gut, resulting in
the development of bile acid diarrhoea (BAD). - ✔✔A therapeutic trial with a bile acid
sequestrant such as cholestyramine is most often used for both the diagnosis and
treatment of BAD.
Reducing fat intake may also be beneficial.
Fiber supplementation may help to produce a more formed stool and could be used as
an adjunct treatment when appropriate.
✔✔Treatment of PTSD - ✔✔An SSRI or SNRI should be used first as monotherapy and
should be optimized before an additional agent is added.
Prazosin is an effective augmenting therapy for patients with PTSD and sleep
disturbance/nightmares.
✔✔Injections for shoulder impingement syndrome - ✔✔Subacromial injection of a
corticosteroid may provide pain relief for up to several weeks but does not alter long-
term outcomes.
✔✔Acne appearing at which one of the following ages should prompt detailed endocrine
laboratory testing for possible underlying systemic disease? - ✔✔Mid-childhood i.e. 5yo
✔✔A 5-year-old male is brought to your office after passing an intestinal worm. He lives
on a farm with cattle, pigs, and dogs. He has never travelled very far from home. He
does not have any respiratory symptoms or diarrhoea, but has experienced some
abdominal bloating. - ✔✔Ascaris lumbricoides is a large roundworm that typically infects
the ileum. Symptoms are variable but large infections can lead to intestinal obstruction.
Pinworms are much smaller and typically present with anal pruritus.
Tapeworms can be large, but are flat and segmental in appearance, and are typically
found in the stool as segments called proglottids.
Hookworms are also round, but are typically 6-12 mm in length. They are a significant
cause of anemia in children globally.
,✔✔Precocious puberty in boys - ✔✔Penile enlargement before 9yo
Isolated sparse pubic and axillary hair growth and axillary odour is referred to as
premature adrenarche, and represents high levels of dehydroepiandrosterone rather
than activation of the hypothalamic-pituitary-gonadal axis that leads to puberty.
✔✔Incidental isolated leukocytosis - ✔✔For most cases without a clear cause, a repeat
CBC with differential and a peripheral smear review are indicated to confirm
leukocytosis, determine subtypes, and look for concerning abnormalities on the smear.
✔✔The drug class of choice for the management of breathlessness in end-of-life care is
- ✔✔Opiates
When administered at appropriate doses, opiates do not reduce or compromise
respiratory status and do not hasten dying. Opiates help to reduce the sense of air
hunger in patients with dyspnea.
✔✔Avoid Donepezil (used in Alzheimer's, cholinesterase inhibitor) in those with
syncope - ✔✔Due to increased risk of bradycardia (+ prolonged PR)
✔✔Hypertension in paediatric population - ✔✔All paediatric patients with confirmed
hypertension should have further evaluation to check for renal dysfunction as well as
other cardiac risk factors.
Additionally, renal ultrasonography is recommended to evaluate for renal disease and
echocardiography to evaluate for end-organ damage that would affect treatment goals.
Additional studies, such as plasma renin and catecholamine levels or renovascular
imaging, may be indicated in children with abnormalities on initial evaluation that
suggest secondary causes of hypertension.
✔✔Patients on valproate who present with altered mental status or encephalopathy -
✔✔Hyperammonaemia
✔✔Somatic symptom disorder - ✔✔Characterized by multiple unexplained physical
symptoms, insistence on surgical procedures, and an imprecise or inaccurate medical
history.
SSRIs and tricyclic antidepressants (esp. Amitriptyline) have been found to be the most
effective pharmacotherapy.
✔✔What is the most accurate and appropriate manoeuvre to detect an
anterior cruciate ligament tear? - ✔✔Lachman test
, ✔✔De Quervain's tenosynovitis usually occurs with repeated use of the thumb and is
characterized by pain in the radial wrist. The course is typically self-limited but can last
for up to a year, so waiting would not be a good option. - ✔✔Immobilization in a thumb
spica splint and an NSAID for 1-4 weeks.
✔✔Parvovirus 19 (erythema infectiosum) - ✔✔The rash is a faint, maculopapular,
irregular, reticulate exanthem that covers thighs and the inner aspects of upper arms.
Symmetric synovitis is present in several distal and proximal interphalangeal joints and
in the metacarpophalangeal joints. Small effusions, warmth, and tenderness are noted
in her left wrist and right elbow.
✔✔Cervical lymphadenopathy with signs of infection i.e. fever, inflammation - ✔✔Treat
empirically with antibiotics and evaluate for improvement in 2-3 days
✔✔H pylori treat and test strategy - ✔✔Appropriate for patients with dyspepsia who are
younger than 55 years of age and have no alarm symptoms for gastric cancer.
✔✔What additional test results must be documented before offering preexposure
prophylaxis for HIV with emtricitabine/tenofovir (Truvada)? - ✔✔Antibody testing for HIV
(as Truvada is inadequate in treating HIV), Hepatitis B surface antibody and antigen,
renal panel, STI screening, UPT
✔✔Scaphoid fracture is the most common carpal bone injury. This injury tends to occur
when the wrist is hyperextended and the hand is pronated and radially deviated. - ✔✔A
thumb spica cast (a short arm cast with the thumb immobilized) for 6-10 weeks is
appropriate for nondisplaced distal fractures. Surgical treatment should be considered
for displaced or proximal fractures.
✔✔Red flags for tinnitus - ✔✔Pulsatile, unilateral, or tinnitus associated with asymmetric
hearing loss is more likely to be associated with a pathologic cause.
✔✔Nursemaid's elbow/pulled elbow - ✔✔Subluxation of the radial head is one of the
most common injuries in children under 5 years of age. It occurs when the child's hand
is suddenly jerked up, forcing the elbow into extension and causing the radial head to
slip out from the annular ligament.
This is a clinical diagnosis that usually does not require imaging prior to attempted
reduction, either by hyperpronation or the supination and flexion method.
✔✔Treating moderate non purulent cellulitis - ✔✔Penicillin, ceftriaxone, cefazolin, or
clindamycin alone.
