ABFM ITE UPDATED EXAM SCRIPT QUESTIONS AND
ANSWERS RATED A+
✔✔10. You see an adult patient who has chronic urticaria and no other known chronic
conditions. He continues to experience hives after a 3-month course of daily loratadine
(Claritin).
Which one of the following would be the most appropriate addition to his treatment
regimen at this time?
A) A short course of oral corticosteroids
B) Cyclosporine
C) Ranitidine (Zantac)
D) Narrow-band UV light treatment - ✔✔ANSWER: C
First- and second-generation H1 antihistamine receptor antagonists are generally
considered first-line treatment for chronic urticaria, and approximately 60% of patients
experience a satisfactory result. Second-generation options such as loratadine have the
added benefit of a lower likelihood of side effects such as drowsiness. For those who
fail to achieve the desired result with monotherapy using an H1 antihistamine receptor
antagonist, the addition of an H2 antihistamine receptor antagonist such as cimetidine
or ranitidine is often beneficial. The tricyclic antidepressant doxepin has strong H1 and
H2 antihistamine receptor antagonist effects and has been used as an off-label
treatment option in some studies. A short course of oral corticosteroids, narrow-band
UV light treatment, or cyclosporine can be used in the management of recalcitrant
chronic urticaria, but these are considered second- or third-line adjunctive options.
✔✔11. A 10-year-old male has an 8-mm induration 2 days after a tuberculin skin test.
He shares a bedroom with his 18-year-old brother who was recently diagnosed with
tuberculosis. There are no other historical or physical examination findings to suggest
active tuberculosis infection and a chest radiograph is normal.
Which one of the following would be most appropriate at this point?
A) Monitoring with annual tuberculin skin testing
B) Observation and repeat tuberculin skin testing in 3 weeks
C) Rifampin (Rifadin) daily for 4 months
D) Isoniazid daily for 9 months
E) Once-weekly isoniazid and rifampin for 3 months - ✔✔ANSWER: D
This patient's close contact with a person known to be infected with tuberculosis (TB)
places him at risk for infection, so screening for TB is indicated. For this patient, testing
with either a tuberculin skin test or an interferon-gamma release assay is appropriate.
Based on CDC guidelines an induration 5 mm at 48-72 hours following an intradermal
injection of tuberculin is a positive test in individuals who have been in recent contact
with a person with infectious TB, those with radiographic evidence of prior TB, HIV-
infected persons, and immunosuppressed patients. For other individuals at increased
risk for TB, the threshold for a positive test is an induration 10 mm at 48-72 hours. For
those with no known risks for TB infection, the induration must exceed 15 mm in size to
be considered positive. Once positive, there is no indication for additional skin tests.
,A positive screening test along with a review of systems, a physical examination, and a
chest radiograph that do not show evidence of active infection confirms the diagnosis of
latent TB. For children age 2-11 years, treatment with isoniazid, 10-20 mg/kg daily or
20-40 mg/kg twice weekly for 9 months, is the preferred and most efficacious treatment
regimen. The shorter 6-month treatment course is considered an acceptable option for
adults, but it is not recommended for children. The use of rifampin alone or in
combination with isoniazid is also an acceptable option for adults but not for children
under the age of 12.
✔✔12. A 62-year-old female with diabetes mellitus presents to your office with left lower
quadrant pain and guarding. She has a previous history of a shellfish allergy that
caused hives and swelling.
Further evaluation of this patient should include which one of the following?
A) Ultrasonography of the abdomen
B) CT of the abdomen and pelvis with oral and intravenous (IV) contrast
C) Oral corticosteroids and antihistamines, then CT of the abdomen and pelvis with oral
and IV contrast
D) Intravenous corticosteroids and antihistamines, then CT of the abdomen and pelvis
with oral and IV contrast
E) Laparotomy - ✔✔ANSWER: B
Evaluation of this patient should include CT of the abdomen and pelvis with oral and
intravenous (IV) contrast. There is no reason to inquire about shellfish allergies prior to
CT with IV contrast, because premedication is not needed. There is no correlation
between shellfish allergies and allergic reactions to contrast. Patients with moderately
severe to severe reactions to IV contrast in the past would need pretreatment with
corticosteroids.
✔✔13. A 45-year-old female who works as a house cleaner presents with left shoulder
pain. On examination she has pain and relative weakness when pushing toward the
midline against resistance while the shoulder is adducted and the elbow is bent to 90°.
With the elbow still at 90° she is unable to keep her left hand away from her body when
you position her hand behind her back.
This presentation is most consistent with an injury of which one of the following
tendons?
A) Deltoid
B) Infraspinatus
C) Subscapularis
D) Supraspinatus
E) Teres minor - ✔✔ANSWER: C
This patient's pain and weakness while pushing against resistance reveals weakness on
internal rotation of the shoulder, which suggests a possible tear of the subscapularis
tendon. The inability to keep her hand away from her body when it is placed behind her
back describes a positive internal lag test, also suggesting involvement of the
,subscapularis tendon. The infraspinatus and teres minor are involved in external
rotation rather than internal rotation. The supraspinatus and deltoid are involved in
abduction of the shoulder.
✔✔14. An 8-year-old male is brought to your office because of acute lower abdominal
pain. He is not constipated and has never had abdominal surgery. You suspect acute
appendicitis.
Which one of the following would be most appropriate at this point?
A) Plain radiography
B) Ultrasonography
C) CT without contrast
D) CT with contrast
E) MRI - ✔✔ANSWER: B
Ultrasonography is recommended as the first imaging modality to evaluate acute
abdominal pain in children. It avoids radiation exposure and is useful for detecting many
causes of abdominal pain, including appendicitis. After ultrasonography, CT or MRI can
be used if necessary to diagnose appendicitis. Abdominal radiography is helpful in
patients with constipation, possible bowel obstruction, or a history of previous
abdominal surgery.
The American Academy of Pediatrics Choosing Wisely recommendation on the
evaluation of abdominal pain states that CT is not always necessary. The American
College of Surgeons Choosing Wisely recommendation on the evaluation of suspected
appendicitis in children says that CT should be avoided until after ultrasonography has
been considered as an option.
✔✔15. You see a patient with a serum sodium level of 122 mEq/L (N 135-145) and a
serum osmolality of 255 mOsm/kg H2O (N 280-295). Which one of the following would
best correlate with a diagnosis of syndrome of inappropriate antidiuresis?
A) A fractional excretion of sodium below 1%
B) Elevated urine osmolality
C) Elevated serum glucose
D) Elevated BUN
E) Low plasma arginine vasopressin - ✔✔ANSWER: B
The syndrome of inappropriate antidiuresis (SIAD, formerly SIADH) is related to a
variety of pulmonary and central nervous system disorders in which hyponatremia and
hypo-osmolality are paradoxically associated with an inappropriately concentrated urine.
Most cases are associated with increased levels of the antidiuretic hormone arginine
vasopressin (AVP). Making a diagnosis of SIAD requires that the patient be euvolemic
and has not taken diuretics within the past 24-48 hours, and the urine osmolality must
be high in conjunction with both low serum sodium and low osmolality. The BUN should
be normal or low and the fractional excretion of sodium >1%.
Fluid restriction (<800 cc/24 hrs) over several days will correct the hyponatremia/hypo-
osmolality, but definitive treatment requires eliminating the underlying cause, if possible.
In the case of severe, acute hyponatremia with symptoms such as confusion,
, obtundation, or seizures, hypertonic (3%) saline can be slowly infused intravenously but
might have dangerous neurologic side effects.
Elevated serum glucose levels may cause a factitious hyponatremia, but not SIAD.
✔✔16. A 45-year-old African-American male returns to your clinic to evaluate his
progress after 6 months of dedicated adherence to a diet and exercise plan you
prescribed to manage his blood pressure. His blood pressure today is 148/96 mm Hg.
He is not overweight and he does not have other known medical conditions or drug
allergies.
Which one of the following would be the most appropriate initial antihypertensive
treatment option for this patient?
A) Chlorthalidone
B) Hydralazine
C) Lisinopril (Prinivil, Zestril)
D) Losartan (Cozaar)
E) Metoprolol - ✔✔ANSWER: A
Lifestyle modifications addressing diet, physical activity, and weight are important in the
treatment of hypertension, particularly for African-American and Hispanic patients.
When antihypertensive drugs are also required, the best options may vary according to
the racial and ethnic background of the patient. The presence or absence of comorbid
conditions is also important to consider. For African-Americans, thiazide diuretics and
calcium channel blockers, both as monotherapy and as a component in multidrug
regimens, have been shown to be more effective in lowering blood pressure than ACE
inhibitors, angiotensin II receptor blockers, or -blockers, and should be considered as
first-line options over the other classes of antihypertensive drugs unless a comorbid
condition is present that would be better addressed with a different class of drugs.
Racial or ethnic background should not be the basis for the exclusion of any drug class
when multidrug regimens are required to reach treatment goals.
✔✔17. An 85-year-old female with metastatic breast cancer requests hospice care. She
has type 2 diabetes mellitus, stage 3 renal failure, and heart disease.
The patient's eligibility for hospice care will be based on her
A) age
B) cancer diagnosis
C) comorbid conditions
D) life expectancy
E) Medicare Part B plan - ✔✔ANSWER: D
Eligibility for hospice care is based on a life expectancy of 6 months or less in the
natural course of an illness. A majority of hospice patients have cancer but it is not a
requirement to qualify for hospice care. Age is not relevant. Comorbid conditions may
affect longevity but are not required. For those insured by Medicare, Medicare Part A
provides hospice care but Medicare Part B does not.
ANSWERS RATED A+
✔✔10. You see an adult patient who has chronic urticaria and no other known chronic
conditions. He continues to experience hives after a 3-month course of daily loratadine
(Claritin).
Which one of the following would be the most appropriate addition to his treatment
regimen at this time?
A) A short course of oral corticosteroids
B) Cyclosporine
C) Ranitidine (Zantac)
D) Narrow-band UV light treatment - ✔✔ANSWER: C
First- and second-generation H1 antihistamine receptor antagonists are generally
considered first-line treatment for chronic urticaria, and approximately 60% of patients
experience a satisfactory result. Second-generation options such as loratadine have the
added benefit of a lower likelihood of side effects such as drowsiness. For those who
fail to achieve the desired result with monotherapy using an H1 antihistamine receptor
antagonist, the addition of an H2 antihistamine receptor antagonist such as cimetidine
or ranitidine is often beneficial. The tricyclic antidepressant doxepin has strong H1 and
H2 antihistamine receptor antagonist effects and has been used as an off-label
treatment option in some studies. A short course of oral corticosteroids, narrow-band
UV light treatment, or cyclosporine can be used in the management of recalcitrant
chronic urticaria, but these are considered second- or third-line adjunctive options.
✔✔11. A 10-year-old male has an 8-mm induration 2 days after a tuberculin skin test.
He shares a bedroom with his 18-year-old brother who was recently diagnosed with
tuberculosis. There are no other historical or physical examination findings to suggest
active tuberculosis infection and a chest radiograph is normal.
Which one of the following would be most appropriate at this point?
A) Monitoring with annual tuberculin skin testing
B) Observation and repeat tuberculin skin testing in 3 weeks
C) Rifampin (Rifadin) daily for 4 months
D) Isoniazid daily for 9 months
E) Once-weekly isoniazid and rifampin for 3 months - ✔✔ANSWER: D
This patient's close contact with a person known to be infected with tuberculosis (TB)
places him at risk for infection, so screening for TB is indicated. For this patient, testing
with either a tuberculin skin test or an interferon-gamma release assay is appropriate.
Based on CDC guidelines an induration 5 mm at 48-72 hours following an intradermal
injection of tuberculin is a positive test in individuals who have been in recent contact
with a person with infectious TB, those with radiographic evidence of prior TB, HIV-
infected persons, and immunosuppressed patients. For other individuals at increased
risk for TB, the threshold for a positive test is an induration 10 mm at 48-72 hours. For
those with no known risks for TB infection, the induration must exceed 15 mm in size to
be considered positive. Once positive, there is no indication for additional skin tests.
,A positive screening test along with a review of systems, a physical examination, and a
chest radiograph that do not show evidence of active infection confirms the diagnosis of
latent TB. For children age 2-11 years, treatment with isoniazid, 10-20 mg/kg daily or
20-40 mg/kg twice weekly for 9 months, is the preferred and most efficacious treatment
regimen. The shorter 6-month treatment course is considered an acceptable option for
adults, but it is not recommended for children. The use of rifampin alone or in
combination with isoniazid is also an acceptable option for adults but not for children
under the age of 12.
✔✔12. A 62-year-old female with diabetes mellitus presents to your office with left lower
quadrant pain and guarding. She has a previous history of a shellfish allergy that
caused hives and swelling.
Further evaluation of this patient should include which one of the following?
A) Ultrasonography of the abdomen
B) CT of the abdomen and pelvis with oral and intravenous (IV) contrast
C) Oral corticosteroids and antihistamines, then CT of the abdomen and pelvis with oral
and IV contrast
D) Intravenous corticosteroids and antihistamines, then CT of the abdomen and pelvis
with oral and IV contrast
E) Laparotomy - ✔✔ANSWER: B
Evaluation of this patient should include CT of the abdomen and pelvis with oral and
intravenous (IV) contrast. There is no reason to inquire about shellfish allergies prior to
CT with IV contrast, because premedication is not needed. There is no correlation
between shellfish allergies and allergic reactions to contrast. Patients with moderately
severe to severe reactions to IV contrast in the past would need pretreatment with
corticosteroids.
✔✔13. A 45-year-old female who works as a house cleaner presents with left shoulder
pain. On examination she has pain and relative weakness when pushing toward the
midline against resistance while the shoulder is adducted and the elbow is bent to 90°.
With the elbow still at 90° she is unable to keep her left hand away from her body when
you position her hand behind her back.
This presentation is most consistent with an injury of which one of the following
tendons?
A) Deltoid
B) Infraspinatus
C) Subscapularis
D) Supraspinatus
E) Teres minor - ✔✔ANSWER: C
This patient's pain and weakness while pushing against resistance reveals weakness on
internal rotation of the shoulder, which suggests a possible tear of the subscapularis
tendon. The inability to keep her hand away from her body when it is placed behind her
back describes a positive internal lag test, also suggesting involvement of the
,subscapularis tendon. The infraspinatus and teres minor are involved in external
rotation rather than internal rotation. The supraspinatus and deltoid are involved in
abduction of the shoulder.
✔✔14. An 8-year-old male is brought to your office because of acute lower abdominal
pain. He is not constipated and has never had abdominal surgery. You suspect acute
appendicitis.
Which one of the following would be most appropriate at this point?
A) Plain radiography
B) Ultrasonography
C) CT without contrast
D) CT with contrast
E) MRI - ✔✔ANSWER: B
Ultrasonography is recommended as the first imaging modality to evaluate acute
abdominal pain in children. It avoids radiation exposure and is useful for detecting many
causes of abdominal pain, including appendicitis. After ultrasonography, CT or MRI can
be used if necessary to diagnose appendicitis. Abdominal radiography is helpful in
patients with constipation, possible bowel obstruction, or a history of previous
abdominal surgery.
The American Academy of Pediatrics Choosing Wisely recommendation on the
evaluation of abdominal pain states that CT is not always necessary. The American
College of Surgeons Choosing Wisely recommendation on the evaluation of suspected
appendicitis in children says that CT should be avoided until after ultrasonography has
been considered as an option.
✔✔15. You see a patient with a serum sodium level of 122 mEq/L (N 135-145) and a
serum osmolality of 255 mOsm/kg H2O (N 280-295). Which one of the following would
best correlate with a diagnosis of syndrome of inappropriate antidiuresis?
A) A fractional excretion of sodium below 1%
B) Elevated urine osmolality
C) Elevated serum glucose
D) Elevated BUN
E) Low plasma arginine vasopressin - ✔✔ANSWER: B
The syndrome of inappropriate antidiuresis (SIAD, formerly SIADH) is related to a
variety of pulmonary and central nervous system disorders in which hyponatremia and
hypo-osmolality are paradoxically associated with an inappropriately concentrated urine.
Most cases are associated with increased levels of the antidiuretic hormone arginine
vasopressin (AVP). Making a diagnosis of SIAD requires that the patient be euvolemic
and has not taken diuretics within the past 24-48 hours, and the urine osmolality must
be high in conjunction with both low serum sodium and low osmolality. The BUN should
be normal or low and the fractional excretion of sodium >1%.
Fluid restriction (<800 cc/24 hrs) over several days will correct the hyponatremia/hypo-
osmolality, but definitive treatment requires eliminating the underlying cause, if possible.
In the case of severe, acute hyponatremia with symptoms such as confusion,
, obtundation, or seizures, hypertonic (3%) saline can be slowly infused intravenously but
might have dangerous neurologic side effects.
Elevated serum glucose levels may cause a factitious hyponatremia, but not SIAD.
✔✔16. A 45-year-old African-American male returns to your clinic to evaluate his
progress after 6 months of dedicated adherence to a diet and exercise plan you
prescribed to manage his blood pressure. His blood pressure today is 148/96 mm Hg.
He is not overweight and he does not have other known medical conditions or drug
allergies.
Which one of the following would be the most appropriate initial antihypertensive
treatment option for this patient?
A) Chlorthalidone
B) Hydralazine
C) Lisinopril (Prinivil, Zestril)
D) Losartan (Cozaar)
E) Metoprolol - ✔✔ANSWER: A
Lifestyle modifications addressing diet, physical activity, and weight are important in the
treatment of hypertension, particularly for African-American and Hispanic patients.
When antihypertensive drugs are also required, the best options may vary according to
the racial and ethnic background of the patient. The presence or absence of comorbid
conditions is also important to consider. For African-Americans, thiazide diuretics and
calcium channel blockers, both as monotherapy and as a component in multidrug
regimens, have been shown to be more effective in lowering blood pressure than ACE
inhibitors, angiotensin II receptor blockers, or -blockers, and should be considered as
first-line options over the other classes of antihypertensive drugs unless a comorbid
condition is present that would be better addressed with a different class of drugs.
Racial or ethnic background should not be the basis for the exclusion of any drug class
when multidrug regimens are required to reach treatment goals.
✔✔17. An 85-year-old female with metastatic breast cancer requests hospice care. She
has type 2 diabetes mellitus, stage 3 renal failure, and heart disease.
The patient's eligibility for hospice care will be based on her
A) age
B) cancer diagnosis
C) comorbid conditions
D) life expectancy
E) Medicare Part B plan - ✔✔ANSWER: D
Eligibility for hospice care is based on a life expectancy of 6 months or less in the
natural course of an illness. A majority of hospice patients have cancer but it is not a
requirement to qualify for hospice care. Age is not relevant. Comorbid conditions may
affect longevity but are not required. For those insured by Medicare, Medicare Part A
provides hospice care but Medicare Part B does not.
